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An overview of my book ‘Living better with dementia: champions for enhanced communities”.



I hope you find this overview of my book ‘Living better with dementia: champions for enhanced communities’ useful.

It is written by me.

And the Forewords are Prof Alistair Burns, the England clinical lead for dementia, Kate Swaffer (Alzheimer’s Australia, Dementia Alliance International, and University of Wollongong, Australia), Chris Roberts (Dementia Action Alliance Carers Call to Action, Dementia Alliance International), and Dr Peter Gordon (Consultant Psychiatrist in dementia and cognitive disorders, NHS Scotland).

It will primarily assess where we’ve got to, along with other countries, in improving diagnosis and post-diagnostic care, and assess realistically the work still yet to be done.

My thesis will articulate why the ‘reboot’ of the global “dementia friendly communities” must now take account of various issues to be meaningful. It will argue for a difference in emphasis from competitive ‘nudge’ towards universal legal and enforceable human rights promoting dignity and autonomy.

It will also argue that dementia friendly communities are meaningless unless there is a shift in the use of language away from ‘sufferers’ and ‘victims’, while paying tribute to the successful “Dementia Friends” initiative.

It will, further, argue that dementia friendly communities are best served by a large scale service transformation to ‘whole person care’, and provide the rationale for this. A critical factor for enhancing the quality of life of people living better with dementia will be to tackle meaningfully the social determinants of health, such as housing and education.

The thesis will also argue that dementia friendly communities must also value the behaviours, skills and knowledge of caregivers in wider support networks. This is essential for the development of a proactive service, with clinical specialist nursing input deservedly valued, especially given the enormous co-morbidity of dementia.

 

This title will be published by Jessica Kingsley Publishers, in early 2015.

Chapters overview

 

Chapter 1 provided an introduction to current policy in England, including a review of the need for a ‘timely diagnosis’ as well as a right to timely post-diagnostic care. This chapter also provided an overview of the current evidence base of the hugely popular “Dementia Friends” campaign run by the Alzheimer’s Society and Public Health England, to raise awareness about five key ‘facts’ about dementia. It was intended that this campaign should help to mitigate against stigma and discrimination that can be experienced by people living with dementia and their caregivers.

 

Chapter 2 comprised a preliminary analysis of stigma, citizenship and the notion of ‘living better with dementia’. This chapter explained the urgency of the need to “frame the narrative” properly. This chapter also introduced the “Dementia Alliance International” which has fast become a highly influential campaigning force by people living with dementia for people living with dementia.

 

Chapter 3 looked at the various issues facing the timely diagnosis and post-diagnostic support of people living with dementia from diverse cultural backgrounds, including people from black, Asian and ethnic minority backgrounds, people who are lesbian, bisexual, gay or transsexual, and people with prior learning difficulties.

 

Chapter 4 looked at the issue of how different jurisdictions around the world have formulated their national dementia strategies. Examples discussed of countries and continents were Africa, Australia, China, Europe, India, Japan, New Zealand, Puerto Rico and Scotland.

 

Chapter 5 looked at the intense care vs care debate which has now surfaced in young onset dementia, with a potentially problematic schism between resources being allocated into drugs for today and resources being used to fund adequately contemporary care to promote people living better with dementia. An example was discussed of how the policy of ‘Big Data’ had gathered momentum across a number of jurisdictions, offering personalised medicine as a further potential compontent of person-centred care. This chapter also considered the impact of the diagnosis of younger onset dementia on the partner of the person with dementia as well. A candid description was also given about the possible sequelae of the diagnosis of young onset dementia on employment, caregivers, and in social isolation.

 

 Chapter 6 focused on delirium, or the acute confusional state, and dementia. It considered the NICE guidelines for delirium, and the pitfalls in considering the relationship between delirium and dementia in English policy.

 

Chapter 7 was the largest chapter in this book, and took as its theme care and support networks. An overview of how patient-centred care is different from person-centred care was given, and how person-centred care differs from relationship-centred care. The literature inevitably has thus far focused on the ‘dyadic relationship’ between the person with dementia and caregiver, but a need to enlarge this to a professional in a ‘triangle of care’ and extended social networks was further elaborated and emphasised. Finally, the importance of clinical specialist nurses in ‘dementia friendly communities’ was argued, as well as the Dementia Action Alliance’s “Carers Call to Action”. Different care settings were described, including care homes, hospitals – including acute hospital care, and intermediate care.

 

Chapter 8 considered eating for living well with dementia. This chapter considered enforceable standards in care homes, including protection against malnutrition or undernutrition. The main focus of the chapter was how people with dementia might present with alternations in their eating behaviour, and how the mealtime environment must be a vital consideration for living better with dementia.

 

Chapter 9 looked at a particular comorbidity, incontinence. The emphasis was on conservative approaches for living well with dementia and incontinence. Other issues considered were the impact of incontinence on personhood per se, and the possible impact on the move towards an institutional home.

 

Chapter 10 argued how the needs for people living better with dementia would be best served by a fully integrated health and social care service. This chapter provided the rationale behind this policy instrument in England.  The chapter also considered various aspects of what would be likely to make ‘whole person care’ work, including data sharing, collaborative leadership, care-coordinators, responsible and accountable ‘self care’, and the multi-disciplinary team. This chapter also considered how it was impossible to divorce physical health from mental health and social care, and explained the intention of the longstanding drive towards ‘parity of esteem’ in English policy.

 

Chapter 11 considered the importance of the social determinants of health. A focus of this chapter was on education, and its impact on a person living with dementia. However, the main focus of this chapter was housing, including ‘dementia friendliness, downsizing, and green or public spaces.

 

Chapter 12 considered whether ‘wandering’ is the most appropriate term. The main emphasis of this chapter were the legal and ethical considerations in the use of ‘global positioning systems’ in enhancing the quality of life of persons with dementia and their closest ones.

 

Chapter 13 considered a number of important contemporary issues, with a main emphasis on human rights and “rights based approaches”. While there is no universal right to a budget, the implementation of personal budgets was discussed. The chapter progressed to consider a number of legal issues which are arising, including genetic discrimination in the US jurisdiction, dementia as a disability under the equality legislation in England, and the importance of rights-based approaches for autonomy and dignity. Finally, the issue of engagement was considered.

 

Chapter 14 was primarily concerned with art and creativity. This chapter took as its focus on how living with dementia could lead to art and creativity, and how the cultural needs of people living with dementia could best be furnished through laughter, poetry and art galleries or museums. This focus also looked at the exciting developments in our understanding of the perception of music in people living with dementia, and how music has the potential to enhance the quality of life for a person living well with dementia.

 

Chapter 15 looked at the triggering of football sporting memories in people living well with dementia. This chapter considered the cognitive neuroscience of the phenomenon of this triggering, and presented a synthesis of how the phenomenon could be best explained through understanding the role of emotional memory in memory retrieval, how autobiographical memories are represented in the human brain usually, the special relevance of faces or even smells such as “Bovril”.

 

Chapter 16 looked at the impact of various innovations in English dementia policy, giving as examples including service provision (such as the policy on reducing inappropriate use of antipsychotics or the policy in timely diagnosis) and research. This chapter also contemplated the principal factors affecting how innovations can become known, and what ultimately determines their success.

 

Chapter 17 looked at how leadership could be promoted by people living with dementia. This chapter considered who might lead the change, where and when, and why this change might be necessary to ‘recalibrate’ the current global debate about dementia. This chapter considered how change might be brought about from the edge, how silos might be avoided, the issue of ‘tempered radicals’ in the context of transformative change to wellbeing as an outcome; and finally how ‘Dementia Champions’ are vital for this change to be effected.

 

Please note that Beth is not endorsing this book – this image is entirely separate and is taken from the main event for G8 dementia – we’re all proud of Beth’s work meanwhile!

