Making dementia a priority locally

I didn’t know what to expect. I have been to various conferences on dementia run by dementia charities in the past. They seemed to be stuck in a particular groove, with the same over-exhausted catchphrases and ambitions.

I went to the Alzheimer’s Society annual conference yesterday just round the corner from Victoria Station in Westminster, not knowing what to expect. I went there with a completely open mind, in a very good mood, and with a highly positive outlook. I was not to be disappointed.

The theme of the conference was making dementia a priority locally.

It was the first time where I had been to a conference since my mum had been diagnosed with dementia in London in 2017. She died in the heatwave last year. I had probably last gone to a my last dementia conference around 2016.

I have a background in dementia, having published several books on it, papers on it spanning more than a couple of decades now, and various talks at national and international conferences.

It was the first time I had seen Prof Paresh Malhotra. for about twenty years. I have a lot of time for Paresh as we are exact contemporaries, and I remember him from about twenty years ago as a junior in London.

The policy marked a clear and material step change away from the vagueness (for me) of ‘dementia friendly communities’. I think the pandemic saw a clear breakdown of this policy where ‘dementia friends’ could not be relied upon to look after the loneliness in society with dementia.

It was super to see Chris Larkin who’d been up at the crack of dawn to be there.

Next year the conference will apparently focus on equality, diversity and inclusion. There was an outstanding session on this yesterday which put a lot of meat on the bones here, providing detail touching upon the complex issues of race and sexuality for example. There is still much to do – for example to look at other protected characteristics, perhaps especially liability.

There was much discussion of diagnosis. For me, the ‘secret’ about diagnosis is not the technology, although innovation is to be welcomed. It is simply the infrastructure of following people up reliably, making sure that they are not lost within the system. And we have a duty to make sure that we can plan far ahead, which does unfortunately need precise details about the workforce for the NHS and social care. It is unlikely that someone who wants a diagnosis of dementia, especially from a BAME background, will want to face the ‘8 am phone scramble’ for example to just get an appointment. We need to align policy for dementia and delirium more cogently.

I first met the super clever Marie Cooper when she was the first to do work every else was doing – before mum even had been diagnosed with dementia even.

I think the Events team of the Alzheimer’s Society have to be massively congratulated. I found John and Zula Suchet’s talk as ambassadors moving, and I cried during the Dementia Choir session thinking of mum all the time.

I felt that the atmosphere and the culture of the Alzheimer’s Society in a really good place. Kate Lee CEO was exuding great vibes all day, sporting new Converses, and correctly proud of her charity.

I’ve thought a lot about ‘living with dementia’. I think the world of Chris. I think to be blunt it is an injustice to think of dementia as only the negative stereotypes in the final stages. None of us know what is going to happen the next minute. Very voice has to be at the table. Leave your assumptions at the door.

The conference had the feeling of a wedding reception to me. People I can call my friends, especially Adelina, were great to see – and Adelina’s outputs on dementia research are second to none.

I think this was the best dementia conference I’ve ever been to – with a real attention to detail, including high standard research presentations, definite inclusion of the lived experience, and attention to detail including accessibility of the built environment.

Hilda Hayo, chief of Dementia UK, was there. It was lovely to see and to chat with her.

A real credit to Kate Lee, the events team and the entire Alzheimer’s Society. I’m so proud of the Society at the current time, working together


Just how far low will Starmer stoop just to become Prime Minister in 2024?

Keir Starmer is a rather simplistic man, or at least pretends to be. He predictably used the Coronation as an opportunistic grab to re-launch his flag and country credentials.

But the nation is in crisis. Whilst Rishi Sunak has come up with a list of five things which he thinks he can deliver on – such as fewer boats and less people on a NHS waiting list, Starmer has come up with five ‘missions’. There is no clear mapping of Starmer’s missions to an improved quality of life or standard of living, such as fewer potholes on the roads. There are many things which some voters did not ‘vote for’ – such as a £250 million coronation ceremony, or a £10 million pop coronation concert, let alone the infamous HS2. But Starmer’s lack of ambition for the country is in stark contrat to his substantial ambition for himself personally.

I don’t wish particularly to rehearse how Starmer has reneged on his plefges which formed the basis of him becoming the democratically elected leader of the Labour Party. I don’t even want tp talk about how he has chucked out of the Labour Party the MP for North Islington, Jeremy Corbyn, who was dogged with problems clearly set out elsewhere such as in the Forde Report. We know from that recent infamous Guardian problem that strong antisemitic tropes are not just confined to one area of the Labour Party, whilst we also know that Jewish members of Labour who have supported Palestine have been suspended by the Labour Party. The ‘antisemtiism’ problem in Labour is far from solved, and nor is any problem with islamophobia. Starmer nonetheless keeps on presenting it as having been ‘cured’, like a cancer which has excised like a successful surgeon. Starmer says that Labour has ‘come back from its worst defeat since 1935’, and yet the vote share of Labour looks likely to have decreased. He leads a divided party, entirely of his making, and presented a range of policy positions on privatisation/nationalisation and EU membership encouraging longstanding members to find a better home in the Liberal Democrats or Green Party.

Some members who find the lure of single market membership at least more understandable than the meaningless mantra of Starmer of ‘making Brexit work’ will find the LibDems undeniably attractive. Some Tories will feel the same. LibDems therefore could become a natural home for ‘remainers’, spurned by the Labour Party and the Conservatives. The well known issue for the more left wing in Labour with the LibDems are the raw memories of the Cameron/Clegg coalition which included, amongst other issues, increased scope for financial competition in an increasingly marketized NHS, legal aid cuts, continuation and worsening of the disability welfare cuts started under New Labour. And then one does not have to have a very long memory to remember the lack of support for Labour, especially over the deeply traumatic Brexit negotiation period, from Jo Swinson, the hapless and politically offensive leader of the Liberal Democrats at the time.

