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


Examination of Witnesses (Question Numbers 80-99)

DEPARTMENT OF HEALTH, SOUTH WEST STRATEGIC HEALTH AUTHORITY AND KING'S COLLEGE LONDON

  Q80  Angela Browning: No, no, how many? How many?

  Mr Behan: I could not give you an exact figure on that, I am sorry.

  Q81  Angela Browning: Since you last appeared before this Committee, have you any idea how many have been put in place?

  Mr Behan: The issue is not dementia champions; it is whether there has been a lead appointed within the hospital, and that figure is changing all the time as awareness grows about the strategy, as we are doing the baseline reviews, as we are taking forward local action plans. The key role of the national clinical director is to drive this further. The Report itself that the National Audit Office published has in one of the tables a recognition by hospital-based consultants of this. It is around the 90% figure for people who are aware of the strategy. We want to drive this strategy hard, and the awareness campaign we launch in March of this year is designed to push on even further to secure that.

  Q82  Angela Browning: I am sorry to be rude, but I asked a specific question for a specific answer, and I have only got two minutes left so I need to push on, but I wonder if you would write to the Chairman.[2] I know that the All-Party Group for Dementia has a particular interest in this, and is seeking freedom of information requests on this very issue; so I think this Committee would like to know how many, and where they are. If you could possibly supply that to the Chairman and the Committee it would be very interesting to see just where they are and who has and who has not got one. At the end of the day, if there is no local passion, pace and drive to make some change—and that is what we are talking about—at hospital level, this is not going to happen. I would like to just ask you this: if you are aged over 65 and you are admitted to hospital, with whatever—fracture of neck of femur or all sorts of things, even onto a ward that is not a trauma ward—my understanding is that all too often if you have other issues like dementia you do not see somebody who specialises in dementia, you see the geriatrician. That is not a specialist service. It has been geriatricians, who are very good people, but who are more generalists. Why is it we have this discrimination against people over 65—and dementia can of course affect people very much younger than that—but for the over-65 population, which is where we are looking, what difference is going to be made in order to assess that patient and get them through and out of hospital, other than the geriatrician if you have not got the dementia specialist in post?

  Professor Banerjee: You are absolutely right. There is a need for specialist dementia expertise in general hospitals, and general hospitals need to prioritise it for themselves because people with dementia are spread right through the whole hospital; but there is also the need for specialist old people's mental health services who are particularly skilled in the diagnosis and management of dementia. The strategy is very clear; that part of the way for delivering that in general hospitals is to generate liaison services, specialist multi-disciplinary services for the diagnosis and management of people with dementia in every general hospital. That is part of the delivery of the strategy, to identify that, along with the ownership of dementia, as part of what acute hospitals do. You are right: if those things are delivered, then you can create an environment that enables people with dementia to get out of hospital quickly, and that has quality improvements and cost improvements for people. The other trick of course is the other elements of the strategy are all there to prevent people unnecessarily entering hospital, and you want to prevent older people from getting into what can be a toxic environment; and once they are there to get them out as quickly as possible. If the strategy as a whole is taken, then it provides the framework to be able to deliver that. It is by delivering the strategy that you achieve the benefits that you have set out.

  Q83  Angela Browning: Chairman, I shall be 65 next year, but I shall not be here. I hope no-one ever refers me to a geriatrician. I shall not be here because I am retiring, but could I put on the record and have it written into the minutes of this Committee that whoever does sit round this table, that we ask the NAO to re-visit this pretty promptly so that this Committee can again look at this issue and report progress from these gentlemen—I would say 18 months maximum.

  Mr Mitchell: Hear, hear.

  Q84  Chairman: Is the National Audit Office happy to do that?

  Mr Morse: Yes.

  Q85  Chairman: Thank you, Ms Browning, for the passion, grip and drive with which you have asked your questions. I wish this was reflected in the Department. If you look at paragraph 2.14, this is the sort of bureaucratic speak of these sorts of reports. It is frankly rather stodgy and turgid. "The Department has commissioned Skills for Care and Skills for Health to map the training needs of the workforce and the training currently available across all sectors, identifying the gaps. The mapping exercise will conclude in March 2010 and make recommendations to inform the Department's workforce action plan." It is all very worthy, but where is the passion, the grip, the drive, and why have you not gripped your workforce up to now, Sir David?

