Post-diagnostic support and care co-ordination improvement programme update: January 2026
Progress update January 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
- Work with 16 health and social care partnerships across Scotland, split into two cohorts over the year. Each cohort runs for 6 months with follow up. The programme includes learning sessions, monthly coaching calls, project surgeries and networking.
- Deliver a core 6 months of improvement support programme for each cohort, followed by 6 months of ‘light touch’ support with coaching calls every 2 months.
- Capture evidence and learning to enable spread.
Examples of impact
Increase in person plans now in place
One HSCP has 100% of new PDS service users using a new improved personal plan and ‘me tree’ since December 2025.
Improved use of frailty assessment in PDS Service
One HSCP has had a three-fold increase in the median number of frailty assessments per week as part of PDS, enabling additional support for frailty.
Identified improvements
“[being part of the improvement programme] has opened our eyes to what might need to be improved within the service.”
Participating team member sharing experience in the improvement programme
PDS Leads network
The network will be celebrating 10 years in 2026.
We host the PDS Leads Network with over 90 members that meets four times a year.
The network is our main forum for recruitment to our improvement programme cohorts.
Driving change
15 HSCPs participating in the programme
- Cohort 1: 8 teams completed initial 6-month improvement cycle, now testing ideas.
- Cohort 2: 7 teams started their improvement journey in October 2025.
Recently completed milestones
- Four learning sessions completed with cohort 1.
- Cohort 2 teams attended the three learning sessions held so far.
- Monthly coaching calls are taking place with cohort 2 teams.
- Face-to-face site visits planned with cohort 2 teams.
- Evaluated our improvement programme with cohort 1 team and already implemented changes.
- Listening to team feedback, we provided project surgeries on personal planning and young onset dementia.
Using quality improvement
- Driver diagrams to understand evaluation.
- Process mapping to understand PDS pathways.
- Qualitative feedback from carer’s centre.
- Gathering feedback from PDS group work.
- Focus groups with people with lived experience.
Aim statement
The development of a personal plan is a key element of PDS. This helps the person with dementia identify what is important for them and to plan for the future.
‘80% of those engaging in PDS will have a personalised plan in place 12 weeks after the initial visit.’
Cohort 1 participating team
7 areas for improvement
- PDS service feedback (2 teams).
- Young onset dementia pathways (4 teams).
- Waiting lists (2 teams).
- Personal plans (6 teams).
- Information provision (2 teams).
- Standard Operating Procedures (3 teams).
- Care plans (3 teams).
Next steps
We have issued communication to PDS Leads to recruit new teams to the programme, focussing on HSCPs we have yet to work with.
Cohort 3 will begin in April 2026.