Living well with corporate capture. What’s the future of the English dementia strategy?

“Citizens have become consumers with status proportional to purchasing power, and former public spaces have been enclosed and transformed into private malls for shopping as recreation or “therapy.” Step by step, private companies, dedicated to enriching their owners, take over the core functions of the state. This process, which has profound implications for health policy, is promoted by politicians proclaiming an “ideology” of shrinking the state to the absolute minimum. These politicians envisage replacing almost all public service provision through outsourcing and other forms of privatisation such as “right to provide” management buyouts. This ambition extends far beyond health and social care, reaching even to policing and the armed forces.”

And so write Jennifer Mindell, Lucy Reynolds and Martin McKee recently about ‘corporate capture’ in the British Medical Journal.

Alistair Burns, England’s clinical lead on dementia, recently concluded a presentation on the clinical network for London with the following slide:

Alistair clearly does not mean ‘Dementia is everyone’s business’ in the “corporate capture” sense. Instead, he is presumably drawing attention to initiatives such as Brighton and Sussex Medical School’s initiative to promote dementia awareness at all levels of an organisation (and society).

 

 

The comparison with diabetes is for me interesting in that I think of living well with diabetes, post diagnosis, as conceptually similar to living well with dementia, in the sense that living well with a long term condition is a way of life. And with good control, it’s possible for some people to avoid hospital, becoming patients, when care in the community would be preferred for a number of clinical reasons.

Where I feel the comparison falls flat is that I do not think that it is possible to measure outcomes for living well with dementia easily. Sure, I have writen on metrics used to measure living well with dementia, drawing on the work of Sube Banerjee, Alistair’s predecessor.

It might be possible to correlate good control with a blood test value such as the HBA1c, and it steers the reward mechanism of the NHS for rewarding clinicians for failure of management (e.g. laser treatment in the eye, foot amputation, renal dialysis), but the comparison needs some clinical expertise to be pulled off properly.

The issue of breaking down ‘barriers’ between primary and secondary care is an urgent issue, and ‘whole person care’ or ‘integrated care’ may or may not help to facilitate that.

But the question of who gives the correct diagnosis of dementia, or even verifies it, won’t go away.

Having done Dementia Friends myself, a Public Health Initiative delivered by the Alzheimer’s Society, I feel the initiative is extremely well executed from an operational level. I think it’s pushing it for a member of the public to think that an old and doddering lady crossing the lady might have dementia and requires help, as medicalising ageing into dementia is a dangerous route to take.

The £2.4 million programme is funded by the Social Fund and the Department of Health. 

There are a number of important clinical points here.

People with dementia need to be followed up across a period of time for a diagnosis of dementia to be reliably made, and ‘in the right hands’, i.e. of a specialist dementia service.

Some people have ‘mild cognitive impairment’ instead, and will never progress to dementia.

There are 149,186 dementia friends currently. This number is rapidly increasing. The goal is one million.

Furthermore, there are many people given a diagnosis of dementia while alive who never have it post mortem. And the diagnosis can only be definitively made post mortem.

Seth Love’s brilliant research (and he is an ‘Ambassador’ to the Alzheimer’s BRACE charity) is a testament to this.

This policy plank for me will also go back to the issue of whether policy is putting sufficient resources into the diagnostic process and beyond. Stories of people being landed with a diagnosis out of nowhere and given not much further information than an information pack are all too common. A well designed system would have counselling before the diagnosis, during the diagnosis, and after the diagnosis.

Ideally, an appointed advisor would then see to continuity of care, allowing persons with dementia to be able to feel confident about telling their diagnosis to friends and/or family. The advisor would ideally then give impartial advice on social determinants of health, such as housing or education.

But all this requires money and skill. There is no quick fix.

The areas of action for the Prime Minister’s Dementia Challenge are: dementia friendly communities, health and care and improving research.

The term ‘dementia friendly communities’ is intrinsically difficult, for reasons I have previously tried to introduce. A concern must be the ideology behind the introduction of this policy in this jurisdiction. The emphasis has been very much on making businesses ‘business friendly’, which is of a plausible raison d’être in itself.  This, arguably, is reflected in the list of chief stakeholders of the dementia friendly communities champion group.

It happens to fit very nicely with the Big Society and the ‘Nudge’ narrative of the current government. But it sits uneasy with the idea that it is in fact a manifestation of a small state which bears little responsibility apart from overseeing at an arm’s length a free market.

And meanwhile, the care system in England is on its knees. Stories of drastic underfunding of the care system are extremely common now.

An army of millions of unpaid family carers are left propping up a system which barely works. There appears to be little interest in guiding these people, with psychological, financial and/or legal burdens of their own, to reassure them that all their hard work is delivering an extraordinary level of person-centred care.

But this for me was an inevitable consequence of ‘corporate capture’. The G8 World Dementia Council does not have any representatives of people with dementia or carers.

That is why ‘Living well with dementia’ is an important research strand, and hopefully one which Prof Martin Rossor and colleagues  at NIHR for dementia research will give due attention to in due course. But all too readily research into innovations, ambient assisted living, design of the ward, dementia friendly communities, assistive technology, and advocacy play second fiddle to the endless song of Big Pharma, touting how a ‘cure’ for dementia is just around the corner. Yet again.

So what’s the solution?

The answer lies, I feel, in what happens in the next year and beyond.

The Prime Minister’s challenge on dementia was developed as a successor to the National Dementia Strategy, with the challenge of delivering major improvements in dementia care, support and research. It runs until March 2015.

Preparatory work to produce a successor to the Challenge from the Department of Health (of England) is now underway in order that all the stakeholders can fully understand progress so far and identify those areas where more needs to be done.

The Department of Health have therefore commissioned an independent assessment of progress on dementia since 2009.

There are a number of other important pieces of work that are underway, which will provide information and evidence about progress and gaps. For example the All Party Parliamentary Group on Dementia chaired by The Baroness Sally Greengross OBE are producing a report focused on the National Dementia Strategy, and the Alzheimer’s Society has commissioned Deloitte to assess progress and in the autumn will be publishing new prevalence data.