There is clearly a market failure in the privatised utility industries. The water industry seems to have suffered from a lack of basic investment, leading to burst pipes and waste, against the back of unconscionable profit for directors and shareholders, including foreign institutional investors. Privatising a state run monopoly to all intents and purposes has produced a ‘cash cow’ which has been diaastrous for the customer. Rail fares are through the roof, energy companies have also acted recklessly. Whichever way you look at it, these markets are a mess, and a sad indictment of at least thirteen years of Tory government. It is a well known failed economic model. That Labour seems not to want to fix any of it is not progressive – and it is not radical. And it is definitely a missed opportunity.  Starmer and Streeting, despite having been given years to think about it, have offered nothing yet to solve the NHS workfore crisis, reform social care, or produce a sensible solution to the crisis in general practice. They have sat on the sidelines during the deeply traumatic strikes by nurses and junior doctors, and literally lives have been lost as a result.

The path to power for Keir Starmer factors in an implosion of the vote for the SNP following internal problems to do with finances, the resignation of Nicola Sturgeon and so on. Unofficial hopes might also include a racist backlash against Hamza Yousaf, and a genuine lack of interest in independence for Scotland. I think that these hopes are unduly optimistic as far as the perspective of English voters. There is a vague hope of people wishing to install Starmer that Scottish voters will be stupid enough just to think ‘anyone but the Tories’, but this is to deny the deep anger against the Supreme court judgement on Scottish independence, the power grab on the gender recognition bill, the lack of consultation over a Brexit which has clearly detrimental against the Scottish economy, and so on. The decline in Scottish Labour was exacerbated by the disastrous politics of Kezia Dugdale, and looks likely not to recover in the near future. All of this convincingly points to Labour looking unable to achieve a majority, but likely to be the largest party in a hung parliament.

Keir Starmer can therefore become Prime Minister under these circumstances in 2024, despite an intense poverty of ambition or political skill. The more interesting projection is what happens after 2014 to around 2019. In that period, he will have to deliver a position on Brexit, and on the ‘small boats’ having got rid of, presumably, the Rwanda option. The good aspect of a potential 2024 victory for Starmer’s Labour might be an avoidance of the withdrawal from the European Convention of Human Rights. But it is hard to understand what exactly he will do on the European Union, the economy or the NHS to make it possible for him to win the next general election in 2024. What happens in the interim is anyone’s guess – such as the comeback of Boris Johnson, perish the thought, or the re-emergence of the culture wars and identity politics. The obvious fracture in the Labour Party, between the left (or those who supported Jeremy Corbyn’s policies)  and the ‘centrists’ shows no sign of healing, and divided parties generally don’t win elections even after a period of prolonged silencing.

Keir Starmer worked for Jeremy Corbyn in his shadow cabinet, and supported Boris Johnson’s clearly awful Brexit deal. Keir Starmer is a simplistic man, but I do not deny his abilities in other quarters. He is capable of creating nasty division in what should be a ‘broad tent’, and seems incapable of taking important and decisive action on Europe, the economy, or the NHS and social care.  It is pretty inevitable that the writing is on the wall for the Tories, but all of the success of Starmer hinges on the implosion of the Tories and their inability to ‘make Brexit work’. Starmer has been the recipient of much goodwill from the media, and has avoided drawing any personal criticism of his mishandling of Brexit. But if Starmer becomes Prime Minister in 2024 on the back of ‘Anyone but the Tories’ he is going to need a sensible programme of government to deliver and to maintain the trust of voters. And then ‘Mr Softie’ or ‘Mr Hindsight’, who has agreed with much of the current Tory programme for government, may have bitten off more than he can chew.

A delight of small things

Sometimes you can’t predict everything.

I like reading books. One book I really enjoyed was ‘The joy of small things’, by Hannah Jane Parkinson. The idea behind the book is pretty fundamental – to take a number of ‘small things’ like being a regular in a local café and to talk about them.

It lead me to go onto read a similar book called ‘Delight’ which I had to buy from a specialist bookseller. It was at that time I took up an unanticipated hobby of reading and collecting second hand books.

Because I am fundamentally a contrarian, to the point I like being disliked, I began collecting books which some people want to ‘cancel’ by authors including Roald Dahl, Iain Fleming and Agatha Christie. I find the whole subject of the right to offend and the right to be offended fascinating. I have found myself slow to call out blatantly offensive material, but this gives me an opportunity to reflect.

I find dementia offensive. I appreciate other people’s rights to present positive aspects of it. This I think is probably done out of good intentions, such as not trying to scare people about the gravity of it. The problem becomes when the picture of dementia is not one I, or other carers, recognise.

In that case, it can become rather too easy to think you’re doing a bad job of being an unpaid family carer.

My mum died last July, after probably a few years of suffering from the disease. And I do mean ‘suffering’. Without going into the details, it caused innumerable problems and loss of function. I struggle to see any positive sides to it.

I occasionally listen to other people’s views about dementia. This week, I caught Richard Spurr on LBC chairing a phone-in on dementia. As usual, it reminded me of my own experiences, and how fraught it was with logistic issues such as organising a lasting power of attorney.

One thing I do remember clearly is how I felt mum had died even before her physical death. For me, caring for her was essentially continuing to love her.

I’m no expert in dementia, but I do ‘get’ the need to make the loved one feel as if they’re safe and secure.

This means doing things he or she can’t do. This can be framed as ‘loss of control’ – but I call it helping someone out of love.

I am not frightened of the word ‘care’. I am not so paralysed ideologically that I must insist on calling it ‘support’ euphemistically.

I still love my mum, to the point that I can’t quite believe that she is physically dead. But without her I would not be alive. I lead my life as if she is still with me.

I have now never been happier, knowing she is no longer ‘suffering’. I am not waiting to die but not in any unhappy way. Actually, I have never been happier.

I probably got to know my mum in a way I probably wouldn’t have done had she not had dementia. For this I am grateful.

I cherish every small memory of her – and this aligns with my experience of recovery that if the elephants don’t get you the ants certainly will. This is why I still to this day refuse to throw away her Indian bangles or clean pyjamas I bought her.

Things happen by accident. I wonder if the dementia happened by accident almost. I suppose that is serendipity. I once asked the late Sir Richard Doll what serendipity is – after he said publicly in a lecture at Cambridge that his discovery of a link between smoking and lung cancer was ‘serendipitous’.