  Mr Behan: I think the NAO Report said that this strategy was well led at the national level and that the challenge was to drive it at the local level. I think there is passion within the Department about how to take this forward and begin to drive improvements in this. Paul Burstow's question to me was about the social care workforce. His point was whether it has moved forward from where it was the last time we were in front of the Committee. My answer was it has moved marginally through that. What we are looking for in this audit is to be absolutely clear what skills are required to respond to the increasing numbers of people with dementia and Alzheimer's and ensure that the workforce is there. Skills for Care and Skills for Health are the two sets of workforce councils that are responsible for driving the workforce strategy. They comprise mainly of employers who will take ownership of this. The strategy here—I am sorry if it reads as being dull and turgid—is an essential prerequisite to ensure that we can drive improvements and ensure that our improvement strategies are clear in terms of what we are attempting to take forward, and we can be clear that we are making progress. At the minute, as Paul Burstow's question identified, we have got a very simple measure in the social care workforce of how well qualified they are. It is largely whether they have an NVQ2 qualification or NVQ4 qualification. One of the key issues around NVQs, as I am sure some members of the Committee are aware, is whether it gives sufficient attention to the issues around dementia care and people that do not have cognition. One of the challenges as we move forward is to ensure that the curriculum adequately reflects that in much the same way as the Report has recommended we take action for GPs, et cetera. I am sorry it reads as dull and turgid, but I would argue that it is a very essential part of taking it forward.

  Chairman: You are doing your best.

  Q86  Dr Pugh: I would like to ask a quite friendly question. In my notes it says that £15.9 billion is estimated as the total cost of dementia services in 2009. I am highly suspicious of big numbers and certainly big estimates and it does strike me that in treating people with dementia you are also going to treat many people who are frail, who have complex medical needs, and who may well have other social needs that are not specifically to do with dementia. How capable are you of disaggregating a figure like that into the real costs of dementia as opposed to the costs of dealing with elderly people in troubled circumstances?

  Sir David Nicholson: Which particular figure is this?

  Q87  Dr Pugh: It says here that the estimated total cost of dementia care in 2009 is £15.9 billion. Do you agree with that?

  Sir David Nicholson: I think it is as good an estimate as we have—it is as good as we can have. It is a highly complex area. You are absolutely right. People with dementia may have a whole series of other chronic conditions attached to them as well. It is quite difficult to disaggregate that particular bit of expenditure, as you say, but I think it is as good an estimate as we have seen.

  Q88  Dr Pugh: What is the sum spent on specific medical interventions to deal with dementia as an illness?

  Professor Banerjee: I can help disaggregate that because I was involved in generating the figures for the original report, the Dementia UK report. What you find is that of that £15.9 billion, at figure 5, that includes three main elements of cost. The first and the largest is that of institutional care for people with dementia, so the cost of care homes. For those individuals that is calculated on the basis of the number of people who have got dementia who are in care. Increasingly, if you do not have dementia you do not go into a care home, so actually it is the cognitive impairment from dementia and the disability that comes from that that determine if you are going into a care home. That is a fairly stable figure and that is the largest element of it and that is costed well. The NHS costs are small and those are the NHS costs that are more or less directly attributable to dementia care; so those are not about carrying out hip replacements on people with dementia. They are not even the extra time spent in hospital for people with dementia because we are not able to calculate that. They are the services directly provided for people with dementia. Those are relatively small and those are assorted throughout the course of the illness. We do not have community—

  Q89  Chairman: I am going to stop you there.

  Professor Banerjee: One more thing.

  Chairman: You have got to try and give shorter answers; it is not fair on them.

  Q90  Dr Pugh: If you would like to give the last sentence.

  Professor Banerjee: The final part of it is the opportunity costs that fall to families because the immense amount done by families does need to be costed, and this was costed at minimum wage.

  Q91  Dr Pugh: Okay, a useful response. You are saying NHS medical costs are relatively small. In the Report it talks about extra money being provided through the Department of Health, but paragraph 3.8 concludes by saying: "There is no extra funding for councils, no additional financial provision has been made for dementia in local government expenditure plans for 2009-2010 and 2010-2011, and there are no ring-fenced grants from the Department for dementia services." Given what you have just said, if the situation with regard to the EMI needs—and obviously these vary from council to council because the demography are different, are not reflected adequately in councils' spending and what councils have available to them, is it not a pretty hopeless task to deal with this problem in isolation in the Health Service?

  Professor Banerjee: There is absolutely nothing hopeless about enabling people to understand whether they have dementia or not. What health services can particularly bring to the piece is to give people that vital piece of information which is that they have dementia—

  Q92  Dr Pugh: Sorry to stop you—in terms of the state tackling this issue, not to look at local government funding for EMI provision is a very serious mistake, from what you said about—

  Professor Banerjee: The whole of our strategy was based upon it being a joint health and social care strategy. You cannot look at dementia sensibly without looking at the social care elements as well as the healthcare elements because these are indivisible parts of people's course of dementia in the seven or 12 years they may live with dementia. Our strategy is very specific in covering in detail the social care as well the healthcare elements.

