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

Examination of Witnesses (Question Numbers 20-39)


  Q20  Chairman: Obviously, early diagnosis is absolutely essential and we have got to have equal access to memory services. Ivan Lewis, your Minister, promised us, the country, in February 2009, that there was going to be a memory clinic in every town. It is not going to happen, is it? It has now been downgraded so there will be memory services in every town, but by a memory clinic in every town we think that you are going to be going to a dedicated building where your GP will send you to be assessed in the early stages. That is not going to happen, is it?

  Sir David Nicholson: I will ask Sube to speak about this, but one of the things we have been doing is identifying the elements of a memory service which leads to the outcome that you want. It may be that bricks and mortar are not what is required, so it is—

  Q21  Chairman: So why were we promised a memory clinic in every town?

  Sir David Nicholson: I will just ask Sube to explain to you what the memory service might look like.

  Professor Banerjee: I generated many of the bits of the strategy that talk about memory services so I am very happy to fill in what might be expected of such a service. What the strategy advocates is that every PCT should commission a memory service that works for all of the population who might develop dementia. So you have in each PCT a memory service that does three things: it essentially makes the diagnosis well, then breaks that diagnosis well to people with dementia and their carers, and then provides the immediate care and support that is needed for people with dementia and carers. That service can be provided in a variety of different places. We have costed what the service might cost for an average PCT for 50,000 older people; but much of that might be delivered within people's homes rather than in particular clinic settings; so it is not clinics and bricks and mortar that matter, but it is teams of people carrying out good-quality work. If you are looking at the numbers of people you would expect those services to be looking at, they are going to be assessing in an average PCT of 50,000 people something like 900-1,000 people per year. This requires the commissioning of services to do that. We have clear examples of PCTs where those sorts of services have been developed and are delivering for people. In terms of what "good" would look like in terms of those services, it would be the fact that they just do not deliver to the small minority of people—

  Q22  Chairman: I am going to stop you now because we have to have brisk answers because other Members want to get in and I do not want to hog any more time, except to say the one thing that alarms me about what you have just said, Sir David—you talked about cuts. Does this mean that the strategy that you have alluded to is now at risk?

  Sir David Nicholson: I did not say cuts at all. The NHS has been given what in the jargon I think is described is a flat real assumption to make about its resources for the next period ie, whatever we need to invest we need to find from somewhere else in the service, and that is exactly what we are planning to do; and that is what the basis of the strategy is.

  Q23  Mr Bacon: Sir David, can you explain to me what a tier 1 priority is within the vital signs indicator set?

  Sir David Nicholson: Yes, it is a national target and the Department sets out what it is and when it has to be delivered, and is more prescriptive about how it is delivered.

  Q24  Mr Bacon: It is performance-managed by the Department?

  Sir David Nicholson: It is performance-managed by the strategic health authorities.

  Q25  Mr Bacon: Can you describe to me then what a tier 2 priority within the indicator is?

  Sir David Nicholson: Tier 2 targets are targets that are identified nationally as being important, but it is up to PCTs to decide the timing with which they implement them, depending on local circumstances.

  Mr Bacon: And it is performance-managed by the SHA again?

  Sir David Nicholson: Strategic Health Authorities, yes.

  Q26  Mr Bacon: What is a tier 3 priority?

  Sir David Nicholson: These are important issues which it is up to individual PCTs to decide whether to take forward or not.

  Q27  Mr Bacon: Is dementia mentioned in tier 1?

  Sir David Nicholson: Dementia is not mentioned in any of them.

  Q28  Mr Bacon: It is not?

  Sir David Nicholson: No.

  Q29  Mr Bacon: I was looking back at the transcript of the hearing which we had on 15 October 2007. One of the things you said was that—because we had the talk about Mike Richards and cancer and cardiac and stroke and so on.

  Sir David Nicholson: Yes.

  Q30  Mr Bacon: One of the things you said was: "Dementia now has its place in the sun." That was then. "When we have looked across our priorities as a whole we have seen we are clearly making significant progress in cancer, coronary heart disease, waiting times and after the publication of the stroke strategy, stroke services"—because we have had hearings on each of those things over the years—"dementia now has its place in the sun."

  Sir David Nicholson: Yes.

  Q31  Mr Bacon: Can you define for me what dementia having its place in the sun means? You say this in the present tense in October 2007, "Dementia now has its place in the sun." What does that mean? What did it mean when you said it?