 

 

Beth

 

The chapter on art, music and creativity for my new book on living better with dementia



The following are the journal references for my chapter on art, music and creativity for my book “Living better with dementia: champions for enhanced friendly communities”. Please do let me know if you wish to have any further academic papers cited. And also please do let me know if you wish local initiatives or innovations to be featured in my chapter, and I will do my best to include them if appropriate.

Very many thanks.

theatre

Amaducci L, Grassi E, Boller F. Maurice Ravel and right-hemisphere musical creativity: influence of disease on his last musical works? Eur J Neurol. 2002 Jan;9(1):75-82.

Basaglia-Pappas S, Laterza M, Borg C, Richard-Mornas A, Favre E, Thomas-Antérion C. Exploration of verbal and non-verbal semantic knowledge and autobiographical memories starting from popular songs in Alzheimer’s disease. Int Psychogeriatr. 2013 May;25(5):785-95. doi: 10.1017/S1041610212002359. Epub 2013 Feb 7.

Beard, R.L. Art therapies and dementia care: A systematic review 2012 11: 633-656.

Bisiani L, Angus J. Doll therapy: a therapeutic means to meet past attachment needs and diminish behaviours of concern in a person living with dementia–a case study approach. Dementia (London). 2013 Jul;12(4):447-62. doi: 10.1177/1471301211431362. Epub 2012 Feb 15.

Blood AJ, Zatorre RJ. Intensely pleasurable responses to music correlate with activity in brain regions implicated in reward and emotion. Proc Natl Acad Sci U S A. 2001 Sep 25;98(20):11818-23.

Budrys V, Skullerud K, Petroska D, Lengveniene J, Kaubrys G. Dementia and art: neuronal intermediate filament inclusion disease and dissolution of artistic creativity. Eur Neurol. 2007;57(3):137-44. Epub 2007 Jan 10.

Camic PM, Chatterjee HJ. Museums and art galleries as partners for public health interventions. Perspect Public Health. 2013 Jan;133(1):66-71. doi: 10.1177/1757913912468523.

Camic PM, Tischler V, Pearman CH. Viewing and making art together: a multi-session art gallery-based intervention for people with dementia and their carers. Aging Ment Health. 2014 Mar;18(2):161-8. doi: 10.1080/13607863.2013.818101. Epub 2013 Jul 22.

Camic PM, Williams CM, Meeten F. Does a ‘Singing Together Group’ improve the quality of life of people with a dementia and their carers? A pilot evaluation study. Dementia (London). 2013 Mar;12(2):157-76. doi: 10.1177/1471301211422761. Epub 2011 Oct 31.

Chakravarty A. De novo development of artistic creativity in Alzheimer’s disease. Ann Indian Acad Neurol. 2011 Oct;14(4):291-4. doi: 10.4103/0972-2327.91953.

Crutch SJ, Isaacs R, Rossor MN. Some workmen can blame their tools: artistic change in an individual with Alzheimer’s disease. Lancet. 2001 Jun 30;357(9274):2129-33.

Eekelaar, C., Camic, P. M., Springham, N. Art galleries, episodic memory and verbal fluency in dementia: An exploratory study. Psychology of Aesthetics, Creativity, and the Arts, Vol 6(3), Aug 2012, 262-272.

Fletcher PD, Clark CN, Warren JD. Music, reward and frontotemporal dementia. Brain. 2014 Oct;137(Pt 10):e300. doi: 10.1093/brain/awu145. Epub 2014 Jun 11.

Fletcher PD, Downey LE, Witoonpanich P, Warren JD. The brain basis of musicophilia: evidence from frontotemporal lobar degeneration. Front Psychol. 2013 Jun 21;4:347. doi: 10.3389/fpsyg.2013.00347. eCollection 2013.

Fornazzari LR. Preserved painting creativity in an artist with Alzheimer’s disease. Eur J Neurol. 2005 Jun;12(6):419-24.

Gjengedal E, Lykkeslet E, Sørbø JI, Sæther WH. ‘Brightness in dark places': theatre as an arena for communicating life with dementia. Dementia (London). 2014 Sep;13(5):598-612. doi: 10.1177/1471301213480157. Epub 2013 Mar 13.

Gold K. But does it do any good? Measuring the impact of music therapy on people with advanced dementia: (Innovative practice). Dementia (London). 2014 Mar 1;13(2):258-64. doi: 10.1177/1471301213494512. Epub 2013 Jul 26.

Gordon N. Unexpected development of artistic talents. Postgrad Med J. 2005 Dec;81(962):753-5.

Gross SM, Danilova D, Vandehey MA, Diekhoff GM. Creativity and dementia: Does artistic activity affect well-being beyond the art class? Dementia (London). 2013 May 22. [Epub ahead of print]

Guétin S, Portet F, Picot MC, Pommié C, Messaoudi M, Djabelkir L, Olsen AL, Cano MM, Lecourt E, Touchon J. Effect of music therapy on anxiety and depression in patients with Alzheimer’s type dementia: randomised, controlled study. Dement Geriatr Cogn Disord. 2009;28(1):36-46. doi: 10.1159/000229024. Epub 2009 Jul 23.

Hafford-Letchfield T. Funny things happen at the Grange: introducing comedy activities in day services to older people with dementia–innovative practice. Dementia (London). 2013 Nov;12(6):840-52. doi: 10.1177/1471301212454357. Epub 2012 Jul 9.

Holland AC, Kensinger EA. Emotion and autobiographical memory. Phys Life Rev. 2010 Mar;7(1):88-131. doi: 10.1016/j.plrev.2010.01.006. Epub 2010 Jan 11. Review.

Hsieh S, Hornberger M, Piguet O, Hodges JR. Neural basis of music knowledge: evidence from the dementias. Brain. 2011 Sep;134(Pt 9):2523-34. doi: 10.1093/brain/awr190. Epub 2011 Aug 21.

James IA, Mackenzie L, Mukaetova-Ladinska E. Doll use in care homes for people with dementia. Int J Geriatr Psychiatry. 2006 Nov;21(11):1093-8.

Janata P. The neural architecture of music-evoked autobiographical memories. Cereb Cortex. 2009 Nov;19(11):2579-94. doi: 10.1093/cercor/bhp008. Epub 2009 Feb 24.

LaBar KS, Cabeza R. Cognitive neuroscience of emotional memory. Nat Rev Neurosci. 2006 Jan;7(1):54-64. Review.

Lazar A, Thompson H, Demiris G. A systematic review of the use of technology for reminiscence therapy. Health Educ Behav. 2014 Oct;41(1 Suppl):51S-61S. doi: 10.1177/1090198114537067.

Mezirow J. (2000) Learning to think like an adult. In J. Mezirow and Associates, Learning as transformation: Critical perspectives on a theory in process. (pp. 3-33). San Francisco: Jossey Bass.

Miller BL, Boone K, Cummings JL, Read SL, Mishkin F. Functional correlates of musical and visual ability in frontotemporal dementia. Br J Psychiatry. 2000 May;176:458-63.

Miller BL, Cummings J, Mishkin F, Boone K, Prince F, Ponton M, Cotman C. Emergence of artistic talent in frontotemporal dementia. Neurology. 1998 Oct;51(4):978-82.

Miller, B.L., Yener, G, Akdal, G. (2005) Artistic patterns in dementia, Journal of Neurological Sciences (Turkish), vol. 22(3), pp. 245-249.

Mitchell G, McCormack B, McCance T. Therapeutic use of dolls for people living with dementia: A critical review of the literature. Dementia August 25, 2014 1471301214548522.

Mitchell G, McCormack B, McCance T. Therapeutic use of dolls for people living with dementia: A critical review of the literature. Dementia (London). 2014 Aug 25. pii: 1471301214548522. [Epub ahead of print]

Mitchell G, Templeton M. Ethical considerations of doll therapy for people with dementia. Nurs Ethics. 2014 Sep;21(6):720-30. doi: 10.1177/0969733013518447. Epub 2014 Feb 3.

