Examination of Witnesses (Question Numbers
140-159)
DEPARTMENT OF
HEALTH, SOUTH
WEST STRATEGIC
HEALTH AUTHORITY
AND KING'S
COLLEGE LONDON
Q140 Mr Curry: Are the care needs
of men and women different? Does one gender have different needs
than the other gender?
Professor Banerjee: Both genders
have the same sorts of needs in terms of increasing physical disability
and therefore needs for activities of daily living but also psychological
and behavioural problems of dementia, including dangerous behaviour,
as well as wandering and those things. That happens across the
genders. One of the problems that women have in particular is
that male carers live less long because they die earlier, so you
end up with more women living alone and therefore being looked
after by children who may be distant from the home. There is a
difference but it is all to do with longevity.
Q141 Mr Curry: And children may well
be at work. As we know, the sociology of the family has changed
so enormously over the last generation or so.
Professor Banerjee: But there
are still the people who give up work in order to care for their
elderly relatives.
Q142 Mr Curry: Two quick points.
The diagnosis by GPs—as you know it is quite difficult to
actually get to see a GP now, especially if you want an appointment
for the next day because they still say you have to phone back
in the morning. The idea that a patient might be their customer
is still alien to large numbers of the British Medical Association,
as far as I can see. How good are GPs? If you go along and say,
"I'm a bit worried about dad?" You are not going to
get a home visit of course because that is a thing of the past.
How confident are you that the people who are at the front-line
are competent to provide that early diagnosis upon which a huge
amount of not just welfare of the patient but your costings ultimately
depend?
Professor Banerjee: This is very
important and we worked very closely with the College of General
Practitioners and with others to understand that interface. As
I said earlier, if you ask GPs to do something impossible, such
as to diagnose early dementia and to sub-type that dementia in
their surgery in seven minutes, they are not going to do it. But
if you ask them to do something simple and reasonable like what
they do for other illnesses, which is to be vigilant for signs
that are worrisome and then refer those on to a place, to a specialist
service that is specifically designed for that, you will find
that GPs are entirely able to do that.
Q143 Mr Curry: But they need the
family members to bring it to their attention?
Professor Banerjee: What we need
to do is change the attitudes of general practitioners and others
from sloughing off a request saying there is something wrong with
dad, or whatever, and changing it to saying "If you are worried
about his memory then why not go to the memory service and they
will sort out what is going on."
Q144 Mr Curry: As money gets tighter
we are likely to find more and more arguments about the efficacy
of drugs. If you think your dad or mum or yourself might benefit
then you think NICE should jolly well approve it. These are very
difficult things to manage, are they not, to say to somebody,
no, that is not value for money. In an illness which has so many
emotions attached to it as this has, that is going to be particularly
difficult. How are we going to manage that denial to patients
of things which they think might help? How does the public interest
take precedent over the individual interest?
Professor Banerjee: With respect
to anti-dementia drugs, if you are looking in the next two to
five years then what you are looking at is that it will be unlikely
that there will other drugs that will come on-line that have a
major impact, and the ones that are available will become generic
drugs, and so their unit costs will decrease and there will be
no barrier in terms of cost for individuals receiving those medications.
Chairman: I think Mr Burstow has another
question.
Q145 Mr Burstow: It is a request
for a note[4]
actually. Part of this has been a discussion about managing risks
to delivering this strategy going forward, whether it be cost
pressures or whether it be issues about training. Could you provide
us with a list of the risks that you will be seeking to manage
and you would expect NHS organisations to manage to deliver this
Strategy on time, because I think it would be quite useful when
we have the further follow-up review in 18 months' time to see
how those risks have been managed. In particular with regard to
continuing care, to which Sir Ian Carruthers referred, clearly
there is a huge cost pressure there, partly being driven because
of the courts ruling in certain ways and also because of the new
guidelines. I would assume therefore that the Department has done
some modelling about this and has used economic models to come
up with an estimate of what the likely cost will now be. Is there
such a figure and if it is not available today can you provide
us with a note that sets out the Department's estimate of the
extra costs that will arise from that?[5]
Sir David Nicholson: Yes.
Q146 Mr Bacon: Professor Banerjee
said that the demographic trends were very predictable because
there was something already in their brains, but I did not catch
what he said.
Professor Banerjee: If you are
going to develop Alzheimer's Disease, which is the most common
dementia, it is likely that the cellular changes in your brain,
the cell death, very subtle changes, are happening 20 or 30 years
before the actual symptoms of dementia become apparent, even the
earliest symptoms of dementia. This is a neuro-degenerative disorder
that is affecting your brain many years before it becomes clinically
significant.