Indeed the corporate entity known as Deloitte Access Australia (a different set of management consultants in the private sector) produced in September 2011 a report on prevalence of dementia estimates in Australia.

Deloitte themselves have an impressive, varied output regarding dementia.

But of course they are not interested in dementia solely. “Deloitte” is the brand under which tens of thousands of dedicated professionals in independent firms throughout the world collaborate to provide audit, consulting, financial advisory, risk management, tax, and related services to select clients.

Apparently, once all this work has been concluded a decision will be made on the focus and aims of the successor to the PM’s challenge.

The current Coalition government has been much criticised in parts of the non-mainstream media for the representation of corporate private interests in the Health and Social Care Act (2012).

I believe people who are interested in dementia, including persons with dementia, caseworkers and academics, should make their opinions known to the APPG in a structured articulate way in time. I think not much will be achieved through the pages of the medical newspapers.

And only time will tell whether the new dementia strategy will emerge in time before the next general election in England, to be held on May 7th 2015.

It could be a case of: all change please.

 

 

This blogpost first appeared on the ‘Living well with dementia’ blog.

 

Does a seismic democratic deficit bode well for the NHS?

As far as “earthquakes” go, this was not a bad one for Ed Miliband.

Did the earth move for him?

Probably not, as, in the European elections, Labour finished behind UKIP but ahead of the Conservatives, while its vote share was up by nearly 10% on 2009. In the local elections, Labour boasted of wins in areas such as Cambridge, Croydon and Crawley where it hopes to gain parliamentary seats next year. Labour took comfort from a strong performance in London, a key general election battleground with 73 seats, where Ukip’s appeal proved less potent. But arguably Labour’s gains fell well short of the 400 council seats experts said it needed to show it is on course for general election victory. A Ukip surge in Essex saw Labour lose control in Thurrock.

Is it Ed Miliband’s fault that Ed Miliband or even Labour seem out of touch with the rest of the country? Or could Miliband be doing more? Critics have argued that ‘the cost of living crisis’ is synthetic, but such critics have tended to be metropolitan journalists who spend much of the time abroad anyway.

Are the people in London basically wrong? Labour seized control in battleground London boroughs including the council said to be “David Cameron’s favourite”. Hammersmith and Fulham has been hailed as an exemplar by Mr Cameron, but Ed Miliband’s party claimed a coup by snatching the borough. After sweeping the local elections, Labour dominated Lewisham’s European election vote too, taking 32,507 of the borough’s votes, ahead of the second-placed Green Party, who won 10,228 votes. UKIP finished third (8,720), ahead of the Conservatives (8,161). The Lib Dems trailed-in fifth (4,252). These of course have been huge battlegrounds for the NHS.

And Nick Clegg looked upset and tired. The Liberal Democrats’ strategy going into this campaign had been to try to attract pro-European voters with an appeal for an open-minded, generous-hearted Britain, but going head-to-head with UKIP leader Nigel Farage in a TV debate back-fired. By far the most significant policy announcement made by the Lib Dems at their conference last year was that the party will pledge to protect the NHS and schools from cuts after 2015. Nick Clegg suggested that both budgets should be ring-fenced until 2020. And, under the 2012 Legal Aid, Sentencing and Punishment of Offenders Act, implemented earlier this year, access to legal aid in civil cases has already become far harder for children and young people under the age of 25.

UKIP spokesperson Suzanne Evans is reported as saying that UKIP did not make a breakthrough in London, in part due to the capital’s “well-educated” population. But what are these arguments that Labour is taking to the capital on the NHS? Chuka Umunna, MP for Streatham, is for example citing the £3bn top down reorganisation which nobody voted for, the “efficiency savings” returned to the Treasury without being put back into frontline care, and the problems in the A&E service known as the “barometer” of the NHS.

The inevitable refrain will be to question whether Labour did enough on this occasion to head towards Downing Street. On the good news, it does not think it’s already done it. The media have given Ed Miliband a pasting for not remembering the name of a local leader, nor for eating a nutty with due etiquette. But these are not make or break issues for people concerned with the NHS, like the amount spent on the private finance initiative, safe staffing, the concerns of whistleblowers, whether the NHS can afford or have the energy yet to implement whole person or integrated care.

UKIP is apparently going to hone in on a few geographical areas and to consolidate efforts on developing policy. One of the policy areas it must develop is in the NHS, where it has given off a garbed mood music through Paul Nuttall MEP on making the NHS more ‘efficient’. There has even been talk of GP charges in the UKIP repertoire. This would all matter if UKIP were a serious contender. Whilst it still appears likely with first past the post they are unable to make gains in electoral seat numbers it seems likely that they have the ability to be a pain the arse for a number of seats in London. With the Liberal Democrats having been annihilated again, and rumours of their death once again exaggerated, it is uncertain how pervasive immigration is going to be in the 2015 general election. While immigration appears to have gained an elevated importance, because of the effect it has in other policy areas (such as immigrants ‘using our NHS’ or ‘stealing our NHS’), it is perhaps possible that Labour is still not showing an ‘electoral leg’ by signing up to the austerity agenda (e.g. NHS ‘efficiency savings’), not considering how to increase taxation to fund the NHS and social care adequately, or even taking fully the argument to the public that health pervades much of Labour’s message, for example in housing or education. It would pervade more of their message if they were true socialists of course, but many dispute whether the Labour Party has ever demonstrated much socialism to write home of since Hugh Gaitskell and Nye Bevan.

As the late Tony Benn would have remarked there’s a definite sense of history repeating itself. Maybe in the rural leafy suburbs, where citizens are not yet surrounded by cosmopolitan comrades, people are so struck with the fear of globalisation that they cannot bear to bring themselves to vote Labour. And there is some sense to that, as Labour is a card carrying member of free movement of capital as well as free movement of persons. But Labour does wish to promote an unique selling point of giving empoyees’ rights compared to multinational companies (though it has to be said that UKIP has struck a chord with many on the left wing by slagging off multinational companies).