Omar R, Hailstone JC, Warren JE, Crutch SJ, Warren JD. The cognitive organization of music knowledge: a clinical analysis. Brain. 2010 Apr;133(Pt 4):1200-13. doi: 10.1093/brain/awp345. Epub 2010 Feb 8.

Pezzati R, Molteni V, Bani M, Settanta C, Di Maggio MG, Villa I, Poletti B, Ardito RB. Can Doll therapy preserve or promote attachment in people with cognitive, behavioral, and emotional problems? A pilot study in institutionalized patients with dementia. Front Psychol. 2014 Apr 21;5:342. doi: 10.3389/fpsyg.2014.00342. eCollection 2014.

Ramachandran, VS, Hirstein, (1999) The science of art: a neurological theory of aesthetic experience. Journal of Consciousness Studies (6), no.6-7, pp.15-51.

Rankin KP, Liu AA, Howard S, Slama H, Hou CE, Shuster K, Miller BL. A case-controlled study of altered visual art production in Alzheimer’s and FTLD. Cogn Behav Neurol. 2007 Mar;20(1):48 61.

Roe B, McCormick S, Lucas T, Gallagher W, Winn A, Elkin S. Coffee, Cake & Culture: Evaluation of an art for health programme for older people in the community. Dementia (London). 2014 Mar 31. [Epub ahead of print]

Salimpoor VN, Benovoy M, Longo G, Cooperstock JR, Zatorre RJ. The rewarding aspects of music listening are related to degree of emotional arousal. PLoS One. 2009 Oct 16;4(10):e7487. doi: 10.1371/journal.pone.0007487.

Seeley WW, Matthews BR, Crawford RK, Gorno-Tempini ML, Foti D, Mackenzie IR, Miller BL. Unravelling Boléro: progressive aphasia, transmodal creativity and the right posterior neocortex. Brain. 2008 Jan;131(Pt 1):39-49. Epub 2007 Dec 5.

Stevens, J 2012, ‘Stand up for dementia: performance, improvisation and stand up comedy as therapy for people with dementia; a qualitative study’, Dementia, vol. 11, no. 1, pp. 61-73.

Takahata K, Saito F, Muramatsu T, Yamada M, Shirahase J, Tabuchi H, Suhara T, Mimura M, Kato M. Emergence of realism: Enhanced visual artistry and high accuracy of visual numerosity representation after left prefrontal damage. Neuropsychologia. 2014 May;57:38-49. doi: 10.1016/j.neuropsychologia.2014.02.022. Epub 2014 Mar 11.

Takeda M, Hashimoto R, Kudo T, Okochi M, Tagami S, Morihara T, Sadick G, Tanaka T. Laughter and humor as complementary and alternative medicines for dementia patients. BMC Complement Altern Med. 2010 Jun 18;10:28. doi: 10.1186/1472-6882-10-28.

Tanaka, Y, Nogawa, H, Tanaka, H. (2012) Music Therapy with Ethnic Music for Dementia Patients, International Journal of Gerontology Volume 6, Issue 4, December 2012, Pages 247 257.

Topo, P, Mäki,O, Saarikalle, K, Clarke, N, Begley, E, Cahill, S, Arenlind, J, Holthe, T, Morbey, H, Hayes, K, Gilliard, J. Dementia October 2004 Assessment of a Music-Based Multimedia Program for People with Dementia vol. 3 no. 3 331-350

Woods RT, Bruce E, Edwards RT, Elvish R, Hoare Z, Hounsome B, Keady J, Moniz-Cook ED, Orgeta V, Orrell M, Rees J, Russell IT. REMCARE: reminiscence groups for people with dementia and their family caregivers – effectiveness and cost-effectiveness pragmatic multicenter randomised trial. Health Technol Assess. 2012;16(48):v-xv, 1-116. doi: 10.3310/hta16480.

Zeilig H. Gaps and spaces: representations of dementia in contemporary British poetry. Dementia (London). 2014 Mar 1;13(2):160-75. doi: 10.1177/1471301212456276. Epub 2012 Aug 17.

Trivialising dementia – too much inappropriate rocking of the boat?



When I wrote my highly successful book, “Living well with dementia”, using the phrase deliberately from the 2009 English dementia strategy document for England, I never knew the phrase was being bastardised so much for often very trivial initiatives in dementia.

On the other hand, I had huge delight in seeing its immediate relevance to a carers’ support group I went to last week.

I feel deeply hurt that the serious issues in my book, such as advocacy for mental capacity, the presentation of the cognitive neurology of the dementias, or the use of ambient-assisted technology have not been widely discussed amongst the wider community.

In that, I feel the book has failed.

I welcome proposals for the next Government to maximise money into actual service, and to re-establish health funding in line with other comparator countries.

Commissioning in dementia is now not based on what is best for the person for the person with dementia, but what is best for your Twitter commissioner friends.

I look forward to the Health and Wellbeing Boards playing a pivotal rôle in establishing some sort of normality for what commissioning in living well with dementia might be as a value-based outcome.

The strangehold of “shiny”, “off the shelf” “innovative packages”, in the drive for the current Government to ‘liberalise’ the financial market in dementia has acted for a cover for disturbing, unacceptable cuts in dementia service provision in the last few years.

I remember ‘boat rocking’ the first time around from the elegant work of Prof Debra Meyerson.

I do not wish to promote frontline professionals, many of whom have spent seven years at least at medical school or in their nursing training, to become lambs to the slaughter in the modern NHS and social care.

Keeping it real, we know that real frontline professionals in medicine and social care, even if they are not in a downright toxic environment requiring whistleblowing, can find it dangerous being risk appetitive.

Indeed, being risk appetitive, while great for innovation and leadership, can literally be deadly for patient safety.

The next Government has enough on its hands with enforcing care home standards and sanctioning for offences against the national minimum wage for paid carers as it is.

We have to think for a second for the vast army of paid workers in the NHS, as well as the rather well paid people who like their shiny new boxes, I feel.

The schism between the social media and what is happening at service level I think is most alarming, and perhaps symptomatic about how the health and social care services have begun to work in reality.

All too often, I am having first hand experience of busy frontline nurses being dragged in front of entrepreneurs in their local dementia economy to hear shills beginning, “I don’t have first hand experience of caring in dementia, but…”, before the hard sell.

This is tragically being reflected on the world stage too, though I do anticipate that the G7 legacy event from Japan which is looking carefully at their experience with care and support post diagnosis, next year, will be brilliant.

It is important for leaders in dementia to have authenticity.

I have severe doubts and misgivings about what gives the World Dementia Envoy the appropriate background and training in dementia for him to be in this important post.

It is all too easy for ‘thought leaders’ in corporate-like medical charities to have no formal qualifications or training in medicine, nursing, or social care, and opine nonetheless about weighty issues to do with policy.

I am concerned that the global ‘dementia friendly communities’ policy plank appears to have been straightjacketed through one charity in England, when it is patently obvious that various other charities such as the Joseph Rowntree Foundation have made a powerful contribution.

The media have largely not engaged in a discussion about living well with dementia, but engaged simply with Dementia Friends or a story arising out of that.

I am alarmed about the lack of plurality in the dementia research sector.

I think the All Party Parliamentary Group (“APPG”) for dementia have done some valuable work, but their lack of momentum on specialist nurses including Admiral nurses, spearheaded by the charity Dementia UK, seriously offends me.

I am sick of how the notion of ‘involvement’ of people with dementia has been abused in service provision mostly, although I am encouraged very much by initiatives such as from DEEP and Innovations in Dementia.

I think there have been genuine improvements in engaging people with dementia in research, through a body of work faithfully peer-reviewed in the Dementia Journal looking at heavy issues such as the meaning of real consent.

I am now going to draw the line of tokenistic involvement of people with dementia to front projects without any meaningful inclusion.

And in fairness, this tokenistic involvement is, I am aware, happening in various jurisdictions, not just England.

All too often, “co-production” has become code for ‘exploitation’ rather than ‘active partnership’.

The prevalence of dementia is actually falling in England, it is now thought.

The ‘dementia challenge’ was our challenge to making sure that we adequately safeguarded against people rent seeking from dementia since 2012.

In that, I think we have spectacularly failed.

I am overall very encouraged, however, with the success of the huge amount of work which has been done, including from the highly influential Alzheimer’s Society, and from the communitarian activism of “The Purple Angels”.

All this ‘radicalism’ has taken on a rather ugly, conformist twang.

radicalism

Now is though time to ‘take stock’, as Baroness Sally Greengross, the current chair of the APPG on dementia, herself advised, as the new England dementia strategy is being drafted ahead of the completion of the current one in March 2015.

The real influencers of English dementia policy aside from #G8dementia



top 100

In a rather strange Stakhanovite way, certain health magazines are strangely obsessed with the fetish of the ‘top 100′. I am as such not a great advocate of, “Everybody has won, and all must have prizes.” immortalised by Chapter 3 of Lewis Carroll’s Alice’s Adventures in Wonderland, but as someone who has devoted all of his entire life to dementia academia I do find somewhat curious (to put it politely) the judgments of those outside the dementia field about who are most influential to other people outside the academic dementia field, in their “world of dementia”. However, corporates need ‘symbols’ of their ‘success’ to attract inward attention and investment, so I’ll simply leave them to their own pathetic whims.

The issue of who “influences” a given network is currently of huge interest in modern ‘actor network theory’ (ANT). ANT was first developed at the Centre de Sociologie de l’Innovation of the École nationale supérieure des mines de Paris in the early 1980s by staff and visitors. Network thinking has contributed a number of important insights about social power. Perhaps most importantly, the network approach emphasises that power is inherently relational. An individual does not have power in the abstract, they have power because they can dominate others.

Network analysts often describe the way that an “actor” is embedded in a relational network as imposing constraints on the actor, and offering the actor opportunities. Actors that face fewer constraints, and have more opportunities than others are in “favourable structural positions”. Having a favoured position means that an actor may extract better bargains in exchanges, have greater influence, and that the actor will be a focus for deference and attention from those in less favoured positions. However, a key deference is that the people mentioned below do not consider themselves as requiring deference or attention. Their devotion to the living with the dementias is crystal clear. There can of course be “inhibitors”. We all know who they are: they actively stifle the activities of some members of the community.

There are many laboratories around the world which publish widely in the world on cognitive and behavioural neurology: how people think, and the brain processes involved. Of the off top of my head, I can think of Prof Bruce Miller at the University of California and San Francisco, Prof Martin Rossor at the National Hospital for Neurology and Neurosurgery and University of London (UK), Prof Facundo Manes at Favorolo Hospital, Argentina, Prof David Neary at the University of Manchester (UK), and Prof John Hodges of NeuRA, Australia.

There are of course people in fields to do with living well, for example defining wellbeing, measuring wellbeing, assistive technology, ambient assisted living, design of the home, design of the ward, and design of the built environment. Research in all these areas in English dementia policy is currently extremely important. I would go so far as to say that the people successfully working in, and publishing on, these areas around the world are much more important than the health ministers and corporate representatives who spoke at the ‘G8 dementia’ conference last week.

One person who does deserve a special mention though, even though all must have possibly have prizes, is Beth Britton. Beth’s interview captured attention at last week’s #G8dementia, and rightly so. Beth’s father had vascular dementia for 19 years. It began when Beth was around 12 years old, and would go on to dominate Beth’s life in her teens and twenties. Her father, whom she clearly adores, went for ten years without a diagnosis and he then spent none years in three different care homes. He passed away in April 2012, aged 85.

Norman McNamara from Devon was diagnosed with dementia a few years ago when he was just 50. After his diagnosis, Norman, from Torquay, began blogging online about his experiences and during a phone call with a friend he had the idea of organising the first Dementia Awareness Day on 17 September 2011. Norman particularly is really helpful in offering insights about what it’s like to ‘live with dementia’. In his recent blogpost, for example, he talks about how he doesn’t wish to be seen as being on some ‘journey’. He talks poignantly about how he is ‘living with’ dementia, not ‘dying from’ dementia, stating correctly that we are all in fact dying if one took this approach.

Kim Pennock, from Thornton-le-Dale, gave up her part-time job at Beck Isle Museum to help care for her mother who has the dementia of the Alzheimer type. Kim has become one of only 50 worldwide ambassadors for a pioneering new project to make communities safer for people with dementia. When her mother was first diagnosed, Kim said the family found it almost impossible to find the information and help they needed. Conversely, Lee set up the incredible ‘Dementia Challengers’ website to help people with dementia and the carers the right info they need to help them to live well.

In Australia, Kate Swaffer is committed to meaningful dialogue with a wide range of stakeholders about the critical issues impacting a person living with a diagnosis of dementia and their loved ones. When a person with dementia ‘comes out’ about their diagnosis, and openly admits they are living with the symptoms of, and diagnosis of dementia, there are a number of reactions and responses. Kate is one of the world’s most powerful advocates for dementia and the elderly, living well with a diagnosis of dementia; and she describes herself on Twitter (@KateSwaffer) as an “author, poet, blogger, and always trying to be a nice person”.

Back in the UK, Fiona Phillips speaks directly from her first hand experience as her mother had Alzheimer’s until her death in May 2006 and her father, who was diagnosed with the disease shortly afterwards, died in February 2012. In January 2009, Fiona presented Mum, Dad, Alzheimer’s and Me, an incredibly moving “Dispatches” documentary on Channel 4, featuring Fiona talking candidly about her struggles caring for both her parents during their respective illnesses and investigating the difficulties faced by people with the dementia of the Alzheimer type, and their families to get adequate care and support. Fiona has written a book “Before I Forget”, about her relationship with her parents and their dementia.

There are certain people who do understand particular areas of dementia policy and education. Lucy Jane Marsters is one such example, being a specialist nurse. Gill Phillips has also been pivotal in raising awarneness, generally, of the significant to personal-centred approaches in questioning quite deeply entrenched assumptions. There are also some brilliant people in innovations, such as Mike Clark, Prof Andrew Sixsmith and Prof Roger Orpwood in telemedicine and telehealth. Activities and healthy living communities are also extremely important; despite challenges in funding, like many in the dementia world, Simona Florio has been utterly resolute in supporting members of the excellent Healthy Living Club in Stockwell.

For years, magnificent Scot Tommy Whitelaw travelled the world running global merchandising operations for the Spice Girls, Kylie and U2. However, over the past few years he had become a fulltime carer my late mum, Joan, who had vascular dementia. His motivation as a carer came from the love he had for his own mum, and his experience has shown me just how tough it is to live with dementia and how many struggles it can bring. For the last year, he has been collecting carer’s life stories to raise awareness. Tommy is now working on The Dementia Carers Voices project with the Health and Social Care Alliance which will build on my ‘Tommy on Tour’ campaign by engaging with carers, collecting their life stories and raise awareness amongst health and social care professionals on both dementia and caring.

Caring for someone with dementia clearly infuses some with an incredible passion for the subject which you simply is hard to match. Sally Marciano has talked openly about supporting her mum supporting her father who later died of a dementia. She has talked openly about how the system didn’t work properly, but is very constructive about raising awareness and educational skills in the healthcare sector.

In March 2013, filmmakers and scientists come together at an event to increase the public understanding of dementia. A series of short films about dementia was presented by James Murray-White, will precede a discussion with researchers from the University of Bristol and other institutions supported by “Alzheimers BRACE”, a local charity that funds research into Alzheimer’s disease and other forms of dementia. James’ activities include being a freelance writer, journalist, reviewer, and filmmaker. James was in fact featured in last week’s #G8dementia media coverage.

Sarah Reed’s mother had Alzheimer’s disease for ten years. As a result of this, she became passionate about the quality of life of older people, especially those with dementia.?? She left a design career to found “Many Happy Returns” in order to innovate, research and develop evidence-based products to connect young and old, especially those with dementia, more meaningfully. Her goal has to change the experience of dementia for those who have it for the better, by persuading care organisations and carers everywhere that good care counts for nothing without good communication – and then helping them to deliver it.

And of course there are some brilliant influencers in the world of medicine who don’t simply regurgitate the copy fed to them. Dr Peter Gordon has produced a number of original films and articles about the ethics of the diagnosis, particularly the need for a ‘timely’ rather ‘early’ diagnosis, and potential conflicts of interest between the medical profession and the pharmaceutical industry. Dr Martin Brunet has likewise become massively influential in articulating the debate, especially, from the medical profession’s perspective of a policy ‘target’ to increase diagnosis rates. While Martin’s work is not easy, his perspective and substantial experience as a GP is invaluable, particularly in redressing other people’s motives which can too easily be too motivated by surplus and profit.

And, of course, a top influencer, even though ‘all shall have prizes’, is Prof Alistair Burns. Alistair is the clinical lead for dementia in England, and has a highly influential position in NHS England. Alistair clearly has a number of different stakeholders with which he needs to have a fair legitimate discussion about English policy. He has nonetheless steered the policy through rather turbulent times. As a senior academic and person within higher education, and someone who clearly has a very ‘human perspective’ too, his contribution to English dementia policy has been much valued and much appreciated.

Actually, I’m being totally ingenious. Most of us are actually one big happy family in the network I’m in. We have our disagreements, but we value each other. We don’t inhibit one another (which is what can go wrong with networks). For a list of #dementiachallengers, please go to the list in the top right corner of this blog. You’ll see for example Charmaine Hardy, who cares for, and adores, her husband who has a very rare form of dementia called primary progressive aphasia. Though having a well deserved break for once in Norway, for once, you can catch her on Twitter!

The “Friends and Family Test” – lessons from the “Do you masturbate often?” question



kiosk for Friends and Family Test

In whatever way you wish to ask the question from an expert statistician, a reasonable statistician will spit bullets at the methodology of “The Friends and Family Test”. Like Trip Advisor, it is susceptible to a phenomenon called ‘shilling’, where fake respondents bias the sample with their fake appraisals. The Friends and Family Test (FFT) is a single question survey which asks patients whether they would recommend the NHS service they have received to friends and family who need similar treatment or care. Conceptually, it is of course a terrific idea to ask the patient what they think of the NHS, but it is susceptible to too many uncontrolled variables for the result to be particularly meaningful; for example, how long after the clinical event should you ask the patient to ‘rate’ the episode? The responses to the FFT question are used to produce a score that can be aggregated to ward, site, specialty and trust level. The scores can also be aggregated to national level.

Most people in the public are very slightly interested in the geeky way in which statisticians produce the results, The scores are calculated by analysing responses and categorising them into promoters, detractors and neutral responses. The proportion of responses that are promoters and the proportion that are detractors are calculated and the proportion of detractors is then subtracted from the proportion of promoters to provide an overall ‘net promoter’ score. NHS England has not prescribed a specific method of collection and decisions on how to collect data have been taken locally. Each trust has been able to choose a data collection method that works best for its staff and people who use services. The guidance suggests a range of methods that can be adopted including tablet devices, paper based questionnaires and sms/text messages, amongst others. How you collect the data adds a further level of complexity to the meaningless nature of these data.

There is a phenomenon in statistics called the “social desirability responding” (“SDR”), a tendency of respondents to answer questions in a manner that will be viewed favorably by others. It can take the form of over-reporting “good behaviour” or under-reporting “bad,” or undesirable behaviour. The tendency poses a serious problem with conducting research with self-reports, especially questionnaires. This bias interferes with the interpretation of average tendencies as well as individual differences. There might be an age-related effect; older patients have tended to hold the NHS with greater reverence, whatever their political loyalties might be, compared to younger patients who believe in a market and/or believe they are ‘entitled’ to the NHS.

Topics where socially desirable responding (SDR) is of special concern are self-reports of abilities, personality, sexual behaviour, and drug use. When confronted with the question “How often do you masturbate?”, for example, respondents may be pressured by the societal taboo against masturbation, and either under-report the frequency or avoid answering the question. Therefore the mean rates of masturbation derived from self-report surveys are likely to be severe underestimates. Social desirability bias tends to be highest for telephone surveys and lowest for web surveys. This makes web surveys particularly well suited for studies of sexual behaviour, illicit activities, bigotry, or particularly threatening topics. Fundamentally, respondents do not answer questions the same way in person, on the phone, on paper or via the web. Different survey modes produce different results. Robert Groves, in his 1989 book “Survey Errors and Survey Costs“, argues that each survey mode puts respondent into a different frame of mind (a mental “script”). Face-to-face surveys prompt a “guest” script. Respondents are more likely to treat face-to-face interviewers graciously and hospitably, leading them to be more agreeable.  Phone interviews prompt a “solicitor” script. Respondents are more likely to treat phone interviews the way they treat calls from telemarketers, making them more likely to go through the motions of answering questions in order to get the interviewer off the phone.

That is why reasonable statisticians take care when comparing the results of surveys conducted by different modes. Humans process language differently when reading, when listening to someone over the phone, or when listening to someone in the same room (when visual cues and body language kick in). It is no surprise that these different modes lead to different behavior by respondents. The lack of a standardised methodology in the FFT means that there are likely to be, what are known as, mode effects. Mode effect is a term used to describe the phenomenon of different methods of administering a survey leading to differences in the data returned. For example, we may expect to see differences in responses at a population level when comparing paper based questionnaires to tablet devices. On a positive note, mode effects do not prevent trusts from comparing their own data over time periods when they have conducted the test in the same way, as any biases inherent in the individual approaches are constant over the period.

Much money has been pumped into the FFT, and one wonders whether the FFT would stop another Harold Shipman or Mid Staffs. Even Trusts with excellent ratings, such as Lewisham, are in the “firing line” for being shut down. So one really is left wondering what on earth is the point of flogging this dead policy horse?

The English dementia policy: some personal thoughts



 

The last few years have seen a much welcome progression, for the better, for dementia policy in England. This has been the result of the previous Government, under which “Living well with dementia: the National Dementia Strategy” was published  in 2009, and the current Government, in which the Prime Minister’s Dementia Challenge in 2012 was introduced.

Dementia is a condition which lends itself to the ‘whole person’, ‘integrated’ approach. It is not an unusual for an individual with dementia to be involved with people from the medical profession, including GPs, neurologists, geriatricians; allied health professionals, including nurses, health care assistants, physiotherapists, speech and language specialists, nutritionists or dieticians, and occupational therapists; and people in other professionals, such as ‘dementia advocates’ and lawyers. I think a lot can be done to help individuals with dementia ‘to live well'; in fact I have just finished a big book on it and you can read drafts of the introduction and conclusion here.

It is obviously critical that clinicians, especially the people likeliest to make the initial provisional diagnosis, should be in the ‘driving seat’, but it is also very important that patients, carers, family members, or other advocates are in that driving seat too.  I feel this especially now, given that there is so much information available from people directly involved in with patients (such as @bethyb1886 or @whoseshoes or @dragonmisery) This patient journey is inevitably long, and to call it a ‘rollercoaster ride‘ would be a true understatement. That is why language is remarkably important, and that people with some knowledge of medicine get involved in articulating this debate. Not everyone with power and influence in dementia has a detailed knowledge of it, sadly.

