Examination of Witnesses (Questions 120-138)
NATIONAL HEALTH
SERVICE
15 OCTOBER 2007
Q120 Mr Williams: Your reply was
full of questions and no answers. It says here in our briefing,
"There is a lack of clarity over who is responsible/accountable
for improving dementia care". At the moment, we get the impression
that no one is—in a meaningful, operative sense. If they
are, they are just becoming aware of the need to be.
David Nicholson: We have
identified dementia services as a priority.
Q121 Mr Williams: When?
David Nicholson: The Minister
announced it in August.
Q122 Mr Williams: In August?
David Nicholson: Yes.
Q123 Mr Williams: By gosh. Then what
happened—for example, in 2002? The single assessment process
was to be introduced by April 2002. Five years later, it is still
not in use. Only 46% of community health trusts are using it.
There is a big difference between deciding that something needs
to be done and actually getting around to doing it. Nothing has
been done, or virtually nothing, in that case.
David Nicholson: David can
say something about the single assessment process, but I have
said that dementia services were not a priority. They are now.
Q124 Mr Williams: From August?
David Nicholson: The Minister
identified it as a priority in August, absolutely.
Q125 Mr Williams: Sir John, when
did you provide the Department with a copy of the Report for it
to clear the facts with you? When did it first see what the Report
was going to look like?
Karen Taylor: About three
months before publication.
Q126 Mr Williams: That would have
been about July, would it not?
Sir John Bourn: It was published
on 4 July, so three weeks before that.[1]
Q127 Mr Williams: Just before August—in
my calendar, anyhow.
David Nicholson: I am sorry,
but I am being a bit dense here. Just spell out what you are trying
to tell me.
Q128 Mr Williams: I am suggesting
to you that it became a priority just before you came to this
Committee and that, if you are not called to this Committee again
soon afterwards, it will cease to be a priority.
David Nicholson: That is
completely not the case.
Q129 Mr Williams: Well, what happened
to the 2002 scheme?
David Nicholson: David can
say something about the single assessment process, but what we
are saying here is that the important thing about improving services
for people with dementia is that you have to have a systematic
approach to doing it across the whole range of services. It is
no good doing one bit in isolation from the rest of it.
When we have looked at our clinical priorities
as a whole across the NHS, we have seen that we are clearly making
significant progress in cancer, coronary heart disease, waiting
times, and, after the publication of the stroke strategy, stroke
services. Dementia now has its place in the sun and we have the
opportunity to put the focused attention of the system on improving
services. That seems to me a good thing, not a bad thing.
Q130 Mr Williams: What machinery
does it have, again, for its place in the sun?
David Nicholson: I am sure
that Mark can tell you about that, but it is about saying that
it is a priority, and about me and Ministers taking every opportunity
to say that dementia services—
Q131 Mr Williams: I asked what machinery
it has.
David Nicholson: I am
just saying that the second part of that machinery is the allocation
of resources. We have just had the Comprehensive Spending Review,
and we are now working through the issue of resource allocation
to the NHS. The third issue is the operating framework, which
is the planning document that we set out for the NHS in December,
and from which the NHS must implement the plans that we approved
in March. It will have to set out how it will make dementia a
priority in real terms in communities.
You asked me about the machinery.
Q132 Mr Williams: That is what I
am coming back to. Who is responsible for that machinery, and
accountable for it?
David Nicholson: I have overall
responsibility.
Q133 Mr Williams: But who has responsibility
for the whole lot?
David Nicholson: Mark in
the Department is responsible for delivering that element of the
machinery.
Mark Britnell: May I just
take a second of your time to explain that the operating framework
basically signals a handful of priorities? An analogy has been
made with cancer and stroke, and what Mr Nicholson and I are saying
is that the operating framework is signalling the production of
specific guidance next year to those who invest locally? They
are called primary care trusts. Because of the machinery through
the joint strategic needs assessment with local authorities and
social care through local area agreements, the simple answer to
your question is that Mr Nicholson has overall responsibility,
but those chief executives and boards that run primary care trusts
obviously have the local responsibility to invest in local health
needs. What we are saying in the operating framework is that it
is one of a handful of things that we are directing PCTs to address
next year. It is assuming greater responsibility to complement
announcements that Ivan Lewis and others have made on a national
strategy.
In response to Mr Bacon's question about
moving quickly, we know some things to be true already. We know
that the evidence base from Dementia UK and the National Audit
Office is making it much more compelling, straightforward and
clear for commissioners—local PCTs—to invest in early
diagnosis and, potentially, memory services. The operating framework
will draw commissioners' attention to early investment, which
will improve life and ultimately, over a period, save money for
the public exchequer and for health and social care. That is why
we are confident this time that our thinking is joined up.