The question of whether London is representative or not of a democratic deficit or not is relevant in that we do not know yet whether Labour is following or leading. Whenever the question of leadership in any political party rears its ugly head, the question is: and replace with whom? There may be some who believe that Ed Miliband should be replaced by Andy Burnham, Yvette Cooper or Chuka Umunna, but there are possibly as many who believe that he should not be replaced by one of these three. Ironically, the person who stands to influence the NHS policy the most for Labour, whether it’s on ‘efficiency savings’, the overall spend or the NHS, Ed Balls MP, is generally not flavour of the month.

Whatever, the 2015 election will thankfully not be won by Nick Robinson getting excited about Nigel Farage. It will be, not to be hyperbolic, be a make or break election for England, especially regarding the NHS is concerned. Now is the time that true socialists should make their opinions clear about what they want to see from a future Labour government. On the list of ‘things to do’ are regulation of healthcare professions and repeal of the Health and Social Care Act (2012), and. while these issues are far more sophisticated than anything UKIP have to offer, one of the reasons why people might be exasperated with Ed Miliband and Labour is a distinct lack of national policy. And people do care about the NHS to vote on NHS issues: see, for example, arguably, those who did vote Green or the National Health Action Party whom some people say offer quite an attractive offering on the NHS.

And what we’re all trying to avoid from Labour is too little too late. This is above all what many of us got a flavour of from the local and European elections, despite some good gains.

Rumours of the political death of Ed Miliband have been greatly exaggerated. But he can’t be a ‘one trick pony’.

The ‘rumours of my death’ quotation, attributed originally to Samuel Langhorne Clemens, has a long history.

Ed Miliband’s political journey, via Haverstock Hill Comprehensive School and Oxford University, by comparison has been much shorter. He does not appear to have gone via many checkouts along the way, though his nearest checkout would have been at Morrisons at Chalk Farm Road had it existed then.

But socialism did exist then. Miliband is clearly intent on fixing markets, but socialism, arguably, would prefer to get rid of them. Such an analysis will inevitably take you through hybrid economies, or the feasibility of the implementation of socialism in various countries. But the refrain that Ed Miliband is not a ‘socialist’ does not particularly appear to worry him.

Whatever Miliband’s formulation on the structure and function of the National Health Service, it’s more likely to be interesting than him eating a chip butty, or whether he can remember a local leader’s name from a dimly lit studio in London.

Miliband’s view on the running of the health and social care system may not often openly discuss payment by results or root cause analyses in patient safety, but nor does Mr Farage’s. Ultimately, Miliband needs to produce a vision on the NHS is more coherent than Farage’s, Clegg’s, or Cameron’s.

And this job is not particularly difficult. Clegg will be interested in the goals of competition lawyers, and Cameron with that of private providers. Farage is yet to unleash his crack squad focus group on health, so we have no idea what his offering will be.

You’d be forgiven for thinking that Ed Miliband is totally buggered politically. But the pained expressions of John Mann and Graham Stringer as sore losers undermine their credibility as critical friends.

They are readily available for vacuous commentary from a supine BBC, which hailed the finding of zero councils for UKIP as an ‘earthquake’.

And Labour did perform on decent objective measures, such as the overall number of seats and the popular share of the vote. One of the myriad of untold stories is the complete implosion of the popular support of the Conservative Party. That Party know they’re stuck with David Cameron, and no Tory wants to break ranks ahead of Newark (a seat likely to be won by the Tories.)

Patrick O’Flynn, chief communications officer for UKIP, may be congratulated on producing Nigel Mirage, a figment of a new Jerusalem in politics which does not exist.

The UKIP message is claimed to be ‘selling on the doorstep’, but it does not seem to be selling particularly well on the doorsteps on metropolitan centres of England such as Newcastle, Manchester, London, Birmingham or Bristol.

To say it is an earthquake is a disingenious as selling cod roe as caviar. Sure, Ed Miliband needs to be more convincing about the ‘cost of living’, but most people can smell a rat when it is Andrew Neil, recently returned from Dubai, who complains that the ‘cost of living’ message is not getting through. Or Patrick O’Flynn, former Chief Political Editor for the Daily Express, is responsible for selling the message that the modern political class continues with the same Oxbridge types on a revolving door basis.

The BBC may have captured the safe seat of Nick Robinson (no innuendo intended), but rumours of Ed Miliband’s demise or death have certainly been greatly exaggerated. While the ‘35% strategy’ clearly promotes a strategy of the bland leading the bland, it has succeeded in completely annihilating the Liberal Democrats as a credible force in politics.

Ed Miliband must up his game, and have a very clear vision on the NHS which he can articulate without looking strained. While the ‘cost of living crisis’ may be resonating, particularly with some in London, Ed Miliband cannot be seen as a one trick pony, particularly if real wages overtakes the cost of living later this year as predicted.

Whether or not UKIP gets sucked in to fill this vacuum depends on UKIP’s ability to co-form a Government. And for this it needs MPs. The idea of Liberal Democrats repealing their own legislation, propping up a Labour administration with insufficient numbers to form a majority, is simply enough to fill anyone with dread.

But Labour does need some support from the chattering classes, particularly existentialist Green voters in the Guardian.

The NHS needs an innovative ‘blockbuster’ now. That is to be brought back under the State.

The term “innovation” must be one of the most misused terms in the media. It simply means a different way of doing things, such as a product or a service, whose popularity and effectiveness ultimately govern its success.

And yet the term has been strikingly bastardised to be used in conjunction with a whole plethora of memes such as “ageing”, “technology” and “unsustainable”. The right wing has been consistently ‘on message’ in this script.

Ed Miliband in Manchester gave last night what was a perfectly plausible speech on the NHS last night. Excerpts of it have indeed been posted on our blog. And there was the usual ‘red meat’, to be accompanied at some later date by how realistic the costings are.

But the legitimate concern of voters, whether hardworking or not, is he who pays the piper calls the tune. It may not be the frontline staff with whom Ed Miliband had photo opportunities earlier this week.

