The Bristol Dementia Wellbeing Service (BDWS) – Devon Partnership Trust – HC – #MHAwards18

The Bristol Dementia Wellbeing Service (BDWS) is an innovative primary care service delivered in partnership between Devon Partnership NHS Trust and Alzheimer’s Society, currently in its fourth year of operation. The service works alongside GPs, other health professionals and partner organisations across Bristol to support people with dementia with help when and where people want this, and in a way that suits them. Each GP practice in Bristol has a named Dementia Practitioner and Dementia Navigator. Practitioners are qualified members of the care team who work closely with the person with dementia and their GPs and can provide specialist memory assessments or offer therapeutic interventions to support people and their families at difficult times throughout their illness.

Highly Commended in Specialist Services Category - #MHAwards18


  • From start: No
  • During process: Yes
  • In evaluation: Yes


  • Peer: Yes
  • Academic: No
  • PP Collaborative: Yes

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Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.

The Bristol Dementia Wellbeing Service (BDWS) is an innovative primary care service delivered in partnership between Devon Partnership NHS Trust and Alzheimer’s Society, currently in its fourth year of operation. The service works alongside GPs, other health professionals and partner organisations across Bristol to support people with dementia with help when and where people want this, and in a way that suits them. Each GP practice in Bristol has a named Dementia Practitioner and Dementia Navigator. Practitioners are qualified members of the care team who work closely with the person with dementia and their GPs and can provide specialist memory assessments or offer therapeutic interventions to support people and their families at difficult times throughout their illness. Dementia Navigators support people with a diagnosis and those close to them, working in a person-centred way to identify local groups and activities in the community that can maintain the independence and enhance the quality of life for people with dementia.

The service has a dedicated care home liaison team who support best practice, working alongside providers, managers and champions across Bristol’s nursing and residential homes. The service also operates a Memory Clinic, enabling GPs to access support with diagnosis for the most complex of presentations. The service operates from three hubs across Bristol, ensuring each team is able to respond to local needs. The service also has an Access Point (8am to 8pm, Monday to Friday) where anyone can call in for advice and support. Its website is regularly updated with news and local support ( and also reaches out through social media (Twitter: @BristolDWS)


What makes your service stand out from others? Please provide an example of this.

The service is a successful example of a partnership between an NHS trust and the third sector. The close working between practitioners and navigators ensures that individuals are supported through clinical and non-clinical aspects of dementia care from diagnosis to end of life, including intensive support for people with the most complex needs. For GPs, hospitals, care homes and other organisations, the service provides education and training to help them deliver the best possible support for people living with dementia. The service has been designed to facilitate communication and partnership working, avoiding duplication. Unlike many services BDWS does not discharge. As long as someone wants to receive the service, they will remain with the service throughout their dementia journey, from diagnosis to end of life. When someone is referred they are visited by their own dementia navigator and (staffing changes aside) their navigator remains the main point of contact for the person with dementia and their carers/family. This provides a consistency of care and relationship that service users and carers tell us is really important.

People’s identities, needs and wishes are at the heart of bespoke Wellbeing Plans that are developed in partnership with the person with dementia and their families or loved ones and our staff use Life Stories as an approach to building relationships and understanding the individual behind each diagnosis. The service is committed to making Bristol a dementia-friendly city and a unique part of the service is its community development coordinators who work in each hub, focusing on the access and support needs of people affected by dementia across different community groups. An additional community development coordinator was employed last year to work exclusively to provide education, focusing on primary and secondary schools. This has been hugely successful and in less than a year, the service has gone from approaching schools to engage with the service to being approached by schools for support. To date, over 2,500 pupils have received awareness, consisting of 7 assemblies and 23 Dementia Friends sessions.


How do you ensure an effective, safe, compassionate and sustainable workforce?

