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The Liberal Democrats and UKIP should pledge to repeal the Health and Social Care Act
Ed Miliband, Andy Burnham, and the whole of Labour have pledged robustly that a direction to repeal the Health and Social Care Act (2012) will be made in the first Queen’s Speech of a new Labour Government.
It is said that David Cameron and Nigel Farage are to be issued with a joint challenge to declare that they will rule out any attempt to repeal the ban on foxhunting if they form a pact in the event of a hung parliament.
Evan Harris on 6 March 2012 identified the impact that the Lansley legislation would have to turbo-boost marketisation and privatisation of the NHS.
He warned Liberal Democrat colleagues not to touch it with a bargepole:
“It has no friends among even the non-party-political royal colleges, and has no mandate in those areas where it goes beyond the coalition agreement. The political impact will be to retoxify the Tory brand – which they are welcome to do, of course –, but also, by association, to damage the Lib Dems.”
The assurances given by Lord Clement Jones have turned out to be hollow:
“In putting down amendments, we have no hostility to competition as such, merely a desire to make use of the opportunities that the TFEU and European competition law offer member states to avoid the NHS being treated like a utility, such as gas and electricity.
Under the EU treaties, Article 106 of the Treaty on the Functioning of the European Union states:
“Undertakings entrusted with the operation of services of general economic interest … shall be subject to the rules contained in this Treaty, in particular to the rules on competition, insofar as the application of such rules does not obstruct the performance, in law or in fact, of the particular tasks assigned to them”.
Member states have certain discretion as to which services are services of general economic interest. By ensuring healthcare services for the purposes of the NHS are services of general economic interest and that the “task” of co-operation between services is “assigned” to the healthcare providers, it should be possible to provide some protection from less desirable aspects of competition law.”
This year saw Cambridgeshire and Peterborough NHS Foundation Trust awarding G4S Integrated Services a £3.9 million contract to provide domestic cleaning, portering and catering support across its property portfolio. The three year agreement, with the option to extend for a further year, will see G4S initially delivering services to 34 sites across Peterborough and Cambridgeshire, with further locations likely to be added in the future. Cleaning will be provided across the contract, with additional portering services and catering support at some specific sites.
Privatisation does not require a complicated definition. It’s simply the transfer of public sector resources into the private sector. Even the late Sir Keith Joseph, widely thought to be “brilliant” by the late Margaret Thatcher herself, and who was thought to be the principal “architect” of Thatcherism, ended up trying to keep afloat businesses in the public sector rather than privatise them. This was during his time as Secretary of State for Trade and Industry.
There is generally a feeling that the Coalition government, a joint enterprise between the Conservatives and the Liberal Democrats, went much further in privatising the NHS than the Thatcher government even dared to. And the worst aspect of this was there was absolutely no inkling that this would happen. There was no mention of this even in the Coalition Agreement of 2010.
There is no official policy by UKIP on the NHS yet.
This is absolutely staggering. The late Tony Benn used himself to warn people against voting for people who are ‘false prophets’. UKIP seem alarmingly reluctant to acknowledge the number of people from black asian minority ethic background who actually work for the NHS and bring value to it everyday.
It is now felt that there is quite a high chance of a ‘hung parliament’, although Labour activists are desperate to fight for a Labour government at Westminster with a healthy majority. It appears that the mainstream right-wing press have given up the ghost, in the form of David Cameron.
It is curious why the Conservative Party haven’t ditched their leader, like they did famously in 2010, but the most parsimonious explanation is that it would make sense to find a new leader after the expected catastrophe of the 2015 election. Ditching Cameron now might mean that they would have to ditch a new leader further in 2015. Besides, the Conservatives and Liberal Democrats have become a tried and tested product as far as the City are concerned.
The current Government, and people who sail with her such as BoJo, have fiercely defending the City’s interests in Europe as far as banker bonuses are concerned. They have resisted the ‘Mansion Tax’, which is widely thought to be introduced by Ed Balls as Chancellor in the first Budget of a Labour Government, as a windfall tax to produce a cash injection into the NHS. Furthermore, the City still has lucrative contracts in the form of the private finance initiative which have yet to be renegotiated properly from this Government; and also they have been very successful in promoting social impact bonds, the PFI equivalent for social enterprises, with the current Government which has used mutualisation to Trojan horse rent seeking in response to Mid Staffs.
Certain dividing lines have now got to be laid for the sake of the public good.
I feel that it is essential that David Cameron, Nick Clegg, and Nigel Farage are to be issued with a joint challenge to declare that they will rule out any attempt to resist the repeal of the Health and Social Care Act (2012).
Nigel Farage, for all his faux socialist credentials, seems unseen to resist formally the privatisation of the NHS; in fact his henchmen over the years have prided themselves on the ‘efficiency’ of the private sector, despite the growing allegations of fraud and inefficiency from the outsourcing companies used by the current government to deliver the smaller State.
Nick Clegg not only has a PR problem; he has a major issue with the content of what the Liberal Democrats stand for. It is widely known that there is discontent about his party’s ‘differentiation’ policy, which has seen the Tories and the Liberal Democrats telling the voters why each other party is clearly unfit for government. The charge sheet against the Liberal Democrats, including a weak economy (not enough till receipts from income tax to fund public services), demolition of legal aid, privatisation of NHS, misery for a mass of disabled citizens through botched welfare reforms, is substantial.
As a minority party, the Liberal Democrats would be asked to repeal the Health and Social Care Act (2012) which is possible but simply weird. It is clear that the Liberal Democrats, Conservatives and UKIP are clearly capable of running the NHS into the ground.
A lot of energy was put into fighting the Liberal Democrats on the toxic firestorm hospital closure clause, clause 119, which the Liberal Democrats were instrumental in protecting. Norman Lamb, for all his soothing words, has been the Minister of State in office while social care has imploded; the social care budget has not been ring fenced, coincidentally, since 2010.
There was a popular joke on Twitter this year that turkeys joked, “It’s like humans voting for UKIP”.
David Cameron, if he is still leader in 2015, or whoever is in charge of that toxic brand, will clearly be in no position to repeal the Health and Social Care Act (2012). The least worst option is that the Liberal Democrats and UKIP should pledge not to resist the repeal of the Health and Social Care Act (“Act”), but the hope is that a strong Labour government will have renewed vigour in assessing the political weather. Even better, they should pledge to repeal the Act.
That is, the component of the private sector in the mixed health and care economy has gone way too far. The health and care sectors should never be run anywhere for the benefit for shareholders offering care in 15 minute slots or below the minimum wage. The health and care sectors should not be so fragmented as they are now. People should be collaborating with each other to offer excellent clinical care, not competing with each other.
The vote is the most critical weapon of influence any of us has. Even more than ever, it is vital that it is used wisely.
The general public have never needed the NHS campaigners as much before. The situation is critical.
“The past is a different country. They did things differently there.’
One of the favourite weapons in the armoury of supporters of the present Coalition is that the warning claims over the NHS have been in the past ‘exaggerated’ or ‘scaremongering’.
And yet today broke records being broken, for the longest waits in the Accident and Emergency departments in England; and a record number of emergency admissions.
The National Health Service currently has a statutory duty to promote innovation. But nobody would have thought that Mr. Hunt (who is not a professional surgeon, or professional medic, to my knowledge) would have ‘done things differently'; by adding a ‘Spring Crisis’, ‘Summer Crisis’ and ‘Autumn Crisis’ to a ‘Winter Crisis’.
Put simply, sadly the claims by NHS supporters do not constitute merely ‘scaremongering’. It may have been urgent to ‘save the NHS’ in the past; as indeed Labour had to do in 2007 when the service was teetering on the brink last time. But the situation is now critical.