Fifty shades of government, apart from green, have been obsessed with inflicting ‘transformative’ changes, perhaps ‘charismatic’ visions, without ever consulting the wider population. Examples include the private finance initiative, or ratcheting up the NHS into a competitive market.

But Nigel Farage, whether or not he is ‘establishment’, has struck a chord with some voters. I don’t mean with his allegedly racist twangs, but I mean his ‘trust the voter’ skit. He bangs on about the referendum which he knows will never see the light of day.

Labour’s argument for why the NHS needs private companies working for it remains unconvincing with many voters. That’s why the National Health Action Party or the Green Party are watched so keenly by many.

The argument is possibly not as complicated as that justifying our membership of the European Union, but it is one which is best left to the voters to justify.

Labour in pursuing its ‘35% strategy’, where it can squeeze into office on the back of disaffected Liberal Democrat voters, is by definition risk averse. But with taking low risks the return can be very low. Labour’s lack of “blockbuster” is potentially alarming.

And many of the arguments can be discussed under the assumption that GPs work for the NHS. The BMA’s “#YourGPcares” campaign is calling for long-term, sustainable investment in general practice now to attract, retain and expand the number of GP, expand the number of practice staff, and improve premises that GP services are provided from.

The pitch for state ownership is pretty basic. Ed Miliband MP, Leader of the Labour Party, yesterday Labour’s new GP guarantee as part of the next government’s plan to improve services for patients, ease the pressure on hospitals, and restore the right values to the heart of the NHS.

Speaking in Manchester, he underlined his determination to put the health service at the centre of Labour’s campaign over the next year, beginning with these local and European elections.

But it feels as if Ed Miliband is making a meal lacking the key ingredients.

Andy Burnham MP’s ‘NHS preferred provider’ is conspicuous by its absence in the speech.

Only once Ed Miliband has slain this dragon, he can be given to talk about how primary care is best delivered. Labour is aware of its history of “polyclinics” first proposed by Professor the Lord Darzi of Denham in his review of healthcare in London for NHS London “Healthcare for London: A Framework for Action”.

The Labour Government at the time argued that this was a way of providing more services in the community closer to home and at more convenient times (including antenatal and postnatal care, healthy living information, community mental health services, community care, and social care and specialist advice).

Ed Miliband seems to care about ‘privatisation of the NHS’, in that he cared to mention ‘ending’ it.

But this is again at odds with what Simon Stevens has been thinking about.

A “Free School” is a type of Academy, a State-funded school, which is free to attend, but which is not controlled by a Local Authority.
Like other types of academy, Free Schools are governed by non-profit charitable trusts that sign funding agreements with the Secretary of State.

Supporters of Free Schools, such as the Conservative Party, including that they will “create more local competition and drive-up standards” They also feel they will allow parents to have more choice in the type of education their child receives, much like parents who send their children to independent schools do.

But Ed Miliband also talking about ‘ending competition’ which is somewhat against the mood music Simon Stevens was singing in his appearance against the Commons Select Committee.

It’s innovative bringing something back into state control, but could make good ‘business sense’, akin to insourcing a service which had been previously outsourced.

The main arguments for state control and ownership of the NHS are that such a drive would encourage co-operation, collaboration, equity; services could be properly planned not fragmented; and services would not be run for shareholder dividends.

It’s undoubtedly true that there could be operational changes to be made, such that patients could plan their GP appointments without having to ring up as an emergency at 8.30am the same day.

NHS GPs overall say that they are working flat out, and, short of having greater resources, no political gimmick will help them. Instead of lame slogans such as “Hardworking Britain Better Off”, and making do with “35%”, Labour could do something really innovative – and return to a socialist approach.

‘Saving the NHS for the public good’, on the other hand, is not a vacuous gimmick. It’s what many people in Labour also believe, possibly. More importantly, it’s the title of a current party election brodcast by the Green Party. It might be the case that Ed Miliband is left wing than the Labour Party membership. This has been mooted here. If so, “bring it on!”

You wouldn’t get a plumber to mend your fuse box. so why would you let Farage near the NHS?

I saw up close and personal how some people vote in elections. My mum asked me to work out how to package her postal vote using the declaration, ‘envelope A’ and ‘envelope B’. Whilst I did not actually see how she did the vote itself, I did ask my mum how come she did the vote in seconds.

“It’s what I always vote.”

I can well believe that. She attends, like many, the NHS – in her cataracts. She will have a procedure done on the NHS, and yet I know she has very little in how the NHS works.

She has only ever attended our local A&E in London with me very infrequently. We had to queue for hours, but we put this down to being infrequent attenders, ‘being unlucky’, ‘to be expected’ etc.

I bet you if that if  you were to ask my mum about section 75, or clause 119. If you asked her about Jos and the other Lewisham campaigners, she would immediately start smiling though.

That nice man, Nigel, is possibly a man you might like to have a drink with, particularly if you liked drinking. I definitely do not wish to imply he’s a problem drinker, despite wishing to be down the pub during the day.

But in much the same way you wouldn’t like a plumber to mend your fuse box, the chances are you wouldn’t like UKIP to run the NHS.

You might be tempted ‘to give them a go’, particularly if you feel the elections do not matter.

But the factors stopping you voting from UKIP require you partly to have decided that they would be incompetent at running the NHS.

It is incredibly difficult to work out what  the official UKIP policy on the NHS. It appears that they’re in favour of the usual corporate memes of ‘private sector efficiency’ – for all we can tell they would have been in favour of section 75.

They appear to be in favour of free trade, but not necessarily as a member of the European Union. I have never heard them voice an opinion on the EU-US free trade treaty investor protection mechanisms. This may or may not change the landscape of how multinational corporates can take over running of bits of the NHS, and get away with it.

Nigel Farage simply fell apart in his interview with Andrew Neil, but I don’t suspect many people in the general public watched it carefully. I know my mum for example couldn’t care less that his tax policies, i.e. how you pay for the NHS, are simply incoherent.

So I don’t particularly need to make a rational argument that Nigel Farage and UKIP running the NHS would be like getting the presenters of BBC News to do complicated brain surgery.

