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

Examination of Witnesses (Question Numbers 60-79)


  Q60  Mr Burstow: Will a two-thirds reduction be achieved in two years?

  Mr Behan: The report is very measured and balanced, and you know yourself—you have done a lot of personal work in this area—we have tried to ensure that we have listened to what Professor Banerjee said about this medication being helpful to some people and equally it needs to be addressed.

  Q61  Mr Burstow: So will it be done in two years?

  Mr Behan: We are confident that if we have established the audit and established the baseline, we can then begin to see year-on-year improvements in the way that these—

  Q62  Mr Burstow: Will that be done in two years?

  Mr Behan: Yes.

  Q63  Mr Burstow: Mr Behan, you said when we had this hearing a couple of years ago that 70% of the social care workforce had no qualifications and many of them are without training. What would you say the current estimate is of the numbers without qualification?

  Mr Behan: Well, we know that the numbers with NVQ level 2 have improved year on year, so it is slightly better than it was last time, but marginally so and not significantly so—

  Q64  Mr Burstow: Would you let us have a note,[1] and maybe have a better figure once you have had a chance to check were we have got to? What are the levers you are using to drive that forward more quickly, given, as you have just said, that it has not progressed that much since you gave that estimate of 70%?

  Mr Behan: Last year the Department published a Workforce Strategy, which was designed to demonstrate exactly how we intend to take forward the development of the social care workforce over the next period.

  Q65  Mr Burstow: In the Report, on page 29, paragraph 2.11, that refers to the difficulties around social care registration and how that is going to be delayed for several years. Can you say what has caused that delay?

  Mr Behan: We are looking at the approach that needs to be taken. The policy in relation to professional registration of the workforce has been reviewed following Shipman and Allitt. The nature of that professional registration we need to apply. There is a question about whether you take a post-graduate approach as there has been with GPs to largely an undergraduate—

  Q66  Mr Burstow: The thing I am most interested in, with respect, are those who work in people's homes, domiciliary care workers, who are unlikely to be graduates at this stage, although that may be a long-term and excellent aspiration. The question really is when are they going to be registered with the General Social Care Council.

  Mr Behan: The Government's policy is it will continue to consider that issue. We have issued a statement on that saying we are reviewing our policy and we will review a range of different options about how this can best be secured.

  Q67  Mr Burstow: You are quite right that there have been a lot of statements issued. There was one in April 2005 which promised that a decision would be made about this that year, and there was no decision. There was another one in July 2005, and then in February 2008 we were told it would all go live that year; and then we were told it is going to be April 2010. Now I understand that it is not going to happen for an undefined period of time. When will domiciliary care workers be registered with the General Social Care Council, after six years?

  Mr Behan: It still remains the Government's objective to secure the safety of people using care services by registering that workforce. The key issue is how best to secure the registration of that workforce. Arguably we need to think through in today's climate how best we can secure that, and that is what we will do.

  Q68  Mr Burstow: It has taken you six years to think it through. How many more years do you think it will take before you come up with a decision?

  Mr Behan: I would hope that it can be resolved as quickly as possible.

  Q69  Mr Burstow: Would you care to put a timescale on that?

  Mr Behan: As quickly as possible.

  Q70  Mr Burstow: As quickly as possible. Will that be within the calendar year?

  Mr Behan: As quickly as possible.

  Q71  Mr Burstow: I wanted to ask Sir David about research. When you came to the Committee in 2007 you told us, and we have had exchanges about it already today, that dementia was a key priority for the Government. Why therefore did government investment in research in that area fall by 7% in the year after you came to the Committee?

  Sir David Nicholson: One of the things about the research programme is that it is organised years in advance so it is quite difficult in those circumstances to turn something on and turn something off.

  Q72  Mr Burstow: When do you think the tap will be turned on, then?

  Sir David Nicholson: We had a summit of all the major research organisations and people in July. We are expecting a whole set of plans to come forward from that for research for next year, so we would expect that to increase in 2011/12/13.

  Q73  Angela Browning: I apologise for being late, Chairman, but I was attending a funeral, as you know. I should declare my interest to the Committee that I am Vice President of the Alzheimer's Society. Gentlemen, from what I have heard, having come in late, is clearly the core of what we are talking about this afternoon is that you have created a strategy which has yet to be implemented, and you have missed a golden opportunity for that strategy to be included in the national operating framework first tier. I hear you now explaining to us the way you intend to work towards implementation. I would like to hear today "passion, pace and drive, in transforming dementia care", because that is what it says in the NAO Report is needed. At the moment, from what I have heard so far, we just seem to be going through the process. It is all about process. Dementia is about people but this Committee of course is also about money, so can I ask you about money? I am sure you have read the Alzheimer Society's report called Counting the Cost. When I look at that, and I see about people with dementia who are admitted to hospital not because they have dementia, but dementia then becomes a part of their care—we are talking about large numbers of people here—fracture of femur: very common in elderly people; total prosthetic replacement of hip joints; urinary tract infection; and TIAs (transient ischaemic attacks). According to Alzheimer's, if you could reduce the stay in hospital for everybody who goes in and is admitted under those titles but who also has dementia, by one week and one week only, because we know that people with dementia stay in hospital a lot longer than everybody else in those conditions, you would save £86 million. What is to stop you putting that into practice now?

  Sir David Nicholson: Ian Carruthers who is working on this directly in the South West will be able to give you an indication of what they are doing there. You are absolutely right about that, and indeed it was identified as part of the Government's document NHS 2010-2015, that dementia is one of the five long-term conditions that has the real benefit both to improve quality for our patients but also to save significant amounts of resource, which currently is wrapped up in the acute sector. We are absolutely focused on that as one of the potential benefits for the service going forward.

  Q74  Angela Browning: Forgive me, Sir David, we know it is going to be a benefit, but when you say "we are focusing on", what does that mean? What are you doing? Tell us in layman's terms: what are you doing to reduce by one week the stay of everybody with dementia who goes in with a fractured hip or with a minor stroke? What are you doing?

  Sir Ian Carruthers: The National Audit Office Report also includes that and it has a different figure when including falls—was my reading of it—so the figure when combined was something like 130 of the 385 you identified. What we are doing at the present time as part of the £20 billion savings—each region is looking at how it can reduce the length of stay in a number of areas, and they are putting plans together in order that they can be activated. They do need of course some re-design of the system because it is predicated on reducing the stay and obviously, people have to have support in the community and so on. In our region at the present time, because, as the Report says, we have one of the biggest challenges and diagnosis gaps, we have embarked on a process where, with the Alzheimer's Society and colleagues in social care, the DRD, with someone we took out of the job, with clinical leadership, and an assessment of every PCT where we have gone and engaged in local settings, identifying with carers, users and professionals what it is that needs to be done. We are at the point now where we are putting an action plan together, of which that will form part. We will start to look at how the services get into place in order to address that. Clearly, before you take the beds out you have to have adequate support to manage people away from home. In fact, there is a conference in the South West tomorrow on this where district general hospitals are coming together to look at an audit we have done of the Royal United Hospital, Bath, which is saying how we can help people be better cared for and managed quickly through the process, based on what happens in the district general hospitals. We are looking to do that. In fact, it will be vital for the future. It is vital and a key component in funding the impact assessment, and we need to go through, creating the infrastructure as well as taking the money out.

  Q75  Angela Browning: We can all see why this is of benefit to patients. It saves money and it creates a substantial pot of money that we understand although not ring-fenced—you decided not to ring-fence it—theoretically could be used to implement your strategy when it comes on line.

  Sir Ian Carruthers: Yes.

  Q76  Angela Browning: But if that is the case, why is it that just that element of it was not rolled out as part of the operating framework?

  Sir Ian Carruthers: If I could continue, I think the Committee rightly has put a lot of pressure on about the operating framework and priority, and if you look at the analysis—and we are not the only region because I have seen the briefings of all regions—every region has done a baseline review—we just happened to start first. The reason we did it is because when you look at a local determinant all our PCTs recognise in the South West this is going to be a major challenge, probably the biggest challenge we face. Therefore, we collectively decided to do that work. The point I wanted to make is that just because it is not a priority in the operating framework, it does not mean nothing has been done. I can cite lots of practical differences that have been made in the last year to people with dementia in the South West. So I can understand why you are focusing on this, but the fact is that every region is taking this forward, even though it is in the local determined category.

  Q77  Angela Browning: Chairman, thank you. Obviously, I am familiar with the South West; I am a South West MP, and as far as I can gather the South West has been something of an exemplar in leading the way here, but I am concerned nationally. We do have postcode lotteries right across healthcare. Clearly, it is good for people in the South West, where we have a large retired population, but not so good for people in other areas if this is not rolled out because the concern about the failure to use the national operating framework as an opportunity is because of course there is really no local priority on the PCTs now, because they know that if it is not included they are not going to be judged on their performance in this area.

  Sir David Nicholson: But they are, in a sense—

  Q78  Angela Browning: Against what criteria?

  Sir David Nicholson: They will be judged against a whole set of criteria as part of the work that Ian has described and we have described. Every PCT has to do a baseline assessment; they do not have a choice over whether they do it or not; they have to set out where they think they are in terms of dementia services. We have brought all of those in and David and his team and Ian have been going through them, identifying their strengths and weaknesses. Out of that discussion then comes an action plan. By the end of March every PCT has to have clear goals in identifying how they are going to implement the arrangements for the dementia strategy in their area, so that is a very powerful mechanism for making people focus on it and take it forward. It seems to me that is a really good way of doing it. I accept that it is not in the operating framework but I think that set of plans we have is much more likely to get us success in this area, because what we have not been able to do in dementia, which is one of the issues around the others, is that there is not one measure or two or three measures that are identified by everybody as being the particular measures that you should use in these circumstances. We have been reluctant over the last two or three years to identify more national targets as part of the way we do it.

  Sir Ian Carruthers: If I could add to that, the other thing is that the growth in continuing care and changes in eligibility criteria in our region is in excess of £50 million this year, and a lot of that will be to support people with dementia. Therefore, what is in the local interest is that we get services that are good for people. You have highlighted in the other areas of good practice in the Report intermediate care and some of the Leeds dementia care stuff—all of which highlight how it is possible to improve the system, spend less money, care for people better, avoid unnecessary admission, and that is not only in the public interest of the individual, but it is also in the economic interest and the well-being of the system. The incentive is to get better. I think that because times are tough, no-one can ignore that type of issue.

  Q79  Angela Browning: I am very concerned about how this translates locally, right down to hospital and even ward level. How many dementia champions are now in post in hospitals?

  Mr Behan: Not enough.

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