He said simply, laughing: “Looking for a needle in a haystack, and finding the farmer’s daughter.”

Arrested development. Give me a break.

I haven’t been on a date for years, if not decades.

The honest truth is that I don’t intend to go on a date including, and up to, the day I die.

Caring for my mum with dementia taught me a lot about giving back to somebody who unconditionally loves you.

I had a conversation at the weekend with one of the many London black taxi drivers from North London who are originally Turkish – and Muslim. We invariably have been chatting about ‘fasting techniques’ and the ongoing holy festival of Ramadan.

Many of them have had a family experience of dementia. The conversation comes usually onto the question of ‘what do you do?’ I can see right through this, of course, as it’s a polite way of asking why I am going to a department store in Oxford Street during the working day.

The conversation comes onto dementia. I agree with the taxi drivers that caring for my mum was not really a ‘duty’, but a relationship I found rewarding, difficult and emotionally moving.

Ramadan has been difficult for me, as the main hobby of my life, reading the papers while having a slow cup of green tea or fresh mint tea, had been taken away from me. I now do Ramadan on alternate days.

I try to sit on my own, on a table, here in North London. I think about how I don’t really want a job, or to do anything much.

I saw virtually my friends all get married, some divorced, some have kids. One or two died.

After my mum died last July, I decided to reflect. Grief comes in waves, sometimes with me having disastrous days. Some good days though. I think about her all the time, and how much she supported me. I remember her hopes she had for me to have a family of my own, or for me to be a successful doctor.

I was ill in my 30s, and had no help for my alcoholism until I met a psychiatrist privately. He effectively saved my life. I remember vividly waking up on the top floor of my local NHS hospital in 2007, having had a two month coma. A foot and mouth epidemic had happened, and there had been a change of Prime Minister.

With my illness, and subsequent caring stint, it feels as if my life is one of arrested development. I find myself catching up on things I might have done in my 20s. I enjoy the weekly singles chart. I know that Ed Sheeran will on Friday bring Miley Cyrus’ nine week reign at number one.

At the age of 48, even though I have no wish to, I find myself within earshot of loud conversations of ‘first dates’ at local cafés.

Before the five hundredth repeat, these had been vaguely tolerable. My noise cancelling headphones worked well, and I learnt to bring out my lack of eye contact and socially inept self to the full.

But I came to realise that these conversations would follow a highly predictable format. Like a job interview, one could easily travel along a motorway of where did one go to University, a subtle promotion of how much Papa is paid, why one wanted to have a well paid job, a recent book, a recent holiday which featured a high performance sport, and so on.

Occasionally parents, aged roughly my age, would come up. And I would feel bad.

I have spent years trying not to eavesdrop, and I can’t put my headphones and read my book for every such conversation. I have spent years not interrupting. I have spent felt years cultivating the appearance of the stupid one in the corner who is a social drop out; that’s been the easy bit.

I mentioned today to someone this standard format of ‘first dates’, normally climaxing in the fumble of who should, could or would pay the bill. She, a fellow leftie, said: “Oh my God, they sound exactly like the conversations you read in gossip magazines”.

I. wouldn’t. know.

Following my mum’s death, I have thought a lot about mortality. With essentially no immediate family, I don’t ‘want to’ die, but I am ‘prepared’ for death.

A lightbulb moment for me was when I realised that nobody lives for ever. People I see wondering around my locality, like Alan Bennett, Jon Snow or Andrew Marr, like me will be dead in fifty years’ time.

Don’t get me wrong. It’s great to live life to the full. But some of us can be forgiven for deliberately choosing not to.

When I’m 65. The precarity of delirium. #WDAD2023

I’m not sure that I ‘understand’ delirium, frailty or dementia.

I think few do.

Before the person I ended up caring for 24/7 was officially diagnosed with both frailty and dementia, I had been aware of the magical significance of the number ’65’. Rather like the number 42 being the meaning of life, as attributed to the iconic ‘Hitchhiker’s guide to galaxy’, 65 remains magical for the cut-off between neurology and psychiatry when it comes to dementia services.

I’m old enough to remember when the consultant in Cambridge, whose firm I was once in in 2001 as a house officer, mooted there should be a defence of the term ‘department for medicine of the elderly’. At first it might seem inappropriate you compartmentalised older adults this way, after all 61-70 is very different to 71-80 or 81-90. On the other hand, older people do have specialist needs which come with age.

I came across by relative accident the word ‘precarity’ as applied to frailty from a scientific paper. I think of ‘frailty’ akin to ‘vulnerability’, but the word ‘precarity’ appears bolder than that. It encompasses a meaning of being precarious or uncertainty. In all my time being a family carer, I was struck by the fact that the prevailing wind would change at an instant.

Amanda Grenier’s analysis of precarity made me wonder why older patients with delirium are quite so precarious politically. Grenier cites the dictionary definition:

“Accordingly, ‘precarious, adj.’ is defined as both ‘a right, tenancy’ (that is, something held or enjoyed by the favour of and at the pleasure of another person) and a condition whereby one is ‘vulnerable to the will or decision of others’. The uses of the concept ‘precarious’ range from ‘a line of argument, inference, opinion, etc. [that is] insecurely founded or reasoned, doubtful, dubious’, to something ‘dependent on chance or circumstance; uncertain; liable to fail; exposed to risk, hazardous; insecure, unstable’, to something ‘subject to or fraught with physical danger or insecurity; at risk of falling, collapse, or similar accident; unsound, unsafe, rickety’ (‘precarious, adj.’, nd).”

Governments will argue that they are spending more and more money on care, but it seems that the money being spent is less because the money has to be stretched with such increasing demand. It is impossible to avoid a discussion of how delirium care can be managed successfully with such powerful constraints.

Grenier again,

“The concept of precarity highlights how decisions made about frailty and care are thus political. While the implications of neoliberal priorities and practices are most obvious on marginalized groups who no longer have access to the services they require, an analysis carried out through the lens of precarity also reveals how political priorities and particular responses create ‘care gaps’, and thus how the concept and practices related to frailty operate to reduce and limit access to services and supports. “

If anything, care at home, with an army of unpaid family carers like I once was, or more strategically delivered care, at home will come under increased scrutiny.