They might win a sizeable proportion of the vote, but, when it comes to the general election, their offerings on health, education, world affairs, benefits, home affairs, and foreign policy will mean they will never be asked to form a government.

They keep Question Time and Any Questions amused, as well as other current affairs programmes, and I dare say they’ll do sufficiently well in the European Elections to ensure they continue being invited to perform their hopeless skit.

But it would take an earthquake of some sort for my mum to wish to vote for them. That’s why I don’t think they’ll make it.

The nature of political discourse suffers when everything turns into an acute crisis

There’s little doubt that many find the nature of political discourse in the UK entirely contrived. Politicians, with few noteworthy exceptions, can look as if they’re not taking issues seriously, mouthing words from a script given to them, and appear utterly self-serving.

The King’s Fund have given their view on what might happen in the general election of 2015, with an increasing number of people interested in the NHS. But the fundamental issue remains that many people do not feel as if they voted in any sense for the policy changes in the NHS just coming to an end. Various campaigners, including these two, have tried their best to articulate a general unease amongst various voters, but it seems as if Ed Miliband is much more keen to mention repeatedly ‘the cost of living crisis’, rather than refer to what is happening to the NHS.

It wasn’t that long ago since we heard there were ’24 hours to save the NHS’, in a charge that ended up taking on a rather cartoonish character some non-Labour supporters allege.

By definition, all crises must come to an end. Labour’s difficulty with the current ‘cost of living crisis’ is that many feel that the causes of the ‘crisis’ have been a slow burn for ages, including changes in the energy market under a previous Labour administration. So Labour can attempt an argument that ‘not the right people are benefiting from the recovery’, in much the same way there’s been the wrong type of snow on some train lines. But the massive problem with this argument is that the people who might be benefiting from the economic recovery might be exactly the same people whom Labour tried to woo in the Blair-Brown years.

Yes, that’s right.

These are the same people Lord Mandelson has been ‘intensely relaxed’ about. Labour over its dead body would not like to bring in a whopping property tax to clobber very wealthy people. Polly Toynbee in a Guardian podcast recently remarked that it was possible that a person could see an increase in the price of his own house more than the net profit of going out to work (deducting presumably transport) expenses. And yet this is the sort of stuff which Piketty is interested in, and which Labour would rather not touch with a bargepole. So one has to enquire casually does Labour actually know what a crisis is?

“I don’t think other people in the world would share the view [that] there is mounting chaos” were in fact the precise words of the then Labour Prime Minister, Jim Callaghan.

Some have mooted that the three words, “Crisis – what crisis?” helped bring down the last Labour government in 1979, even though the man generally thought to have uttered them – Jim Callaghan – did not in fact do so. And yet the Sun journalist who fashioned that headline caught the popular impression of a government unaware of a very serious state of affairs which had sneaked up on it. Indeed, much politics is about image – and certainly Labour want to implant in people’s minds an impression of an out-of-touch incompetent administration not ‘fit for purpose’.

Crises in medicine are though interesting and precisely defined. An “Addisonian crisis” or “adrenal crisis” is a constellation of symptoms that indicates severe adrenal insufficiency. This may be the result of either previously undiagnosed Addison’s disease, a disease process suddenly affecting adrenal function (such as adrenal haemorrhage), or an intercurrent problem (e.g. infection, trauma) in someone known to have Addison’s disease (the latter is therefore ‘acute on chronic’). It is a medical emergency and potentially life-threatening situation requiring immediate emergency treatment. Characteristic symptoms can include a sudden penetrating pain in the legs, lower back or abdomen, severe vomiting and diarrhea, resulting in dehydration, a low blood pressure, a reduced level of blood glucose, and confusion.

Ed Miliband also feels his crisis is very real, if not as such ‘life threatening’. Miliband has previously promised to rescue Britain’s struggling middle classes by boosting their living standards as he warns that the “cost-of-living crisis” will last for at least another five years. He that living standards are “the greatest challenge of our age” and will be at the heart of his party’s general election campaign next year. He has rejected calls from within his own party for him to change his strategy because the economy is improving.

But there may be trouble ahead for Miliband. The “cost of living crisis” is about to turn around, according to a forecast from the Institute for Fiscal Studies (IFS). In its so-called green budget, the IFS predicted that wages will start to rise faster than inflation in just a few months’ time, but it also warned that public spending cuts would continue to hit consumers. In particular, it said spending on the NHS was due to fall by 9% per person over an eight-year period. However, it did forecast that consumers would see their real wages – which allow for inflation – increase for the first time in five years. Likewise, ahead of the Eastleigh by-election, Iain Duncan Smith reported Britain faces a “crisis” of increased immigration from Romania and Bulgaria, as all three major parties consider their response to the UKIP Eastleigh surge. Called to the Commons to explain how the government plans to deal with new immigrants from within the European Union once existing restrictions are lifted next year, the work and pensions secretary said he was working to “tighten up” what benefits were payable to new arrivals.

“There is somewhat of a crisis over this,” he said. “Some people want to come here solely to claim benefits.”

Twitter is incredibly democratising for political parties, liberating them in getting their message across. David Axelrod, Labour’s newly appointed senior strategist and Barack Obama’s closest long-term political adviser, will apparently make mobilisation of Labour’s grassroots central to the election campaign.  Axelrod himself has stressed that he could not help Labour succeed at the next election without the mobilisation of local communities, adding – in his first effort to energise Labour members – that the world would be watching the outcome of the 2015 vote. The Guardian has revealed that Axelrod was joining the Labour campaign team as a senior strategist. And Miliband has been talking about creating a ‘social movement’ for ages, perhaps inspired by his brother’s interest in ‘Movement for change’. But also the great thing about Twitter is that one can easily out the postcode lottery of pledges made by the main political parties – what a LibDem says in Cumbria might turn out to be very different to what a LibDem says in Oxford, say on the NHS.