The last few years have seen a litany of errors in public health policy; such as in standard packaging of cigarettes, or minimum pricing of alcohol. It has been impossible for the Conservatives and the Liberal Democrats, who are both devoted to the multinational free movement of capital, to act in the true public interest.
But by far the worst event to have happened were the Conservatives and Liberal Democrats getting onto the state books the ‘Health and Social Care Act’.
The Liberal Democrats’ contribution to this statutory instrument cannot be underestimated by any means. Despite the noblest actions of a minority of ‘good LibDems’, such as Dr Charles West, the cheap words of some LibDems Peers in the debate over the toxic ‘section 75′ made their position perfectly clear.
Section 75 of ‘the Lansley Act’, which senior Conservatives now claim not to have understood, couldn’t have been clearer. It was a clear departure from the previous law. It laid out a clear threat in law for the first time a legal threat to any commissioners departing from putting contracts out to formal competitive tender, if there were not a sole bidder.
The Liberal Democrats, Conservatives and UKIP may now show what can best be described as ‘amnesia’ over this instrument which some of them actually legislated for, as well as the £3bn ‘top down reorganisation’ which David Cameron swore blind would never be introduced, but “the facts speak for themselves”: or, as my learned legal colleagues, put it, ‘res ipsa loquitur’.
Andy Burnham MP this morning in an article in the New Statesman laid bare the sheath of lies by Nick Clegg in the House of Parliaments over the NHS.
Sadly, while Jeremy Hunt and Dan Poulton fiddle while the NHS collapses, there is a record number of admissions in emergency departments in England, and the most vulnerable people are labelled ‘bed blockers’ by a supine and ineffective English media as they cannot leave hospital to a social care system which has now collapsed through starvation.
Labour argues that it last used the private sector in needing to address a ‘backlog’ in demand, but the question is how the NHS get to this state in the first place? It’s because for decades, as NHS campaigners rightly argue, the NHS and social care systems have been given the bare minimum to carry out their functions.
NHS managers, many of whom are generously paid more than their ability might suggest, and certainly much more than frontline nurses implementing a policy savaged by staffing cuts in the name of ‘efficiency savings’, have been trying to balance the books through a number of mechanisms, such as laying off staff, not giving existent staff a pay rise, or paying corporates loan repayments for PFI or lawyers for doing their administration.
Labour possibly can argue then it was a temporary measure to pay off people in the private sector to do the work the NHS had been carrying out, but the mainstream parties should be in the business of delivering a well functioning NHS. As Andy Burnham MP said in launching his party’s campaign on the NHS in the European Election in 2014, we’ve got a sad state when the Conservatives and LibDems are competing for the lowest social care bills irrespective of whether the services are awful.
And it’s sacracant to criticise the NHS managers, but any reasonable guardian of these managers will ask why they have allowed their own senior pay to balloon;
why performance management of Doctors and nurses in the NHS is so poor, with performance management being regularly done by the regulator not by human resources;
why so much money has been siphoned off for ‘transaction costs’ of law and admin the implement the NHS reforms;
why PFI contracts have been so poorly negotiated such that the cost to the State is enormous;
how come so many private providers are being directly paid out of the NHS monies provided by taxpayers;
why there seems to be an enthusiasm to pay short-term locum staff at exorbitant rates instead of investment in the current workforce;
and so on?
The Health and Social Care Act (2012) drove the NHS over the edge. Put simply, the NHS and social care systems would not be able to survive another sudden legislative mechanism designed to privatise the NHS?
On this Camilla Cavendish is simply incorrect. You would have thought with all her experience she should have come up with a better definition of ‘privatisation’ on BBC Question Time last night. it is the standard argument of those who say it is not privatisation to say that privatisation is accompanied by a ‘tell Sid’ type flotation (also called the “initial public offering’).
It is not.
Privatisation is simply wholesale transfer of assets and resources from the public sector to the private sector.
There has been every possible last-ditch effort to deny this was NHS privatisation from the current neoliberal Coalition parties. It is definitely privatisation. The taxpayer is paying private companies for functions which the State should be providing, without private companies footing properly their part of the ‘bill’ including for training of the current workforce of professionals.
The ratcheting up of how ‘it is not privatisation’ or ‘we should look at whether private provision is a bad thing’ is a testament to this.
Quite simply, the NHS would not survive another five years of the Conservatives. We should rally around NHS campaigners of all parties to ensure the Conservatives and Liberal Democrats are not re-elected nationally to run the NHS for their benefit.
The National Health Service is not supposed to be run for the benefit of private sector ‘rent seekers’, or MPs who also have interests in the private health industry. Keep our NHS public. Keep the NHS National run for the public good.
Support your NHS campaigner. He or she needs you.
The ‘NHS Five Year Forward Plan’ is a clever marketing stunt, and is barely a statement of strategy
There’s no “magic money tree”, except when you’re signing off HS3 on a ‘nod and a wink’ for £7 billion, or interventions in Iraq and Afghanistan for £30 billion.
As a piece of marketing, for Simon Stevens to set out a stall for the rôle of the NHS in a global economy, “the five year plan” was nice and succinct. As a piece of strategy, it is dreadful. It’s dreadful – even if you decide to take the view that health policy is entirely market-driven or “value-based”, and not in any way written through a sophisticated clinical prism.
The irony of a “five year plan” for the National Health Service is pretty quick to see. “Five year plans” were, of course, used by Stalinist Russia. Nazi Germany preferred ‘four year plans’ as a strategy for war readiness, in comparison.
It is reported that the “Five Year Forward View”, published last week by NHS England, is a collaboration between six leading NHS groups including Monitor, Health Education England, the NHS Trust Development Authority, Public Health England, the Care Quality Commission and NHS England.
And yet ironically the future of two of the contributing organisations is under doubt. In a fringe meeting earlier this at the Labour Party Conference, it was again mooted what the precise function of Monitor might be. This is because it is definite that an incoming Labour Party government, in its first Queen Speech, will repeal the Health and Social Care Act (2012), a much loathed piece of legislation. This leaves the precise functions of Monitor uncertain.
One possibility which Burnham is seriously contemplating is whether Monitor, if it continues to exist, serves to regulate the integration of services as would be expected in ‘whole person care’. Burnham intends to introduce ‘NHS preferred provider’, which could insist on the NHS being the lead provider in contracts for as long as ten years in the ‘prime contractor model‘.
And the future of the Care Quality Commission was put on a cliff-edge with the report of the Sir John Oldham Commission, again to do with whole person care. It would make much more sense to reform the regulators to oversee health and care with a single regulator in future. This would again be in line with the regulation of health and care professionals, much needed, and proposed by the English Law Commission, but kicked into the long grass by the current Government as it ran out of time.
The “5 year Forward View” to all intents and purposes reads like a marketing document, a wish-list for further privatisation of the NHS. It may ‘pack a punch‘, from the BBC which has unreservedly succeeded in throttling any discussion of the NHS reforms. But talk of ‘accountable care organisations’, as developed in Spain and the United States, and the emphasis on preventive health packages so keenly sold by multinational corporates, are paradigmatic of a wish-list of a privateer.
The document is a naked shill, intended to carry on the ‘case for change’ which has been made exhaustively by think tanks such as the King’s Fund which, some might say, were instrumental in giving the catastrophic policy of market competition in the National Health Service some legs in the first place.
But the runes are clearly there.
Take, for example, the seemingly-modest proposal of “integrated care commissioning”. The policy of personal budgets in the full glare of sunlight looks incredibly anaemic. Unanswered questions exist how a universal health system is going to be successfully merged with a means-tested care system. NHS England tried, unsuccessfully, to head this issue off at the pass as far back as in 2012.