It is possible to ignore someone who is delirious, in terms of person-centred care, especially a hospital patient who is sleeping all the time. This is fraught with encouraging risks – such as pressure sores or blood clots (both of which can exacerbate a delirium). Management of a delirious patient to all intents and purposes can be an outpost of veterinary medicine unless you make an effort to involve the patient or carers, or to acknowledge the distress.

You could then find one minute that things were going well. The person you cared for seemed to be sleeping OK, eating and drinking well, moving around OK and reasonably attentive. But then the next morning she could be a totally different person, even accounting for the dementia.

Personal care was now impossible. She didn’t feel like taking her breakfast. And she wanted to sleep a lot even having had a good night’s sleep.

Frailty for me brings with it a sense of complexity in a way I simply don’t understand. It doesn’t surprise me at all that with increased frailty there appears to be a greater prevalence of delirium. Living with frailty is undoubtedly a new normal, but I cannot comprehend how it is possible to live well with delirium.

Delirium seems to mean that the person has difficulty recognising himself or herself, or others, and might talk incoherent rubbish. There is as yet no single bullet to treat this condition, in the same way you might give an antibiotic for pneumonia or anti epileptic for epilepsy.

This is in large part due to the fact that delirium occupies a position of mystery. We know remarkably little about the neural basis of it – what turns it on (other than precipitating and predisposing causes), what keeps it going, and what turns it off. The neural substrates remain to a large extent a mystery, and remain a roadblock to its effective medical treatment.

Delirium seems to ‘recover’ of sorts – but how many people truly recover is a bit of a known unknown. Inroads are being made here.

I don’t deny delirium prevention can be effective through good healthcare, for example attention to mobility, hydration, pain relief, and so on. But what brings it on suddenly in a person living with dementia is scary. We can do our best to understand it for non-hospital settings as well as hospital settings, but there are major holes in our knowledge still. There is yet to be done a conclusive trial as to whether delirium prevention can lead to dementia prevention, although this possibility seems promising given observations such as the fact recurrent delirium episodes might be related to greater cognitive impairment.

The ‘living well with dementia’ narrative was obscured with the fact that it was introduced at a time which coincided with worldwide financial austerity due to a global financial crash. The search for a magic bullet seemed like the perfect excuse, arguably, to strip down the welfare state, such that ‘care’ and ‘dependency’ became dirty words.

Being delirious is, whatever spin, a very precarious state. Without oversight, there is a possibility you could wander off and cause havoc. That’s why laws exist on mental capacity and deprivation of liberty to act as necessary and proportionate measures.

The precarious state in delirium without intervention can become a self-fulfilling doom cycle. In ways we do not really understand, frailty can lead to delirium. this delirium can lead someone to stop eating and so on, lose weight, stay in bed become increasingly frail and reconditioned. And for some the delirium might be linked to some cognitive damage.

I’ve never thought that certain admissions can be completely ‘avoided’. Nor do I think that dementia in the older person is as nice and tidy as dementia in a younger person, for example with a single gene defect.

An inability to spot or detect delirium, in whatever care setting (even at home, in a hospice, in a care home or in a hospital) is something all practitioners should be aware about – like chest pain. We know that delirium somehow adds to the chances of mortality in a way not simply explicable by the medical complications. Greater awareness and attention to care, as well as a research strategy, is needed.

Gary Lineker is more than a troublesome tweeter. He is a Trojan Horse for the political expression.

Peter Hitchens made one fundamental mistake in his Daily Mail article about Hitler. That mistake was not to argue that Hitler was ‘left wing’. The article served its function, in being a click magnet, and also in trolling individuals of a certain political persuasion.

The fundamental mistake was to define politics in terms of ‘left wing’ and ‘right wing’. Nowadays it is hard to tell the difference between extreme left wing and extreme right wing. But it is also true that politics is not a summation of a million referenda. One of the few people who believed in referenda apart from David Cameron was of course Mussolini.

It is easy to be hyperbolic about the impact of Gary Lineker’s tweeting. Simple solutions would have included a quiet email from Tim Davie or Robbie Gibb to ask him to delete it. But the problem with the tweet is that it is entirely factually correct.

The language used by Braverman, ‘invasion’, is problematic. If Braverman cared about the optics of such a sensitive policy, she has failed.

She has become her own worst enemy, for different reasons to how Boris Johnson became his own worst enemy. There was an important discussion to be had about planning for migrants, for example through the known problems in social housing and local authority services. She has strangled at birth any discussion of this.

This can also be held to be a success. By offering the ultimate ‘dead cat’ of a problem which became opened up through inadequate foreign policy after Brexit, and by ramping up the rhetoric over immigration, Braverman has blown out of the water any sensible debate about this.

This has obliged the Tory Party to resort to a ‘culture war’. But the Gary Lineker tweet neutralises two culture war weapons.

Firstly, freedom of expression. You cannot ‘half believe’ in freedom of expression. This is like being half pregnant.

You may immediately riposte by saying ‘but the law says..’ Too often the law has been used as an argument to shut down any debate.

You may disagree with what he has to say, but his right to say it should be defended. It’s no different to Andrew Neil, Michael Portillo or Lord Sugar ‘having a voice’.

Secondly. it’s Gary Lineker just being ‘nice’ isn’t it? This causes a problem for the Tories. Boris Johnson was not given superstar status because of his immaculate attention to detail. It wasn’t even that he was ‘particularly nice’, as certain people might testify.

In a race between members of the Tory Party and personalities like Carol Vorderman, Marina Purkiss, Jemma Forte or Gary Lineker, the Tory Party cannot expect to win however well articulated their policies.

Gary Lineker has become a ‘lightning conductor’ partly due to massive unpopularity of the Tory Party. Aside from the fact that the Tory Party is an incoherent mess, and their policy solutions become even more desperate to bail themselves out of their self-inflicted ‘forced errors’, their only hope of scraping through is a divided Labour Party.