“Lucky Generals” are the ad agency that produced the broadcast for Labour. Apparently the controversial Party Election Broadcast, known as “The Un-credible Shrinking Man” has not just been produced as a brief  comedy experiment. They have been paid good money to obey instructions from their client – the Labour Party, to deliver strategically against what they have been told are the Labour Party’s goals. That’s “the 35 per cent strategy”. As the political arithmetic under the constituency boundaries means Labour only needs to poll the 35 per cent it currently polls to win a majority (as opposed to 42 per cent for the Tories), Labour appears to have decided to hold on to what it’s got. That PEB is designed to do two things to the Lib Dems. It tells disaffected voters from 2010 who have defected to Labour why they should stick with them. And it signals to the Liberal Democrats now, they can forget to aspire any repetition of Matthew d’Ancona’s “In it together” with Miliband’s Labour.

In a way, the persistent pathology in the National Health Service has lasted for decades. Factors include a chipping away in real terms in overall budget, poor budget allocation, PFI loan repayments, the need for efficiency savings, nurses not getting pay increases, delays in A&E, delays in seeing a GP, and so on. But there is concern that such a ‘lean’ large entity will simply be unable to bear any small shock to the system. Astra Zeneca and Pfizer are much in the news headlines these days. They are both powerful multinational pharmaceutical companies which have much in common with film companies. They will both produce their fair share of bananas and donkeys, but they only need one huge blockbuster to survive. Similarly, the Labour Party, if it found its blockbuster policy, might find itself with a consistent poll lead of a few percentage points in the run up to the General Election to be held on May 7th, 2015. The reason the ’35 perent’ strategy might be sensible for Labour is that the risks of a blockbuster going wrong for Labour are huge. This is Labour’s election to lose, given the massive unpopularity of the current Con-Dem coalition for a number of diverse reasons.

A ‘blockbuster’ might indeed come in the form of the Labour Party producing a political signal to bring all the PFI hospitals immediately into state control – but many of these contracts are due to run out in 2017-9 anyway; or might be to ‘renationalise the NHS’ , building on the left populist strength of the desire to renationalise the railways. The latter, a sort of ‘reverse clause 4’ moment for Ed Miliband, could be boom or bust for Miliband, but no-one would really know until the move is executed. Miliband would almost certainly for the chop if Labour lost the general election in 2015. But how he lost it, if indeed he does, can only be a matter of speculation now. It is widely predicted that UKIP will ‘win’ the European elections, with the Labour Party coming second. But what happens in third place is of considerable significance – might the Green Party manage to capture a lot of disaffected voters themselves, throwing the Liberal Democrats into 4th place?

If that materialises, what happens to the Liberal Democrat and Green vote between 2014 and 2015 is of massive significance. The problem that Ed Miliband has is that the cost of living crisis may not be a sustainable crisis. But an opportunity for Ed Miliband is that the performance of the NHS continues to decline, such that there is a genuine acute-on-chronic crisis in the NHS. Campaigners on the NHS have done a terrific job so far, but the best is yet to come (or ‘the worst’ depending on your perspective).

If you don’t stand for something, you’ll fall for anything

There are in fact very few people who have never made a mistake.

But if you don’t stand for something, you’ll fall for anything.

On the same day that the group “Progress” announced that they were looking forward from ‘New Labour’, Alex Andreou gave a powerful first-hand account of why he wished to vote Green in the European Elections.

Yesterday, Labour revealed its latest PPB, “The Un-credible Shrinking Man”.

On the downside, it contain no details of policies about what Labour intends to do in the next parliament, and has been criticised for trivialising politics.

But arguably it has succeeded in ‘getting people talking’. And supporters of the Labour Party argue that the ‘schoolboy politics’ is no worse than the attack that Gordon Brown caused unilaterally a world recession.

There is less than one year until the General Election to be held in the UK on May 7th 2015. At this point in time, Labour is barely ahead in the opinion polls.

Whilst it’s felt that the ‘cost of living crisis’ is very important to Labour and Ed Miliband, there’s no doubt of the existence of groundswell of opinion which wants Labour to do something on the NHS.

Andy Burnham MP has made clear that the direction of the NHS currently is wrong – he wants more integration, less fragmentation. He says that Labour took the market approach too far, and specifically wishes to repeal the entire Health and Social Care Act (2012) and the clause 119 empowering fast closures of ‘failing’ NHS hospitals.

He has also laid out a vision for ‘whole person care’, where the NHS will take responsibility for the whole care of a person, including social care. Local authorities could be well placed to make commissioning decisions, linking up to community leisure clubs, education or housing.

But there’s a feeling that Labour needs yet further a ‘big idea’ which could give them a sustainable margin of a few points ahead of all the other major political parties.

It is quite unlikely that the minimum pricing of alcohol or standard packaging of cigarettes are the hugely populist policies Labour can introduce, not least because of Labour’s dense phobia of offending libertarian sensitivities.

There’s always enough money for an allegedly illegal war, the Chilcot Inquiry or high speed 2. Possibly at the back of the mind of Labour’s voters is a commitment for a well funded NHS and social care system. Paying off PFI loans may not be an enforceable manifesto pledge, but an intention to do something significant about PFI might be hugely popular.

It seems likely too that the general public hate sudden closure of local A&Es and hospital facilities. The public need to be reassured that redesigning of services is not out of a overzealous drive to cut the welfare state, but there are proper mechanisms in place to listen to what patients in the NHS in their locality want.

They say the greatest asset of any organisation are the people within it. Labour can do no harm in listening to nurses, doctors, other healthcare professionals, or even other political parties who might be sympathetic to a socialist approach.

At the moment, it seems that the general public feel that the pendulum has swung too far in the opposite direction, with a keenness to bend over backwards for the benefit of corporates including the pharmaceutical industry.

Labour of course needs space to get its message across, which is difficult with the current media, and it will inevitably need some time. A concerning issue is whether Ed Miliband has left this too late, and what rabbit is pulled out of the hat is a bit anaemic-looking in the event.

Above all, it’s not entirely clear what Labour stands for. Andy Burnham MP and his entire team are undoubtedly doing their best, but being in opposition means that they are not able to get their way on certain issues fully, such as negotiation of the investor protection clauses in the EU-US free trade treaty.