  Sir David Nicholson: What it meant then and what it means now is that, first of all, there was an enormous amount of national attention on dementia—that is the first thing—and the outcome of that national attention was the development of a major strategy for dementia across health and social care, something that had never been done before.

  Q32  Mr Bacon: Hang on, the strategy was not available at the time of our hearing.

  Sir David Nicholson: No, no, since the hearing I am saying. You were asking what having its place in the sun meant. We put a lot of emphasis, a lot of focus and a lot of resource behind development of the strategy. As you know, a strategy that is written by a small number of pointy-headed people in Richmond House seldom has connection with the service as a whole; so it was very important for developing that strategy that we got the best international evidence and we got as much engagement with the service as we could to make it real. That is what it meant then. It also meant that the Government identified £60 million and £90 million over the last two years of the CSR to give an indication of the kind of resources that would be required to invest in dementia at a time, subsequent to the strategy, which is around planning the way in which the service will develop over the next period. That is not to say that in lots of parts of the country—and you will know this as well as I—there has been significant investment and development in dementia services, and we will be able to give examples of it, but giving it that national focus was really important.

  Q33  Mr Bacon: In that case, why was appointing a national clinical director not made to happen more quickly, because we discussed this in October 2007?

  Sir David Nicholson: Yes, we did.

  Q34  Mr Bacon: I was concerned because of the example of Mike Richards and we discussed it specifically, and Professor Banerjee, who was here, as he was just now, was passionate on the subject—and I remember thinking, "Ah-ha, there is probably our national clinical director"; although apparently not because we have had Professor Burns since last Friday—but I asked you about this and whether you could get on with the appointment of a national clinical director to help drive the strategy, and indeed would it be necessary to wait until the publication of the green and white versions of this report before going ahead, and you said "no". In fact, you said: "No, and if we are not careful we will lose a whole year if we don't get something moving forward."

  Sir David Nicholson: Yes.

  Q35  Mr Bacon: You did lose a whole year; you lost the whole of 2008, and it was June 2009, was it not, before you failed to appoint a national clinical director when you realised you needed one for old people and one for dementia and could not find somebody who could do both. Why did it take that long?

  Sir David Nicholson: David will talk about that in a while. I do not think we have lost time in those circumstances. There has been a huge amount of work gone on in the service, both in developing services and taking them forward in that period. The idea that we were a kind of service sat there waiting for the appointment of a national clinical director is not the case.

  Mr Behan: I am the lead official in the Department responsible for the appointment of a national clinical director, and I take full responsibility for that. As Sir David has said, we did go out and tried to combine the roles and found that was not possible. We went out and advertised again, and we are absolutely confident in the two appointments we announced last week.

  Q36  Mr Bacon: Why did it take so long?

  Mr Behan: Because we wanted to search and secure absolutely the right candidate. We tried to combine the roles and we found it was not possible to do that; but we have not stood still while this has been happening. We published commissioning guidance in July. We published a—

  Q37  Mr Bacon: Of?

  Mr Behan: July 2009.

  Q38  Mr Bacon: What was going on then during 2008?

  Mr Behan: We were recruiting. We published the strategy. We went through consultation. We set up external reference groups. We worked with the key stakeholders. Neil Hunt of the Alzheimer's Society chaired the external reference group. We had a nation-wide consultation event to secure the views of people with dementia and their carers about what the essential elements should be of the dementia strategy, and that information generated the strategy, which we published in early 2009. It was one of the largest and most comprehensive consultation events. We wanted to make sure that we reflected the views of those people with dementia and their carers and the key stakeholders, in the way that we designed the strategy.

  Q39  Mr Bacon: You are the Director General; you have got these deputy regional directors around the country whose job it is to influence and promote and lead this, and they are working to you basically: how do they force the pace, if you like, when there is no local leadership in place yet?

  Mr Behan: They have been working hard on both raising the profile, and in March of this year our national awareness campaign begins and we will have TV, radio and online as well as newspaper adverts to raise the profile of this. But the deputy regional directors have been leading on the baseline reviews at a local level so that each local authority and PCT by March of this year will have a joint action plan that will take forward the delivery and implementation of the National Dementia Strategy but at a local level. They have been leading to secure that local ownership, working alongside SHAs and local authorities and PCTs.

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