Examination of Witnesses (Question Numbers
20-39)
DEPARTMENT OF
HEALTH, SOUTH
WEST STRATEGIC
HEALTH AUTHORITY
AND KING'S
COLLEGE LONDON
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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