Personal health budgets, which Simon Stevens has continued to speak moistly of, are the perfect vehicle for introducing ‘top ups’ and ‘copayments’, threatening the fundamental principle of universal, free-at-the-point-of-need.
And moves, not contained in the ‘5 year plan’, spell out an ominous direction of travel. It has just been announced that the much maligned contract for processing ATOS, given under the last Government to ATOS, is to be given to a company called Maximus, which has a proven track record in handing long term care packages in other jurisdictions.
“Independent” think tanks have never shrugged off successfully the “power of the prepaid cards”, see for example the DEMOS initiative. It has always been vehemently denied that there will be no merging of universal credit and healthcare provision, although Liam Byrne’s account of Jennie Macklin in Australia painted a rather different story in an article in the Guardian provocatively entitled “Let’s help disabled people achieve their full potential“.
Like a multi-national corporate document, the “5 year plan” is high on marketing but poor on strategy. A good example of this is given on page 36 in relation to a ‘threat’ facing the National Health Service, that of recurrent pay freezes to the majority of nurses whilst the economy is reputed to be recovering.
The seemingly innocuous line, at the end of page 35, reads: “For example as the economy returns to growth, NHS pay will need to stay broadly in line with private sector wages in order to recruit and retain frontline staff.” But it is well known that any wish to pay nurses a wage that reflects the value that runs through their work like letters in a stick of rock will be strongly resisted by the Treasury, while the Conservative Party will prefer further to tattoo the words of low taxes onto his breast plate of ideology.
There are other clear examples of the document clearly lacking in clarity. For example, page 33 sees a promotion of ‘personalised medicine’, how the NHS and “our partners” (meaning in the third and private sector, actually) might deliver the genome based ‘revolution’. Again, the document’s thrust is one of marketing, not clear strategy. There is no mention of the changes in resource allocation which would be required to serve this revolution, essentially seeing hardworking taxpayers subsidise the shareholder dividends or surpluses of large corporate-like charities. There is absolutely no mention of the changes in the legislative framework that would be needed, as in the United States, to prevent genetic information non-discrimination. But here again the document serves its marketing function – as a prospective prospectus for would-be investors wishing to spot lucrative opportunities in the NHS as a data mine.
Like there is no mention of “NHS preferred provider”, unsurprisingly there is no mention of “whole person care”. And yet, even if Labour fail to win an outright majority, it will seek to implement this being the largest party in Government. And this policy is set to see a profound change in the landscape of health and care provision for England.
In any business strategy, one is obliged to think of the political, economic, social, technological, legal and environmental headwinds (affectionately known as “PESTLE” to business strategists). A good example of social changes in the five years might have been, for example, a change in direction of the NHS being seen as resentment as costing much money, despite its striking efficiency, but one which values its workforce (for example in the salary of most of its nurses).
Looking at the political headwinds, it is quite incredible for example there is no mention of trade agreements such as TTIP and the investor-to-state dispute settlement clauses. If this ‘5 year forward plan’ had been at all serious, it would have been included, not least as it is a headwind which could drastically throw off course further the direction of travel of the NHS as a state-run health service.
Simon Stevens’ vision is a ‘charismatic vision’ of sorts. But a vision does not have to be particularly credible for it to get populist appeal or succeed. It just needs to be communicated clearly, with supine and compliant supporters in the trade media.
If the document were a ‘heads up’ for how we could afford a NHS through general taxation which was genuinely universal and free at the point of need, this document would have served a function. As it is, the document is a lubricator for mechanisms which could optimise the part that the private sector has to play, with no mention of the dogs being unleashed in the global marketplace – in much the same way Cameron refused to signpost “the top down reorganisation”. It is impossible for a strategy document for the NHS simply to airbrush out the political and legal factors which will be at play in the lifetime of the next Government. As it is, the NHS ‘5-year forward view’ is a basic piece of marketing, which as a strategic plan scores 0/10.
Burnham announces plans to implement a National Health and Care Service over ten years
The Shadow of Secretary of State for Health, Andy Burnham MP, says that he has tried to produce an answer ‘which people can believe in, and which people can buy into’.
This is particularly timely, as it is well known that Labour intend to make the NHS a major general election issue next year.
The Conservatives and Liberal Democrats are now deeply unpopular over their management of the NHS, as evidenced, for example, by the campaigners who converged on Trafalgar Square recently on behalf of the “Darlo Mums”.
Over successive governments and most recently, the finances of social care have suffered massively.
Speaking at a fringe event for the Fabian Society in Manchester yesterday, Burnham felt that things are not satisfactory as the response to an ageing society has been through a medical model.
Burnham’s problem is that he is about to be bequeathed a fragmented illness service, not a national health service; and that the system is patient-focused on ill people not person-focused on people through health and illness. Burnham feels that focusing on people will enable a greater focus on friends and families too.
Burnham feels that the “ever-increasing hospitalisation” of an ill ageing population will not work, and that hospitals are becoming increasingly dysfunction all the year round due to a social care system which has been malnourished over successive governments.
“This failure piles pressure on the acute system”.
Burnham further adds that people “are battling in caring for people with complex needs”, and that “these silos are not ones which can afford any more”.
This policy is anticipated to bring in housing, education, and leisure strands in due course.
But the urgency for Burnham is to deal with people having to avoid recounting their personal stories repeatedly to different people; and that professionals are often making clinical decisions on the basis of incomplete information.
The intention is, ultimately, to bring together systems for physical health, mental health and care. Sir John Oldham had earlier in the fringe event observed that the general public can have a poor understanding of the word “social” in relation to ‘social care’.
Burnham intends to set out a ten year plan for a whole person care, fully accepting the findings of the Oldham Commission, and which “endorses” the findings of the Barker Commission from the King’s Fund.
Such a plan will be strongly attractive to those vociferous critics, such as Sir David Nicholson the immediate predecessor of Simon Stevens as the CEO of NHS England, that health policy has traditionally been adopted on the basis of the electoral cycle.
This system will be a “National Health and Care Service”, which will realign an activity-based tariff for episodes of illness to produce a single ‘year of care’ budget for each person covering his or her physical, mental or social meeds. This, Burnham feels, will support prevention and wellbeing.
At first the idea was to have a pooled integrated budget across health and care, but, in the subsequent question/answer session, Burnham made extremely clear that he was mindful of the need to move away from privatised fragmented care; and to move away from compulsory personal health budgets which had not been proven to work well.
Burnham, instead, signposted plans to be announced later this week that he would instead advocate a general ‘rights based approach’, where citizens could be given realistic expectations of the development of personal care plans according to their needs.
Burnham emphasised that he remained unconvinced that personal budgets were the sole instrument that could achieve this aim.
He is of course extremely mindful of the public’s overwhelming lack of appetite for the marketisation, outsourcing or privatisation of the NHS.
As an example of ‘market failure’, Burnham cites how councils in their wish to compete to keep council tax bills low end up failing on high quality care.
Interestingly, he also feels that this plan has the potential to be ‘radical’, allowing people can be supported to care, enabling full personalisation.
Such a system will involve a “care coordinator”. This has already been mooted publicly very recently by the Shadow Minister for Care, Liz Kendall MP, as a point of contact for the elderly to navigate themselves through the maze of information including care information.
Such a rôle, it is felt, might not be for general practitioners, but possibly for specialist nurses. The voluntary sector, such as Dementia(UK) which developed the innovative specialist “Admiral” nurses programme, might be well placed to act as these coordinators.