Every fortnight, the service holds management meetings which cover a rotating agenda which reflects the CQC domains: effective, well-led, caring, responsive and safe. The service also has a clinical agenda. Key messages from these meetings are communicated the same week to teams. Staff receive monthly line management and clinical supervision and the service invests in training and education to support staff, including regular staff development days and monthly lunchtime seminars. Staff can also access monthly reflective practice groups and staff wellbeing groups. Some of the wellbeing initiatives have included mindfulness sessions, photography, access to electric bikes and engaging in ‘time to talk’ mental health days. Our teams also enjoy a shared lunch! Staff are encouraged to take on ‘champion’ roles across a number of sub-specialties (including frailty, younger onset dementia, learning disability, human rights and equalities) which helps ensure the resilience of the service.

Champions have developed pathways and protocols with other providers, including the local authority, shared best practice with colleagues and made proposals for service development. Staff are supported to attend conferences and training relevant to their champion role. The service takes positive steps to promote a diverse workforce and ensure opportunities are shared with community groups and promoted through our social media channels. Our adverts always welcome applications from those with lived experience, and there is a shared passion for improving services for people affected by dementia in Bristol, as for many staff this is personal as well as professional.


Who is in your team?

The service has 94 staff but some roles are job shares / reduced hours. In terms of actual numbers of staff, the service has: • dementia practitioners (Bands 5/6) – 32 • dementia navigators (Alzheimer’s Society post) – 27 • senior managers & clinical managers (Bands 7/8) – 11 • practice leads (band 7) – 2 • consultant psychiatrists – 1 • clinicians/doctors – 4 • Group activity support manager (Alzheimer’s Society post) – 1 • community development coordinators (Alzheimer’s Society post) – 4 • clinical psychologist (Band 8) – 1 • assistant psychologist (Band 5) – 1 • administration (Bands 3/4) – 9 • assistant research practitioner (Band 4) – 1 In terms of WTE, we have 23 WTE Navigators and 25 WTE Practitioners (of which 9 WTE work into Care Homes). Most other posts above are full-time.



How do you work with the wider system?

The service has effective partnerships and processes in place through joint working with other mental health services (crisis pathway, inpatient wards and liaison psychiatry), social services and the service also worked with learning disability services to create a joint pathway. The service has seconded three practitioners to work alongside our local acute hospital trusts in supporting people with dementia in hospital and improving proactive and safe discharge, enabling patients to return to their usual place of residence in a safe and timely way. Working alongside hospital trust colleagues, these practitioners have developed an action plan which will be delivered over the coming year. The service has also streamlined the process for carers to receive support plans/carer breaks by working closely with the Council’s Integrated Carers Team and offering a single assessment. 128 Trust Assessments were completed for carers in 2017/18 resulting in 104 support plans to the value of £27,750.


Do you use co-production approaches?

The service works closely with others to ensure the voice of people with dementia is heard and helps to develop the service. Monthly service user/carer reference groups operate in the true spirit of coproduction and community development coordinators help ensure the service is connected and listening to Bristol’s diverse communities and that it is able to respond with an accessible service. Last year, the service worked closely with community groups and those affected by dementia in these communities to produce a series of 6 short films to tackle some of the myths and stigma about dementia, including key messages around prevention, diagnosis, treatment and support. The service has 2 carers who sit on our monthly operations meeting alongside our commissioner. Both these carers also have a wider role within Bristol Mental Health.


Do you share your work with others?

The service website ( is developed through listening to the needs of clients, and we have implemented website accessibility tools in response to requests from clients. The website includes a range of community resources which we regularly update. An ‘offline’ version of this is also produced and shared with people in their ‘Dementia Packs’ which everyone receives when they enter the service, recognising that our service user group may not be as connected online as their younger peers! The service also produces an annual Quality Account reflecting back on the previous year of service which is shared with stakeholders and the wider public. The service also attends regular events across the city including Bristol Pride and the Islamic Cultural Fayre, providing a range of resources relevant to the event and improving awareness of dementia and the range of help and support available both within and beyond the service.


