Examination of Witnesses (Questions 40-59)
NATIONAL HEALTH
SERVICE
15 OCTOBER 2007
Q40 Mr Touhig: You are not on top
of this issue, are you?
David Nicholson: We have
been doing things: the older people's national service framework,
the mental health national service framework—a series of
activities to take services forward. But it is not enough, and
it is not giving to the service the radical change that is required.
Mr Touhig: You are really not on
top of it.
David Nicholson: What is
really—
Mr Touhig: You are not on top of
it, are you?
David Nicholson: We are absolutely
on—
Q41 Mr Touhig: We are spending £14.3
billion on this, and we are still in the bottom three in the European
Union on care for people with dementia.
David Nicholson: We acknowledge
that we have something to do, and that is why we—
Q42 Mr Touhig: That is a staggering
amount that, is it not—£14.3 billion? You could get
a few operations done for that, could you not?
David Nicholson: It is a
huge amount of money, but the reason for tackling it is not to
save money but to improve services for patients, and particularly
to improve services for patients who do not get a service at the
moment.
Q43 Mr Touhig: What are the top three
improvements that you would say that you are getting for spending
£14.3 billion? What are the three top improvements that we
are getting for spending such a vast amount of money in dementia
care?
David Nicholson: The problem
we have with dementia care is that the improvements are scattered
around the system in various parts of the country. I can take
you to lots of places where there are significant improvements:
in Croydon, with memory services; in Leeds, with services for
people with complex needs; and in Cambridge—there are lots
of good examples around the country where people are improving
services. What we have not got is a systematic approach, and it
is not good everywhere. That is the focus of our attention.
Q44 Mr Touhig: Page 24 of the Report
states that someone who gave comments to the focus group had to
wait three and a half years for a diagnosis.
David Nicholson: I have
come across people who have waited a long time for diagnosis,
but I think that I have to take you back to what we said in part
of the original conversations. What can often happen is that someone
presents themselves to a GP and the GP will say, "Yes, you
have got a memory problem but you are getting old." I have
had cases where people have been moved around the system for two
or three years because of that, because when they hit the service
people do not have the expertise, understanding or knowledge—
Q45 Mr Touhig: It is a prejudice
against age, is it not, that is endemic in the National Health
Service?
David Nicholson: It is an
issue in society in general, not just in the NHS, when it comes
to memory issues. I am sure that Sube sees this every day in the
way that he operates.
Q46 Mr Touhig: We have 476,000 carers.
These are unpaid people who look after their loved ones and so
on. It costs about £25,000 to look after a person per year.
These people give up their jobs, their careers, to look after
a loved one. Are you not ashamed that you have let those people
down?
David Nicholson: I do not
think that we have let them down. Again—I am sure that many
people around this room will meet and talk to carers—they
are relatively modest in what they require. They regard what they
do as an important part of their lives and those of their loved
ones.
Q47 Mr Touhig: They are filling a
gap that you should be filling.
David Nicholson: I do not
accept that, but we have a responsibility to support them and
to help them to do it and to make it as easy as possible. What
they want is a system that works for them, not against them, and
that is what our responsibility is.
Q48 Mr Touhig: So, we have £14
billion, over 500,000 people with dementia in England, and nearly
500,000 carers, and you do not think that there is some great
responsibility on the National Health Service to make some improvement
here?
David Nicholson: Of course
there is. That is why we have put together the team that we put
together to develop the strategy. That is why we have said that
if there are emerging findings from the strategy that we can put
in place earlier we will do that through the operating framework
this November and that we will work with Sube and his team to
make sure that we have a dementia service that puts us in the
top three rather than the bottom three.
Q49 Mr Touhig: Page 24, paragraph
2.1, tells us that early diagnosis and intervention are cost-effective,
and that despite the fact that it improves the quality of life
of people with dementia, early diagnosis is being prevented because
GPs have poor knowledge of dementia and lack training. You know
this as a fact; why are you tolerating it?
Professor Banerjee: The figures
and findings speak for themselves; the system is not working properly.