In the alternative, social care practitioners might be particularly well suited for a care coordination rôle for people with dementia, as they command expertise in decision-making and capacity. Social care practitioner leads in this context would help to overcome a barrier to cultural integration, furthermore; this is especially important given the often perceived hierarchies of the professions involved.
“Carers will no longer be peripheral to the system, but central to the development of a care plan.”
This plan would be established over a ten year period to integrate services around the individual, not through a sudden ‘top down reorganisation’.
A potent steer for this would come from the Health and Wellbeing Boards.
It is expected that the Labour Party will also use their party conference this year in Manchester to emphasise its intention to repeal the Health and Social Care Act (2012) in the first Queen’s Speech of an incoming government in 2015.
Jackie Ashley, Sir John Oldham, who chaired the Oldham Commission, and Kate Barker, who chaired the Barker Commission of the King’s Fund, panel members yesterday evening, all agreed that it was unlikely that politicians would openly wish to pledge to raise taxes for health and care. The way in which this had been politically debated in the 2010 UK general election, it is felt, had been unimpressive.
Nonetheless, the general sentiment was that the public would appreciate an open discussion of how sustainable funding for health and care systems could be achieved.
Jackie Ashley, who writes for the Guardian, explained the difficulties in the news media approaching this topic, when headlines consistently remained fixated on crises in the NHS.
The general policy trend has been try to support people who wish to live and to be cared for at home independently.
However, Ashley alluded to the need to avoid a narrative that hospitals are necessarily bad and non-hospitals are necessarily good.
It is felt that when the NHS was originally set up it was not designed to be catering for people in their 90s with their multiple clinical care needs.
Nonetheless, Oldham urged the need for NHS England to move away from the needs of hospitals, and urged, as an example, a greater number of representatives from local authorities (currently involved in commissioning social care) on NHS England.
For a condition such as one of the dementias, citizens have the perception of their care needs being financially punished through the need to pay for care; this is, for example, in contrast to a condition such as one of the cancers, where the NHS appears willing to pay for expensive medications often.
Equity, equality, fairness and justice will therefore be key aims of this new National Health and Care Service.
“These are some silos which we desperately must get rid of”, exhorts Burnham passionately.
Finally, Burnham wishes this to be a plan for the National Health and Care Service fit for purpose for a 21st century, synchronising at last the wishes of the public, professionals and politicians.
Labour can make political weather on the NHS, but it shouldn’t be thrown off track by gale force winds
Political decisions will always be made, but are unlikely to be representative if certain people don’t wish to be part of the political process.
It is hard to know what has caused a decline in political engagement, but politicians not appearing to listen might be a major factor. The social media has empowered a plurality of opinions, which means that it is less easy for politicians to speak with a collective voice on issues. The traditional narrative is that people ultimately care about the economy, as economic competence is the sort of issue which can make or break political parties. However, it’s very likely that residents of Lewisham care about local hospital closures, and hospital campaigns can gain momentum and traction whatever the state of national politics.
Voices of Labour who are interested in social justice, solidarity, equality, equity, solidarity or cooperation are not in fact in a minority, whatever the current state of the Blairite arm of the political party. While think tanks prioritise concepts such as ‘accountability’ and ‘co-production’, authentic voices on the left do not feel that their brand of politics is irrelevant. The question inevitably arises – if the current party is doing what you want to do, why should you stand for election? It is possibly the case that many people will nonetheless vote for Labour, despite reservations on the ‘welfare cap’, because the modern political system does not offer them any realistic choice. ATOS were contracted to do welfare benefits in the last government, and it is likely that some other outsourcing company will assume the mantle.
Labour clearly will state that it is insufficient for political parties to lose elections for others to win them, and they should formulate coherent policies of their own. But likewise nobody will expect Ed Miliband to reveal his hand until much closer to the election. Many people do not come into contact with the NHS when young, although there are many who do, and it is possible that Labour will wish to hone its offering on general health issues as well as the National Health Service. The recent Clegg v Farage debates have highlighted some appetite for single issue politics, when charismatically explored in ‘leaders debates’.
The forthcoming European elections will give a good indicator as to the relevance of the NHS to people’s lives, arguably. The fate of Louise Irvine and Rufus Hound will possibly provide good clues as to whether people in the general public care as much about the NHS as much as NHS campaigners clearly do. The National Health Action Party – NHAP – to be national will need to have coverage throughout the country, but there has always been concern about whether they might realistically gain enough seats to prevent Labour from winning an overall majority. Nonetheless, this Party feels serious that the NHS is a major political issue, and it is a genuine policy issue what they feel they can achieve over and above what a Labour government might. It is possible that that the NHAP might prevent a Labour MP from being elected in Stafford. I met someone recently who was adamant that, with the right resources, NHAP could win in Stafford. Likewise, it’s possible that Clive Peedell could win against David Cameron in Witney, where arguably Labour do not have a realistic chance of winning.
With the second rabbit to come out of George Osborne’s hat in the form of pension reforms, the first being inheritance tax, it’s possible that Labour can’t take the running of the economy as a vote winner in the 2015 general election. Some people still blame Ed Balls as too intimately implicated in the economic policy of the last administration. It is therefore counterintuitive to imagine then that Labour will wish to ignore its potential strengths such as social justice. Despite the concerns over ISTCs and PFI in previous Labour government, and the events running to Mid Staffs, it is still controversial whether people feel strongly enough about Labour’s record not to vote for them. Even hardened Socialists might be keen to contribute to the election of a Labour government than to see the continuation of a Conservative one.
The £2.4 bn top down reorganisation resulting from the Health and Social Care Act (2012) is a major faultline in national policy. Most seasoned pundits are aware of the calamitous effects of competition on national policy, but it is far more likely that members of the general public are unconcerned about ‘section 75′. As sure as night follows day, it’s likely that Labour will oppose privatisation, but the logical conclusion of this is that it supports state ownership. Its inability to call for this publicly speaks volumes. And the people who argue that this country is fundamentally right-wing know they’re being economical with the truth. Unpopular policies from the right have included the astronomic pay of certain investment bankers, the cost of energy bills, the general failures of privatisation policies, perceived attacks on the welfare state, and an enthusiasm to introduce tuition fees in universities denying access-to-education. Whilst Labour is unlikely to voice loudly that ‘capitalism kills’, Labour potentially can make some political weather on the NHS and on health issues such as ‘whole person care’. This will require some strength in the leadership of the Labour Party, but it should not be thrown off course by the equivalent of gale-force winds.
Andy Burnham needs a mandate to secure the future of the NHS
The media are obsessed about making immigration a make-or-break issue for political parties. Column inches are devoted to UKIP totally disproportionately to the number of MPs they actually have.
While George Osborne will squeak his aspirations for hardworking people, ‘putting right what so badly wrong’, the country is less than impressed. He will ask for credit while doing his lap of honour, completely oblivious to the cost-of-living crisis forced upon the British public through unfettered privatisation of public services causing distorted competitive markets. However, Osborne doesn’t understand the distress of disabled human casualties at the hands of ATOS. He is instead obsessed by a race to the bottom which has made insignificant progress in tackling corporate tax avoidance. He has made little progress in the exploitation of workers in zero-hour contracts.
It is said that the civil service are already making plans for a Labour government on May 8th 2015. Anyone who has lived through Lord Kinnock asking ‘Are you all right?’ in the Sheffield Rally of 1992 will know not to count their chickens while they are still in the incubator.
