This practice developed a primary care memory service that has reduced the diagnosis time for dementia from the national average of three years to four weeks.
In 2009, it saved £400,000 in secondary care costs by redesigning the care pathway for its practice population of 8,000 patients.
Dr Ian Greaves and his team started by adding two questions about memory to the checklist used on patients attending QOF clinics.
Those with memory concerns were visited at home by a health visitor, to carry out checks for dementia, depression, and social circumstances, and to arrange blood and urine tests.
A monthly clinic was organised at the surgery with a specialist old age psychiatrist, and the health visitor would attend with the patient and their carer.
The specialist was given access to the data collected and the patient's medical records, so he could make a diagnosis and create a care plan, including a social care assessment and direction to support from charities.
Dr Greaves said GPs on average were detecting 40 per cent of dementia cases and referring them to secondary care.
'The other 60 per cent were not getting a diagnosis or the care they needed. I wanted to reach those people, make the diagnostic process efficient, and keep everything in primary care.'
About one third of the patients visited are diagnosed with dementia. Other diagnoses include depression, B12 deficiencies, alcohol or medicines abuse and brain tumours.
'The improvement in care for the dementia patients has been tremendous, and all but two patients have remained at home rather than going in to nursing homes.'
Now Dr Greaves is helping South Staffordshire PCT launch a £700,000 service in July this year, with memory clinics in every practice served by six 'dementia facilitators' collecting data in homes.
'This is the way that practice-based commissioning should be working,' said Dr Greaves. 'Clinicians should devise the pathways, and the administrators create the service specification. GPs should not have to take responsibility for everything, but they can bid to run the service if they want to do so.'
|Click here for all the Enterprise Awards 2010 winners|