Examination of Witnesses (Question Numbers
100-119)
DEPARTMENT OF
HEALTH, SOUTH
WEST STRATEGIC
HEALTH AUTHORITY
AND KING'S
COLLEGE LONDON
Q100 Geraldine Smith: Can I say first
of all I would like to be positive because I think there are some
great strides made in the National Health Service overall, but
this is an area that people are becoming much more concerned about.
Awareness is very important. There is not a great deal of awareness
about dementia. You say that early diagnosis would make a very
big difference to people and it would mean them spending much
less time in a care home at the end of their life. Why is that
the case? What is different about it?
Professor Banerjee: The public
actually does not understand it. We have a major problem with
respect to what people understand about dementia and there are
fixed false beliefs, firstly that dementia is a natural and normal
part of ageing, which it is just not. It is a disease that becomes
more common with age but even at the age of 80 we have only got
25% of people with dementia. The idea is there that nothing can
be done about dementia, when the fact is that there is a tremendous
amount that can be done to enable people to live well with dementia.
But in order to have that help you need to know that you have
got dementia. You need to know that you have the illness. A major
problem that we have in our system is that only a third of people
get diagnosed, and when they do that is late in their illness
generally, at a time of crisis, when it is too late to give people
help. We have a system whereby people do not ask for help because
they believe it is a normal part of ageing, where help is not
available because services are not set up to do that; and there
is an avoidance of making the diagnosis rather than facilitation
to make that diagnosis. What we also found is models that show
that this can change. It can change in particular areas. The strategy's
first priority, first theme, was to improve public and professional
attitudes and understanding of dementia, and that is a programme
of work that started with the Worried About your Memory
campaign that we set up with the Alzheimer's Society, and that
is going to go into a much larger higher gear come March time.
That will deliver a national media campaign that will help people
to understand that it is legitimate to be worried about your memory.
Q101 Geraldine Smith: Does the Report
not say though that GPs' awareness has not improved?
Professor Banerjee: I think it
is improving a little. One of the things about this is that if
you ask GPs to do something impossible, which is to make a diagnosis
for dementia in primary care and to sub-type it, which is what
you are asking them to do, they will not do it. If you ask them
to do something possible, which is if you are worried about symptoms
of dementia you refer people to a memory service to have a diagnosis
made, then they will do that.
Q102 Geraldine Smith: So you need
those memory clinics.
Professor Banerjee: You need the
memory services and you also need the education, both in terms
of the undergraduate curriculum for the primary care and other
doctors, but also continuing professional development that improves
the skill of our current medical workforce.
Q103 Geraldine Smith: The specialist
support services available once a person has been diagnosed—I
came across a young person, a constituent in their fifties that
had been diagnosed, and they were not being offered any specialist
service until their condition had deteriorated.
Professor Banerjee: There are
major problems with quality of care provided for people with dementia
across the country. What the strategy has done is given us a really
clear picture of the warts that we have in our system, and also
given us a plan to be able to deal with that. What that requires
is someone to have accurate diagnosis as early as possible, plugging
into services which exist and improving social care—things
that will work across diversity, including younger people dementia
and older people dementia. You only do that if you prioritise
dementia, and the problems that we have are symptoms of the lack
of prioritisation.
Q104 Geraldine Smith: But I know,
as a politician, that people talk about the Health Service and
they want to know that they are not going to die of heart failure
or a heart attack or cancer. The big killers are natural priorities
and people are not thinking about dementia.
Professor Banerjee: Dementia is
one of the very few illnesses that people, if you talk to them,
will rate as worse than death. Dementia is perceived as a worse
illness to have than cancer, and it is the fact that people have
not talked about it. The stigma of dementia has clouded everyone's
desire to be able to talk about it so that we can do things about
it. I think we are starting to dispel that and I think the strategy
has identified that that is a legitimate area for us to intervene
in. That is why there is this campaign to try and change that.
Q105 Geraldine Smith: Do you accept,
though, that there is still a long way to go between your strategy
and what I see on the ground? What can I go back and tell my constituents
who have relatives that might be suffering with dementia? What
positive messages; what can you say has changed in the last three
years; and what improvements; and where will we be in the next
five years?
Professor Banerjee: Is that a
question to me?
Q106 Geraldine Smith: I think all
of you.
Professor Banerjee: In five years'
time I would hope that there would be a national network of memory
services so that everybody, when they first have problems with
memory, are referred to those services, and so that people know
they have dementia as early as possible so they can get on with
planning their own lives and make choices for themselves, rather
than those choices being made for them later on at a time of crisis.
I would hope that every general hospital would see dementia as
a priority and see it as a legitimate part of what they do, because
if they do it well they will do the care of their patients better;
their quality will be improved by improving the quality for dementia.
I would hope that every social services department would have
a well-developed arsenal of services for people with dementia
with which you could meet people's needs, both in people's homes
and also in care homes when they need to. I would hope that we
would have a third sector that was providing peer group support
for people with dementia and I would hope that we would have systems
to support people on the whole of their trip through dementia
right from diagnosis to end-of-life care, delivering quality all
the way . We could do that in five years but we can only do that
with will and with a lot of concentration in delivering this.
I think the strategy, if it is delivered, will deliver that.
Mr Behan: We set out to deliver
seven priorities as part of the strategy to ensure that we could
be focused in the way that we move forward. The seven areas were:
early diagnosis, the questions you have been asking about memory
clinics; how we can improve community based services; the services
that are there to support people living in the community with
dementia; how we can continue to deliver and roll out the carers
strategy to support people who are providing direct care to people
with dementia; key challenges around general hospital care; psychiatric
liaison services which exist in hospitals to ensure that exactly
those people with fractured neck of femur are being assessed by
a clinical specialist in psychiatry; how we can improve the quality
of people's experience in care homes. We have about 240,000 people
living in care homes. About 60% to 80% of those have some degree
of dementia, so getting the quality of those services right.
