How the acute medical take can generate into chaos for persons with dementia

The independent Future Hospital Commission was established by the Royal College of Physicians in March 2012 to find solutions to the current challenges facing the NHS – a rising number of acute admissions, the increasing number of patients who are frail, old, or who have dementia, patients with increasingly complex illnesses, systemic failures of care, poor patient experience, and a medical workforce crisis.  The NHS leaflet on the 6Cs here. Even for the official 6Cs, powerful forces are at play in undermining the acute medical take. The ‘Good 6Cs’ can find themselves competing with the ‘Bad 6Cs’, which can determine the outcome of the acute general medical take. One year on after the publication of the last Francis Report on Mid Staffs, there appears to be common themes in what can go wrong.

12Cs revised

1. Care

Care is described as a “core business”, perceiving each event with a patient as a transaction which is a potentially billable event.” Caring defines us and our work” indeed is true; as it defines to some extent how people get paid. Unfortunately, the way in which care goes wrong is pretty consistent in the narrative. For example, nurses may be too ‘posh’ to care. In this version, nurses who are too academic are incapable of caring for which there is little published evidence. The other more likely version is that junior nurses are “too rushed to care”. This is understandable, in that if there are ten people still waiting to be clerked in, it can be hard for all professionals to focus on taking a proper history and examination without cutting corners, for examination in completing an accurate neurological examination of the cranial nerves. However, the emergency room often cultivates a feeling of a conveyor belt, with a feeling of “Now serving number 5″. A patient experience is not going to be great if the doctor, nurse or AHP appears rushed in clerking in a patient. The patient feels more like they are in a sheep dip as “continuity of care” between different medical teams suffers.

2. Compassion

“Compassion is how care is given through relationships based on empathy, respect and dignity.”  Again there is some irony in the same management consultants outfit recommending compassion by healthcare professionals, when the same professionals have recommended ‘efficiency savings’. Compassion in the NHS can of course be extremely difficult to deliver from the nurses remaining after there have been staff cuts, and the remaining nurses are having to work twice as fast ‘to beat the clock’, or a target such a “four hour target”.

3. Competence

“Competence means all those in caring roles must have the ability to understand an individual’s health and social needs.” This is of course is motherhood and apple pie stuff. The problem comes if the NHS ‘productivity’ is improved with lateral swapping of job rôles: that some functions are downgraded to other staff. Health care assistants might find themselves doing certain tasks which had been reserved for them. If there’s mission creep, the situation results of receptionists triaging a patient, rather a physician’s assistant doing a venflon. Competence of course cannot be delivered by untrained staff delivering an algorithm, as has been alleged for services such as NHS 111.

4. Communication

Communication is central to successful caring relationships and to effective team working. The overall “no decision about me without me” mantra of course has been made a mockery of, with unilateral variation of nursing and medical contracts (with adjustments to terms and conditions, and pay, of staff by NHS managers without any dialogue.) If you don’t communicate any errors in clinical care to the patient (reflected in the ‘lack of candour’ below), the patient and relatives are bound to leave with an unduly glossy version of events of the acute medical assessment. This can of course bias the outcome in the ‘Friends and Family Test’.

5. Courage

“Courage enables us to do the right thing for the people we care for, to speak up when we have concerns.” Take the situation where your Master (senior nurse) is wishing to implement a target, but you’re the one rushed off your feet with missing drug charts, no investigations ordered, no management plan formed as the patient was shunted out of A&E before the 4 hour bell started ringing? Are you therefore going to be able to speak out safely against your Master when your Master is the one who determines your promotion? If you’re made of strong stuff, and completely fastidious about patient safety, you might decide ‘enough is enough’ by whistleblowing. But the evidence is that whistleblowers still ultimately get ‘punished’ in some form or others.

6. Commitment

“A commitment to our patients and populations should be the cornerstone of what we doctors, nurses, and allied healthcare professions do, especially in the “experience of the patients.””.  Of course, if you get a situation where junior staff are so demoralised, by media witch hunting, it could be that people are indeed driven out of the NHS for working for other providers, or even other countries. A commitment to the public sector ethos may have little truck if you’ve got more interest in ‘interoperability’, or ‘switching’, which are of course the buzzwords of introducing ‘competition’ into healthcare systems.

There can be some downright ‘yang Cs’ epitomising danger for the acute medical take and hospital.

7. Chaos

If for the sake of hitting a target, drug charts aren’t written up, investigations not ordered, an inaccurate management plan produced, that is no victory at all. This can only lead to chaos later down the line for nursing teams for ‘receiving wards’.

