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


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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