Post-diagnostic support and care co-ordination improvement programme update: August 2026
Progress update August 2026
Improvement programme
The programme aims to ensure people with dementia will have improved experience of, and access to, person-led post-diagnostic support and care co-ordination, which meets their individual needs.
The programme uses the PDS Quality Improvement Framework to support self-evaluation and improvement planning with participating teams.
By learning and improving together we aim to reduce unwarranted variation and improve the quality of PDS and care co-ordination.
What we do
- Working with 20 health and social care partnerships (HSCPs) across Scotland, split into three cohorts.
- Delivering a core 6 months of improvement support for each cohort, followed by 6 months of ‘light touch’ support with coaching calls every 2 months.
- Capturing evidence and learning to enable spread.
Examples of impact
Waiting times
65% reduction in waiting times from diagnosis to first contact.
Service evaluation
All service users are offered the opportunity to feedback on their PDS using a new evaluation process.
Networking
Participating teams have connected with each other around young onset dementia, frailty assessment and PDS group work.
Frailty assessment
Completion of frailty assessments has tripled, now approximately 17 each week are being carried out.
Identified improvements
“We have seen a vast improvement in the quality of the patients’ care plans, They are more person centred.”
Cohort 2 participating team member sharing experience in the improvement programme.
PDS Leads network
The PDS leads last met on 10 June. A cohort 2 team presented on how they embedded frailty assessments into their PDS assessments.
The chair stood down after 4 years – the vice-chair will be stepping in. We are in the process of recruiting a new vice-chair from the existing network.
“Thank you so much for such informative presentations today and really useful information”
Driving change
20 HSCPs participating in the programme
- Cohort 1: 8 teams completed their 12-month improvement cycle and are continuing to make improvements.
- Cohort 2: 7 teams started their improvement journey in October 2025 and now on bi-monthly coaching calls.
- Cohort 3: 5 teams started their improvement journey in May 2026.
Recently completed milestones
- Cohort 2 held its final learning session on 8 April. Teams shared their progress from the initial 6-month improvement support phase.
- Cohort 3 – 5 HSCP teams began their initial 6-month improvement journey with learning session 1 on 22 April.
- Cohort 3 teams completed their service self-assessment in May using the Quality Improvement Framework.
- Gathered feedback from cohort 1(12-month follow-up) and cohort 2 (6-month follow-up).
- Monthly coaching calls are taking place with cohort 3 teams and planning site visits.
Using quality improvement
- Teams initially go through the process of understanding their system and identifying and testing change ideas using QI tools and methodology.
- Teams use a range of tools including process mapping, driver diagrams and PDSAs (plan, do, study, act).
Aim statement
One cohort 1 team reported all individuals accessing PDS receive a clearly documented personalised plan that reflects their needs preferences and priorities, and that this plan is reviewed and updated in line with Essential 5 components of PDS.
Themes for improvement
Participating teams across the 3 cohorts reported the following themes for improvement:
- Personal Planning
- PDS Support Planning
- Young Onset Dementia services
- PDS pathway for learning disability
- Groupwork
- Information sharing/systems
- Waiting lists
- Frailty
- Service user feedback
Next steps
- Continue to offer improvement support to all participating teams.
- Visit cohort 3 teams.
- Present a poster to Alzheimer Europe (October) on the implementation of the PDS QIF.
- Develop and publish a final report reflecting on the programme’s impact (December 2026).