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

The Bristol Dementia Wellbeing Service (DWS) is an innovative primary care service delivered in partnership between Devon Partnership NHS Trust and Alzheimer’s Society, currently in its fifth year of operation. The service works with GPs, other health professionals and other partners 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.

Highly Commended in Specialist Services Category - #MHAwards18


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


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

Find out more


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

The Bristol Dementia Wellbeing Service (DWS) is an innovative primary care service delivered in partnership between Devon Partnership NHS Trust and Alzheimer’s Society, currently in its fifth year of operation. The service works with GPs, other health professionals and other partners 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 including for the most complex of presentations and 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.

There are also Navigators with a carer focus including an integrated process with the Council’s Integrated Carers Team to deliver carer’s assessments to access vital support and respite. 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 offers an enhanced function which works proactively to respond to escalation or concerns, liaise with acute trusts during hospital admission, and work in partnership to facilitate a safe discharge and ensure on-going post-discharge support. 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.


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. The service does not discharge. As long as someone wants to receive the service, they will remain with DWS throughout their dementia journey, from diagnosis to end of life. When someone is referred to the service, 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. 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, we have gone from approaching schools to engage with the service to being approached by schools for support.



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. We also have a clinical agenda. Key messages from these meetings are communicated the same week with our hub 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 younger people with 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. We have developed a range of staff across the service, and all of the current Team Managers were previously recruited as Dementia Practitioners and retain an element of clinical specialism in their leadership roles. Our Clinical Service Manager was also previously a Team Manager and Dementia Practitioner. Team Administrators have also developed and taken on Dementia Navigator roles. For those Dementia Navigators who have moved on from the service, many have been inspired to study and qualify as professionals. We take 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?

We have 97 staff in the service but some roles are job shares / reduced hours. In terms of actual numbers of staff, we have: • consultant psychiatrists – 1 • specialty doctors – 4 • clinical psychologist (Band 8) – 1 • assistant psychologist (Band 5) – 1 • dementia practitioners (Bands 5/6) – 33 • dementia navigators (Alzheimer’s Society post) – 28 • dementia support workers (Band 4) – 3 • senior managers & clinical managers (Bands 7/8) – 8 • practice leads (band 7) – 1 • business support manager (Band 5) – 1 • administration (Bands 3/4) – 8 • assistant research practitioner (Band 4) – 1 • dementia support managers (Alzheimer’s Society post – manages navigators) – 3 • group activity support manager (Alzheimer’s Society post – manages CDCs) – 1 • community development coordinators (Alzheimer’s Society post) – 4 • side by side coordinator (Alzheimer’s Society post) – 1


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 have also worked with learning disability services to create a joint pathway. We recently seconded three practitioners to liaise with local hospital trusts to supporting people with dementia in hospital, improve awareness of each other’s service and processes, and explore ways to improve a proactive and safe discharge, enabling patients to return to their usual place of residence in a safe and timely way. This project led to the service designing the enhanced support function to further maintain and develop this partnership. We have 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 Trusted 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 ‘Focus on Dementia Network’ groups operate in the true spirit of coproduction and the service has benefitted from the input of those with lived experience when redesigning Wellbeing Plan templates or expanding the accessibility of the service’s website. Our community development coordinators help ensure the service is connected and listening to Bristol’s diverse communities, and that we are able to respond with an accessible service. In 2017 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. These short films have now been viewed over 4,000 times and have received recognition both nationally and internationally.


Do you share your work with others? If so, please tell us how.

We have a service website ( which is developed through listening to the needs of our 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! We produce an annual Quality Account reflecting back on our previous year of service which is shared with stakeholders and the wider public.


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

Under our contract with our commissioner (BNSSG CCG previously Bristol 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 • 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 engaged with research opportunities through the service • 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. In respect of the National Minimum Dataset, we monitor the recording of information relating to identity and have 100% for age, gender and ethnicity. With a lot of positive effort from staff we have 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 we recognise 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 and continue to receive more responses each year, from 100 in 2016/17 to 290 in 2017/18 and 383 in 2018/19. In the last year alone, 99% of returns have been positive, indicating that people would be likely or extremely likely to recommend our service to a friend or family member. 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) “My wife was given a thorough, friendly, un-hurried, lengthy interview by [Practitioner] who quickly gained her trust. The interview was a pleasurable experience. Follow up phone calls have been unhurried and most helpful, Great efforts have been made to make my wife feel at ease, An EXCELLENT service.” (Carer) “The service is absolutely amazing. Our navigator is lovely and has been so helpful. There’s a light at the end of the tunnel now. She has helped us set up care for Grandad and I don’t think we’d be as far along now as we are without her. We can’t thank you enough! We aren’t alone anymore.” (Carer)


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

We have completed a Service Evaluation after our first year of service and are currently finalising our Interim Service Evaluation. The service is now actively engaged with research, with established connections with the Clinical Research Network (CRN) in Bristol, alongside academic colleagues in Bristol’s two universities. We have supported a range of studies, including AD Genetics (genetics study into Alzheimer’s Disease), Aqueduct (Review of crisis provision) and a study comparing the service experience of BME to non-BME service users.



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

We work closely with our commissioner, meeting quarterly to discuss the service, its operation and performance, and agree priorities as necessary. The service was recently recommissioned for a further two years. We are 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 service seconded practitioners to work across the two local hospital trusts which has led to the development of the service’s enhanced support function, providing early-intervention to reduce/avoid hospital admission, ensure effective liaison during hospital stays, and support a safe discharge. The service also supports a number of initiatives in partnership with local organisations including: • Alive Activities – promoting horticultural therapy through gardening, especially in care homes. • Woodland Wellbeing (under Forest of Avon Trust) – Sensory and rewarding activities in two local woodland settings for people affected by dementia, including intergenerational days and winter crafts sessions. • Talking Therapies (via the Harbour) – Couples Counselling and Intensive Psychotherapy • Music & Memories (via Reminiscence Learning) – interactive performances, stimulating memories for people with dementia and carers • Partnership with Age UK for the provision of financial and legal advice has led to over £500k in benefits and allowances claimed in each of the last two years, alongside over 100 Lasting Power of Attorney directives.