I am very honoured to have my paper on the behavioural variant of frontotemporal dementia to be included as one of a handful of references in the current Oxford Textbook of Medicine. You can view this chapter, provided you do not use it for commercial gain (!), here.

I should like to direct you to the current draft of a video by Prof Alistair Burns, Chair of Psychiatry at the University of Manchester, who is the current National Clinical Lead for Dementia. You can contact him over any aspects of dementia policy on his Twitter, @ABurns1907.  I strongly support Prof Burns, and here is his kind Tweet to me about my work.  I agree with Prof Burns that once individuals can be given face-to-face a correct diagnosis of dementia this allows them to plan for the future, and to access appropriate services. The problem obviously comes from how clinicians arrive at that diagnosis.

I am not a clinician, although I studied medicine at Cambridge and did my PhD on dementia there too, but having written a number of reviews, book chapters, original papers, and now a book on dementia, I am deeply involved with the dementia world. I am still invited to international conferences, and I personally do not have any financial vested interests (e.g. funding, I do not work for a charity, hospital, or university, etc.) That is why I hope I can be frank about this. Clinicians will be mindful of the tragedy of telling somebody he or she has dementia or when he or she hasn’t, but needs help for severe anxiety, depression, underactive thyroid, or whatever. But likewise, we are faced with reports of a substantial underdiagnosis of dementia, for which a number of reasons could be postulated. Asking questions such as “How good is your memory?” may be a good basic initial question, but clinicians will be mindful that this test will suffer from poor specificity – there could be a lot of false positives due to other conditions.

At the end of the day, a mechanism such as ‘payment-by-results’ can only work if used responsibly, and does not create an environment for ‘perverse incentives’ where Trusts will be more inclined to claim for people with a ‘label’ of dementia when they actually do not have the condition at all. A double tragedy would be if these individuals had poor access to care which Prof Burns admits is “patchy”. In my own paper, with over 300 citations, on frontal dementia, seven out of eight patients had very good memory, and yet had a reliable diagnosis of early frontal dementia. Prof Burns rightly argues the term ‘timely’ should be used in preference to ‘early’ dementia, but still some influential stakeholders are using the term ‘early’ annoyingly. On the other hand, I wholeheartedly agree that the term ‘timely’ is much more fitting with the “person-centred care” approach, made popular in a widespread way by Tom Kitwood.

I am still really enthused about the substantial progress which has been made in English dementia policy. I enclose Prof Burns’ latest update (draft), and the video I recorded yesterday at my law school, for completion.

Prof Alistair Burns, National Clinical Lead for Dementia

Me (nobody) in reply

 

 

Avoiding the rollercoaster: a policy for dementia must be responsible



Rollercoaster

 

 

The last few years have seen a much welcome progression, for the better, for dementia policy in England. This has been the result of the previous Government, under which “Living well with dementia: the National Dementia Strategy” was published  in 2009, and the current Government, in which the Prime Minister’s Dementia Challenge in 2012 was introduced.

Dementia is a condition which lends itself to the ‘whole person’, ‘integrated’ approach. It is not an unusual for an individual with dementia to be involved with people from the medical profession, including GPs, neurologists, geriatricians; allied health professionals, including nurses, health care assistants, physiotherapists, speech and language specialists, nutritionists or dieticians, and occupational therapists; and people in other professionals, such as ‘dementia advocates’ and lawyers. I think a lot can be done to help individuals with dementia ‘to live well'; in fact I have just finished a big book on it and you can read drafts of the introduction and conclusion here.

It is critical obviously that clinicians, especially the people likeliest to make the initial provisional diagnosis, should be in the ‘driving seat’, but it is also very important that patients, carers, family members, or other advocates are in that driving seat too.  I feel this especially now, given that there is so much information available from people directly involved in with patients (such as @bethyb1886 or @whoseshoes or @dragonmisery) This patient journey is inevitably long, and to call it a ‘rollercoaster ride‘ would be a true understatement. That is why language is remarkably important, and that people with some knowledge of medicine get involved in articulating this debate. Not everyone with power and influence in dementia has a detailed knowledge of it, sadly.

I am very honoured to have my paper on the behavioural variant of frontotemporal dementia to be included as one of a handful of references in the current Oxford Textbook of Medicine. You can view this chapter, provided you do not use it for commercial gain (!), here.

I should like to direct you to the current draft of a video by Prof Alistair Burns, Chair of Psychiatry at the University of Manchester, who is the current National Clinical Lead for Dementia. You can contact him over any aspects of dementia policy on his Twitter, @ABurns1907.  I strongly support Prof Burns, and here is his kind Tweet to me about my work.  I agree with Prof Burns that once individuals can be given face-to-face a correct diagnosis of dementia this allows them to plan for the future, and to access appropriate services. The problem obviously comes from how clinicians arrive at that diagnosis.

I am not a clinician, although I studied medicine at Cambridge and did my PhD on dementia there too, but having written a number of reviews, book chapters, original papers, and now a book on dementia, I am deeply involved with the dementia world. I am still invited to international conferences, and I personally do not have any financial vested interests (e.g. funding, I do not work for a charity, hospital, or university, etc.) That is why I hope I can be frank about this. Clinicians will be mindful of the tragedy of telling somebody he or she has dementia or when he or she hasn’t, but needs help for severe anxiety, depression, underactive thyroid, or whatever. But likewise, we are faced with reports of a substantial underdiagnosis of dementia, for which a number of reasons could be postulated. Asking questions such as “How good is your memory?” may be a good basic initial question, but clinicians will be mindful that this test will suffer from poor specificity – there could be a lot of false positives due to other conditions.

At the end of the day, a mechanism such as ‘payment-by-results’ can only work if used responsibly, and does not create an environment for ‘perverse incentives’ where Trusts will be more inclined to claim for people with a ‘label’ of dementia when they actually do not have the condition at all. A double tragedy would be if these individuals had poor access to care which Prof Burns admits is “patchy”. In my own paper, with over 300 citations, on frontal dementia, seven out of eight patients had very good memory, and yet had a reliable diagnosis of early frontal dementia. Prof Burns rightly argues the term ‘timely’ should be used in preference to ‘early’ dementia, but still some influential stakeholders are using the term ‘early’ annoyingly. On the other hand, I wholeheartedly agree that the term ‘timely’ is much more fitting with the “person-centred care” approach, made popular in a widespread way by Tom Kitwood.

I am still really enthused about the substantial progress which has been made in English dementia policy. I enclose Prof Burns’ latest update (draft), and the video I recorded yesterday at my law school, for completion.

Prof Alistair Burns, National Clinical Lead for Dementia

Me (nobody) in reply

 

 

We've just had a huge debate about the NHS. It's just a pity that it's been the wrong one.



 

 

 

 

Think of how much time we’ve just all spent, in thinking about the way in which services will be mostly put out for competitive tendering in the National Health Service. One of the first rules in law is that you fight your battles to the hilt, but, at first, you pick the right battles first. This is precisely what Labour appears not to have done. When Harriet Harman recently said on Question Time that the Conservatives are definitely not ‘to be trusted with the NHS’, Harriet curiously did not refer to the battle and war just won by the Conservatives (and Liberal Democrats) over NHS procurement. And yet the public desperately want Labour to stand up for the NHS. One member even suggested that, if Labour gave its unequivocal backing for restoring the NHS, Labour could even find itself with a massive vote winner.

