Our Vision
Our vision, created by our partners, stakeholders and those with direct and lived experience is that through this strategy:
“We will support people affected by dementia to live well throughout their lives, receiving a timely diagnosis, and the right support at the right place and time. Together, we will develop Dementia-friendly communities with the person, their choices, dignity and what is important to them at its centre”.
Introduction
Dementia is a set of symptoms caused by diseases that damage the brain, leading to problems with thinking and memory beyond normal aging. It affects not only those with dementia but also their families and carers, and can often lead to a lack of understanding and stigma. While it's more common in older people, young-onset dementia can also occur, bringing its own unique challenges.
Every person's experience with dementia is different. Many continue to live full, active lives, but for others, daily tasks can become very difficult. Symptoms change or can get worse over time and how this happens is different for each person with Dementia. Some people with Dementia live alone or rely on one carer, which can increase their risk of feeling isolated. Recognising these diverse experiences is key to providing caring and personalised support for people with dementia and their families and carers.
Dementia in Sutton
In Sutton, dementia is a growing concern. As people live longer, the number of individuals affected by dementia is rising, including those diagnosed at a younger age.
Local data shows:
- about 2,107 people aged 65 and over in Sutton have dementia, but only about 74% (1,559 people) have been officially diagnosed.
- Sutton's dementia rate (0.7%) is similar to the England average.
- early-onset dementia (under 65) is expected to slightly increase from 55 to 60 cases between 2023 and 2040, mostly in the 50-64 age groups.
- for those 65 and over, dementia cases are projected to rise by nearly 40% by 2040, with the biggest increase in the 90+ age group.
Our goals and how we plan to achieve them
This is Sutton's first joint dementia strategy, and it's built on the experiences and views of people living with dementia, their families, carers, and the health and social care teams who support them. We listened to what people told us, looked at other successful approaches to support, and used health evidence to set the strategy’s priorities and worked with partners, stakeholders and people with Dementia, their families and carers to shape our approach.
Some key ideas from our discussions include:
Community is key
Local groups (voluntary, community, heritage, faith-based) are vital for support, activities, and helping people stay connected. They are crucial partners in making sure dementia care is fair and easy to access, especially for Sutton’s diverse communities.
Prevent, reduce, delay
With 45% of dementia cases potentially preventable, there's a huge chance to improve lives and reduce strain on health and social care services. Lifestyle changes that have been identified to prevent dementia also help lower the risk of developing other long-term health conditions. Participants in community engagement sessions consistently asked for practical tips on how to prevent dementia for themselves and their loved ones.
Early diagnosis matters
We want to challenge the notion that dementia only affects older people and encourage earlier conversations about potential symptoms. An early diagnosis helps people better plan their care, make decisions about their future, and access support sooner in their dementia journey.
Planning for the future
It's important to plan for changes as dementia progresses, including respite care, legal documents (like Lasting Power of Attorney), and decisions about moving to residential care or end-of-life care. Advanced care and contingency planning helps people stay independent longer and ensures their wishes are met.
Co-production and listening
We are committed to involving people with lived experience in everything we do – from developing new programmes to improving existing support and helping put individual care plans into place. This ensures care plans truly reflect the wishes of people with dementia and their families.
Training and toolkits
The groups of people and individuals taking part in activities to develop this strategy showed a strong desire for training to understand dementia and support people with dementia better (including professional carers). Community and heritage-based groups also asked for workshops to recognise signs of dementia, how to help people in distress and befriend people with dementia and loneliness.
Working together and sharing resources
Many of our priorities connect with other local strategies (Carers, Mental Health, Learning Disabilities, Adult Social Care Prevention). We aim to strengthen these links to provide coordinated community-based support. The new Dementia Hub is a great example of this, offering a single point of access for support for people with dementia, their families and carers after a diagnosis.
By working together, we aim to improve daily life and access to support for people with dementia, their families and carers in Sutton.
Goal: To reduce the number of people diagnosed with dementia in Sutton by promoting actions that can prevent, delay, or reduce the risk of dementia.
Key facts:
- Up to 45% of dementia cases may be preventable through lifestyle changes (Lancet Commission, 2024)
- Prevention should begin in childhood and continue throughout a person’s life.
- Combining efforts across a few risk factors (diet, exercise, social connection, hearing and eye checks, smoking cessation) is most effective.
- Even with a family history, individuals can lower their risk of developing dementia through making healthy lifestyle choices
What we aim to do:
- collaborate across health and social care partners to link healthy lifestyle and ill-health prevention messaging with a "what’s good for the heart is good for the brain" campaign, focusing on the recognised 14 modifiable risk factors.
- create new dementia prevention programmes and resources with local community and heritage-based groups, ensuring they are accessible, culturally appropriate, and available in multiple languages.
- map current partnership commissioning and community-based programmes to identify opportunities for targeted interventions for groups of people shown to be at high risk of developing dementia.
- explore how dementia prevention programmes can support and increase access to services offered through GPs, Integrated Health Teams, and Public Health (for example: social prescribing, smoking cessation, vision and hearing checks)
Goal: To ensure people can recognise the early signs of dementia, know where to seek support and ask for an assessment, and receive timely, accurate diagnoses with clear, accessible information on next steps for care and support.