Jeremy Hunt’s strategy of trying to frame Andy Burnham for all the woes of the NHS has spectacularly backfired. Hunt, trapped by the legacy of Lansley’s “Health and Social Care Act” which he dares not mention, gets nostalgic about Mid Staffs in the same way that motorway drivers slow down on the opposite carriageway at the sight of a car crash, but he has offered no constructive solutions about how efficiency savings don’t turn into dangerous staffing cuts. Hunt is also spectacularly lacking in insight as to why NHS whistleblowers don’t appear to be protected, despite all the promises. He talks and acts like somebody who has little experience of how the medical and nursing staff do their professional work and seems unconcerned about citizens losing their local hospitals.
The media have also been given a free run in running down the NHS. Memes such as ‘the NHS is unsustainable’ have gone unchallenged remorselessly, with think tanks known to be sympathetic to private health providers offering impassionate advice. The statement ‘the NHS is unsustainable’ has become dangerously confused with the statement ‘the NHS is underfunded’, with NHS Trusts running a deficit more of a sign of the notion we can’t afford the NHS rather than we’re giving it sufficient resources. Once you frame the narrative in these terms, it gets extremely dangerous for right-wing politicians. The debate no longer is about cutting your coat according to your cloth, a phenomenon clearly familiar to people with low incomes, but instead the debate turns into the people with the higher incomes in society not ‘pulling their weight’. The public seem keen to ‘out’ the nonsense of Osborne’s claim “we’re in it together”. And the right – even though there is no evidence that the left believe the opposite – certainly don’t want to go down the road to looking as if they’re unpatriotly running the country down “because we cannot afford it”.
And of course we are never going to be able to trust the Conservative administration when legislation appears from nowhere to implement a £2.4 bn reorganisation. We seem to be able to afford this, and yet we cannot afford a pay rise for the majority of nurses in the NHS. And if we can’t afford the NHS, how come many Trusts are running the bare minimum of frontdoor staff, while millions are returned unspent to the Treasury? Managers might be fulfilling their four hour target but medical teams in the rest of the hospital are left picking up the pieces over investigations not requested or results not followed up. For many, the economy and the cost of living crisis are huge issues. But the NHS also remains a totemic issue for Labour.
Andy Burnham needs to establish a few basic groundrules. He has pledged to repeal the loathesome Health and Social Care Act, and to remove clause 119 ‘the hospital closure clause’. He definitely needs to pledge to make sure that the NHS is not privatised further under his watch. He needs to be unashamed of securing an adequate level of funding, even despite the neoliberal fetishes of austerity currently.
This might stop ill-informed political commentators from spewing out their corporate memes for the duration of a Labour government. But time is running out – for those of us who wish to protect the NHS, we need to stop looking inwards, but need to start campaigning hard.
Concerns about the paired associates learning test for dementia
To begin to understand how a cathode-ray TV set works, I could remove one component called the “transistor”, and the picture disappears. It would be an incorrect conclusion to say that the purpose of that transistor is to produce the picture. However, I could argue correctly that the transistor was somehow part of the system required to produce the picture.
If I showed the transistor was particularly “hot” while the TV set was on, producing a picture, it might be reasonable for me to conclude the transistor was involved in producing the picture.
This is the sort of basic approach still used to work out what is going on in the brains and minds of people with Alzheimer’s disease, typical presentations of which might be memory problems. You can see whether removing parts of the brain in humans produces similar effects to the problems in thinking found in Alzheimer’s disease. Or alternatively, you could just try to look at the system of components in the brain which might be contributing to memory in brains working normally.
Whatever, it’s a puzzle. In this particular case, it’s a puzzle to solve correctly.
An innovation culture in the diagnosis of Alzheimer’s disease
David Cameron praised Cambridge Cognition’s work in developing new innovative tests for Alzheimer’s disease in the G8 summit held towards the end of last year.
There has been concern that some individuals with Alzheimer’s disease do not receive their diagnoses in a particularly fast way. A number of explanations for this have been offered, including medical personnel not being able to spot the symptoms of Alzheimer’s disease easily.
It is also helpful to understand what an “innovation” is. An innovation might be a product which enables you do something much more easily, and depends for its success popular uptake by the user. Strictly speaking, paper was an innovation too. However, the rise in cost of diagnosing Alzheimer’s disease, arguably, is an intriguing example of “Baumol’s cost disease“.
Individuals with Alzheimer’s disease have memory problems which are typically not thought to be qualitatively similar to those found in ageing elderly individuals. Often such people have real problems in navigating around environments. It is clearly a very laudable aim to have a bedside test which might be able to alert a physician to an underlying memory problem in Alzheimer’s disease.
The benefits and concerns, and my passing involvement
There are a number of important caveats here. Not all dementias are Alzheimer’s disease. There are in fact hundreds of dementias, some of which are reversible. Whatever test is used, the test should be sensitive enough to identify reliably a genuine thinking problem in Alzheimer’s disease, but should not be so ‘broad brush’ the test also misattributes memory problems, say found in the ‘mild cognitive impairment’ or even depression, to Alzheimer’s disease. Such mislabelling can perceivably cause distress, and cause people to be caught up in the medical system for further lengthy tests when they should not have been in the first place. On the other hand, it is of concern that the diagnosis might be missed in some people, and hence the drive from the Department of Health and the Alzheimer’s Society in “The Prime Minister’s Dementia Challenge”.
I wish Cambridge Cognition well, not least because I have worked with CANTAB whilst a graduate student at the University of Cambridge. In fact, some of my papers are cited in their bibliography. Their search facility is here.
The CANTABmobile “paired associates learning” test
To explain the “paired associates learning” test from first principles, and I’m not using actual screenshots, imagine me presenting you with a number of blank boxes dotted around the screen.
And I open each box in turn and reveal a shape to you. I can present the problem with a varying number of shapes.
After showing you all the shapes, I then present to you a shape and ask you to identify the box in which it was first presented.
Cambridge Cognition in welcoming the Draft National Plan to Address Alzheimer’s disease in my opinion set out entirely correctly the advantages of this computerised testing battery; including fast, not culturally biased, not heavily loading on language, norm-referenced, culturally unbiased, and easy-to-use.
The reasoning behind it being sensitive to early Alzheimer’s disease – but what about mild cognitive impairment?
To understand why the narrative for the test being so attractive in early Alzheimer’s disease, you have to understand that this test has been found to be sensitive to functions of particular brain areas. If you chop out bits of the brain near the front of the head (frontal cortex) or near the ear (temporal cortex), performance on this task is impaired, as Prof Adrian Owen showed when he was a post-doctoral fellow (paper here). With hindsight, perhaps Owen should have looked at the effects of other brain areas further back in the brain, such as the parietal cortex, which are also now thought to be important in memory for spatial cues.
A consistent finding has been loss of brain cells in the “entorhinal cortex”, in the temporal cortex, early in Alzheimer’s disease (see for example here). Therefore, that the paired associates learning test should identify memory problems in early Alzheimer’s disease immediately makes intuitive sense.
But the issues I feel are much more complicated, and I wish Cambridge Cognition well in clarifying them.
If it’s not Alzheimer’s disease, what else could be causing the memory problems?
One possibility is “mild cognitive impairment”. It is described, for example on the authoritative Mayo Clinic website, that:
“Mild cognitive impairment (MCI) is an intermediate stage between the expected cognitive decline of normal aging and the more serious decline of dementia. It can involve problems with memory, language, thinking and judgment that are greater than normal age-related changes. If you have mild cognitive impairment, you may be aware that your memory or mental function has “slipped.””
David Hart, Senior Business Development Manager of Cambridge Cognition, kindly sent Dr Peter Gordon the rationale for the use of the CANTAB task by Dr Andrew Blackwell, their Chief Scientific Officer (as produced on Peter’s blog here).