8. Crisis

When things get out of hand, some of the more hyperbolic allegations might conceivably happen. With people lose the plot, they are capable of anything. And if the system is too lean, and there’s a road traffic accident or other emergency, or there’s an outbreak of rotavirus amongst staff, there may be insufficient slack in the system to cope.

9. Cuts

Whilst patient campaigners have been right to emphasise that it’s more of a case of safe staffing rather than a magical minimum number, there’s clearly a number of trained staff on any shift below which it’s clearly unsafe for the nurses to deliver good nursing care. Cuts in real terms, even if that’s the same budget (just) for an increased numbers in an elderly population, can of course be a great motivator for producing unstable staffing, as the Keogh 14 demonstrated. That might be especially tempting if ‘financially strained’ NHS FTs are trying to balance their budgets in light of PFI loan repayments.

10. Collusion

This can affect a nurse’s ability to communicate problems with courage, if senior nurses are colluding with certain consultants in meeting targets. This means that medical consultants who are recipients of the non-existent drug charts, non-existent management plans, or non-existent investigation orders can probably take one or two weeks to ‘catch up’, but the ‘length of stay’ gets extended. Frontline staff can take the risks. But senior nurses can collude with the management to deliver ‘efficiency savings’ and promote themselves. That’s not fair is it?

11. Lack of Candour  

This target-driven culture of the NHS, and excessive marketing of how wonderful things are, must stop.  A lack of honest communication with the patient through candour can lead to patients never knowing when things go wrong. This is a cultural issue, and it may be legislated upon at some point in the future. But without this cultural willingness by clinical staff to tell patients when things have unnecessarily got delayed through the missing drug charts etc., they will only get to know of things going badly wrong.

12. Complaints  

If things go badly wrong, they may generate complaints. These complaints may as such not matter if the system completely ignores complaints. For example, there has been only one successful judicial review against the PHSO since 1967. The recent review of the complaints process  for NHS England has revealed how faulty the process is. There has been criticism of the clinical regulators in their ability to enforce patient safety too, particularly in light of Mid Staffs.

As you can see, the system is delicately balanced. If transparency is the best disinfectant, it’s time to reveal the other six Cs for a start? The most important thing of course may be Culture, the 13th C.

Being number 13, it may be worse than unlucky for some.

Is prevention of dementia merely a pipe dream?


Predicting the future on the basis of your past is of course the ultimate goal of the shopping industry.

It also seems to be the goal of healthcare, as consumer behaviour and patient care appear to converge in ever-marketised healthcare.

When you ‘sign up’ for a health subscription somewhere, one day, it’s possible you’ll be offered “packages” most suitable for you. Consider them like targetted adverts on Facebook. Of course, with disease registries compiled on your behalf by public health through data sharing, tomorrow’s world is getting ever closer.

So how much of dementia is in your ‘control’, if you haven’t yet developed it?

Is prevention of dementia a pipe dream?  There are, after all, many factors which we’re born with which can have a huge influence. These are known as generic factors.

Amazon, the world’s largest online retailer, is already testing unmanned drones to deliver goods to customers. The drones, called Octocopters, could deliver packages weighing up to 2.3kg to customers within 30 minutes of them placing the order. Amazon has filed a patent that will allow it to ship a package to you before you even know you’ve bought it.

To give you another example, I know someone who was being given sponsored ads for hotels in Bilboa after Facebook had picked up her location by GPS.

Now back to the past.

Back to Black in fact.

The Black report was a 1980 document published by the Department of Health and Social Security (now the Department of Health) in the United Kingdom, which was the report of the expert committee into health inequality chaired by Sir Douglas Black. It was demonstrated that although overall health had improved since the introduction of the welfare state, there were widespread health inequalities.

Full Text of the Black Report, supplied by the Socialist Health Association website.

Surprisingly enough, it’s not all doom and gloom.

Modulating the environment might have some sort of impact on prevention of dementia, even if we don’t yet know how big or small this impact is.

The study of exceptionally long-living individuals can inform us about the determinants of successful aging. There have been few population-based studies of centenarians and near-centenarians internationally. But a recent study involving individuals 95 years and older were recruited from seven electoral districts in Sydney provided evidence that dementia is not “inevitable” at this age and independent living is common.

Low socioeconomic status in early life is well known to affect growth and development, including that of the brain; and it has also been shown to affect the risks of other chronic diseases.

