GP-based Admiral Nurse service challenges the stigma of dementia

A nurse-led service is helping to change perceptions of dementia in a community in Suffolk

Patients and families living with dementia in Southwold are benefiting from the specialist care and advice of a practice-based Admiral Nurse service – the first of its kind in Suffolk.

Trailblazers: Melinda Mortimer (left) and Cathy Ryan who are part of the Admiral Nurse service at a practice in Suffolk

The service is based at Dr Castle and Partners, a general practice located at Sole Bay Health Centre in Reydon, a village near Southwold. It has been jointly funded by Dementia UK and Sole Bay Care Fund, the practice's registered charity. One of its first objectives is to help Southwold and the surrounding areas to become more dementia-friendly.


'Being able to part fund the service for the greater good of our patients and the local community is brilliant,' says community matron Cathy Ryan. 'It is the first time an Admiral Nurse has been attached to a general practice in Suffolk and it is exciting. If we can demonstrate that this works and supports our community, it could be a trailblazer for improving dementia support in other areas. It feels so positive. I have been here for 11 years and the difference the service has made already is astounding.'


Dementia UK Admiral Nurses


The service began as a two-year project. Ms Ryan is a Queen’s Nurse and had wanted to establish an Admiral Nurse service in the area for some time. While attending the Queen’s Nursing Institute’s annual conference last year, she met Dementia UK’s chief executive and learned that the charity was keen to develop a service in the Southwold area.

Community needs

The Admiral Nursing service at Sole Bay is led by Melinda Mortimer, who took the role on in March. She has previously worked as an Admiral Nurse with the Royal British Legion and at a memory service at Central and North West London NHS Foundation Trust. Ms Mortimer will receive ongoing training and development support from Dementia UK.

Although she is based at the health centre, she tends to see patients at home or out in the community in local cafes. 'We want the service to fit the community and be led by what patients and carers need,' says Ms Mortimer. 'When I first see people, I carry out a 17-point assessment which looks at the patient and the carer’s mental and physical health needs. I provide one-to-one emotional support for carers and use counselling skills to talk about any challenging issues they are experiencing and offer practical advice and tips. I also provide health advice and talk to them about the importance of looking after themselves, as well as helping families deal with issues around loss and adjusting to changes in their role when a loved one is living with dementia. This involves opening up difficult discussions about advanced care planning.'


Dementia UK Admiral Nursing services in primary care 


Older population

Dr Castle and Partners is a small practice that has a patient population of about 5,500. Southwold has a particularly high amount of older people and the majority of patients at the practice are over the age of 75. Eighty patients have a confirmed diagnosis of dementia and there are more than 50 others with memory-related symptoms and signs of cognitive impairment. The practice has a proactive system in place where patients over 65 who have not seen a GP for six months are asked to come in for a check-up.

Another aim of the service is to improve the perception of dementia in the local community. 'There is stigma attached to dementia and what getting a diagnosis means in this area,' says Ms Ryan. In the past, two of the local care homes were unable to look after residents with dementia and this has had a lasting effect, leaving many older people fearful about receiving a diagnosis.


people are living with dementia in the UK. This is expected to rise to one million by 2021

Source: Alzheimer’s Society

'People do not want to come and tell us they are having problems with their memory. We have to change the mindset about dementia and help patients accept their diagnosis and move forward with our support.'

As the service grows, Ms Mortimer’s role will also involve providing support to patients and families who have not yet received a diagnosis but do have symptoms. 'We are still working on what my role will be as I am here to complement the local memory services.'

Feedback from patients and carers has been positive. 'The families are so thankful that I have visited them and will be coming back to see them,' says Ms Mortimer. I feel humbled and privileged that they have trust in me in such a short space of time. They really open up and let out what they have been holding in for such a long time. They tell me they are just so grateful that someone is there to support them.'

'A personal crusade to make this happen' 

'It has been a passion of mine to get this going for years and to see it come to fruition is amazing,' says Cathy Ryan. 'My mother had dementia and I cared for her for ten years – I actually gave up work for two years to look after her. I found there was no support when I needed help and I had no one to talk to. When I went to my local social services when I needed urgent respite, they did not get back to me for 12 weeks – not even a phone call. I was at breaking point then.

'I am a professional, so I know what is out there and I knew my way around the system but when it came to dementia, there just seemed to be nothing. A few years later, I found out about Admiral Nurses and wondered why there wasn't one in Southwold. At the time, there were none in the whole of Suffolk. It has been a personal crusade to make this happen. Admiral Nurses are a lifeline for families that have challenging experiences of living with dementia. You cannot put a price on that support – it is phenomenal.'

Support through every stage of life with dementia

Dementia UK’s business development officer Charlotte Harris has been instrumental in setting up the Admiral Nurse service at Sole Bay Health Centre. 'We were particularly excited to develop a service in Southwold as it is an opportunity to be part of the change in how dementia care is provided for families,' says Ms Harris. 'Ms Mortimer’s role offers local families support through every stage of life with dementia, from diagnosis to bereavement support. We hope this will build confidence in the local community so people will seek support about a diagnosis. This could range from concerns about memory or cognition changes, emotional or physical changes, changes in their ability to complete daily tasks or social isolation and a loss of independence.'

Julie Penfold is a freelance journalist

For more information

Sole Bay Health Centre

Dementia UK 

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