Examination of Witnesses (Question Numbers
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
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
diseaseit 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 youSir
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
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 publishedand Karen has explainedit
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 saidmy 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 noteand I think I have said this to the Committee
beforeis 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 Dementiathe 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 Wakefieldand
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.