But there are some aspects of policy which Labour does need to distance itself from, such as running the NHS to profit private shareholders rather than providing a comprehensive health service. It needs to lay down markers that it believes the protagonists of competition in the NHS overplayed their hand.

In an ideological vacuum for the Labour Party, many socialists are genuinely concerned that the Labour Party will plump for off-the-shelf corporate policy ‘ready meals’, instead of putting due attention into a carefuly-designed homegrown recipe.

It may have to go as far as forming a spirit of ’45, but this will not be easy. But surviving the last Con-Dem government shouldn’t be in principle worse than surviving the Second World War.

I love GPs

A blogpost on general practice in the UK would not be complete without a smiling person with a stethoscope, in the same way that all articles on dementia must have wrinkly hands on display.

I have nothing particularly clever to say about primary care at this point.

But have I ever mentioned that I do love GPs?

My regular Doctor, Stuart, whom I virtually always see, knows my medical history backwards. And it’s not for the ‘faint hearted’.

I became physically disabled at the age of 33, during a two month coma, successfully managed on the ITU of the Royal Free in Hampstead.

Stuart knows I am no longer depressed.

Stuart knows I have had no epileptic fits since I gave up drinking alcohol.

Stuart knows I’ve been in recovery from a severe alcohol dependence syndrome for about seven years now. He can do whatever gamma glutaryl transferase levels he wants to look for surrepticious drinking, if he so wishes.

Primary care does intrigue me, as my late father whom I adored was a single-handed GP outside of Brighton for about 30 years. Things have changed a lot. I dare they’re about to be transformed again.

I am also an asthmatic, and therefore I was lapping up all the media missives about being empowered by the NHS.

I craftily got an emergency appointment the same day by phoning up at 8.30 am.

The GP I saw (not Stuart) was excellent.

Admittedly, I gave a perfect history of someone who needed to be stepped up from the British Thoracic Society guidelines for asthma, from inhaled salbutamol to inhaled salbutamol and inhaled steroid.

I left with a prescription for clenil – #happy.

I might have overplayed my hand. At one point, I was dangerously close to being referred for spirometry. “I am a lifelong non-smoker”, I declared emphatically!

Ho hum, but living with various chronic conditions does give me a lot of insight in how the NHS functions behind all the shouting of Westminster.

I moaned on Twitter yesterday that I might have to have my inhaler technique checked to get my prescription for clenil.

A GP educator commented wryly, “We’re in a no-win situation. We’re complacent if we don’t assess you, we’re obstructive if we do.”

Anyway – stet – I love GPs.

Please, if you’re a GP, vote in the RCGP elections. Four of them follow me on Twitter.

For once, I am saying nothing.

Trisha GREENHALGH, Simon GREGORY, Clare GERADA, Mayur LAKHANI, Philip WILLIAMS, Martin MARSHALL, David MUMMERY Joanne REEVE, Steve MOWLE, Clare TAYLOR, John COSGROVE, Stuart SANDERS, Sue RENDEL, Mary LOWTH, John CHISHOLM, Chandra KANNEGANTI, Elaine McNAUGHTON, Martin BRUNET, Hussain GANDHI and Stephanie de GIORGIO.

Ed Miliband should not be so obsessed about the economy, but talk about the NHS

Time after time, voters in polls and in focus groups return the finding that they don’t especially trust any mainstream political party with their handling of the economy.

But in a forced choice, a small majority of voters think the Conservatives are ‘better at handling the economy’.

This of course depends on what your definition of the economy is. If it means the rich getting a lot richer, that is possibly true. And don’t forget Lord Mandelson was ‘intensely relaxed about that too’.

Gordon Brown and Ed Balls are adamant that they’ve won the argument on needling to pump money into the investment banking sector to avert a ‘Great Recession’.

However, David Cameron and Nick Clegg appear to have succeeded in spinning repetitively their yarn that it was Labour that ‘brought the economy to its knees’.

And it seems Ed Miliband is equally obsessed about ‘winning the argument’. Miliband is continuing with the line that the cost of living outstrips real wages, even though it is widely reported that this trend will reverse sometime this year.

But Miliband possibly is on surer ground with ‘zero hour contracts’, and the financial insecurity of some who have them. He would be on massively firmer ground if he were to attack the lack of access of justice through the closure of law centres through legislation introduced by this Government.

He would be on much firmer ground if here were to attack the changes in employment rights such as unfair dismissal.

There’s no doubt that the ‘cost of living crisis’ is important to many – with the well known #shockedface when many of us open our energy bills.

But he almost appears to mention the NHS as an after thought. Now is the time when Labour should produce a series of announcements on what it wants to do, aside from leaks on public health which look pretty deliberate in the Daily Mail.

Labour could campaign strongly to ensure that the English Law Commission’s proposals on the regulation of clinical professions see the light of day, with Jeremy Hunt having made this such a totemic issue.

Labour could hone in on the incredible waste in PFI loan repayments, and their subsequent effect on budgets regarding safe staffing. These have been identified by Margaret Hodge’s team in the Public Accounts Committee.

It could decide to wish to implement legislation which makes it a certainty there’ll be no hospital closures appearing from nowhere and any discussion of changes to health services will require a meaningful discussion with the local community first.

It is up to Labour to choose the narrative too. People desperately want Labour, and Ed Miliband, to take a lead on the NHS. As Carville said, “It’s the economy stupid….. but don’t forget about healthcare.”

Personal budgets for dementia. What’s the harm in them, and are the right people benefiting?

Personal budgets held by individual people might allow more flexibility in choice and control over health services. So what’s the harm in them?

Barry Schwartz’s famous book “The paradox of choice”, summarising a lot of other evidence, contests the assumption that maximising collective welfare of citizens is achieved through maximising individual freedom.

