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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