Upon discharge from Memory Assessment Services to primary care, a dementia advisors is planned in advance, with a specific joint working protocol/shared care pathway for medication.

After the Memory Assessment Service diagnoses you with dementia they will write to your GP to set out how they will work together to manage the care of your dementia and what their responsibilities will be.
Any medicine you have been prescribed for dementia will be continued and monitored by your GP.
For extra information, evidence and best practice please scroll down to the bottom of the page.

Regional offerings

Dementia Wellbeing Plan for Greater Manchester; Dementia United

The Greater Manchester dementia wellbeing plan promotes personalised planning conversations with people living with dementia and carers about their needs and wants. The plan ensures an improved standard of care planning for people living with dementia and also facilitates sharing across the system. It will be available as a standardised plan which can be accessed and shared digitally between practitioners; as well as being available from the website for people affected by dementia to be using when having person centred care plan reviews

National offerings

MSNAP Memory Assessment Service Standards

The Royal College of Psychiatrists have a national accreditation programme for Memory Services against key standards. The website outlines the standards and the process.

NICE Dementia Guidance

This guideline brings together all the research and evidence which covers assessment, diagnosis, treatment and support. It is for people at risk of developing dementia, people who are referred for assessment, people living with dementia as well as being for family and friends and health and social care staff and commissioners. It aims to improve care by making recommendations on standards people should expect to receive from their assessment, care and support as well as on training.
We have provided links to the NICE guideline for dementia and a further link is provided to guidance on how to delay or prevent the onset of dementia.
National Institute for Health and Clinical Excellence (NICE) NG16 (2015) Dementia, disability and frailty in later life – mid-life approaches to delay or prevent onset:
National Institute for Health and Clinical Excellence (NICE) (2019) Dementia: assessment, management and support for people living with dementia and their carers:


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Royal College of Psychiatrists (2020) MSNAP Standards for Memory Services:

  • "Patients and their carers (with patient consent) are involved in decisions about discharge plans.
  • For people living with dementia who are taking antipsychotic medication, the team maintains responsibility for monitoring their physical health and the effects of antipsychotic medication for at least the first 12 months or until the person's condition has stabilised, whichever is longer. Thereafter, the responsibility for this monitoring may be transferred to primary care under shared care arrangements.

NHS Blog, Dementia advisors and peer support networks have a vital role to play: "Alistair Burns, NHS England’s National Clinical Director for Dementia, explains the importance of support for people once they have been diagnosed: The need to support people with dementia, their families and carers is the next step following a diagnosis. The aim of high quality support is to ensure that people can live well with dementia and the importance of high quality support is recognised in the National Dementia Strategy (NDS) and the Prime Minister’s Dementia Challenge."

Best Practice Resources

HEALTHBRIDGE, The National Evaluation of Peer Support Networks and Dementia Advisers in implementation of the National Dementia Strategy for England: -

Genio, briefing paper on dementia advisors: -

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