 

Labour is clearly going through policy strands with a fine tooth comb, looking at, for example, the way in which multinational companies might employ workers at below the national minimum wage; effectively, controlling immigration through a wage policy. It does not appear to have worked out unequivocally whether it would reduce the rate of VAT, meaning possibly that the state borrowing requirement would temporarily increase. But do you see what they all did there? For days, weeks, or even months, we have been subjected to a relentless debate about EU immigration, when most surveys probably place the issue at number ten on the list of voters’ concerns. Unsurprisingly, the economy remains in ‘pole position’, but the ability of Labour to turn the opinion of the public, particularly in the South of England, away from the idea that Labour is ‘fiscally incontinent’ remains unconvincing. Labour is still considered to be the “tax and spend” party, for example, and Miliband appears painfully aware of that. So, when it comes to policy, there seems to be an odd combination of Labour shooting itself in the foot, or completely picking the wrong battles. And then you add in a complete inability to look at elephants in the room. Labour, to state the obvious, has no ability to implement any of its policies, if it is unable to win a General Election, and the confidence of Labour to win an election on its own is reflected accurately in Lord Adonis promoting his book that ‘if he were to form a new Lib-Lab pact, he wouldn’t start from here.

 

The NHS remains pivotal in Labour’s electoral chances, and Labour has been unable to use the resentment over the section 75 NHS regulations to maximise political capital. Why this should have happened in itself is interesting, as Andy Burnham, MP for Leigh, is a more than capable Shadow Secretary of State for Health. One of the issues is an ability to choose the right battle, possibly. Burnham, with some support from the right-wing media and thinktanks, has been banging on about integrated and whole-person care. Whether through conspiracy or cock-up, there will be short-term interest in how integrated care might be delivered. Think about a justification for State spending in the ‘mission impossible’ of implementing a NHS IT system. Why on earth would a right-wing libertarian government promote something which is national? Why on earth should you abort an ethos of ‘bonfire of the QUANGOs’ to introduce the biggest QUANGO in the country, viz NHS England? Whether you’re into conspiracy or cock-up, the integration of financial and medical information (including mental, physical and social care systems) allows for the perfect infrastructure for an insurance-based system. Insurance works on the basis of misrepresentation or non-disclosure to invalidate claims, so ‘big data’ serve a perfect storm for this. It won’t have escaped anybody’s attention that Labour (as indeed the Conservative Party) has been heading towards an insurance-based system for social care, so it does not require a massive ideological leap to think how this could be extended for all care with time. This does not involve any degree of paranoia, please note.

 

There is overwhelmingly an intellectual depravity in the bereft notion of producing policy through poll results and focus groups. New Labour clearly loved focus groups, with Philip Gould in ‘The Unfinished Revolution’ having devoted much airspace to developing a product in line with customers’ wishes. Of course, the Conservatives have a special affinity for polling organisations themselves, Nadhim Zadawi, in 2000 he co-founded YouGov and on its flotation became its CEO. YouGov is now one of the world leaders in political and business information gathering, polling and analysis. It employs over 400 staff on three continents and is listed on the London Stock Exchange. Again – it begs the question on why should Labour should wish to outdo the Conservatives on its own ability to use polling data? One of the polls which has become a toxic meme is how a high proportion of all voters would not mind who provides the NHS services, as long as it’s free at the point of use. However, this is intrinsically linked to other questions. Would you be prepared more in national insurance if it meant the NHS were able to provide a more comprehensive (universal) service?

 

It is indeed correct to state that the costs of renationalising the NHS might be overwhelming, although no accurate costings of this have ever been discussed properly. We do know, however, that the current cost of the NHS reorganisation is in the region of £3bn, but estimates of the actual cost inevitably have to be taken with a pinch of salt, as say the cost of Margaret Thatcher’s funeral. But to use this issue as a wish to stop discussion of this area is lazy, as one of the issues, as indeed as with Thatcher’s funeral, is that is this a sensible use of money compared to how it could be used elsewhere (so called “opportunity cost“)? Some people argue that the marketisation of the NHS has failed, in that any money spent on restoring a state-funded NHS would be money well spent. Restoring a state-funded service would get out of the idea of private companies being driven by maximising their profit margin, and not running a ‘more for less’ approach for delivering a service. Cynics might argue that the cost of restoring a state-run service is peanuts compared to waging a war abroad. Many remain unconvinced about the mantra that economic competition drives up quality, when it is the professional standards of healthcare staff, including doctors, nurses and allied health professionals, which appear to be at the heart of quality. The debate we have just had about the mode of procurement in the NHS was not one any of us as such elected; in other words, it has no mandate. If the Conservatives and the right-wing media appear so pre-occupied about having a referendum next parliament on our membership of the EU, many are (rightly) asking why Ed Miliband cannot ask for a mandate to take sensible decisions about the nature of the NHS. It is a given that there will always be a proportion of services which are outsourced to the private sector, but the question should be ‘how much’. Whilst a full-blown privatisation of the NHS has not happened yet, we have not even had a discussion of how much of the NHS should be outsourced.

 

And anyway Labour has to ask what really concerns all voters? In Mid Staffs and Cumbria, it is reported that there have been concerns about patient safety, and it may be mere coincidence that Labour failed to convince the voters in both places in the local elections over their offerings. However, there is certainly a ‘debate to be had’, about whether “efficiency savings” in the NHS are justified to produce surpluses in the NHS which get ploughed back into the Treasury (and therefore might be used for international overseas aid rather than frontline care.) Labour equally seems unable to look another ‘white elephant’ in the eye. That is of course the concept of a NHS hospital going bust. Should a NHS Trust which is in financial difficulty be simply allowed to go insolvent after a period of administration, or should the State pump money into it to maintain a local service to people in the community? This requires a fundamental reappraisal of how important “solidarity” and “social democracy” are, in fact, to Labour, and whether it wishes to use its extensive brand loyalty to have a mature, if sobering, discussion of the extent to which it wishes to fund a SOCIALIST National Health Service. Whilst in extremis it can be argued that a nostalgic return to ‘The Spirit of ’45” is not attainable, and is the wrong solution for the wrong times, there is a genuine perception that Labour has lost sight of its founding values. And why has this not been addressed in focus groups? It is well known that, in marketing, if you ask the wrong questions, you ubiquitously get the wrong answers.

 

Labour needs a mandate to confront these issues. And it should not be afraid to look for a resounding mandate, either. Whilst it might stick its fingers in its ears, and claim it’s nothing to do with them (arguing instead for integrated, “whole person” care), unless these ideological issues are confronted, NHS policy will continue to go down a right-wing path. For example, there is not much further to see GP ‘businesses’ being offered by the private sector, and the NHS pays for them; in this model, GP ‘businesses’ could operate under a standard 5-year contract, using NHS branding, under a ‘franchising’ model like Subway. And “The Tony Blair Dictum” is far from resolved, although currently there are issues more worthy of ‘firefighting’ in service delivery, such as the fiasco over ‘1111’. Labour’s problem is that it does not see the NHS as a ‘vote winner’, in the same way it doesn’t see the plight of disabled citizens experiencing difficulty with their benefits or people feeling genuinely threatened by ‘the bedroom tax’ as a top priority. Whilst Labour is unable to prioritise its issues in a way to align its aspirations with the concerns of the general public, there is no way on Earth it can hope to govern a convincing majority. If Labour wishes to learn a really useful trick from marketing, it could no better than to look at the ‘GAP analysis’ – looking at what the current situation is, and what the expectations of people are, and thinking how to get to a position of what people want. If people actually want a socialist universal, comprehensive NHS, paid for not in a private insurance system, Labour can be expected to work hard for a mandate to deliver this. If it doesn’t, that’s another matter, and it can witter on about whole-person care to its heart’s content.

We've just had a huge debate about the NHS. It's just a pity that it's been the wrong one.



Think of how much time we’ve just all spent, in thinking about the way in which services will be mostly put out for competitive tendering in the National Health Service. One of the first rules in law is that you fight your battles to the hilt, but, at first, you pick the right battles first. This is precisely what Labour appears not to have done. When Harriet Harman recently said on Question Time that the Conservatives are definitely not ‘to be trusted with the NHS’, Harriet curiously did not refer to the battle and war just won by the Conservatives (and Liberal Democrats) over NHS procurement. And yet the public desperately want Labour to stand up for the NHS. One member even suggested that, if Labour gave its unequivocal backing for restoring the NHS, Labour could even find itself with a massive vote winner.

