Examination of Witnesses (Questions 1-19)
NATIONAL HEALTH
SERVICE
15 OCTOBER 2007
Q1 Chairman: Good afternoon, and
welcome to the Public Accounts Committee, where today we are looking
at the Comptroller and Auditor General's Report, Improving
services and support for people with dementia, which, from
what we read in the Report, appears to be the Cinderella of all
Cinderella services. Mr Nicholson, would you like to introduce
your team?
David Nicholson: I am the
Chief Executive of the NHS, and with me are Professor Sube Banerjee,
who is leading some of the work on the strategy for dementia,
Mark Britnell, who is Director General of the Department for commissioning
and system management, and David Behan, who is a Director General
with particular responsibility for local government and social
care.
Q2 Chairman: We asked the National
Audit Office to take a particular interest in the matter before
us. This could be a very important hearing and I hope that we
raise the issue of dementia up the political agenda, as we did
for those of stroke, hospital-acquired infections and now, most
topically, obesity. I think that the work of this Committee was
instrumental in raising the importance of the latter.
We are now dealing with dementia, which
affects nearly 500,000 people and costs £14 billion a year—in
some estimates. Obviously, it is a hugely important issue, and
to some of us it seems that it is rather like cancer in the 1950s.
A stigma is attached to it, people are not necessarily told about
it early enough and there is a feeling perhaps that the cures
are not very effective. I think, therefore, that this hearing
could be very important in raising the issue.
In response to this Report, Mr Nicholson,
you set up a working group in order to develop a strategy for
dealing with dementia. Given the huge personal and financial impact
of dementia, why did you not do it before? Why did you wait for
the National Audit Office to jog you into setting up the working
group?
David Nicholson: You are
absolutely right. This is a very important issue for us to tackle,
from the Department's point of view, and from that of the NHS
and social care. However, the idea that we have done nothing in
the past is not completely true. A lot of work has been done on
dementia—for example, the older people's national service
framework, the Let's Respect project carried out by CSIP (Care
Services Improvement Partnership), the Everybody's Business service
and the Quality and Outcomes Framework. A whole series of things
have been done over the last few years to try and improve services
for this group of patients.
Having said all that, the issue has not
been identified as a national priority, which is reflected in
the work and the emphasis that we have put on it over the last
few years, during which time coronary heart disease, cancer, waiting
times and other such issues have been regarded as priorities,
as opposed to dementia. The great thing about the NAO's Report
and the Government's response is that the Minister, Ivan Lewis
identified dementia as a Government priority and hopefully, in
today's conversation, we will be able to reinforce the fact that
that will be the case. We are going to put things into place to
make that happen. That is why we have set up the working group
to put together a strategy for dementia.
A whole series of individual interventions
will not necessarily make the changes that we need for these patients
and their carers. An overarching strategy that sets out everything
from the epidemiology of dementia, through research and development
and staffing to the way in which patients are identified and treated
is the right approach.
Q3 Chairman: Has the working group
met yet?
David Behan: We have put
the programme board together. The programme board is chaired by
me, and Mark Britnell is on the board, to get the health and social
care—
Q4 Chairman: So it has not met?
David Behan: The project
group, which sits under the programme board, has met.
Professor Banerjee: We have
met on four occasions. I chair the group.
Q5 Chairman: It has met?
Professor Banerjee: The working
group to develop the strategy has met on four occasions, and we
have worked to identify the three main themes that we will be
working on. The membership of the external reference group, which
is chaired by the Alzheimer's Society, has been agreed, and that
group is due to meet very soon, so the work has started in earnest.
We have identified the three main themes that need to be addressed,
which are early identification, public attitudes and understanding—
Q6 Chairman: But the main group has
not actually got down to work?
Professor Banerjee: No, the
main group has got down to work.
Q7 Chairman: What are its time scales?
How urgent is this? Are we talking about six months or a year?
What is it?
Professor Banerjee: We have
been set a year to deliver the strategy.
Chairman: Okay.
David Nicholson: Having said
that, an important document for the NHS is the operating framework,
which comes out at the end of November, the beginning of December.