Q147 Mr Bacon: Are there things that
one can do for that preventatively like eating more seaweed or
beetroot or whatever it is?
Professor Banerjee: Certainly
what is true, and we have said it in the Strategy, is that what
is good for your heart is good for your head.
Q148 Mr Bacon: So red wine then?
Professor Banerjee: Things that
are good for your heart in terms of good exercise, good eating,
not smoking, all of those things are likely to be of benefit in
preventing not the Alzheimer's element of the dementia but the
vascular element of dementia that is very common in later life
as well. The same health messages that we have about healthy lifestyle
also are likely to mean that if you do those things you also decrease
the potential likelihood of some elements of dementia as well.
There is a lot of work that needs to be done identifying early
markers of dementia and work that needs to be done to look at
the prevention of dementia. That is in the future. There is an
immense amount of work that is going on at the moment in research
terms.
Q149 Mr Bacon: A quick question for
Mr Behan or perhaps for Sir Ian, I do not know. Figure 10 describes
Strategic Health Authority Leads. Sir Ian, you are described as
the SHA Dementia Lead. I take that that is within the Department
of Health rather than for your own SHA?
Sir Ian Carruthers: Yes, I am
a member of the National Implementation Board.
Q150 Mr Bacon: When is says SHA Dementia
Lead that means you are "the", singular, it is one?
Somebody is shaking their head behind you. What I really want
to know is in figure 10 when it says strategic health authority
leads, how many of them are there?
Mr Behan: Each SHA has a lead.
Q151 Mr Bacon: So there are ten leads?
Mr Behan: Yes.
Q152 Mr Bacon: When it calls them
regional leads and then underneath it divides them between SHA
leads and consultant old age psychiatrists. Are the strategic
health authority leads the same people as these regional deputy
directors in each case?
Mr Behan: They may be or there
may not be.
Q153 Mr Bacon: But there are ten
of them?
Mr Behan: Yes.
Q154 Mr Bacon: So when it says there
100% awareness among strategic health authority leads, what it
means is there are ten people who should know and they all do?
Mr Behan: Yes.
Q155 Mr Bacon: Okay. I just wanted to
check that.
Mr Behan: And they are a key part
to driving forward the Strategy to get from the regional to the
local level. They are driving forward the work that we have got
on the baseline review and overseeing the delivery of action plans
by March of this year.
Q156 Mr Bacon: I thought it would
be quite shocking if two and a half years or two years and three
months after our last hearing there were ten people who ought
to know and they did not all know, so it is reassuring that they
do.
Mr Behan: This is why it is really
important that we are able to communicate to you that there is
a lot of energy driving this forward by people who actually understand
and believe in this Strategy.
Q157 Chairman: Just a quick question
to the Treasury. Will you commit yourself to improving the pooling
of resources across health authorities and social care units?
Mr Gallaher: I would say that
in the Treasury we would always look to resource on a national
basis and on the overall budget and resources we have, and we
would encourage departments to pool resources and local authorities
and the National Health Service where that is needed.
Mr Curry: Since it is the Committee of
Public Accounts the word "resources" means "cash";
it is money we are talking about.
Q158 Chairman: I will not ask a question
here but maybe we could get a note on it.[6]
On page 22 the Lincolnshire whole-system approach is quite interesting,
is it not, because the study found people with dementia are most
commonly in acute beds but most no longer needed to be there.
If those people with dementia who did not need acute care were
cared for in an alternative setting, this would save £500,000
per annum, so perhaps somebody could do me a note on that so we
can put it in our Report. It might be worth flagging up. Lastly,
Sir David, will you commit yourself to recommending to Ministers
when they are drawing up the next Operating Framework of December
2010 that dementia should be a national priority?
Sir David Nicholson: I do not
know whether when we go into the next Spending Review, given the
financial circumstances in which we find ourselves, whether there
will be anything that remains like an Operating Framework.
Q159 Chairman: So the answer is No?
Sir David Nicholson: What I can
say is that from the Department's perspective dementia will continue
to be a priority. We will continue to put the amount of effort
and pace behind it to make it a reality, but this is the most
complex thing that we have ever tried to deliver, certainly in
my experience, of the NHS, covering health, social care, primary
care and the position that the public finances are in also on
this.
Chairman: Thank you, Sir David. It is
now time to sum up. Apparently an early sign of dementia is aggressive
behaviour so I am not going to give you an aggressive summing
up; just to congratulate you on your knighthood, Sir David. And
also to congratulate our witnesses, particularly Mr Behan, because
I always like to congratulate witnesses who show drive and vigour,
particularly younger witnesses, and I hope you have a very bright
future.
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