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


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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