Cambridge Cognition concede that distinguishing between MCI and Alzheimer’s Disease “is difficult”, but this is a distinction that must be arrived at otherwise a test potentially will give “false positives” – but no test is perfection, and it basically is impossible to strive for perfection. What we all trying avoid is where a test for possible dementia itself is expensive followed by a further expensive investigation to show the original result was a false positive – or as the Express euphemistically called it recently, “Dementia diagnosis proved wrong by new super scanner”. (It is important to state clearly here that no details are given how a diagnosis had been arrived at previously for Ros Davies.)
To give them credit, Cambridge Cognition cite the Chandler et al. (2008) paper, but the full citation of this is “Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association Volume 4, Issue 4, Supplement , Pages T551-T552, July 2008″ – i.e. it is a supplement of abstracts not full papers. This particular abstract can be viewed here.
It is hoped that this full study will have been published elsewhere, and if so Cambridge Cognition will need to update their website with the full paper. Notwithstanding this, the numbers of individuals in each group are disappointingly low: there are seventeen with putative MCI and twelve with putative Alzheimer’s disease.
Is this task actually sensitive and specific?
However, the discussion by Dr Andrew Blackwell and colleagues in his 2004 paper is useful. I have more than a passing interest in that paper as the main author on that paper was one of my PhD supervisors at Cambridge, Prof John Hodges. John has also kindly written one of my three Forewords for my book, “Living well with dementia” to be published on January 14th 2014.
Blackwell remarks correctly that this task has been used to distinguish between unipolar depression and Alzheimer’s disease in Rachel Swainson’s study. But is this enough? I looked to the previous Beats study in “geriatric depressive”, and there was nothing forthcoming there. How confident can one be that only early patients with Alzheimer’s disease, and not those severely depressed or with an underactive thyroid, will perform abnormally on the PAL? Personally, I’m not at all confident yet, despite the Swainson study, but these fears can easily be allayed with a sensitivity/specificity study of much higher power.
Blackwell is however correct in citing my study with Dr Andy Lee in that patients with semantic dementia and behavioural variant frontotemporal dementia are relatively unimpaired, though the clinical presentations of the frontotemporal dementias can be quite clearly different in the clinic from Alzheimer’s disease. Completing the double dissociation, I did find that the behavioural variant of frontotemporal dementia did present with rather specific risk-taking decision-making of its own.
But in the meantime the comparison with frontotemporal dementias is useful.
Nonetheless, this approach is being rolled out.
On 28 June 2013, the use of CANTABmobile was described as follows:
“The Guildford and Waverley Clinical Commissioning Group (CCG) is leading the use of an innovative new iPad-based memory assessment system as part of a national push to decrease dementia diagnosis waiting times and streamline the referral process. Accessed through NHS medical professionals, CANTABmobile enables GPs to test a patient’s episodic memory through an easy to use and administer 10-minute cognitive assessment.”
The CANTAB paired associates learning test is pictured under the heading “intuitive touchscreen interface”. if you go to “download information” on this page.
It was covered in the national media here: for example Victoria MacDonald’s report (this page provides a criticism of another report by Victoria MacDonald this time over Prof Brian Jarman’s proposed HSMR data by NHS Consultant, Dr Jacky Davis).
So what does this task test?
In understanding how the task works in reality, I found a paper where Prof Ed Bullmore and colleagues put individuals with Alzheimer’s disease and control subjects performing the task into a scanner really helpful. Bullmore and colleagues frontloaded their discussion with the following comment:
“Independent of the level of difficulty, the majority of subjects in both groups activated a network of brain regions, including the anterior cingulate, lateral, and medial occipitoparietal and frontal cortices, during successful encoding and retrieval.”
This is interesting as it doesn’t point to the usual suspects of the narrative, i.e. the entorhinal cortex and other parts of temporal lobe. Even Andrew Blackwell had described how the damage to the entorhinal cortex might possibly account dor deficits on the paired associates task:
“The transentorhinal region is a complex transitional area located between the entorhinal region proper and the adjacent temporal isocortex. It has been suggested that damage to this site in early [Alzheimer's disease] disrupts reciprocal connections with the hippocampal formation and that this disruption underlies deficits in episodic memory.”
But on reflection is this wholly a surprise? Ed Bullmore and colleagues from their results, also from Cambridge, discuss that the lateral parietal activations reported during episodic memory tasks are thought to reflect recognition processes and retrieval processing of spatial information. Medial parietal activity has been proposed to underlie imagery and retrieval success.
I don’t feel it’s altogether surprising given what is known about the build-up of pathology in Alzheimer’s disease, either. The authors of one study looking at this report that:
“[18F]FDDNP-PET signal was significantly higher across widespread cortical regions in subjects with poorer neuropsychological test performances. Strong correlations were seen in the entorhinal, orbitofrontal, and lateral temporal cortices, temporoparietal and perisylvian language areas, parietal association cortices, and much of the dorsolateral prefrontal cortex.”
But the Sahakian lab elsewhere did find something was up with the parts in “the hippocampus and associated structures”, i.e. the structures in the temporal lobe, in this task.
But that study was only comparing MCI with normal controls. It did not include patients with Alzheimer’s disease. This is relevant, if you happen to believe that MCI ‘predates’ Alzheimer’s disease, as the authors of that study clearly do:
“Later in the course of the transition from MCI to clinical Alzheimer’s disease, functioning of the MTL deteriorates further to an extent that such compensatory activity is no longer possible. The hyperactivity in early MCI might then represent a possible predictor or biomarker of the progression to Alzheimer’s disease.”
But in the real world this is far from clear.
However, the evidence of progression of MCI (mild cognitive impairment) to DAT is currently weak. It might be attractive to think that MCI is a preclinical form of dementia of Alzheimer Type, but unfortunately the evidence is not there to back this claim up at present: only approximately 5-10% and most people with MCI will not progress to dementia even after ten years of follow-up (Mitchell and Shiri-Feshki, 2009). Drug companies have been trying hard to push the identification of “biomarkers”, possibly subtle psychological ‘deficits’, scan results or changes in substances in the fluid surrounding the brain (or cerebrospinal fluid). It is no accident that psychological testing and biomarkers were heavily promoted in David Cameron’s G8 dementia speech in Lancaster House at the end of last year.
In summary, I don’t think it can be taken as red that entorhinal cortex problems are causing the observed deficits in the CANTABmobile paired associates learning task.
Conclusion
Overall, my personal view is that the deficits on the CANTAB paired associates learning task are real in early Alzheimer’s disease, but possibly not for the reasons felt by some in their groups. Above all, I don’t care as such, as long as greater numbers of people benefit from a correct diagnosis of Alzhemer’s disease, but I do feel that the logic in their reasoning has gone a bit awry.
My academic viewpoint is utterly irrelevant actually, as above all I wish the whole of the medical profession well in their “war against dementia”.
I’d be the first to admit I’ve got it wrong. I am simply raising the issues in a constructive way that I hope is beneficial for the public interest.
But Dr Mitul Mehta, Reader in Neuroimaging at the IoP, does have his concerns.
Why I wrote ‘Living well with dementia’
“Living well with dementia: the importance of the person and the environment for wellbeing” is my book to be published in the UK on January 14th 2014. I have written it on my own, but I have drawn on the published work a number of Professors working in the field of dementia have sent me. I hope the advantage of having an overview of their research programmes has been to put together with one voice where exactly this approach might be heading using the most contemporary published papers. I am enormously grateful that these busy Professors were able to supply me with their recent papers.
I was asked by my publishers to provide pointers about what a “marketing strategy” for this book might be. I can honestly say that, having given considerable time to thinking about this issue, I have no intention of pursuing a conventional promotion of my book. I don’t intend to do nothing, but I can confidently say that this book will be widely read. I have no intention of flogging it to commissioners, who will have their own understanding of what health or wellbeing is in the modern construct of NHS England’s policy.
