Examination of Witnesses (Question Numbers
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
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 Projectsthis
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
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 efficientlyand 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
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
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
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
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.