Over a decade ago, a real attempt was made to relate early socioeconomic status to later dementia. We found results consistent with the hypothesis that a healthier socioeconomic environment in childhood and adolescence leads to more “brain reserve” (the brain’s ability to cope with increasing age- and disease-related changes while still functioning) and less risk of late-life dementia, including Alzheimer’s disease, later on.

Results from two major cohort studies, led by the University of Cambridge and supported by the Medical Research Council, have reveal that the number of people with dementia in the UK is substantially lower than expected because overall prevalence in the 65 and over age group has dropped.

Three geographical areas in Newcastle, Nottingham and Cambridgeshire from the initial MRC Cognitive Function and Ageing Study (CFAS) examined levels of dementia in the population. The latest figures from the follow up study, CFAS II, show that there is variation in the proportion of people with dementia across differing areas of deprivation,  suggesting that health inequalities during life may influence a person’s likelihood of developing dementia.

The prevalence of dementia in the general population might be subject to change.

Factors that might increase prevalence include: rising prevalence of risk factors, such as physical inactivity, obesity, and diabetes; increasing numbers of individuals living beyond 80 years with a shift in distribution of age at death; persistent inequalities in health across the lifecourse; and increased survival after stroke and with heart disease.

By contrast, factors that might decrease prevalence include successful primary prevention of heart disease, accounting for half the substantial decrease in vascular mortality, and increased early life education, which is associated with reduced risk of dementia.

The study was led by Professor Carol Brayne from the Cambridge Institute of Public Health at Cambridge University. She opined that whether or not these gains for the current older population will be borne out in later generations might depend on whether further improvements in primary prevention and effective health care for conditions which increase dementia risk can be achieved, including addressing inequalities.

In fact, it has been recently appreciated that cardio-metabolic risk factors have been associated with poor physical and mental health.

An association of low education with an increased risk of dementia including Alzheimer’s Disease, the most common cause of dementia globally, has been reported in numerous cross-sectional and longitudinal studies. Education and socioeconomic status are highly correlated, it turns out.

The reserve hypothesis has been proposed to interpret this association such that education could enhance neural and cognitive reserve that may provide compensatory mechanisms to cope with degenerative pathological changes in the brain, and therefore delay onset of the dementia syndrome.

The complexity of people’s occupations also positively influences cognitive vitality, and this relationship becomes increasingly marked with age.

Further evidence from studies suggests that a poor social network or social disengagement is associated with cognitive decline and dementia.

The risk for dementia including Alzheimer’s Disease was also increased in older people with increasing social isolation and less frequent and unsatisfactory contacts with relatives and friends. Rich social networks and high social engagement imply better social support, leading to better access to resources and material goods.

Previous studies have also shown that social determinants not directly involved in the disease process may be implicated in the timing of dementia diagnosis. Possibly the living situation is related to the severity of dementia at diagnosis. If so, primary care providers should have a low threshold for case-finding in older adults who live with family or friends?

Regular physical exercise was reported to be associated with a delay in onset of dementia including Alzheimer’s Disease among cognitively healthy elderly.

In the Kungsholmen Project, the component of physical activity presenting in various leisure activities, rather than sports and any specific physical exercise, was related to a decreased dementia risk. It is generally thought that physical activity is important not only in promoting general and vascular health, but also in promoting some form of brain rewiring.

Various types of mentally demanding activities have been examined in relation to dementia in general, including knitting, gardening, dancing, playing board games and musical instruments, reading, social and cultural activities, and watching specific television programs, which often showed a protective effect.

So it really might not all the doom and gloom, and certainly we are much further forward than we were 33 years ago with the publication of “The Black Report”.

For the record, this Report doesn’t even mention dementia.

Prof Alistair Burns in New Scientist writing “Dementia: A silver lining but no room for complacency” summarised elegantly the situation as follows, on 10 January 2014:

“While it is true that there is no cure, the findings suggest that prevention is at least possible. This must surely explain any reduction in prevalence, so what might be behind it? Improved cardiovascular health, better diet and higher educational achievement are all plausible explanations. This opens up the possibility that people who are able to take control of their lives can reduce their individual risk of dementia.”

So, to answer the actual question.

There is a realistic possibility that we might be able to identify certain people who are most at risk of developing a dementia, and modifying the known risk factors constitutes ‘low hanging fruit’ for policy. If you park aside the corporate capture potential of making new markets through development of health promotion packages, this is indeed an example, shock horror, of where data sharing across the whole population might be helpful and direct the health of the nation in future.