It is the main communication between the Department and the NHS
as to the planning priorities for the next year. We have said
that emerging things that have come out of work so far can go
into that operating framework.
Q8 Chairman: If we look at figure
13 on page 26—this is also mentioned in paragraph 2.4—we
see that between half and two-thirds of people with dementia are
not receiving a diagnosis. Why is that?
David Nicholson: There is
a whole range of issues here; some of them are societal, some
are about professions and some are about the system that we operate.
There are societal fears about dementia, and while the Department
of Health is an important organisation, it is not entirely responsible
for the whole of society's views about these issues, and we would
not kid anyone by any stretch of the imagination if we said that
we can control them all. So fear of dementia is a major issue.
There are also misconceptions about what
can and cannot be done. On the one hand, in society as a whole,
dementia is often seen as something that there is no treatment
for and that you can do nothing about. Among some professionals,
too, there is the view that there is very little that can be done.
There is a lack of confidence among professionals about dealing
with these issues, which is identified very well in the NAO Report.
And we have not had a systematic approach to dealing with this
issue.
Q9 Chairman: So you are now going
to set a time frame on this issue and deal with the issues raised
in the paragraph that says, "Only five people per 1,000 were
diagnosed at age 65-69, compared with an estimated actual prevalence
of 13 per 1,000"?
David Nicholson: Yes, it
will undoubtedly be one of the things that come into this—
Q10 Chairman: So if you are summoned
back in two or three years' time, we will see a completely different
story, will we?
David Nicholson: I think
you will see a completely different story.
Q11 Chairman: As regards those who
are diagnosed, why are so many families left floundering without
any adequate support?
David Nicholson: There undoubtedly
are people who are left floundering after the diagnosis, but that
is not true for everyone. There are some fantastic services around
the NHS and social care system—indeed, I have visited some
in the last few weeks—but this is a complex care pathway.
Dementia is, on the one hand, a long-term condition, but it is,
on the other hand, an issue in relation to end-of-life care. What
we have not done yet is put together a set of pathways that would
be applicable in most circumstances. That is one of the things
that the strategy will have as a priority; indeed, it is one of
the issues dealt with in the work that Ara Darzi and his team
are doing at the moment in relation to the review.
Q12 Chairman: All this is very complex,
but there is a very easy thing that you can do. There are drugs
available at the early stages; they are available in Scotland,
and they clearly do some good by delaying the onset of this disease,
but they are not available in England. It is outrageous, is it
not, as far as our English constituents are concerned, that there
are people being treated in Scotland?
David Nicholson: Judgments
about the use of such drugs are taken by NICE, and we are guided
by that.
Q13 Chairman: But you do not necessarily
need to accept NICE's decision. You did accept it, perhaps gratefully.
Perhaps it resulted in large savings. How much money is involved?
If you had not accepted NICE's recommendations, and if we were
to provide in England the same drugs at the early and middle stages
as are available in Scotland, what would have been the cost?
David Nicholson: I am sorry,
I do not have that figure.
Q14 Chairman: Was it a factor in
your decision?
David Nicholson: No. We accepted
NICE's recommendation.
Q15 Chairman: What would you say
to the Alzheimer's Society, which has produced evidence to suggest
that you, or NICE, did not take account of the cost to carers?
If that had been taken into account, the mathematics might have
been very different.
David Nicholson: This is
obviously subject to appeal.
Q16 Chairman: So did you take account
of the cost to carers or not?
David Nicholson: Well, we
didn't; it was NICE that did it.
Q17 Chairman: Did NICE take account
of it?
David Nicholson: I think
that that will be the subject of the appeal.
Q18 Chairman: Paragraph 1.10 states
that informal carers save the NHS and social care some £5.4
billion a year. Do you accept that? Presumably you do, because
you have accepted the Report.
David Nicholson: Yes, we
accept the Report.
Q19 Chairman: So why do between half
and two thirds of unpaid carers not receive a carer's assessment,
as they are entitled to under the Carers and Disabled Children
Act 2000?
David Nicholson: That is
a figure for all carers, not just carers for people with dementia.
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