What outcome measures are collected, how do you use them and how do they demonstrate improvement?

Under our contract with our commissioner (Bristol CCG, now BNSSG CCG) we have agreed a number of Key Performance Indicators and Activity data which includes: • Time from referral to first appointment being booked (target within 10 working days) • Time from first appointment to receiving a personalised wellbeing plan (target within 12 weeks) • Clients receiving a review/contact at least once every 6 months • Number of carers receiving a formal assessment of their needs • Number of people with dementia consenting to be engaged with research opportunities • Numbers and performance relating to ‘Friends and Family’ test returns and PALS returns • National Minimum Dataset compliance This data is largely captured through our electronic patient record system, RiO and we are currently meeting or exceeding all of our targets. In respect of the National Minimum Dataset, the service monitors the recording of information relating to identity and meets its 100% target for age, gender and ethnicity.


With a lot of positive effort from staff the service has greatly improved compliance for other areas including 96% for marital status, 90% for religion and 92% for first language. Some of these areas will never reach 100% as the service recognises that some of our caseload are awaiting first appointment, and if someone is in crisis, we would wait for a more appropriate time to collect this information. We are also recording data on sexual orientation, disability and gender identity and have supported staff in LGBT+ awareness to give context to the importance of data collection. We are proud of our improvements in Friends and Family test returns both in rate and quality of return, seeing an impressive return rate of 290 in 2017/18 (up from 100 in the previous year), with 97% of returns saying they would be ‘extremely likely’ or ‘likely’ to recommend our service to friends or family members. The below is an example of the kind of comment that we receive through Friends and Family, and we share all comments with our teams: “I find this service very helpful; it’s lovely to be treated as a person not a number. There is always a sympathetic ear and solution to one’s problems and we always feel relaxed talking to the team. Where there has been anxiety, your team of carers have instilled calm in our lives. Thank you for being there” – service user


Has your service been evaluated (by peer or academic review)?

There has been an independent Service Evaluation after our first year of operation and an Interim Service Evaluation is currently underway. Over the last year, the service has actively engaged with research, making connections with the Clinical Research Network (CRN) in Bristol, alongside academic colleagues in Bristol’s two universities. The service aims to ensure that people with dementia are given information to access research opportunities and increases the range of studies that it engages with, developing the capacity to open and recruit to new projects. The service is now research active and has engaged with a number of research opportunities including studies looking at genetic markers relating to Alzheimer’s disease (AD Genetics), evaluation of crisis teams (AQUEDUCT) and an evaluation of BME referral outcomes. Over 30% of the service’s community caseload now actively consent to be approached with research opportunities.


How will you ensure that your service continues to deliver good mental health care?

The service works closely with our commissioner, meeting monthly to discuss the service, its operation and performance, and agree priorities as necessary. The service is responsive to local strategic needs and have agreed CQUIN targets (Commissioning for Quality and Innovation) each year which has included: • Introducing champion roles across the service to ensure service resilience. Each hub now has champions covering dual diagnosis (alcohol), human rights, equality & diversity, prescribing, young onset, learning difficulties, advance planning and frailty. • The service has developed best practice assessment and guidance for residential homes, culminating in a conference on best practice in residential and care home settings. This is part of our ongoing commitment to dementia research and professional development. • The previously mentioned work to develop acute hospital liaison. The service also supports a number of initiatives in partnership with local organisations including: • Growing Support (now under Alive Activities) – promoting horticultural therapy through gardening, especially in care homes • Woodland Wellbeing (under Forest of Avon Trust) – Sensory and rewarding activities in woodland settings for people affected by dementia. • Talking Therapies (via the Harbour) – Couples Counselling and Intensive Psychotherapy • Partnership with Age UK Bristol for the provision of financial and legal advice which resulted in 234 referrals between April 17 and March 18. On behalf of the service, Age UK Bristol were able to claim benefits of £527,874 with 80 Lasting Power of Attorney forms completed, saving clients up to an additional £65,000 in possible solicitor fees.