I do, however, have every intention of addressing what I think is a major shortfall in the medical profession in their approach to dementia. Their emphasis has been, where done well, the exact diagnosis of dementia through an accurate history and examination of a patient, with appropriate investigations to boot (such as a CT scan, MRI, lumbar puncture, EEG or cognitive psychology). The combined efforts of Big Pharma and medics have produced limited medications for the symptomatic treatment of memory and attention in some dementias, but it would simply be a lie to say that they have a big effect in the majority of patients, or that they reverse the underlying the disease process consistently and robustly.
But that’s the medical model, and certainly the ambition for a ‘cure’ is a laudable one. I found the recent G8 dementia summit inspiring, but a bit of a distraction from providing properly funded solutions for people currently living with one of the hundreds of dementias. Many of us in the academic community have had healthy collaborations for some time; see for example one of the Forewords to my book by Prof Facundo Manes, Chair of Research of the World Federation of Neurology (Dementia and aphasia). To say it was a ‘front’ for Big Pharma would be unnecessarily aggressive, but it has been openly admitted in the media that a purpose of the summit was to assist ‘an ailing industry’.
I think to emphasise what might be done for future patients of dementia would be to fail to maximise the living of people with dementia NOW. By this, I mean a correct and timely diagnosis of an individual, the suggestion of appropriate assistive technologies and innovations, appropriate leisure activities, and the proper design of a positive environment (whether that be a ward, a house or external environment).
My book is strongly footed in current research, but I openly admit that research does not have all the answers. I should like there to be a strong emphasis also in non-pharmacological approaches, such as the benefits of life story and reminiscence, art or dancing. Lack of current research certainly does not make these approaches automatically invalid, particularly when you consider the real reports of people with dementia who have reported benefit.
The main reason is that I do not wish to organise attendance in a series of workshops or conferences about dementia is that I do not wish to be perceived as selling a book. I am more than happy to talk about the work if anyone should so desire. A number of my friends are very well-known newspaper journalists, and I deliberately have not approached any of them as I consider this might be taking advantage of my friendship. I haven’t approached dementia campaigners, or other dementia charities, as I don’t wish to get involved in some sort of competition for other people’s attention. I haven’t sought the ‘celebrity backing’ of some senior practitioners in dementia, although Prof John Hodges (a world expert particularly in the frontotemporal dementias) kindly wrote one of my Forewords. If people wish to discuss the issues in a collaborative manner to take English policy further, I’d be delighted.
At the centre of this book is what an individual with dementia CAN do rather what they cannot do. If you’re looking for a cogent report into the medical deficits of people with dementia, you’ll be sorely disappointed. I spent about 10 years of medical training at undergraduate and postgraduate levels, without having heard of personhood or Tom Kitwood’s work once. I think this a travesty. As a person who is physically disabled himself, the need to understand the whole person is of massive personal significance to me. I think that, beyond doubt, future training of anyone in the caring professions, including medicine, will have to start with understanding the whole person, rather than seeing a patient with a series of problems to be cured or symptomatically addressed.
No academic, practitioner, or charity can have a monopoly of ideas, which is why I hope my book will be sincerely treated with an open mind. People have different motivations for why they get involved in dementia; for example, a corporate wishing to be part of a ‘dementia friendly community’ through a charity might have a different guiding principle to an academic at a University wishing to research from scratch some of the fundamental principles of a dementia friendly community. Despite all the “big players”, nobody can match up to THAT individual who happens to be living with dementia; that person is entitled to the utmost dignity and respect, as brilliantly expressed by Sally Marciano in her powerful Foreword.
I am hoping very much to meet up with some personal friends that I’ve met in the #dementiachallengers community on January 18th 2014, and this is as close as I’ll get to the book launch. But I hope you will find the book readable. I don’t feel that there’s any other book currently available which bridges these two totemic topics (dementia and wellbeing); but I hope there are other good reasons for reading it!
Related articles
- Need for Dementia Caregivers Grows as Boomers Age (abcnews.go.com)
- A cure for dementia could be found within twelve years, David Cameron has said (telegraph.co.uk)
- Simple Steps Could Keep People With Dementia at Home Longer: Study (nackpets.wordpress.com)
Living well with dementia: diet not drugs?
There is no cure for dementia currently. The available treatment strategies offer mainly symptomatic benefits. Thus, strategies to prevent or delay onset of dementia by changes in lifestyle factors, such as diet, are therefore important, given finite resources. There is no doubt it’d be wonderful if, after many many years of trying, there might be a breakthrough.
But physicians and politicians have a responsibility to the general public to be honest about what is genuinely achievable. It’s in the interests of charities and research groups which depend on income for their research to raise money for a cure; or in the interests of those research groups wishing to raise money for research which appears linked to that somehow. It’s in the interest of Big Pharma-ceutical companies to raise money for their research funds; and they have a legal duty to their shareholders too. The public appreciate a truthful debate about what might work; and where a lot of monies would in fact would be better spent elsewhere.
It’s certainly low hanging fruit for politicians to support this worthy cause.
However, the scant attention to living well with dementia in many statements, in contrast to drug treatments, is very telling. The Department of Health will, however, be livestreaming the #G8dementia summit proceedings later this week. Details are here.
Not all dementia occurs in the elderly. Nonetheless, it is possible that health problems related to aging (including dementia of the Alzheimer type) are projected to add to the high clinical, social, and economic burden of caring for persons with dementia.
The Mediterranean diet has been associated with reduced risk for a wide range of age-related conditions such as stroke, type 2 diabetes, cardiovascular disease, and all-cause mortality. The traditional Mediterranean diet refers to a multinutrient dietary profile characterized by high intake of fruits, vegetables, cereals, and legumes; low consumption of saturated fats with olive oil as the main source of fat; moderate consumption of fish; low to moderate intake of dairy products (in the form of yogurt and cheese); low consumption of red meat and meat products; and moderate amount of alcohol (especially wine) usually consumed during meals.
Recently, a number of peer-reviewed pieces in the reliable academic literature have presented evidence for an association between a Mediterranean-type diet and decreased risk of dementia. Findings from prospective studies suggest that greater adherence to Mediterranean diet may be associated with slower cognitive decline and reduced risk of Alzheimer disease. In the light of these findings, it has been suggested that improving adherence to the Mediterranean diet may delay or prevent the onset of dementia.
A really helpful review was published by Lourida and colleagues earlier this year in the “Epidemiology” journal (Jul;24(4):479-89). Twelve eligible papers (11 observational studies and one randomized controlled trial) were identified, describing seven unique cohorts.
Despite methodological heterogeneity and limited statistical power in some studies, there was a reasonably consistent pattern of associations. Higher adherence to Mediterranean diet was associated with better cognitive function, lower rates of cognitive decline, and reduced risk of Alzheimer disease in nine out of 12 studies, whereas results for mild cognitive impairment were inconsistent.
Published studies suggest that greater adherence to Mediterranean diet is associated with slower cognitive decline and lower risk of developing Alzheimer disease. Further studies would be useful to clarify the association with mild cognitive impairment and vascular dementia. Long-term randomised controlled trials promoting a Mediterranean diet may help establish whether improved adherence helps to prevent or delay the onset of Alzheimer disease and dementia.
Only today, leading doctors warned the Government the battle against dementia should focus on the benefits of a Mediterranean diet rather than ‘dubious’ drugs. In an open letter to the Health Secretary, they said persuading people to eat fresh fruit and vegetables, nuts, fish and olive oil was ‘possibly the best strategy currently available’ for preventing Alzheimer’s and other memory-robbing diseases.