Those on the left wing are exasperated on the lack of fresh thinking of the monopoly effects of utility companies, or on Brexit, for example. They get exasperated about the lack of support from Labour for Gary Lineker or anyone on strike. Labour despite saying they’re not complacent are behaving as if they are very complacent.

The allegations against members of the Tory front bench on bullying, some already proven, are well known. Gary Lineker provides a further test case as to whether bullies win.

It seems that the BBC leadership and the Tory Party, despite public mutterings from Sunak otherwise, have formed some sort of dubious suicide pact such that they have already decided to go down in flames together.

If that were to happen, Gary Lineker would simply have to find an alternative outlet to present ‘Match Of The Day’.

Being ahead

The famous tweet goes, ‘Anyone who’d be a half decent leader of the Opposition would be twenty points ahead?’ – or something like that.

Things can only get better.

For a few months now, Labour has been way ahead in the opinion polls. Rishi Sunak, as the latest Prime Minister, never really benefitted from a ‘bounce’ in popularity. First impressions of him might be that he’s a bit ‘out of touch’. He comes from a background not unheard of in a Conservative Prime Minister – top public school than Oxbridge than City. He is unlikely to be lying awake at night thinking about his smart meter counting upwards while he heats his (large) house. He is possibly not thinking about the idea of people breaking into his house with a warrant to install a prepaid meter. To all intents and purposes, he is another Prime Minister. His relative popularity in the Red Wall might be more to do with his BAME background, or the financial affairs of his family, than what they really thinking of his policies. Boris Johnson, chief bloviator, has been touring the world – it seems at someone’s expense – and is about to foot a big legal bill defending himself against all sorts of allegations, presumably at the taxpayers’ expense.

This administration confuses me somewhat. When I first heard that Boris Johnson had become leader of the Conservative Party, in my naïvety felt that Jeremy Corbyn would have a very easy time. That was all before he got completely monstered by the media. Fanboys of Keir Starmer on a good day boast how Labour is no longer a ‘protest party’. When empowered by extreme chutzpah and confidence, they say blazingly, ‘There are no longer any Palestinian flags’. It is always hard to work out what is true and what isn’t regarding the Corbyn era. What is definitely true is that there has been an almighty cover up in the media regarding the Forde Report – which some brave journalists have spoken out about. What is also true is that organisations such as Amnesty International have also expressed concern about ‘apartheid’ Israel regardless of awkward words being voiced and apologised for in parliament. What is allegedly true is that members of the Labour Party have been threatened with expulsion, despite being Jewish, for ‘siding’ with the wrong grouping. It is easy to ignore it if you hate Jeremy Corbyn, but socialists generally are unimpressed that they feel that they have been saddled with Keir Starmer under somewhat false pretences.

Whichever way you wish to spin it, Starmer has reneged on all of his promises. The vision of Thatcher, extended and elaborated on by Blair and Cameron, has left us with an awkward legacy of unsafe cladding, huge PFI bills in the NHS and utility companies in England, at odds with the rest of the world, for being privately owned by investors abroad paying tax anywhere other than Britain. The public sector, in as much the legislation has prevented a ‘general strike’, has finally had enough with its lack of remuneration. Not only is the public on their side, but the public sector is populated by the public. Not only has renumeration of workers been poor, but fat cats have become extremely fat, with poor standards in outcomes.

It should be obvious that, given also Kwarteng’s disastrous budget and a string of unforced errors from Johnson, that Starmer would be ahead. But what is so creepy is that he is so unwilling to make a link between economic productivity and the fact we are no longer part of a trade bloc. For all his faults, and we’ve heard them ad nauseam, Jeremy Corbyn proposed in 2019 for the UK to be part of a close trading relationship even despite exiting. Alan Johnson and Sir Stuart Rose were supposedly leading the Remain campaign, but have both disappeared off the face of the planet regarding Brexit. So it’s left to people on the front bench of Labour to ask for a closer relationship with the EU without saying what that is. That is like ripping a wheel off your car, and promising to drive fast with the three remaining wheels. It is not a serious offering. Reeves and Miliband, for all their good points, have been on the subs bench since the early 2010s. Like Starmer, they are not the ‘change’ candidates. They are the stench of no change, epitomised by Reeves promising not to increase your bills – in the same way that Cooper promised not to reverse the outsourcing of the benefits outsourcing.

To say that Labour is a pale imitation of the Tories might be intended as an insult, but it is very much a compliment for those who know that this is the desired strategy. John Rentoul at about 3 am this morning went on the radio with LBC presenter Clive Bull to explain that Starmer is not like Blair, but Starmer still wishes the Labour Party to become closer to the Conservative Party. Rentoul adds that there is no guarantee that things will be ‘better’ under Reeves or Starmer. And there’s the rub. Not only is the offering to the left of Labour that ‘things won’t be worse’ – but there are active differences, such as not nationalising the utility companies, or not supporting the strikers. The calculation is that more Tories will join Labour than Labour lefties leaving Labour. For those who supported and campaigned for Jeremy Corbyn, who judging from his interview with Lewis Goodall is even angrier than ever at injustice, being expected to support Labour is not a ‘given’ any more. Solidarity, a key value within the Labour left, has to all intents and purposes been suspended in a dramatic fashion. Furthermore, Labour lefties who feel very betrayed by prominent people on the Left pleading for people not to vote Labour are ‘expected’ to vote for Starmer now who himself has U-turned on everything so fast he has literally spun himself into the ground like a power drill. They are labelled ‘Tory enablers’.

The next phase of the attack has begun. We are being told that Starmer does not need Scotland to form a majority government. This is close to absolute bollocks in fact, as Scotland, even with the furore over gender recognition and prisoners, is likely to vote nearly 100% SNP. Starmer will require basically all of Labour voters to turn out in England and Wales to get the sort of arithmetic he dreams of, and we know that the ‘swing’ required is now enormous. And factor into that, what does Streeting propose to salvage the NHS? A big recruitment drive, and abolition of non-com status. The tax change raising revenue has been disputed, and the big recruitment drive doesn’t address attrition at every training stage of a doctors’ education. He also wants to oversee a transition from partners to salaried GPs – exactly what multinational corporations want in the integrated care systems as per Health and Social Care Act 2022 – but this will bring the NHS to its knees unless substantially more senior GPs are found from nowhere (or abroad). It all doesn’t add up – and even worse he wants to be sparring in a fight with the BMA, which is a pretty frightful look for Labour which seems to be obsessed with dividing and ruling. Starmer’s self referral for ‘internal bleeding’ is of course the final straw.

