Examination of Witnesses (Question Numbers
120-139)
DEPARTMENT OF
HEALTH, SOUTH
WEST STRATEGIC
HEALTH AUTHORITY
AND KING'S
COLLEGE LONDON
Q120 Mr Mitchell: You were also talking
about early diagnosis saving money. I do not see why that is because
earlier diagnosis means earlier treatment, the treatment is expensive;
I would have thought therefore earlier diagnosis leads to more
expenditure.
Professor Banerjee: That is just
not true.
Q121 Mr Mitchell: Good!
Professor Banerjee: Again, it
is about a stereotype of dementia. If you imagine people with
dementia to be people who are entirely dependent and requiring
high levels of care, then that is where the cost comes, but the
reality is someone with early dementia is no different to yourself
in that they would not be needing—
Q122 Mr Mitchell: —You should
not say things like that to a politician!
Professor Banerjee: I am sorry,
I should not have said that, but any person might have early dementia
and that person will need no more care the day after they are
diagnosed as having dementia than the day before. The cost of
diagnosis is small because that is essentially a clinical assessment,
perhaps a scan. The cost of breaking the diagnosis is small. That
is the individuals, talking to the person with dementia and the
carer, and the cost of care at that point is small as well.
Q123 Mr Mitchell: If early diagnosis
does not lead to treatment, what is the point of early diagnosis?
Professor Banerjee: It leads to
timely treatment when you need it. You will not need your home
care person probably for three or four years at least, and maybe
not at all if you have supported your carer, but what it does
do is enable you to tell the carer what is going on so they can
look out for signs early so if they start to get depressed for
example, they can get treatment for that depression rather than
getting so depressed they need to come into hospital, or if they
start to have behavioural problems, as does happen in dementia,
then you can actually look for non-pharmacological methods that
would be much less harmful for an individual. Basically you prevent
harm by early diagnosis and therefore prevent cost.
Q124 Mr Mitchell: I deduce from that
that I shall be able to manage without a carer until at least
6 May when the election comes along, so I am very cheered by what
you are saying. However, I am a bit bamboozled by what has been
said because all the emphasis in the Report and in our questions
has been that you are dragging your feet and that you are not
taking effective action to implement the same kind of strategy
that has been so successful in breast cancer and stroke. Cynically,
one would assume that because the costs of this are going to be
big, and figure 3 shows the increasing incidence of dementia,
which means that you are embarking on a big expenditure, that
you have been dragging your feet because at the moment you are
trying to cut spending in the Health Service and here you are
embarking on a big extra spend.
Sir David Nicholson: I do not
believe that we are dragging our feet, first of all. This is probably
the most complex and biggest change programme that we have ever
done. This is far more complicated than delivering waiting time
targets and far more complicated than delivering reductions in
health care-associated infection because of the kinds of things
we have been talking about: public awareness; public attitudes
to dementia; the attitudes of the professions to dementia; the
way in which it cuts across primary, secondary and social care;
the point that only a relative small amount of expenditure is
in health care that we can lever; and this issue about planned
and organised care and support for people with dementia is less
expensive than chaotic care later on when people are admitted
into acute hospitals and their carers and their families break
down because of it. That is a massive set of changes to make and
I absolutely assure you that we are not dragging our feet. What
we are trying to do is to make sure that we have plans in place
and people are in the right place to make it happen. There is
nothing worse than if we just implemented a series of initiatives
around the country, which may sound exciting and good but do not
add up to a proper service for patients because it certainly will
not get the benefits that we need and that they need.
Q125 Mr Mitchell: Okay, I accept
the good intentions but it is going to take more money at a time
when the Health Service is going to be fairly strapped for resources.
The local health service told me they are considering the prospect
of cuts and what they will need to cut if they have got to reach
a certain level of cuts.
Sir David Nicholson: The first
thing is just to clarify this issue about cuts. The NHS has been
identified over the next two years as getting what is described
as "flat real", which is the same as we got the year
before plus a little bit for inflation, so the total amount of
money going into the NHS is not being cut.
Q126 Mr Mitchell: Why are they all
going round then thinking about 5% off?