What aspects of your service would you share with people who want to learn from you?

Partnership working presents challenges but a focus on the positive outcomes for people affected by dementia can ensure that operational barriers can be overcome, even if it necessitates the creation of local policies that deviate from wider trust/organisational policies. There is a commitment from the local commissioner and the NHS Trust, working alongside Alzheimer’s Society to the development of the service, both in terms of financial resource to achieve positive outcomes and the capacity to deliver this. As with any service, neither of these are without challenges, but the focus is always retained on the best outcomes for those affected by dementia in Bristol. Partnership working with external agencies is also an on-going commitment. There has been increased staff turnover in GP surgeries which has meant awareness and engagement is an activity that has extended beyond the establishment of the service.




How many people do you see?

The service receives approx. 130 referrals each month across the service. In 2017/18, the service received 1,551 new referrals and had 2,647 open referrals at the end of March 2018. In the same period there were 12,950 contacts with service users, a further 1,785 carer interactions and 2,019 provisions of information Through the partnership with Alzheimer’s Society the service also oversees a number of groups, including Memory Cafes, Singing for the Brain, Carers Groups and Activity groups. All groups remain under review to ensure they are responsive to local need and demand.


How do people access the service?

The majority of people access the service through their GPs. For those with a pre-existing diagnosis, they can self-refer to the service, but the service works closely with their GP. Referrals are triaged based on the link practitioner/navigator associated with the specific GP surgery. This gives continuity of support and relationship between the service and primary care colleagues. For people whose first language is not English, the service supports referral, diagnosis and our Access Point through translation and interpretation. The service regularly secures translation for appointments, and have introduced access to telephone interpretation on our Access Point. Part of the development work through community development coordinators is to promote the service and ways people can access support to the wider community, so ensure that there is equity of access, wherever possible, and the short films in community languages has supported promotion of the service. This is an ongoing project as the service appreciates the need to develop and maintain relationships with community groups and stakeholders


How long do people wait to start receiving care?

As part of our performance measures, all service users should have an appointment booked within 10 working days of a referral being accepted by the service. This appointment depends on the nature of the referral. If the referral is a straightforward diagnosis of dementia with on-going support required, it will be assigned to a dementia navigator. If there is a presenting escalation of need or specific clinical intervention required, it will be triaged to a dementia practitioner. This will then be passed onto the dementia navigator in a ‘step up/down’ approach, as required.

How do you ensure you provide timely access?

The service triages referrals from GPs and if referral is accepted (i.e. GP has discounted other physical health causes of cognitive decline / bloods / scan) then the service will arrange an appointment with the service user within 10 working days. Urgent referrals are triaged to dementia practitioners for intervention. The service operates flexibly between hubs, so for example, where there is sickness / leave pressures in one hub, staff from other hubs have been able to cover and support admin functions / pick-up caseloads as necessary.



What is your service doing to identify mental health inequalities that exist in your local area?

The service was an integral part of a research project into the dementia experiences of people from Black Caribbean, South Asian and Chinese communities which reported in 2017. The service is part of a working group implementing the outcomes of this report which includes GP education, prevention messages and dementia awareness for interpreters relating to BME groups in Bristol. The service is also an active member of the Bristol Mental Health Equality Diversity and Inclusion steering group and contributed to a report on the inequalities faced by Black Caribbean males across the wider Mental Health system.


What inequalities have you identified regarding access to, and receipt and experience of, mental health care?

As above, as part of the research project into the dementia experiences of people from Black Caribbean, South Asian and Chinese communities, the service has identified and is responding to a number of inequalities relating to care, including access to interpreters, engagement in research opportunities and consistency of cognitive assessment.



What is your service doing to address and advance equality?