What we need to do is to understand how the system is not working
properly, and the reports that we have had in the past two or
three years make it clear where the problems are. Then, most importantly,
we need to set in place a different system that will ensure that
individuals get a diagnosis and that services work for family
carers as well as the people with dementia. The fundamental change
that our strategy will focus on making is to enable those with
dementia to get a diagnosis early in their illness and for that
diagnosis to be factored into all the care that they and their
family carers receive.
Q50 Mr Touhig: But you know from
this Report, and surely from your own experience, that many people
are not diagnosed unless they go into hospital for some other
injury.
Professor Banerjee: Absolutely.
Certainly the National Audit Office Report makes it very clear
that the current system is problematic in many areas. It does
not take all of the opportunities that are there to make diagnoses.
We have examples of services that can do such things across the
country; the challenge is to make those happen in other places.
With respect to your point about carers earlier, I spend a lot
of time working with carers, who want to be helped to continue
to care. There are things that services can do that will support
carers in their caring role. Carers do not necessarily want all
the caring to be done by someone else. There are positive things
that come from caring and the quality of life experience—
Q51 Mr Touhig: Have you had any personal
experience of caring for someone with dementia?
Professor Banerjee: I have
professionally, and also my grandfather had dementia. I run a
dementia service.
Q52 Mr Touhig: My wife has, and it
is not easy, I can tell you. Page 48 of the Report says that GPs
can go through their entire career without learning about mental
health at all. What are you doing about that? There have been
some improvements and GPs are now keeping the register that you
referred to because there is a financial incentive under the GPs'
pay scheme. The NHS invented a pay scheme that gave GPs a licence
to print money. Is it not somewhat mercenary that now there is
a financial incentive they are gathering the stats together in
order that we can better assess the needs of people with dementia?
David Nicholson: It is perfectly
reasonable if you have a payment system for GPs that you try and
reflect your clinical priorities and that is what we have tried
to do with dementia, albeit in a relatively modest and limited
way. I was talking to a group of GPs last week who were saying
that you can run a register opportunistically—when people
come to you and present, you can register them as having dementia.
Q53 Mr Touhig: Now there is an incentive,
they are responding.
David Nicholson: That is
absolutely right, but you can take a very proactive role and go
and seek people out. That is absolutely what they should be doing.
Q54 Mr Touhig: I entirely agree with
you, but, coming back to the point I made earlier about age discrimination,
we see from the Report that almost one in four GPs believe dementia
patients are a drain on resources, with little positive outcome.
David Nicholson: Yes, absolutely.
Mr Touhig: That is terrible. It
is unbelievable.
David Nicholson: It is absolutely
right. It is a really important issue for us to tackle because
it is part of the societal view about dementia. It is exactly
part of that that we have to tackle inside the system and outside.
Q55 Mr Touhig: But you are responsible
for training GPs, setting down the guidelines by which they work,
and you are prepared to tolerate—
David Nicholson: No, we are
not prepared to tolerate it.
Q56 Mr Touhig: I hope you will be
doing something more about it.
David Nicholson: Absolutely
right.
Q57 Mr Touhig: We have very little
time, and I appreciate the briefness of your answers. I have one
further question about the care within care homes. The Report
states that only 28% of care places are registered specialist
dementia places, yet 62% of people in care homes have dementia.
If you had an elderly relative with dementia, would you put them
in a care home? I certainly would not.
David Behan: Clearly, one
of the facts that the Report identifies is the population in care
homes who are suffering from dementia. There are some estimates
that would say that in some places up to 80% of people in care
homes are suffering from dementia. The regulator, the Commission
for Social Care Inspection, noted a year-on-year increase in the
number of homes meeting the standards by which they have registered,
so there has been some general improvement. Angela Browning's
question was about the training of the work force and there are
key issues in relation to the training.
Q58 Mr Touhig: There is a constant
turnover of staff.
David Behan: There is a challenge
in that respect and a challenge to commission services in an appropriate
way.
Q59 Mr Touhig: One final point as
I am running out of time, more than 40% of people with dementia
in care homes are prescribed neuroleptic drugs such as haloperidol
and risperidone, which actually worsen their condition. Why do
you tolerate this?
Professor Banerjee: It is
very clear that people with dementia in care homes can have quite
severe and difficult behaviour at times.
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