It’s clear Labour lacks policies, and lacks vision. They are lumbered with an Islington lawyer who seems to hate Jeremy Corbyn, and, even worse, seems to despise socialism.

Don’t be surprised if Sunak wins.

Can Starmer or Streeting really afford to lose the NHS vote?

Labour for the last few years has been too busy facing inwards. It has become obsessed in fighting deeply unpleasant ideological battles, but the people doing so claim that they had no choice. Labour is at danger of continuing to carry on with this protracted fracture rather than embracing the pragmatic issues of government. Labour does however emphasise the need to make practical pledges. The latest onslaught by Starmer and Streeting, however, could prove to be deeply damaging for their reputation as ‘guardians of the NHS’. It seems to want to turn the NHS into another ‘culture war’. If it does, I think it will fail.

I remember when I went to a seminar at the Academy of Ideas earlier this year in Church House. As ever, it was brilliant. We spoke our minds and listened respectfully to the views of others. The discussion was supposed to be on the decline on the NHS. Nobody mentioned the crisis in social care or austerity as factors, which surprised me. I pointed this out to the panel, and I remember being aghast when the director of a right-wing think tank told me that austerity had “nothing to do with it”. This is simply not backed up by the evidence. Even this week, a published report, commissioned by the Conservative Party, drew attention to it.

In recent times, the Conservatives have had a formidable reputation for economic competence. This has been enduring a previous Chancellor, Kwasi Kwarteng, causing a crash in the pound through a mini-budget. The Labour Party has always been seen as the “party of the NHS”. In December 2019, under previous management, Labour under Jeremy Corbyn had again warned about further privatisation of the NHS. Is it possible that Labour is finally going to lose its crown as ‘champion of the NHS’?

Heading into a news break this lunchtime, LBC presenter Shelagh Fogarty had to explain to a caller that a ‘zero immigration’ target was unreasonable, and that the country was not falling apart due to cross channel migrants. Brexit has overwhelmingly been found out to be a disaster, and was meant to solve the problem of ‘taking back control. There is unease about Starmer being unwilling to tackle it. Boris Johnson, meanwhile, the former MP who “got Brexit done”, is said to have pocketed more than £1 million in speaking engagements including in India and Portugal following Brexit. In the last week, Wes Streeting has given three interviews with LBC, and they do repeat the same views. Suella Braverman gave by all accounts this morning a pretty disgusting account of the deaths which had occurred on the English Channel this morning. Labour only a few years ago was pimping out its famous immigration mugs. Starmer, who has distanced himself from all policy from 2019 Labour manifesto, including – presumably – the attack on austerity, does not want to appear too ‘woke’ in case he goes ‘broke’ at the next general election in 2024.

The British Medical Association (BMA have apparently criticised Mr Streeting for what it called “disappointing” comments after he used an interview with the Sunday Telegraph to accuse the union of being hostile towards vitally needed NHS reform efforts. Wes Streeting is proud for not being on the side of the doctors but being firmly on the side of the patient, and this position certainly is more convenient also for attracting the ‘anti woke’ or Red Wall vote. Although it is time and time again said that such voters are not racist, there is a rarely a phone-in on LBC without the caller who blames an increased demand on NHS services by ‘immigrants’. Both Streeting and Starmer do not want to appear ‘close to the Unions’, which is a pathetic thing to pander to as neither the RMT or RCN are affiliated to Labour for example.

A symbol of the decline in the NHS has been the “mad scramble” for the GP appointment at 8 am. Most of us have had experience of ringing up punctually at 8 am to make an appointment only to be “number 42 in the queue” if delayed by a few minutes. GPs have been accused of offering fewer face to face appointments. The BMA have repeatedly pointed out that the promised recruitment drive in general practice never materialised, they have a retention problem with the GP workforce, and there has been a vast increase in the number of appointments overall. In July 2020, the then Secretary of State for health and social care, Matt Hancock, now more associated with ‘jungle washing’, had argued that GP apppintments “should be virtual by default“. GPs have a right to argue, therefore, that they have been delivering a system mandated to them, whilst overstretched and doctored. Streeting made no reference to the crisis in general practise in any of the interviews, presumably because he is trying to present himself as the ‘patient advocate’.

In a new policy paper from earlier this year, the Royal College of Physicians repeated the case for long-term workforce planning and sets out a range of short- to medium-term solutions the government must implement now to keep the NHS running. Wes Streeting has repeated many times his aspiration to grow the workforce of the NHS. To avoid the accusation of ‘overpromising and underdelivering’, Streeting made clear in all his recent interviews that the pledge would be paid for from the money accrued rom the ‘non dom status‘. Discussing the “back and forth”, Wes Streeting told presenter Shelagh Fogarty: “We announced the biggest expansion of NHS staff in history — so we would double the number of medical school places, increase nursing and midwifery clinical training places by 10,000, 5000 more health visitors, doubling the number of district nurses.”

But this in itself is a hopeless solution to the NHS workforce crisis in itself. It took a caller to Shelagh Fogarty’s show, “Felicity from Greenwich”, a doctor, to point out that there is a bottleneck for places at every stage of training. With doctors being unable to find jobs, therefore, it is not surprising they are leaving the profession. There is no structured return to work scheme including extended induction or reasonable adjustments (phased return) for disabled doctors for people who have taken unanticipated leave for years off the register; such a scheme is necessary for re-skilling and building up the confidence of such doctors. There is a pensions crisis in the NHS which means that long-established doctors are having to leave the profession rather than to be clobbered by huge tax bills. Wes Streeting acknowledges the campaign on pensions by the BMA. Ask any trainee how they feel about the increase in medical school places, and you’ll soon have your answers.