The service is committed to equality, diversity and inclusion and whilst its community development coordinators are taking a lead on this work, this is a responsibility for all staff. Community development coordinators review the access and support needs for a number of groups, including Somali community, LGBT+, Chinese, South Asian, and Disability with future focus areas of Gypsy, Roma, Traveller (GRT), Asylum Seekers and those with sensory impairments. The service regularly attends the EDI Steering Groups for both Bristol Mental Health and Devon Partnership NHS Trust. The service also holds its own EDI Steering Group every 6 weeks, which is attended by its Equality Lead and the EDI Champions across the service. This has included: • Development of training days and resources for staff • Piloting Accessible Information Standards compliance for the trust • Working alongside Bristol Mental Health colleagues to develop Trans training/toolkit • Developing EDI policies • Survey of needs for specific communities, i.e. Somali community • Ensuring the service website upgraded to include translation/text to audio As previously mentioned, the service has produced short films to tackle the stigma of dementia in Bristol’s diverse communities. These films were produced in six different languages and include medical professionals, community leaders and those affected by dementia in each community discussing issues including prevention, diagnosis, treatment and support. These can be viewed at our website:



How do you identify the needs of a person using the service ?

During assessment, the dementia practitioner or navigator will discuss the individual needs with the person with dementia and their carers/family. The principle that supports staff in this is ‘life story’ work and understanding the person’s history, important relationships and what will keep them independent and support their own wellbeing. This holistic view is developed into a Wellbeing Plan which includes an acknowledgement of advance planning, risk and crisis contingency, alongside social needs. Through signposting and support, a navigator can support someone to attend a new group, and will often accompany people on their first visit. Navigators and practitioners explore the psychological needs of the people they support during assessment and reviews. If necessary, they will discuss any concerns in clinical team meetings, which may result in a referral to external talking therapy services, whether via Bristol Wellbeing Therapies (IaPT service) or the service’s directly commissioned support for couples/intensive psychotherapy. These external agencies would then carry out a formal assessment prior to agreeing the talking therapy intervention.


How do you meet the needs of people using the service and how could you improve on this?

The service was commissioned in response to what people in Bristol were asking for, and through coproduction it continues to develop the service in full partnership. As previously stated, part of the service’s success is the relationships practitioners and navigators are able to develop with service users, carers and families. Where required, practitioners are involved (step-up) for short-term interventions whether this is an Occupational Therapy assessment of the home environment, a review of medication, or advice on managing risk. After the intervention is complete, the individual is passed back to their navigator (step-down) for ongoing support. It is a reflective service and continue to review what works and what we could do better. The service is currently reviewing pathways for talking therapies, and the care home liaison model, so that it can continue to be responsive to local needs.


What support do you offer families and carers? (where family/carers are not the service users)

For people with dementia, one of the most important aspects is their support network and the service recognises the vital importance of carers in maintaining someone’s independence and wellbeing. Two of the service’s navigators provide dedicated carer support, focusing on practical and emotional support. Wellbeing plans and information/signposting is shared with carers, and navigators support carers to access groups, where they can meet other carers and reduce the isolation that often comes with the caring role. As above, the service streamlined the process for carers to receive support plans/carer breaks by working closely with the Council’s Integrated Carers Team and offering a single assessment. 128 Trust Assessments were completed for carers in 2017/18 resulting in 104 support plans to the value of £27,750.


Population details

Brief description of population (e.g. urban, age, socioeconomic status):

Anyone affected by dementia in Bristol.

Size of population and localities covered:

Predicted prevalence of dementia 4,122 – covering all GP surgeries in Bristol.


Commissioner and providers

Commissioned by (e.g. name of local authority, CCG, NHS England): *

Bristol CCG (now part of BNSSG – Bristol, North Somerset, South Gloucester)

Provided by (e.g. name of NHS trust) or your organisation: *

Devon Partnership NHS Trust


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