Sir David Nicholson: But of course
what happens is the NHS and our patients do not stand still. There
are demographic changes going on in society. Basic demand for
health care is going up in society. Patient expectations are going
up in society. Pay is going up in the NHS. All of those things
need to be paid for so we need to generate the savings to deliver
them, but the important thing about dementia, and that is why
David at the beginning talked about incentives which are so critical,
is if we do nothing we will spend more. If we do nothing what
will happen is all our acute hospitals will be full of people
with dementia who are not being provided with the support and
help and care either up-stream or to their carers and families,
so to do nothing is even worse in value for money terms for the
NHS.
Q127 Mr Mitchell: I hear that point
strongly and I applaud you that we have got some good, strong
answers today. Let me conclude with a question about efficiency
savings. A lot of this is going to be paid for by efficiency savings.
Efficiency savings are like a mirage in the desert. You crawl
towards them and then when you get there you find it is not there;
it is a mirage. A lot of this is posited, as 1.13 says, on bigger
efficiency savings than you are making already and, as 1.15 says,
on efficiency savings which have been very difficult to produce
in the past because you have not been able to get the money out
of other services.
Sir David Nicholson: I was accused
of being long-winded about it earlier so I will not be long-winded
again. The challenge facing us is significant and we have never
done it on this scale before.
Q128 Mr Mitchell: But can you do
it? Can you make efficiency savings?
Sir David Nicholson: There is
small-scale evidence around that shows it works. I have been to
places where they have shown by, for example, better care, better
support for members of staff on orthopaedic wards to understand
dementia much better, who can look after patients—because
a lot of patients on orthopaedic wards have various kinds of dementia—better
training and better organisation you can reduce the number of
beds that you need in orthopaedics because you can get patients
out quicker; better both for the patient and for the service.
We have small-scale examples all around the country where that
is happening. We have never done is nationally at pace and at
scale and that is where the planning is so important and that
is why some people might describe it as dragging our feet. I would
say it is putting plans and rigour in place to make sure you have
got the best chance of delivery.
Mr Mitchell: Thank you.
Q129 Mr Curry: Sir David, you have
emphasised how dependent the Strategy is on an effective interface
between the Health Service and social services.
Sir David Nicholson: Yes.
Q130 Mr Curry: You have said that
the Health Service is going to get "flat real" financially.
Local government is not, is it? If you look hard at what the funding
projections for local government are, they are facing a very serious
problem indeed in real-term cuts. How are they going to deliver
their part of the Strategy in light of that budgetary pressure
they are going to face in an area which is already very difficult?
Sir David Nicholson: I will ask
David to say a bit about that but, in a sense, all of the things
that you have said are correct. Undoubtedly, the whole of the
public sector is going to come under pressure over the next period.
That is why it is so important to us that it is a joint strategy.
In some parts of the country the NHS will spend more and in other
parts local government will spend more, depending on the local
circumstances. The incentive for the NHS—I cannot reinforce
this enough—is if local government do nothing and if the
NHS does nothing, we end up with all the costs in secondary care,
which is the most expensive bit of the system, so the incentive
to do something is great. We are trying to create an environment
where health and social care can work completely together on all
this.
Q131 Mr Curry: The incentives can
be there and you can try and create the environment, but it does
not alter the fact that there is a budget in local government
and all the fine words are not going to add anything to that budget
at all. They have priorities and they are going to be challenged.
Education is going to be another priority. We all know that social
services is a priority. There are going to be pressures children's
services, after the sequence of things that I do not need to explain,
and with elderly people generally because of the ageing process.
How can you be confident that the other half of your pantomime
horse, as it were, is going to be able to keep up with you? Are
you going to find the whole thing is going to be let down not
because anybody is being inefficient but because we just have
not got the cash?
Mr Behan: I think the imperative
for health and social care to come together at a time of exactly
the financial environment you have mapped out is great, because
what we know is that unless they do come together and do this
jointly, the danger is that costs will be passed backwards and
forwards between the two systems. That is why in the base-line
review we have asked people to do this review jointly and that
will lead to a joint action plan. We issued earlier in the year
joint guidance on commissioning, renewed guidance on intermediate
care. 2009 has been a very busy year in the work that we have
done on dementia, to do exactly what you are suggesting; ensuring
that services are joined at the hip. There is no point in having
strong primary care services if care in care homes is poor and
weak. The only thing that happens is people rapidly go in and
out of hospital on a revolving door.