Q107 Geraldine Smith: Do you still
have the problems with the liaison between health and social care
because that still feels a problem to me?
Mr Behan: We continue to insist,
as Professor Banerjee has outlined, that this is a strategy that
goes across health and social care.
Q108 Geraldine Smith: You can say
that but what I am asking is how is it actually working?
Sir Ian Carruthers: I can talk
about the South West but I know this to be the case in different
parts of the country. Dementia, if you have someone in your family
who has it, which I have, is the most difficult thing to deal
with because not only do you see the person disappear but you
also see those around them struggling to cope with something that
they cannot cope with. The thing that I would actually say from
my personal journey in this is the priorities are in here but
we need really to systematically, at scale and pace, change some
of them. The Strategy here was about two years in preparation
and I think that even the Report says that it is too early to
see front-line change on the ground, but it is front-line change
on the ground that is actually crucial. As to where we are on
health and social care, there are good examples. If you go to
Torbay, where there is an integrated arrangement, you can have
very fast decision-making after your assessment. Normally it takes
three or four weeks; there they do it in a few days. You get very
quick access. Hertfordshire, too, if you look at them as an example,
they have put in an alignment of process so there is good practice
between health and social care.
Q109 Geraldine Smith: Can I stop
you there because what I am concerned about is Lancaster and Morecambe
and the surrounding areas that I represent. I want to make sure
that they have really good care. Is one of the problems that there
are different standards across the country and even the drugs
that can slow down dementia, in different parts of the country
people appear to have easier access. That cannot be right. That
has got to change.
Sir Ian Carruthers: I cannot speak
for Morecambe and your constituency but I think that there is
an issue where we should have more common standards across the
whole social care horizon. However, I gather that will be a subject
of great debate as we head over the next few months, because people
do get different things and there are different things on offer.
I know from going through this that whilst people think there
is a lot of community support available, when you are faced with
it, it is not as great as you think, and indeed, the Report says
in here that ends up with too many people prematurely being in
residential care, so we need to develop those services in order
to implement this Strategy.
Q110 Geraldine Smith: Can I say the
most hopeful comments were the comments you made about where you
would like to see things in five years' time.
Professor Banerjee: Thank you.
Q111 Geraldine Smith: If you can
achieve half of that I think we will have gone a long way, but
I guess it is also very expensive.
Professor Banerjee: What we want
is for those changes to be in every part of the country so the
variation that exists in terms of likelihood of getting a diagnosis
and getting various sorts of treatment is evened out and we lose
that variation so that everybody gets good-quality care.
Q112 Mr Mitchell: Can I just pursue
that point about regional differences in prescribing. Sir Ian
seemed to be saying we wanted uniformity, that people should have
access all over the country to the same prescribing. Is that what
you were saying?
Sir Ian Carruthers: What I was
saying was that regardless of where we live we should have access
to the same standards.
Q113 Mr Mitchell: That is not happening,
is it, because at page 17 the Report says there are regional variations
suggesting that people in some parts of the country who might
benefit from the drugs are not receiving them. Why is that?
Sir David Nicholson: Ian is responsible
for the South West and he can tell you what the position is there.
Sir Ian Carruthers: In the South
West we have the big challenge because of the diagnosis gap. We
have a fairly elderly growing population. The diagnosis gap is
significant, as this Report says. That is where we have to go
back, and if I can connect these things, and get GPs trained to
identify people to come forward and receive treatment. The low
use of some of the drugs is actually because we have low diagnosis
because early diagnosis requires, in the main, early treatment
and intervention, so what we have to work on, and others in the
country, is really getting dementia diagnosed much earlier, and
that is very much a staff training and particularly medical training
issue, as Sube said before.
Q114 Mr Mitchell: Can you supply
us with some figures on that, in other words, the proportion of
cases that is getting prescriptions over the country? It is not
supplied in figure 7 on page 17 because that says it is meant
to prove that people in some parts of the country who might benefit
from them are not receiving them, but, in fact, what it says at
the bottom is that this is a measure of "defined daily dose
per diagnosed dementia patient". In other words, people in
Yorkshire and Humberside are getting bigger doses than people
in the West Midlands. It does not tell us how many people are
getting the doses. It just tells us the doses are bigger.
Professor Banerjee: I think this
is a metric that is designed to show a good estimate of the proportion
of people who would meet NICE criteria for the treatment of dementia
who are being treated with drugs, and showing that it varies across
the country.
Q115 Mr Mitchell: Why are they getting
bigger doses in Yorkshire?
Professor Banerjee: There is more
of the drug prescribed per person with dementia but there is very
little prescribed per person with dementia, so what that means
is that on average there are more people being initiated on these
medicines in Yorkshire and the Humber than there are in the West
Midlands. It is not about the dose of the medicines as such; it
is about the number.
Q116 Mr Mitchell: That is not what
it says it is.
Professor Banerjee: I know but
that is because it is using the dose as a way into the amount
of drug that is prescribed there.
Q117 Mr Mitchell: Can we have the
figures in a less confusing form?
Professor Banerjee: These are
National Audit Office figures.
Q118 Mr Mitchell: Of the number of
people who are getting prescriptions in each area.
Professor Banerjee: There are
data on that which are included in the Dementia UK report.
Q119 Mr Mitchell: Can we have them?[3]
Professor Banerjee: Yes, those
are perfectly available.
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