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 a local policy that deviates from wider trust/organisational policies. The local commissioner showed bravery in its commitment into ‘doing things differently’ and a good working relationship with the commissioner is important in embracing innovation and being able to adapt as the needs of the service change. Partnership working is an on-going commitment. There has been increased staff turnover in GP surgeries which has meant awareness and engagement is an on-going activity.


Additional Questions

The following questions are an opportunity for you to provide further details on how you implement positive practice in your service delivery and how you ensure your service is advancing access and equalities.  Answers to these questions will not influence how your PPiMH awards application is assessed, however any responses received may contribute to the potential inclusion of your service/team as a positive practice example within published guidance developed by NCCMH and NHS England.


How many people do you see?

We receive approx. 130 referrals each month across the service. In 2018/19 we received 1,457 new referrals and had over 2,900 open referrals at the end of March 2019. In the same period we had 12,950 contacts with service users with a further 1,785 carer interactions and 2,019 provisions of information Through our partnership with Alzheimer’s Society we also oversee 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 we would work 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. There are three pathways in the service in relation to diagnosis: 1. Straightforward diagnosis made in primary care (AD, vascular or mixed) or other specialist service – this is then referred to the service for navigator support 2. Diagnosis unclear or “unusual” referred to the service for assistance with diagnosis once bloods and CT scan completed. The individual is then seen and assessed by practitioner/or considered by complex diagnostic team. A diagnosis is made and fed-back to patient and GP with recommendations for any medication (if appropriate) and referred for navigator support or if discharged (e.g. Mild Cognitive Impairment with recommendations for further follow up with GP reminders given during regular practice meetings). 3. Complex or atypical presentation. GP refers to practitioner in usual way and practitioner triages referral and asks the service’s complex triage team to review referral and signpost as appropriate. This may include referral to be seen by our complex diagnostic team or referral to cognitive neurology colleagues. For people whose first language is not English, we support referral, diagnosis and our Access Point through translation and interpretation. We regularly secure translation for appointments, and have access to telephone interpretation on our Access Point. Part of the community development work through our community development coordinators is to promote the service and routes of access, so that there is equity of access, wherever possible.

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 ongoing 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?

We triage 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. This evidences that the service is maintaining safe waiting lists and that there is timely access. Urgent referrals are triaged to dementia practitioners for intervention. All other referrals are triaged to dementia navigators for ongoing support. 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. Where clinical medics are low, the service has ensured cover through locum support.



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 ahead of many other services in the collection of data to support approaches to tackling inequalities but we recognise that this is a long-term ambition. The service has consistently high rates of recording against many of the protected characteristics (marital status, age, sex, religion, first language) and has supported staff in the collection of data around sexual orientation, gender identity and disability. 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, we have identified and are responding to a number of inequalities relating to care, including access to interpreters, engagement in research opportunities and consistency of cognitive assessment. The service is actively engaged in a steering group to respond to the above research alongside commissioners, stakeholders and other community groups. Activity to date has included targeted education to GP practices with the highest BME populations in Bristol, a review of translation and interpretation services and development of public health materials to communicate prevention and wellbeing messages related to dementia.


What is your service doing to address and advance equality?

The service is committed to equality, diversity and inclusion through its community development coordinators who lead this work, but is a responsibility for all staff. Our 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 a trans training/toolkit for practitioners • Supporting the development of EDI policies, including Zero Tolerance, Accessible Information and supporting Trans & Non-Binary staff/service users • Survey of needs for specific communities, i.e. Somali community • Ensuring the service website upgraded to include translation/text to audio • Presence at a range of community events including Bristol Pride and the Islamic Cultural Fayre 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 includes 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. Life Story work is the principle that supports the collection of this information and understanding the person’s history, important relationships and ways in which independence and wellbeing can be maintained. This holistic view is developed into a personalised Wellbeing Plan which includes an acknowledgement of advance planning, risk and crisis contingency, alongside social needs. This is a document that can be shared with other agencies, so that what is important to know about someone is communicated effectively (i.e. on admission to hospital, or transitioning from their own home to formal care settings). Through signposting and support, a navigator can support someone to access groups and activities that meet their needs. To minimise barriers and anxiety over trying new things, dementia navigators will often accompany people on their first visit to a new group or activity.


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 we continue 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 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. We are a reflective service and continue to review what works and what we could do better. We have recently reviewed our care home liaison model and have developed a toolkit to support consistency of practice.


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 we recognise the vital importance of carers in maintaining someone’s independence and wellbeing. We have dementia navigators who provide dedicated carer support, focusing on practical and emotional support. We have 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 Trusted Assessments were completed for carers in 2017/18 resulting in 104 support plans to the value of £27,750. 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.



Population details

Brief description of population:

The population of Bristol is estimated to be 459,300 people. Bristol is the largest city in the South West and one of the ten ‘Core Cities’ in Great Britain. Bristol is a urban city, and the service supports all service users registered with a Bristol GP.

Size of population and localities covered:

The caseload is now over 2,900, and we support service users and carers across 3 hubs (North, Central & East, South)


Commissioner and providers

Commissioned by (e.g. name of local authority, CCG, NHS England): Bristol, North Somerset, South Gloucs CCG

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

Devon Partnership NHS Trust





Share this page: