Examination of Witnesses (Question Numbers
60-79)
DEPARTMENT OF
HEALTH, SOUTH
WEST STRATEGIC
HEALTH AUTHORITY
AND KING'S
COLLEGE LONDON
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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