On May 8th 2015, there’ll be a change in government in the UK (unless the arithmetic happens to throw up another Conservative-Liberal Democrat coalition, which is quite unlikely). It is likely that all the major political parties will wish to implement a form of ‘integrated’ or ‘whole person care’, with the merging of health and social care. It is a moot point how early on people, if at all, will be offered the chance of a ‘unified personal budget’.

A particular group of people for whom personal budgets may be considered are persons with dementia. It is therefore perhaps a bit disappointing that some of the same issues which existed many years ago are still lurking in some form even now. No matter how much effort you put into ‘compassion’ or ‘Dementia Friends’, the care system is never going to be acceptable in the light of dangerous financial cuts to social care. The “one size fits all” philosophy seems to be pervasive in the Government approach to personal health budgets, whichever Government pursues it. It’s as if it doesn’t matter who is the singer is because the song is the same: like Pharrell’s “Happy” was originally recorded by Cee Lo Green (allegedly).

Certain people with early dementia might be particularly prone to impulsive or risk-taking behaviour, so there is a reasonable question whether some persons with dementia – despite full legal capacity – are “safe” to have personal health budgets themselves. But this I feel strengthens my argument for a proper system of delivery of personal health budgets, not undermining them. When personal budgets work for dementia, as explained by Colin Royle here, they work very well.

A potential danger is that somebody is given a list of ‘options’ for care support planning, and effectively told to get on with it. It can be difficult to get to the precise details of resource allocation systems, and, without knowing such details, it is difficult to ascertain whether they legally constitute a process acting to the detriment of the group of people with dementia.  This leaves individual local authorities open to an accusation of indirect discrimination, offending the Equality Act (2010). There are various sources of factors which might cumulatively  cause certain people to be more disadvantaged than others: e.g. an ability to ‘self-assess’ one’s needs in a questionnaire (with age being a confounding factor).

Personal budgets might be offered in a number of ways: namely those which were directly commissioned and managed by the local authority, third party managed accounts, direct payments or a mixture of these things. Concerns might come from all sorts of quarters: such as actual budget holders who don’t feel that the resources allocated meet their needs, or the professions who don’t feel  that certain candidates  are suitable in the first place. This is perhaps one of those uncommon instances where ‘cutting out the middle man’ is in fact a dangerous idea. The actual calculation of resource allocation for an individual candidate is emphasised rather than the calculation of running the whole system adequately, in much the same way that the improvement in wellbeing in a personal budget might accrue from having a choice at all rather than the actual proposed care intervention.

Take,  for example, this passage:

“Quality support planning needs the investment of time. In the ideal world, presented by those who ‘run with’ the agenda, everyone is able to take an active part in making decisions for themselves and choosing their own care to meet their needs, as defined by themselves. The reality is that some groups have not been able to engage in the process of taking an active role in their own support planning; they are effectively excluded. This may be because they lack the capacity to manage a direct payment or organise a personal budget themselves, or because they lack support systems around them, such as family to help them do this.”

Clearly not everyone has benefited from the “Prime Minister’s Dementia Challenge”. For example, the Dementia Advocacy Network went bust at the end of last year.  And yet this is precisely the time when people with dementia, and caregivers, need emotional support, and need to be safeguarded against forms of abuse including financial and legal. It appears that people who have benefited most from personalisation are those with the best advocacy and loudest voices. Even with the most-straightforward appearance of self-assessment application procedures for personal budgets might require an enormous amount of professional support.  There are various reasons why persons with dementia might have special obstacles in their uptake of personal budgets, as articulated well by the Mental Health Foundation: two for example include a residual stigma and discrimination against such citizens, and also the fact that some citizens might not have a reliable correct diagnosis in the first place.

Self-directed support (SDS) has as its central feature a personal budget arrived at through an ‘up-front’ allocation of money; though up front allocation to give people power is one element of SDS amongst others and therefore it would be unfair to generalise across all the resource allocation systems techniques. It was introduced as formal policy in 2008, with an original target that all service users should have a personal budget for social care by 2011.  In a recent helpful article, “Personalization of health care in England: have the wrong lessons been drawn from the personal health budget pilots?“, various well-known methodological problems with the original pilots are considered. The authors do, however, propose an extremely constructive way of moving forward, what they call “flexibility through partnership”.

Cheekily, the authors observe:

“As Gadsby points out ‘It seems that in many cases, additional resources[in the PHB group] were provided that enabled individuals to pay for extra services or one-off goods. It is perhaps unsurprising, therefore, that overall improvements were found in wellbeing amongst budget holders’”.

Without advocacy services, then, we really do run the danger of running a two tier service, and this is extremely dangerous, aside from the swathe of legal aid cuts. For a government which prides itself on parity, particularly for empowering new private providers to enter a liberalised market, any proposed system of personal budgets will require  the same quality and opportunity for flexibility to all user groups including those who have no recourse to advocacy. A strengthened social care system would go a long way here. Nobody has a single right answer for personal budgets in dementia so it might not be able to have the exclusive kite mark to match. It’s clear whilst there might be excellent ways of implementing them, there are plenty of bad ways too.

Unfortunately, time is running out a bit, and political leadership and adequate funding – including for advocacy services – are now both essential. And who will benefit? If they work well, they will shift power to the people able to make ‘correct decisions’ in care, but I feel that the whole system has to be fit-for-purpose not the budget mechanism itself. That’s where the State comes in. Who the correct advocates are, as they might not necessarily be carers including unpaid caregivers (though they might be.) Ultimately, the most offensive irony would be to make the tool that offers choice and control compulsory, but this could be expected from politicians who like to give an illusion of choice.

There are still deeply engrained issues about whether people will have enough money to meet their needs. It might be easier to hide downsizing of budgets if they’re called a yet further new name. There are obviously huge problems with merging one universal system intended to be comprehensive and free at the point of need with one which is not and means-tested; and this would not necessarily benefit the person with dementia. And at worst, the wrong type of broker, not professional advocates including social workers, could be profiting but not providing overall benefit. Introducing any transactions into a system absorbs resources, however you attempt it.

We now have to be very careful with resolution of this potentially useful policy plank – otherwise it might be a case of ‘You’ll do’, rather than ‘I do’.