Improving Dementia Services in England - an Interim Report - Public Accounts Committee Contents

Examination of Witnesses (Question Numbers 1-19)


  Q1 Chairman: Good afternoon. Welcome to the Committee of Public Accounts, where today we are considering the Comptroller and Auditor General's Report on Improving Dementia Services in England. We welcome back to our Committee Sir David Nicholson, who is the Department of Health's Accounting Officer and Chief Executive of the National Health Service. Perhaps you would like to introduce your colleagues, Sir David.

  Sir David Nicholson: Yes, we have Sir Ian Carruthers, who is the Chief Executive of the South West Strategic Health Authority, David Behan, who is Director General for Social Care, Department of Health, and Professor Sube Banerjee, who is an adviser to the Department on dementia.

  Q2  Chairman: Thank you very much, Sir David. I should say that we are joined by the Speaker of the Assembly of Kosovo and nine members of the PAC in Kosovo. After this hearing I will make myself available to talk to them. We are talking about dementia services, a very important subject, Sir David. It costs the taxpayer about £8.2 billion a year but a lot of this spending is reactive. What I would like to know from you, Sir David, is that it is two and a half years since we last had this hearing. As you know, this was a subject of great interest to us. Not once, but at least ten times, Sir David, you told this Committee that it was now going to be a national priority. I asked the NAO to report back to us within a year, and here we are, two and a half years later: dementia has still not been included as a national priority. There have been three operating frameworks that you published since the hearing. Why not?

  Sir David Nicholson: First of all, I think it is two years since we have met.

  Q3  Chairman: All right, well let us not quibble if it has been two and a half or two years.

  Sir David Nicholson: And there have been two operating frameworks published. As you know, at the last hearing the important thing for us was the development of a strategy for dementia. There had been a lot of initiatives in the past but not an over-arching strategy which took in all of the complexities of this really important service. The first thing to say is that we spent quite a lot of our time getting the strategy right. No doubt we will develop that as part of the hearing, but we believe that getting that strategy right is absolutely critical. We now have a strategy which the NAO says is ambitious and comprehensive. We have a strategy that is based on evidence. There was a huge amount of work done over that period to get the evidence to see what actually works in practice; and we have a strategy which, in my view, is future-proofed against the challenges we will have in future in relation to finances in the NHS and the public sector in general. I think the strategy is in a really good place and it was really important that we took the time to get that right. We always knew that certainly for the first year or so of the strategy, and perhaps two, we were in the phase of what I think is described as gearing up and making the plans right in order to deliver what is an enormously complex service which covers primary, social and healthcare. So we have been putting all of those things in place, and no doubt, as I say, we will develop that during the hearing. We have identified in the operating framework—

  Q4  Chairman: I am sorry, Sir David, this is all very interesting, but I asked you a specific question. For the sake of reference, the hearing was October 2007, so that is two years four months ago. Three frameworks have been published since then: in December 2007, December 2008 and December 2009. Everybody has a strategy for everything. I would be amazed if you did not have a strategy for anything. I asked you why you told us two years and four months ago that it was going to be a priority. You told us that ten times and you must have known at the time that that was not the case, or very shortly thereafter. You must have known, Sir David, why you decided that you did not want to make it a national priority. Why did you not tell us?

  Sir David Nicholson: What I was trying to set out for you was the fact that it is a priority for the health and social care system.

  Q5  Chairman: You are announcing today that it is a national priority?

  Sir David Nicholson: It has always been a national priority for social care and the Health Service over the last period.

  Q6  Chairman: It is a term of art, is it not, "national priority"? I want to peg you down on this. It is a national priority in the sense of cancer or heart disease—it is that level, is it? What are you saying?

  Sir David Nicholson: It is a national priority. It is set out in the Government's document NHS 2010-2015. There is a national strategy. There is a national—

  Q7  Chairman: Well, can I ask you—Sir David, I want to get this right. Karen, when you were briefing me earlier you said that there were various national priorities that were set out and then dementia was down with the others which was left to the PCT. Explain what is actually going on here, because I am now being told it is a national priority and I want to know the truth.

  Ms Taylor: The operational framework sets out the Department's priorities using vital sign indicators, tier 1, tier 2, tier 3. Tier 1 is performance-managed by the Department of Health and are termed as national priorities; tier 2 are performance-managed by strategic health authorities and the Department of Health can step in and performance manage; and tier 3 are not performance-managed by strategic health authorities or the Department of Health but are up to local PCTs, and dementia—

  Q8  Chairman: That is where dementia is. So it is not a national priority? I do not know why you just do not say, "Actually we cannot make everything a national priority. I am sorry, Mr Leigh; we should not have told you that it was going to be a national priority; I made a mistake; I am sorry." That would be much better, rather than pretending it is a national priority when clearly, according to the frameworks that you yourself published—and Karen has explained—it is not a national priority.