 

Labour is clearly going through policy strands with a fine tooth comb, looking at, for example, the way in which multinational companies might employ workers at below the national minimum wage; effectively, controlling immigration through a wage policy. It does not appear to have worked out unequivocally whether it would reduce the rate of VAT, meaning possibly that the state borrowing requirement would temporarily increase. But do you see what they all did there? For days, weeks, or even months, we have been subjected to a relentless debate about EU immigration, when most surveys probably place the issue at number ten on the list of voters’ concerns. Unsurprisingly, the economy remains in ‘pole position’, but the ability of Labour to turn the opinion of the public, particularly in the South of England, away from the idea that Labour is ‘fiscally incontinent’ remains unconvincing. Labour is still considered to be the “tax and spend” party, for example, and Miliband appears painfully aware of that. So, when it comes to policy, there seems to be an odd combination of Labour shooting itself in the foot, or completely picking the wrong battles. And then you add in a complete inability to look at elephants in the room. Labour, to state the obvious, has no ability to implement any of its policies, if it is unable to win a General Election, and the confidence of Labour to win an election on its own is reflected accurately in Lord Adonis promoting his book that ‘if he were to form a new Lib-Lab pact, he wouldn’t start from here.

 

The NHS remains pivotal in Labour’s electoral chances, and Labour has been unable to use the resentment over the section 75 NHS regulations to maximise political capital. Why this should have happened in itself is interesting, as Andy Burnham, MP for Leigh, is a more than capable Shadow Secretary of State for Health. One of the issues is an ability to choose the right battle, possibly. Burnham, with some support from the right-wing media and thinktanks, has been banging on about integrated and whole-person care. Whether through conspiracy or cock-up, there will be short-term interest in how integrated care might be delivered. Think about a justification for State spending in the ‘mission impossible’ of implementing a NHS IT system. Why on earth would a right-wing libertarian government promote something which is national? Why on earth should you abort an ethos of ‘bonfire of the QUANGOs’ to introduce the biggest QUANGO in the country, viz NHS England? Whether you’re into conspiracy or cock-up, the integration of financial and medical information (including mental, physical and social care systems) allows for the perfect infrastructure for an insurance-based system. Insurance works on the basis of misrepresentation or non-disclosure to invalidate claims, so ‘big data’ serve a perfect storm for this. It won’t have escaped anybody’s attention that Labour (as indeed the Conservative Party) has been heading towards an insurance-based system for social care, so it does not require a massive ideological leap to think how this could be extended for all care with time. This does not involve any degree of paranoia, please note.

 

There is overwhelmingly an intellectual depravity in the bereft notion of producing policy through poll results and focus groups. New Labour clearly loved focus groups, with Philip Gould in ‘The Unfinished Revolution’ having devoted much airspace to developing a product in line with customers’ wishes. Of course, the Conservatives have a special affinity for polling organisations themselves, Nadhim Zadawi, in 2000 he co-founded YouGov and on its flotation became its CEO. YouGov is now one of the world leaders in political and business information gathering, polling and analysis. It employs over 400 staff on three continents and is listed on the London Stock Exchange. Again – it begs the question on why should Labour should wish to outdo the Conservatives on its own ability to use polling data? One of the polls which has become a toxic meme is how a high proportion of all voters would not mind who provides the NHS services, as long as it’s free at the point of use. However, this is intrinsically linked to other questions. Would you be prepared more in national insurance if it meant the NHS were able to provide a more comprehensive (universal) service?

 

It is indeed correct to state that the costs of renationalising the NHS might be overwhelming, although no accurate costings of this have ever been discussed properly. We do know, however, that the current cost of the NHS reorganisation is in the region of £3bn, but estimates of the actual cost inevitably have to be taken with a pinch of salt, as say the cost of Margaret Thatcher’s funeral. But to use this issue as a wish to stop discussion of this area is lazy, as one of the issues, as indeed as with Thatcher’s funeral, is that is this a sensible use of money compared to how it could be used elsewhere (so called “opportunity cost“)? Some people argue that the marketisation of the NHS has failed, in that any money spent on restoring a state-funded NHS would be money well spent. Restoring a state-funded service would get out of the idea of private companies being driven by maximising their profit margin, and not running a ‘more for less’ approach for delivering a service. Cynics might argue that the cost of restoring a state-run service is peanuts compared to waging a war abroad. Many remain unconvinced about the mantra that economic competition drives up quality, when it is the professional standards of healthcare staff, including doctors, nurses and allied health professionals, which appear to be at the heart of quality. The debate we have just had about the mode of procurement in the NHS was not one any of us as such elected; in other words, it has no mandate. If the Conservatives and the right-wing media appear so pre-occupied about having a referendum next parliament on our membership of the EU, many are (rightly) asking why Ed Miliband cannot ask for a mandate to take sensible decisions about the nature of the NHS. It is a given that there will always be a proportion of services which are outsourced to the private sector, but the question should be ‘how much’. Whilst a full-blown privatisation of the NHS has not happened yet, we have not even had a discussion of how much of the NHS should be outsourced.

 

And anyway Labour has to ask what really concerns all voters? In Mid Staffs and Cumbria, it is reported that there have been concerns about patient safety, and it may be mere coincidence that Labour failed to convince the voters in both places in the local elections over their offerings. However, there is certainly a ‘debate to be had’, about whether “efficiency savings” in the NHS are justified to produce surpluses in the NHS which get ploughed back into the Treasury (and therefore might be used for international overseas aid rather than frontline care.) Labour equally seems unable to look another ‘white elephant’ in the eye. That is of course the concept of a NHS hospital going bust. Should a NHS Trust which is in financial difficulty be simply allowed to go insolvent after a period of administration, or should the State pump money into it to maintain a local service to people in the community? This requires a fundamental reappraisal of how important “solidarity” and “social democracy” are, in fact, to Labour, and whether it wishes to use its extensive brand loyalty to have a mature, if sobering, discussion of the extent to which it wishes to fund a SOCIALIST National Health Service. Whilst in extremis it can be argued that a nostalgic return to ‘The Spirit of ’45” is not attainable, and is the wrong solution for the wrong times, there is a genuine perception that Labour has lost sight of its founding values. And why has this not been addressed in focus groups? It is well known that, in marketing, if you ask the wrong questions, you ubiquitously get the wrong answers.

 

Labour needs a mandate to confront these issues. And it should not be afraid to look for a resounding mandate, either. Whilst it might stick its fingers in its ears, and claim it’s nothing to do with them (arguing instead for integrated, “whole person” care), unless these ideological issues are confronted, NHS policy will continue to go down a right-wing path. For example, there is not much further to see GP ‘businesses’ being offered by the private sector, and the NHS pays for them; in this model, GP ‘businesses’ could operate under a standard 5-year contract, using NHS branding, under a ‘franchising’ model like Subway. And “The Tony Blair Dictum” is far from resolved, although currently there are issues more worthy of ‘firefighting’ in service delivery, such as the fiasco over ‘1111’. Labour’s problem is that it does not see the NHS as a ‘vote winner’, in the same way it doesn’t see the plight of disabled citizens experiencing difficulty with their benefits or people feeling genuinely threatened by ‘the bedroom tax’ as a top priority. Whilst Labour is unable to prioritise its issues in a way to align its aspirations with the concerns of the general public, there is no way on Earth it can hope to govern a convincing majority. If Labour wishes to learn a really useful trick from marketing, it could no better than to look at the ‘GAP analysis’ – looking at what the current situation is, and what the expectations of people are, and thinking how to get to a position of what people want. If people actually want a socialist universal, comprehensive NHS, paid for not in a private insurance system, Labour can be expected to work hard for a mandate to deliver this. If it doesn’t, that’s another matter, and it can witter on about whole-person care to its heart’s content.

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