A report from the right wing think-tank Policy Exchange earlier this year provided details a ‘rescue package’ for general practice.  The report from Policy Exchange recommended specifically:

  • The overhaul of the current core GP contract to redefine incentives, reduce bureaucracy and free-up GPs to help the patients with the most complex needs;
  • A £6 billion ‘rescue package’ to enable improvements to general practice premises, data collection and to enable an orderly transition to new contractual models;
  • The ‘levelling-up’ of general practice with a massive boost in high-quality video consultations in areas where there are not enough doctors;
  • The introduction of ‘NHS Gateway’, a more coherent entry point to primary care and to reduce dependency upon the 8am call to the GP surgery for appointments;

The Daily Mail were so enthused it even ran an article promoting this report to its readers, including a section on how the BMA were unable to support the proposal.

Family doctors wanted extra funding to cover the rising national insurance costs and inflation.  But the final contract, given to the BMA just hours before being made public, made no mention of the additional cash it had demanded.

I don’t deny the attraction the Daily Mail must have for Streeting or Starmer, being avid consumers of the Sun and Telegraph. Streeting at no point in his LBC interviews made any mention of why the BMA had been critical of recent proposals, rather leaving the average voter with the impression that the BMA was just a militant union opposed to change. All registered doctors have a regulatory obligation under ‘domain 2’ to commit to improvement of the quality of the service with the General Medical Council, and this inevitably has involved change initiatives.

The Conservatives chose not to implement the Policy Exchange proposal, but were too busy with their own leadership election and the coronation of Liz Truss – who blew a sum vastly larger than this on crashing the UK economy as a sign of ‘taking back control’ (a Brexit dividend) from a ‘Singapore on Thames‘ economy forewarned by her Britannia Unchained movement.

Implementation of technology here might have really helped, however.

I have for nearly a decade commented on how the increasing use of technology is a ‘Trojan horse’ for further marketisation of the NHS. For example, in an article for Open Democracy back in 2015, I commented on a recent speech by Jeremy Hunt, the then Secretary of State for Health. Whatever happened to him?

I wrote,

This month Jeremy Hunt MP gave what he told us was his “most important speech as health secretary”. The speech – delivered at the Kings Fund, and entitled “”Making healthcare more human-centred not system-centred” – fulfilled its function of generating blockbuster headlines, mostly focused on the ‘7 day NHS’ and consultant pay. But there’s been relatively little comment on his new ‘big idea’ – a patient-centric transformation in a post-bureaucratic age, which he calls “intelligent transparency”.

Embracing technology within a nationalised service is sensible. Using technology to privatise a service and to demolish the workforce is a different motive, and one which is bound to cause a problem with core Labour voters. It has been a consistent tactic of the right wing opposition and Wes Streeting to frame anyone who won’t embrace technology as being opponents of change. To give just one example, in August 2022, the RMT reported that a funding deal struck by Transport for London and ministers would attack tube workers’ pay and pensions and would lead to further strike action, RMT have warned. The proposals seemed conditional on attacks on workers’ pensions, potential job losses and a push for pay restraint in the future despite the astronomical rise in inflation and an escalating cost of living crisis. Driverless trains are also part of the reforms insisted on by a previous Secretary of State for transport, despite the huge costs involved and safety concerns. Driverless trains are a massive safety concern for disabled passengers, and are not a trivial matter. To frame protection of the workforce as ‘looking after vested interest’ is a political choice which Starmer and Streeting have decided to take. Technology can be used alongside the workforce to improve their working conditions, and not just as a replacement for the workforce to maximise profit margins. Technology besides is not a universal panacea. The report of the AI chat bot which ‘turned racist’ is notorious. Tay was an chatbot that was originally released in March 2016 which caused subsequent controversy when the bot began to post inflammatory and offensive tweets through its Twitter account, causing Microsoft to shut down the service only 16 hours after its launch.

All people, including clinicians, are the lifeblood of the NHS, and Labour talking over them is poor mood music.

Here, for example, is Labour taking credit for ‘training doctors’. It is the existing workforce who is expected to train others.

At this very second, the likelihood is that Labour might become the largest party in the 2024 general election, but unlikely to win an overall majority. Streeting says that he and Starmer have been working on a plan for the NHS and social care. Many of us remember how traumatic the last NHS reform was in 2012, a ‘top down reorganisation’ which David Cameron had said would never happen (see for example an open letter some of us sent in 2016). The mood music from Streeting was bad, and has opened up much mistrust amongst hardworking professionals within the NHS. Lifelong Labour voters are telling me now that they might never vote for Labour again, given how bad the coverage was. But there are many patients in the voting public, just as there are many NHS staff who want to vote Labour ideally.

Listen to all the podcasts and sign the petitions all you want, but still prepare yourself for eternal opposition

Podcast audiences don’t win elections. Petitions don’t win elections. Political parties win elections in first part the post in the UK elections.

For the first time in my lifetime, I think the era of mass civil disobedience is coming faster than a Labour government. I wonder if you remember the saying that ‘millions of people are relying on the election of a Labour government’. This was also true for the 2019 general election, dubbed the “Brexit election”. It was pretty easy to identify that Boris Johnson was a repellent liar at the time, even pre pandemic. It was obvious that the arrangements in Northern Ireland were a fudge, and that the trade barriers would be pretty ruinous to the macroeconomy of the UK. Labour had the ‘worst performance for many years’, but it is impossible to untangle from that how monstered Jeremy Corbyn was by the media, from James O’Brien to the Guardian, from Alasdair Campbell to other prominent has beens. On offer were ‘far left’ policies, such as a national care service, national education service, ‘free’ broadband – and what you got was Dido Harding, Matt “Jungle Fever” Hancock and Michelle Mone.

I don’t want even to contemplate what degrees of shit will be voted in next time around. One looming disaster is withdrawal from the European Convention of Human Rights – the perfect ‘get out’ clause to allow flights full of legal asylum seekers to fly to Rwanda, or to do other odious activities with cross-channel dinghies as there are no legal routes to enter the United Kingdom. While the Labour Party appears to have big corporate sponsors now, its Union support is dwindling. Labour cannot offer unequivocal support to the workers, some of whom are affiliated through the trades unions. Labour won’t offer to repeal the mercenary anti-Union legislation heavily signposted for the new year, and seems to wish to do its own form of austerity. Yvette Cooper and Rachel Reeves of course are past masters in their activities with welfare benefits, as most of us from that vintage will remember.