  Sir David Nicholson: No, but there are two things I would say about all of that. The first thing is that the operating framework was designed to deliver the last Comprehensive Spending Review, of which dementia was not part. As part of that, the Government said—my Secretary of State said, "There will be no new national targets." Putting that through puts dementia in the place that it is. The important thing for us, though, is to take national action, and by the evidence of what we will talk about in terms of what we have done both in terms of the national action we have taken and the local action we have set out, we believe that that indicates that dementia for us is a national and important objective.

  Q9  Chairman: I do not think we are going to get any further. Let us just make progress, and other Members can come in as they want. Would you look at paragraph 3.8 on page 34. I am asking you about the first £60 million that you allocated to support implementation. You do not appear to be tracking how the £60 million is being spent. As you are not tracking it, how can you assure this Committee, Sir David, that this money is not being wasted?

  Sir David Nicholson: The important thing to note—and I think I have said this to the Committee before—is that we do not earmark money or ring-fence money in that way. We give money out into PCT allocations for them to spend in line with the plans that we and they develop together. The amount of money identified in the strategy was indicative that we thought was required for that first year nationally. You cannot divide it between the number of PCTs, you cannot divide it between the number of organisations because people are in very different places. Also, it is a relatively small amount of money compared, as you say, with the £8 billion that we spend on dementia across health and social care altogether. We are putting into place a series of retrospective audits across the country to identify both how money is being spent in dementia across the totality of the amount you describe, and also that—

  Q10  Chairman: So basically we have no idea whether it has gone on dementia or not.

  Sir David Nicholson: They will have to account for it. Individuals—

  Q11  Chairman: It is worthless—

  Sir David Nicholson: No, I do not think it is worthless.

  Q12  Chairman: Obviously it might well have been spent on dementia and it might not have been, and we will have no idea until this audit happens. By the way, Sir David, here we are meeting on Monday: why did you wait until Friday of last week to appoint a Tsar for Dementia—the last working day before our hearing?

  Sir David Nicholson: Well—

  Q13  Chairman: Was it anything to do with this hearing, by any chance?

  Sir David Nicholson: The first thing is that we decided that we would want a national clinical director for both older people and dementia. We thought there was some sense in that. We went through a process of trying to identify somebody and appoint someone. We failed to get the kind of person that we wanted, the quality, so we went out again to advertise for the two jobs separately. It just so happened that—

  Q14  Chairman: There are 365 days in the year and you just happened to appoint the Tsar on the last working day before this hearing?

  Sir David Nicholson: I can absolutely assure you, it just so happened.

  Q15  Chairman: Okay, I believe you. I always believe you, Sir David.

  Sir David Nicholson: Thank you.

  Q16  Chairman: Shall we look at this £1.9 billion in efficiency savings? Your whole strategy depends on the PCTs delivering this. Frankly, how realistic is this?

  Sir David Nicholson: I think this is difficult; there is no doubt about it because when you look at the position that the NHS in general finds itself in over the next period, we are going to have to face a financial challenge like one we have never faced before in our history. Just to give you an idea, on average—

  Q17  Chairman: All this, Sir David, is generalised waffle; it is not answering what I am asking. Karen, have you got any evidence that any of this extra investment is going on dementia?

  Ms Taylor: The strategy identifies that savings will come four or five years down the line once there are services and support put in place to be able to reduce use of care homes; so it would not be identifiable now. It does depend on reducing the use of care homes and acute hospital beds.

  Q18  Chairman: So is there any evidence that we are going to achieve this £1.9 billion in efficiency savings given that we do not have any evidence so far, Sir David?

  Sir David Nicholson: That is the point I was trying to make. We have not done anything like this before. That is why we took so much time going through the arrangements to put the strategy together because we have never done it. There are signs around the country that people can do it. I was in Wakefield—and I am sure my colleagues can give examples where people are taking resources out of in-patient facilities and moving them into community-based services. I think that is well on-stream around the country as a whole. But, as I say, we have not delivered anything of this scale before. In a sense, the whole point of the first period of the strategy, which you describe as not doing very much with, is to get the plans in place, and that is what we have been doing. It is very important to get it right, and that is what people are focusing on at the moment, and what they have to do by the end of March is present us with an implementation plan, a way in which they are going to make these numbers a reality. We will obviously be in a better place when we have looked at those and considered them to measure the risk as to whether we can actually deliver it or not. That is the nature of the strategy and the way that we are doing it. It will be the end of March before those implementation plans are finished.

  Q19  Chairman: What happens to the strategy if these savings are not realised?

  Sir David Nicholson: There are two or three ways. First of all, we can look to other efficiencies within the system. I do not want to go on about it, but, as you know, we are looking for efficiencies across the NHS as a whole, so there are maybe other places we can look. We have also got to look at the possibility in future that future governments may want to be more generous with their Comprehensive Spending Reviews, so we will be bidding for resources through the Comprehensive Spending Review. Those are the two bases on which we can take it forward; either get more money from the Government or provide it through efficiencies.

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