The letter’s signatories include Prof Clare Gerada, the former chairman of the Royal College of General Practitioners, and Dr David Haslam, chairman of the National Obesity Forum.
It reads:
‘We hope this crisis can be seen as an opportunity towards a real policy change, namely towards a Mediterranean diet, rather than towards the dubious benefits of most drugs.’
It goes on to say the evidence ‘strongly suggests’ that improvements to lifestyle will have a ‘far greater effect’ on the rising tide of dementia than drugs.
The call comes as dementia experts from the G8 countries prepare to travel to London for a summit hosted by the Prime Minister.
Dr Simon Poole, the GP who organised the letter, said: ‘It is all about looking at what pharmaceutical companies can do, which is actually not very much.
‘They talk up their medicine and then it is very often a damp squib. We want some sort of focus on prevention. Educating all generations, including our children, in the importance of a good diet in maintaining health in old age is a project which will take years, but is absolutely essential.’
‘We are calling upon policymakers to not only support the care and treatment of those who are already suffering from dementia, but to make significant investments in work which will see benefits beyond the period of one or two parliaments.’
There has also been a focus on individual components of the Mediterranean diet, such as [omega]-3 fatty acids or olive oil as the main source of monounsaturated fats. Although the advantages of Mediterranean diet are relevant for non-Mediterranean populations, it is often argued that studies are not always comparable because there are substantial differences in dietary composition among countries.
A more detailed examination reveals this is perhaps especially true for fatty acids. Although olive oil is the hallmark of Mediterranean diet, differences in the origin of monounsaturated fats or cooking style (eg, baked vs. fried) could partly explain these inconsistencies. Studies comparing types of olive oil concluded that compared with refined oil, virgin olive oil (rich in phenolic content) has additional anti-inflammatory and antioxidant properties beneficial to cellular function and cardiovascular health.
The Mediterranean diet may exert its effects on cognitive health through multiple biological mechanisms. Relationships with reduced risk of coronary heart disease, hypertension, diabetes, dyslipidemia, and metabolic syndrome have been observed, and these conditions have also been associated with mild cognitive impairment, vascular dementia (a dementia associated with general factors affecting the cardiovascular system such as smoking, cholesterol, diet, family history), or disease of the Alzheimer type.
Sticking to this Meditteranean diet may also facilitate metabolic control because it has been related to improved insulin sensitivity and glucose metabolism. Insulin is a chemical acting in the body which can affect our metabolism – it is an important “hormone” for us.
Furthermore, “oxidative stress” increases with age and results in “oxidative damage”—a state often observed in the brain of patients with Alzheimer disease. Typical components of the Mediterranean diet (namely fruits, vegetables, wine, and virgin olive oil) are rich in antioxidants such as vitamin C and E, carotenoids, and flavonoids. Decreased oxidative stress found in people adhering to a Mediterranean-type diet could partially explain their lowered risk for dementia.
And there’s a plausible biological mechanism for all this. Brain cells (neurone) are protected against oxidative stress by specialist chemicals, called “neurotrophins” (basic proteins) such as the brain-derived neurotrophic factor. There is some evidence that Mediterranean diet may increase plasma brain-derived neurotrophic factor concentrations. Inflammatory processes have also been suggested for Alzheimer pathogenesis. Higher concentrations of C-reactive protein, a nonspecific marker of inflammation, have been associated with increased risk for cognitive decline, Alzheimer disease, and vascular dementia, whereas better adherence to Mediterranean diet has been associated with lower levels of C-reactive protein.
Access to medicine has become a really important issue in the NHS. Already we are getting stories of rationing in the NHS emerging during the period of this Government (such as varicose veins stripping), so it is not particularly surprising if drugs which do have modest effect on memory for dementia are not a top priority. Encouraging people to learn about diet and how this might prevent thinking problems is therefore a worthy aim, as it might actually work better than many of the drugs ‘on offer’. Senior doctors have advised this approach in fact.
Just because it’s not coming from Big Pharma with their massive marketing budgets doesn’t mean it’s a dead duck.
Related articles
- Healthy diet ‘may prevent dementia’ (skynews.com.au)
- Mediterranean Diet is the Key to Preventing Dementia (medindia.net)
- How To Live Longer: Mediterranean Diet Proven To Help Women Live Past 70 (medicaldaily.com)
- Dementia fight must focus on diet, say experts (yorkshirepost.co.uk)
Jeremy Hunt’s message on dementia should have been ‘screened’ for damaging myths
My presumption is that I wish to be extremely positive about HM Government’s own volition about leading the G8 with the subject of dementia.
Also, the “Prime Minister’s Dementia Challenge”, which sets out a roadmap for dementia for this year and next, has been a success which I much admire.
David Cameron and Jeremy Hunt, and their team, must rightly be applauded.
However, some accidental problems with the latest message appear to have crept in unfortunately.
The article in the Telegraph says that, “Health Secretary Jeremy Hunt says it is “utterly shocking” that only half of people suffering from dementia are being formally diagnosed.”
You can watch the video here.
Recently in English policy a skirmish over screening has been temporarily staved off by certain stakeholders avoiding ‘the S word’.
They have decided to plump for the ‘C-word instead’.
“Case-finding”
But in fairness Jeremy Hunt MP, Secretary of State for Health, in the actual “piece to camera” does not use the word “suffering”.
This is particularly ironic as Hunt later says, “”We’ve got to overcome the stigma.”
A major thrust of dementia must be to destigmatise dementia, by emphasise the myriad of things which can be done to help individuals living with dementia, like improvements of the house and the outside environment, non-statutory advocacy or dementia friendly communities.
Hunt’s attempts to overcome the stigma are, unfortunately, somewhat mitigated by his claim that,
“Dementia is a really horrible condition.”
Hunt mentions that “This is not surprisingly because memory is an intrinsic part of all of this.”
The meme that memory problems are synonymous with dementia remains a persistent toxic misrepresentation.
Not all memory problems are dementia (depression can cause profound memory problems.)
Not all dementia presents with memory problems. One of the most common forms of dementia in the age group below 60 is the behavioural variant of frontotemporal dementia.
This presents typically with an insidious change in behaviour and personality, often not noticed by the person himself or herself (but noticed by somebody close by.)
Even some of such individuals can present with plum-normal brain scans.
This small fact would aggravate hugely physics experts to sit on dementia clinical steering groups perhaps, if they knew.
A number of parliamentarians have recently emphasised the need for prevention.
This is indeed a worthy claim.
“You can change your lifestyle to help to stave off the diagnosis.”
However the evidence for this claim is extremely scant.
Non-clinicians in policy must not give false hope to members of society.
This is extremely irresponsible.
Hunt continues, “GPs have been reluctant to give a diagnosis as they’ve thought that ‘nothing is really going to happen'”
There has been in recent years a language depicting war, between GPs and persons with a possible diagnosis of dementia.
There is a very damaging myth, perpetuated by some influential people in the third sector, that GPs are actively withholding a dementia diagnosis in some people.
This claim undermines the credibility and probity of medical professionals, but GPs are relatively defenceless against such a slur.
Hunt says, “If people are worried, come and talk to your GP.”
A moral dementia policy is giving correct support including non-pharmacological interventions to support people living with dementia, as well as support for carers who often experience significant pressures in caring themselves.
People need to be accurately diagnosed with dementia. A wrong ‘label’ of dementia, for a person with no dementia, can do much harm.
Nonetheless, the idea of identifying correctly new people with dementia such that they can be given the right support is a commendable one.
It’s essential though that we do not enmesh this with this policy goal becoming targets, and clinicians being thrown off track by perverse incentives which are not directly beneficial to patients of the NHS.