Q132 Mr Curry: In my own county of
North Yorkshire we know that care homes are groaning because the
increase they have been allowed for local authority-funded people
has been extremely low. Given that there is a direct relationship
between the age of the population and the propensity to develop
dementia, are you satisfied that the local government funding
formulae therefore reflects sufficient weight on the demography
of the population in order to help them cope with this sort of
issue?
Mr Behan: The funding formulae
are the formulae.
Q133 Mr Curry: I know. I ran it for
several years!
Mr Behan: I know you are an expert
about this in your own right so I am not going to do battle around
funding formulae there. The key issue in relation to your own
experience in North Yorkshire is they have made fantastic strides
using tele-care and tele-medicine to reduce the numbers of people
that are going into care homes. The thing about this is to see
this across the whole system and not just look at elements of
the system. Again, I come back to repeat why it is important from
the Department's point of view that we continue to lead this strategy
and see it as being a joint strategy across health and social
care.
Q134 Mr Curry: Can we look at some
actuarial assumptions. I see that on page 15 we have the cost
of dementia predicted to double by 2026. We are living longer
so the more we live then the more we get dementia and the more
it will cost, but the earlier we can diagnose it then we might
be able to reduce those costs, so we have got those things working
in contrary directions. Most calculations as to what is likely
to happen in the future tend to be under-estimations, do they
not, on almost any subject, whether it is the use of the M25 or
whatever? If the worst performed at the level of the best and
if the level of formal diagnosis improved but you then stack that
against people living longer again, is the trend remorselessly
upwards or is it flat real?
Mr Behan: I think the important
point about the figures in the Report is that they were produced
by independent commentators.
Q135 Mr Curry: I have seen that.
I have noticed that.
Mr Behan: A lot of the figures
which have driven our work since 2007 are based on the evidence
from Professor Martin Knapp and his colleagues at LSE, which is
a reputable organisation which has very high standards, so we
have no reason to suspect, Mr Curry, that they are either underestimates
or overestimates. Any projection that is going to 2051 always
stands a risk of being too far in the distance to be reliable,
but certainly what we are looking at to 2020, which is an increase
in 750,000 from just over half a million today, has informed the
way that we brought forward the Dementia Strategy. We think that
is a reliable figure.
Professor Banerjee: I think they
are reliable figures. They are more stable than you might imagine
because we have very good estimates of the population prevalence
of dementia. We have very good demographic projections and the
calculations that we carried out included projections on increased
longevity. We can be pretty sure in 20 years about the people
who will get dementia because those people already will have the
pathologies that will lead to dementias in their brains, so there
will not be major lifestyle things that would either increase
or decrease the prevalence. I think they are fairly stable as
estimates of cost.
Q136 Mr Curry: Have other European
countries made similar projections which would lead you to have
confidence in these projections? Have they had similar sorts of
outcomes?
Professor Banerjee: If you look
at the French Plan Alzheimer, which was brought out just before
ours, that has very similar projections across France and there
has been work done by Alzheimer Europe which has generated these
figures for now, for 20 years' time and for 40 years' time, and
we have exactly the same thing happening across the whole of the
developed world. In the developing world there has been very good
work done by Alzheimer's Disease International which shows that
there is even more of an issue there.
Q137 Mr Curry: Figure 5 has this
little phrase "informal care costs (to families)". What
are they?
Professor Banerjee: These are
the opportunity costs. This is costing what families do for people
with dementia. Most time and most care provided for people with
dementia in their own homes is provided by families, generally
by a spouse living in their own home or a family member.
Q138 Mr Curry: That is what I thought.
Professor Banerjee: So what you
do is you calculate the hours of time they spend doing that and
you cost it at minimum wage. That is the methodology we used.
Q139 Mr Curry: Is there a gender
split in dementia? I ask the question because women tend to live
longer than men so you would therefore assume that proportionately
there are more women than men.
Professor Banerjee: Precisely
that.
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