Key facts:
- early diagnosis allows for meaningful conversations about where someone may be in their dementia journey, choices for treatment and symptom management, and planning for their current and longer-term care
- NHS England aims for a dementia diagnosis within six weeks of GP consultation. Sutton currently achieves this for 85% of people referred to the Memory Assessment Service
- approximately 24% of people in Sutton living with dementia (548 individuals) are undiagnosed
- certain groups (some ethnic minorities, people with learning disabilities, younger adults) may experience delays in diagnosis due to stigma around discussing their mental health, language barriers, or mis-identification of symptoms
What we aim to do:
- collaborate with community and heritage-based groups to develop culturally sensitive and accessible resources on dementia signs, symptoms, and the diagnosis process
- implement Dementia Awareness training for community groups to help identify and support individuals through the diagnosis process
- encourage earlier conversations about the signs and symptoms of dementia in adults under 65 and promote the benefits of an early diagnosis
- ensure family members and carers' views are respected and included throughout the diagnosis pathway
- improve signposting and explore "warm handovers" to the Dementia Hub from all dementia diagnosis points, including hospitals helping to ensure personalised post-diagnostic support at the right time for people with dementia and their carers
- ensure people with dementia receive reviews appropriate for their evolving needs
Goal: To provide a single point of contact for tailored, specialist dementia support in Sutton, reshaping the borough's post-diagnosis offer.
Key facts:
- the Dementia Hub was launched in April 2025, in response to feedback from people with dementia and their carers
- it is a collaboration between the Integrated Care Board (ICB) and Sutton Council
- ervices are primarily delivered by Age UK Sutton (Dementia Advisers) and the Admiral Nursing Service (expert support for families and carers)
- people can self-refer or be referred by various health and social care professionals
Core puropses of the Dementia Hub:
- provides bespoke post-diagnostic support, responding to individual needs at each stage of the dementia journey
- maintains a consistent Dementia Adviser Service, offering a named adviser for ongoing support if desired
- offers accessible information and advice about dementia to all Sutton residents
- accepts self-referrals and referrals from across health and social are (Memory Clinic, GPs, community health teams, voluntary sector)
- supports improved access to and the delivery of care reviews
- facilitates connections to community-based programmes aligned with 'Living Well,’ ‘Caring Well,’ and 'Preventing Well' principles
How to contact the Dementia Hub:
- Call 020 4551 7337
- e-mail dementiahub@agesutton.org.uk
- Age UK Sutton's main helpline: 020 8078 0002
Goal: To support people diagnosed with dementia to remain active, connected, and living independently within their communities for as long as possible.
Key facts:
- "With the right help and support when you need it, many people can - and do - live well and independently with dementia for several years."(NHS, 2024)
- key recommendations for living well include staying social, talking about your dementia (families, employers, friend groups), looking after physical health and wellbeing, and seeking support from social care for people with dementia and their families and carers.
- between July 2023 and October 2023, Sutton saw significant growth in people with dementia supported in the community (from 287 to 559 people)
What we aim to do:
- maintain community-based peer support and explore adding topics like symptom management and tech solutions
- work with Together for Sutton and the local community/voluntary sector to create more opportunities for communities to develop local activities that support people with dementia, their families and carers
- ensure the Dementia Hub has up-to-date information on support for challenging health behaviors (for example, reducing alcohol, smoking cessation, addiction)
- ensure care and support reviews are strength-based, help promote healthy living and give good signposting to healthy living resources
- map and promote current social and healthy lifestyle activities for people with dementia and their carers
- support the further development of social prescribing resources at local GP surgeries
- develop resources with Public Health and Integrated Neighbourhood Teams (INTs) to help prevent social isolation and loneliness
- develop dementia training and toolkits for community, heritage, and faith-based groups to make activities dementia-friendly
- xplore developing a Sutton-specific 'Dementia-friendly' status for local businesses and public areas
- support local asset mapping to identify and share community resources
Goal: To acknowledge and respect the unique insight and expertise of family members and carers, supporting them with support, resources, and services to sustain their wellbeing.
Key facts:
- many people with dementia are supported by unpaid carers, often family members, who play a vital role in their care
- 47% of dementia carers care for a spouse or partner; 45% are children looking after a parent (Dementia Carers Count Survey, 2024)
- 49% of carers report no one else is available to provide care to the person they look after
- 76% of dementia carers have no arrangements in place for when they cannot continue to care for the person with dementia
- the NICE Dementia Quality Standard recommends education and skills training for all dementia carers
What we aim to do:
- continue commissioning peer and one-to-one support for dementia families along all points of a dementia journey and expanding access to local activities
- put workshops and training into place within peer support activities on topics like symptom management, advanced care planning, and Lasting Power of Attorney (LPA)/Deputyships
- improve access to capacity assessments needed for LPA/Deputyships
- link with Sutton Adults Safeguarding Board to support contingency planning for carers, including resources for when a person with dementia goes missing (for example, the Herbert Protocol)
- improve outreach to dementia carers in cultural communities unaware of available support because they do not consider themselves a carer
- link with Sutton’s Mental Health Partnership to improve signposting to mental health support services for carers
- expand upon work under the Carers Strategy to improve access to good quality, reliable, and dementia-trained respite care choices
- update the Sutton Carers Offer with information for dementia-friendly activities
Goal: To support people with dementia and their carers in planning for the later stages of life, including end-of-life care, ensuring wishes are expressed and care is received with dignity and compassion.
Key facts:
- Dementia was the UK's leading cause of death in 2022
- advanced planning helps ensure decisions about end-of-life care are known and respected
- in Sutton, the mortality rate for deaths involving dementia and Alzheimer's Disease has steadily increased, reflecting a national trend
- the strategy aligns with Sutton’s End of Life strategy
What we aim to do:
- ensure people with dementia have access to high-quality palliative care
- start conversations about advanced care planning early within Dementia Hub and health/social care pathways
- ensure cultural awareness around death and dying is included in training for frontline workers
- provide signposting and support for people living alone with dementia to make end-of-life arrangements
- provide signposting to reliable sources for information and advice on legal arrangements related to care and end-of-life wishes
- provide peer and one-to-one wellbeing support to maintain health and wellbeing during the later stages of a dementia caring role and when losing a loved one