  Q93  Dr Pugh: The NAO thesis throughout their Report is that early diagnosis substantially reduces the cost of actual treatment of dementia. There is a map on page 16, which shows what is called a diagnosis gap challenge, which I suppose means in areas like the South West you are diagnosed more slowly than you would be if you were, for example, in London. Am I reading that map correctly? Right. It is obvious then that as a result of the early diagnosis in London and the later diagnosis in the South West there is differential in costs for treating dementia in those areas. In other words, is the NAO thesis correct?

  Professor Banerjee: There is another element to it as well, apart from just the number diagnosed; it is also the number of people with dementia in each area. The number of people with dementia vary per population because of the different age structures across England. So there are different costs across England that are mostly attributable to the age structure of the population.

  Q94  Dr Pugh: So clinicians are generally convinced despite the paucity of evidence, as it were, that the NAO are right in thinking that early diagnosis means lesser cost in the long run?

  Professor Banerjee: Absolutely. There is no doubt if you accept that care homes cost as much as they do and you accept that early intervention can be critical, by reducing by 28%, that is a median of 558 days, the time that people spend in institutional care, then a very simple, small, cheap up-front investment in early intervention can have a tremendous powerful, positive effect in terms of cost; but as importantly it also results in increased quality of life for those people. We have good evidence not just from the National Audit Office but from multiple work including work we have done at the Institute of Psychiatry in King's College, London, modelling on a memory service we set up, so, yes, there is no doubt about that. Added to that are all the things that can happen in the medium term with respect to improving things in general hospitals.

  Q95  Dr Pugh: So clinicians are persuaded of the overall strategy, albeit it is drawn up by pointy-headed people in Richmond House?

  Professor Banerjee: I think the whole point is that it was not drawn up by pointy-headed people in Richmond House. It was drawn up by joint health and social care professionals consulting tremendously widely with the field, and it has validity because of that.

  Q96  Dr Pugh: Can I refer you to page 27 and the graph at the bottom where frontline staff are asked not about strategy but how likely the strategy is to be implemented successfully. There is a huge gap there between what strategic health authority leads think is going to happen and what GPs think is going to happen. What worries me is what consultant old age psychiatrists think is going to happen.

  Sir David Nicholson: I do not think we should be surprised by that.

  Q97  Dr Pugh: We are not.

  Sir David Nicholson: We do have quite a lot of experience in the Department about leading and managing change, and this is not surprising at this particular stage. In fact, it reinforces the reason why it is so important to embed this strategy amongst our people, because unless people get it and understand it, and want it to happen, it simply will not happen. If only it was just as easy as having a rational case at the centre and sending it out to everybody and they would implement it, we would all be in a better place, but it is not like that. If you look down here you can see those people on the front-line who have been in dementia care for a long time who have heard all this stuff around change, and they are more difficult to shift in terms of whether they believe it will happen than those who are responsible for the implementation of it.

  Q98  Dr Pugh: I think it was 15% of consultants who think they have seen the new money spent in their area, and that is a very low figure, is it not? That is elsewhere in the Report. It seems to indicate they are not just sceptical, but they have some evidence for their scepticism.

  Sir David Nicholson: As I say, this was a regular pattern. If you looked at stroke; if you looked at the 18 weeks; if you looked at our attack on MRSA, you will see at the beginning of the process people in this kind of place. Part of the management of change is to persuade people and to engage them in the process to make it happen and given them the power to make it happen.

  Q99  Dr Pugh: Can I ask you about memory services and memory clinics. I first thought that these were organisations that improved your memory and almost thought of enrolling myself; but I understand that they are refining a diagnosis that may originally have been made by a GP. It is a resource commitment. What study has been made of the value for money they provide?

  Professor Banerjee: Lots, and that is precisely the data that was given to the National Audit Office, which they evaluated, and it is the modelling of the value for money of those services that informs the National Dementia Strategy. In terms of the quality of data, there are papers published which very clearly show the long-term savings. There are papers published that show the short-term improvements of quality of life, and, yes, they are valuable, no doubt.

  Chairman: You see, it is so depressing to read here, these reports are very understated, they do not overstate things, but in 2.7 it tells us: "Few front-line staff could identify leaders who were championing dementia, and few could give examples where the profile and priority of dementia at local level had increased. Only 21% of consultant psychiatrists said a senior clinician had taken the lead for improving dementia." This is all in the Report you signed up to; it is not some politician speaking. It is very depressing when we thought we had made so much progress two and a half years ago that we are still struggling with this.



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