Q134 Mr Williams: With your permission,
Chairman, may I ask Sir John if one year from now, he will provide
a snapshot of what progress has been made, what machinery is in
existence, who is accountable, and what progress has been made,
and will he give us an interim report so that we can call people
back next autumn or early winter?
Sir John Bourn: Yes, I will
do that.
Mr Williams: Thank you.
Chairman: I think Mrs Browning has
a couple of supplementaries.
Q135 Angela Browning: Yes, thank
you. I have very little time, so I hope that we shall both be
short.
It would be wrong of me not to say, particularly
while you are here, Mr Nicholson, that Mr Touhig said in his presentation
to you at the beginning that he felt that in the NHS there is
an overall attitude of prejudice to older people in terms of them
receiving the services and support that they need. The Report
refers to acute hospital admissions. One example is the financial
benefits in terms of people who are admitted for fractured neck
of femur, and the difference between those who have no dementia
and those who do. There is a clear financial benefit for improving
the throughput of that group of people.
May I suggest, in the light of what Mr
Touhig said to you, that one of the big problems with elderly
people, whether or not they have dementia, is the fact that when
they present with fractured neck of femur, they are constantly
shuffled down the operating list and their chances of recovery
are reduced dramatically by the way in which they are treated
compared with other trauma patients?
David Nicholson: We have
a lot to do, but there has been significant progress over the
past three or four years in the way in which patients generally
are treated for fractured neck of femur, and that reflects the
fact that the vast majority of them are older people. I do not
accept that there is evidence to suggest that older people are
shuffled down the trauma waiting list.
Angela Browning: They are.
David Nicholson: If you have
evidence of that, I would be happy—
Angela Browning: I have raised the
matter on the Floor of the House, and I continue to read about
it.
David Nicholson: I would
be happy to deal with that.
Q136 Angela Browning: You will appreciate
that for someone with dementia to be subject to nil by mouth for
two, three or sometimes four days in a row before they get to
theatre when they have a fractured hip does not improve their
chances of recovery.
David Nicholson: I agree.
Q137 Angela Browning: May I move
on quickly to Professor Banerjee? So much of the NAO Report and
so much of what we have heard now seems to be predicated on a
massive increase in the resources to GPs, for training and other
things, and to community mental health teams. The Report shows
that at the moment, the average community mental health team deals
with 275 people with dementia when, on average, the number should
be 1,000. Where are the resources going to come from? I cannot
help but feel whatever your committee concludes, the resource
implications—if they are really going to deliver—are
going to be massive.
Professor Banerjee: That
is a very good question. It may have been why people have been
reluctant to consider some of these issues. I do not agree that
there needs to be the massive, gigantic expansion in services
that you suggest in order to deliver, for example, early identification
and treatment of dementia. Models have been developed that show
that you can have a relatively high throughput of cases, that
the quality of that care can be assured and that the outcomes
of those services are good. They are mentioned in the NAO Report.
One reason I think this is possible is
because relatively modest investments can be made that are complementary
to our current services and which will work with them but deliver
much more early identification and intervention and continued
support. It is undoubtedly true that if you put in an early identification
team, there will be knock-on effects for the community mental
health teams. Part of the modelling that has been discussed is
modelling the relative effects of those things. I have every confidence
that a relatively modest investment in a community-based memory
service, along with some enhancement of community mental health
teams to deal with the increased work that comes from that further
down the line, and of adult social care when that comes down the
line, can form a package that makes a step change in the way that
we provide dementia care in the community—at a cost that
is not unaffordable by the NHS.
Q138 Chairman: Thank you very much,
gentlemen. That concludes our inquiry. It has been a very important
day in dealing with this issue. Don Touhig put his finger on it
when he showed how the UK compares so poorly with other EU countries.
On the percentage of people with Alzheimer's disease treated with
anti-dementia drugs, we are behind Italy, Germany, Switzerland,
Denmark, Belgium, Austria, Portugal, Spain, Ireland, Sweden and
France. So, when you do come back in a year's time—I think
this is a very good idea—we really want to see more progress.
David Nicholson: We are absolutely
committed to improving dementia services, and I hope we will see
that in the near future.
Chairman: Well, we will leave it
on that note, then. Thank you very much, Mr Nicholson.
1 Correction by witness: The Comptroller and
Auditor General's Report, which was published on 4 July, was sent
to the Department for working level clearance on 9 May and was
submitted formally by the C&AG for Accounting Officer clearance
on 19 June. Back
| 
