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

Examination of Witnesses (Question Numbers 40-59)


  Q40  Mr Bacon: What incentive does a PCT have to take this seriously, given that it is not a tier 1 or a tier 2 or even a tier 3 priority and it is not performance-managed? What incentive does a PCT have to grasp this, to grip it and push it forward?

  Mr Behan: I think there are many incentives, not least the questions you were pursuing earlier about value for money. We have published some research on Tuesday of last week on Partnerships for Older People Projects—this was University of Kent research which showed that where there are prevention schemes in place there can be a 47% reduction in overnight stays in hospitals locally. That is a powerful incentive to begin to get the quality of these services right first time. I think there are many incentives in the system. I think we need to look at the leverage that is provided by the improved commissioning strategy, the work that people have been doing to develop their local action plans to ensure that services are targeted at those people most in need. But we have also appointed an ambassador to work with the care homes sector, to drive improvements in the quality of care at a local level. The challenges are good challenges. We need to occupy a space so we do not look defensive, nor do we look complacent, but in 2009 we have seen a raft of activity designed to deliver this strategy, and that first year is largely about setting up the strategy; the second year will be about collecting the evidence for the baseline reviews, and the third and fourth years will see us pushing on to deliver this strategy on the ground.

  Q41  Mr Bacon: I must move on to ask Professor Banerjee about memory services. When you said 50,000 in a typical PCT, you meant 50,000 people who might come under the ambit of care, and there would be 900 to 1,000 actual cases in a typical year. Is that what you meant?

  Professor Banerjee: The best estimate for need in a particular area is the number of people over the age of 65 because dementia is associated with age, so by 50,000 people I mean 50,000 people over the age of 65. In those areas you will get 1,000 new cases of dementia a year, and the service will be there to diagnose all of them.

  Q42  Mr Bacon: The £60 million and £90 million over two years is conveniently £150 million, but we do not actually know how much of it ends up being spent on dementia and we will not know this until the audit, but £150 million for 150 PCTs is £1 million each for two years. Say a typical PCT with £1 million extra that they otherwise would not have had, had spent it on all the things you had hoped and wanted them to spend it on, what would it have gone on; what would the expenditure have looked like; what would it have bought?

  Professor Banerjee: Well, for that amount of money in an average PCT you could buy a memory service with ten people running it, which is what you need for it to run—

  Q43  Mr Bacon: How many consultant psychiatrists in there?

  Professor Banerjee: That would be probably with half a consultant psychiatrist and a full-time associate specialist. It would be a multi-disciplinary team with both nursing and doctor and psychology time, and social care would be involved as well as the local Alzheimer's Society. It would provide the place in each PCT for expertise in dementia, and it would be a place which was readily accessible so that people, when they do become worried about their memory, can do something about it and get the diagnosis they need to—

  Q44  Mr Bacon: These ten people would see roughly 20 people a week, making—

  Professor Banerjee: If you get the teams working efficiently—and we have exemplars showing that can be done, and we have published data showing what we have done; we have published metrics showing how much money you might save through generating services like this; and so you would have one of these providing services for an average PCT so that everybody in the PCT gets the care they need.

  Q45  Mr Burstow: Sir David, do you think it is a little misleading for announcements to be made about sums of money that are to be allocated to particular areas like dementia when, as you rightly tell us, there is no longer any ring-fencing or earmarking?

  Sir David Nicholson: I do not think it is misleading. I think it gives people an order of magnitude. It is quite common when such announcements are made to make a case for the general amount that would be expected. It is based, to be frank, on the bids we will have made through the CSR in the first place.

  Q46  Mr Burstow: So it is an order of magnitude.

  Sir David Nicholson: Yes.

  Q47  Mr Burstow: But then, when it comes to what goes on on the ground, there is absolutely no obligation or requirement upon the local organisation to spend it in that area at all?

  Sir David Nicholson: In some areas we take particular action so for example in dementia we decided that the way we would encourage people to spend it was to tell them they would be audited on the use of it afterwards.

  Q48  Mr Burstow: So there will be an audit?

  Sir David Nicholson: Yes.

  Q49  Mr Burstow: Would you also agree that it would be good if PCTs responded to enquiries by Members of Parliament about the use of such money and provided that in a timely fashion?

  Sir David Nicholson: Yes, that would be sensible.

  Q50  Mr Burstow: Going on from there, one of the areas that is in parallel to this is the whole area of carer strategy where similar sums of money have been allocated. To my knowledge, freedom of information requests by local charities have been unable to prise that information out of many PCTs. Do you think that is acceptable?

  Sir David Nicholson: I am obviously not aware of those freedom of information requests. It would seem perfectly sensible to provide it.

  Q51  Mr Burstow: Would you think it would be wrong for a primary care trust to take over three months to reply to a Member of Parliament's enquiries about how much has been spent on carers' grants?

  Sir David Nicholson: I do not know about the complexities of local circumstances so I could not judge that.

  Q52  Mr Burstow: Surely, at the end of the day, if the money is not earmarked, then there has to be local accountability?

  Sir David Nicholson: Yes.

  Q53  Mr Burstow: And that must be PCTs having to spell out how they are spending the money.

  Sir David Nicholson: That is why we have said they will be audited and they will have to publish.

  Q54  Mr Burstow: Can I ask you about the report that was published in November as a follow-through to the strategy around anti-psychotic prescribing. In that report there are a number of recommendations, but one of the things we understand has happened so far is that a national champion has been appointed to deal with the independent sector. What other things have been done; particularly, what communication has been had with the care home sector to make them aware now of the evidence and the need for action to reduce prescribing?

  Professor Banerjee: I can certainly tell you what I did with respect to developing the report and its content. I was very pleased that the findings were accepted, and spent a long time consulting widely.

  Q55  Mr Burstow: Will you forgive me, Professor Banerjee? My question was very specific: what is being done now, because the report is really good; it does spell out what needs to be done: but I want to know what is being done to communicate the recommendations of that report to the people who on the ground have to implement it.

  Professor Banerjee: That is not something that I have been engaged in dealing with.

  Q56  Mr Burstow: Perhaps it is Mr Behan's responsibility and he can tell us the answer to that question.

  Mr Behan: Since Professor Banerjee published the report, the Government considered and accepted the recommendations and an action plan is being developed and that is being communicated. Martin Green, who is the Chief Executive of the largest trade association for care homes, has agreed to act as an ambassador for the care home sector. He is a well-known figure within the care home sector and he is very—

  Q57  Mr Burstow: That is very helpful in terms of what has been done so far. I have a follow-on that I want to ask Professor Banerjee about. In the report you said it should be possible to reduce prescribing of these anti-psychotic drugs by two-thirds.

  Professor Banerjee: Yes.

  Q58  Mr Burstow: Which the report does accept for some will lead to premature death. How long do you think it should take before we can see a two-thirds reduction?

  Professor Banerjee: In my report I set out clearly I believe that it will be possible to reduce current prescribing to a third of current prescribing within a two-year period. That requires a considerable amount of energy and focus, and it requires local PCTs across the country to acknowledge that this must be a clinical governance priority.

  Q59  Mr Burstow: Again, that is a question therefore for Mr Behan. Do PCTs acknowledge that, and what are you doing to make sure that they do acknowledge that priority?

  Mr Behan: What they are doing is part of the action plan, and the recommendations were really about the audit of the workforce and about the specialist input that is required to address the recommendations from Professor Banerjee's report, and we are putting in place that action plan.

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