I think Mick Lynch is putting it a bit mildly when he calls ‘Keir Starmer’. At least vanilla ice cream can be soothing or tasty. Starmer’s rhetoric does not give me any confidence that he is the man to get Britain to a state where it is proud of itself. Far before the pandemic crisis or the Ukraine war, it was very obvious that England was in decline. Nowadays the right wing loons are forced to pillar Meghan Markle and her curtsying to detract from the disgusting state of the country. The UK Labour Party doesn’t seem to care that being in England is positively risky to you and your health. Because of a sustained campaign of underfunding, to fork out billions for pointless projects such as Brexit, there is ‘no money left’ for any of the emergency services. If there’s a fire in your flat or house, run and escape for the hills. You’ll be lucky to get a fire engine. If you have a stroke, take a cab to your local hospital as you might be waiting some time for an ambulance. If you have a burglary, kiss goodbye to your property, and buy lots of cheap tat to replace them with off Amazon. The water and gas are nationalised, owned by private equity from abroad. We’re in the process of getting rid of all the EU safeguards, so we can relentlessly pump sewage into the sea. And so it goes on.

The facts are that Labour doesn’t have a hope in hell of getting many seats in Scotland in the 2024 general election, and that some voters still wouldn’t want to touch Starmer’s Labour due to various factors including lack of policy. Depending on tactical voting, and on various outcomes such as whether Sunak can ‘smash the strike’, we’re looking at Labour possibly being the largest party in a hung parliament. If you want Labour to offer something different on austerity, supporting strikers, net zero, HS2, and so on, forget it. Listen to all the podcasts and sign the petitions all you want, but still prepare yourself for eternal opposition. And don’t even rule out an unprecedented re-election of a spanking new Tory government.

Reflections on being a disabled clinician in the NHS

All of things which worry all clinicians – burnout, feeling overstretched, a workforce which is undervalued and under numbered – worry disabled doctors too. Disabled doctors are good people too.

‘Today I feel male. Today I feel disabled.’

All of this is true for me, channeling my inner FIFA president identity.

Infantino had added that he knows what it means to be discriminated [against]’.

I know that feeling too. ‘Institutional racism’ is not just a description that there are many people who are racist in an institution. But it’s a known issue that systemic racism does exist in the NHS. Partha Kar (find him here) has been chipping away at this iceberg gallantly for some time, and the task of tackling this racism is daunting. I find myself excluded all the time from a seat at the ‘top table’ despite me being physically disabled myself, and having trained in equality law through my pre-solicitor training and in performance management through my MBA. NHS leaders can certainly do better, that I agree with from Roger Kline (find him here) (and many other things especially regarding race equality). I am the specialist advisor for an amazing institution called NHS Practitioner Health (find them here), and my job is to advise our clinicians on how best to look after doctors who are disabled. It’s a great privilege, and with my colleague Dr Kelly Lockwood I produced many resources on being a disabled doctor and how to navigate through the system.

I don’t think we value doctors who are disabled highly enough in the NHS. This is such an enormous waste, especially given the workforce crisis that the NHS is in. As I wrote in the BMJ Leader blog, some experiences of disability are good – some are catastrophic. The NHS can be dire in implementing legal requirements such as ‘reasonable adjustments’ allowing disabled individuals to function properly. I wrote about that too for the BMJ Leader blog. Did you for example know that a phased return to work is actually a legal obligation under the Equality Act as it is classified as a ‘reasonable adjustment’?

I was an unpaid family carer for years, and I never thought of myself as a carer. I have a professional medical identity, which has gestated over many years. That is a big part of my life inevitably. But I don’t think of myself as a ‘disabled doctor’ or a ‘BAME doctor’.

There are advantages of not seeing yourself in terms of a label. For example, you don’t ‘other’ yourself – and see yourself as a hapless victim. I don’t think that I have ever ‘benefited’ personally from any equality, diversity and inclusion initiative in the NHS, especially the costly ones such as conferences and marketing. I do have needs which come out of being physically disabled, such as the need for a chair with a back. Virtually all of us who are learning as registered practising clinicians in the NHS are mindful that there is an optimal clinical learning environment. Most of us are very conscious of our teaching requirements in the NHS. I have published many books in medicine (examples here), and I am much enjoying my Masters in medical education at Nottingham University currently as one of their Scholars. As a member of the Association of the Study for Medical Education, I am very proud to promote our collective values of equality, diversity and inclusion.

I lead the special interest group in the neurology of delirium for the American Delirium Society, and indeed lead a group producing a systematic review – including 4 profs – on the rather niche subject of delirium superimposed on dementia. I say ‘niche’, but a very important presentation on the acute internal medical take. As a member of the Royal College of Physicians of London, I am concerned about the application of research to the everyday care of patients. The ‘internet of things’ – and the pandemic – has made remote working feasible and socially acceptable as far as I am concerned.

I feel sorry that there is a lot of marketing to do with disability, a field known as ‘diversity marketing’. It’s a rather corporate thing to do, with a tendency towards a lot of virtue signalling. The PR for conferences or booklets on #ourNHS can’t be cheap. But the reality is that we need to have proper infrastructure support for occupational health in the NHS. Members of the workforce need to be valued and welcomed, as indeed the General Medical Council described and discussed most impressively. Immaculately produced reports on disability such as that produced by the BMA need to be read, understood and acted upon. Collection of data such as WDES is necessary but insufficient.

There’s quite a few of us who are disabled and who are happy to talk about disability. Somebody I admire is Dr Hannah Barham-Brown (find her here). Somebody who is possibly the most inspirational contemporary I’ve ever met is Dr Kelly Lockwood (find her here).

Finally, I was asked recently what I would tell my younger self about disability. I said this.

I’ve got news for you. Disabled doctors are part of the solution, not the problem.