Pet love: a cat does a weekly visit to a Berlin care home to help in the treatment of patients with dementia. Photo: Getty
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Would you want to know if you had dementia, even when there is no cure?

Dr Phil Whitaker’s Health Matters column. 

The recent rumpus over GPs being given a financial incentive to diagnose patients with dementia represents an escalation in a battle between the medical profession and the government over the conduct of health care in England.

Practices are being offered £55 for each new case of dementia confirmed over the course of the next six months. The Health Secretary, Jeremy Hunt, has defended the plan, saying that rates of dementia diagnosis are “a national shame”, estimating that around half of the people with the condition are currently without a formal label.

What needs serious debate is the underlying assumption that a diagnosis rate of around 50 per cent must inevitably mean poor practice. It is probable that the figure actually reflects many instances of sound holistic care and that the government’s attempts to influence rates of detection will cause more harm than good.

Any medical diagnosis potentially results in three things: information, treatment and access to care services. If none of these is relevant to an individual patient, attempts to arrive at a diagnosis are pointless; and if the diagnostic process causes distress, it is harmful to undertake it.

There is no simple or precise test for dementia. Patients undergo a battery of blood tests, a brain scan and exhaustive assessments of cognitive function to build an overall picture. The process entails several visits to the outpatients’ department, an experience that can be bewildering. Sometimes a clear answer emerges but many are left with inconclusive results and uncertainty about the future.

So who is the medical profession being bribed to push through this diagnostic mill? Much current “under-diagnosis” involves those with mild cognitive impairment (MCI) who are managing perfectly well within their families and communities. Around half of these people might qualify for a diagnosis of early dementia if formally tested. However, there is currently no cure and few effective treatments. Drugs such as cholinesterase inhibitors can improve cognitive function in some patients with moderate or severe Alzheimer’s disease for around six to 12 months (though they are ineffective in the second-commonest form of the condition, vascular dementia).

Yet a thorough review of the available evidence published by Canadian researchers last year showed no benefit to patients with mild forms of the disease: there is no therapeutic advantage in detecting Alzheimer’s at an early stage. Some people with MCI want to know if they are developing dementia, rather than merely experiencing the normal consequences of ageing. But many prefer to let sleeping dogs lie until or unless they start to experience significant problems.

The other patients currently “under-diagnosed” are those with multiple co-morbidities. Being an age-related condition, dementia frequently occurs in people whose health is already dominated by other serious illnesses. These patients are usually taking a panoply of drugs and adding marginally and only temporarily effective dementia medication is often inappropriate. This group is frequently receiving high levels of care services and pursuing a formal diagnosis of dementia would add little or nothing.

GPs are arch pragmatists, skilled at taking into account all facets of individuals’ situations when formulating decisions with them and their families about their health care. When we have treatments that cure or halt dementia, it will be appropriate to seek out those in the early stages and thresholds for investigating cognitive impairment in patients struggling with other severe ill-health will change. At that point, there will be no need for financial incentives. Doctors will do what they’ve always done: act professionally in the best interests of their patients.

In the ongoing NHS funding squeeze, the incentives being dangled by the government will, inevitably, alter medical behaviour and patients will be pushed through a diagnostic process that will bring many no benefit and may cause harm. The government should stop interfering in medical practice and allow doctors the freedom to exercise their professional judgement once again. 

This article first appeared in the 29 October 2014 issue of the New Statesman, British jihadis fighting with Isis

Jeremy Corbyn. Photo: Getty
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Jeremy Corbyn: “wholesale” EU immigration has destroyed conditions for British workers

The Labour leader has told Andrew Marr that his party wants to leave the single market.

Mass immigration from the European Union has been used to "destroy" the conditions of British workers, Jeremy Corbyn said today. 

The Labour leader was pressed on his party's attitude to immigration on the Andrew Marr programme. He reiterated his belief that Britain should leave the Single Market, claiming that "the single market is dependent on membership of the EU . . . the two things are inextricably linked."

Corbyn said that Labour would argue for "tarriff-free trade access" instead. However, other countries which enjoy this kind of deal, such as Norway, do so by accepting the "four freedoms" of the single market, which include freedom of movement for people. Labour MP Chuka Umunna has led a parliamentary attempt to keep Britain in the single market, arguing that 66 per cent of Labour members want to stay. The SNP's Nicola Sturgeon said that "Labour's failure to stand up for common sense on single market will make them as culpable as Tories for Brexit disaster".

Laying out the case for leaving the single market, Corbyn used language we have rarely heard from him - blaming immigration for harming the lives of British workers.

The Labour leader said that after leaving the EU, there would still be European workers in Britain and vice versa. He added: "What there wouldn't be is the wholesale importation of underpaid workers from central Europe in order to destroy conditions, particularly in the construction industry." 

Corbyn said he would prevent agencies from advertising jobs in central Europe - asking them to "advertise in the locality first". This idea draws on the "Preston model" adopted by that local authority, of trying to prioritise local suppliers for public sector contracts. The rules of the EU prevent this approach, seeing it as discrimination. 

In the future, foreign workers would "come here on the basis of the jobs available and their skill sets to go with it. What we wouldn't allow is this practice by agencies, who are quite disgraceful they way they do it - recruit a workforce, low paid - and bring them here in order to dismiss an existing workforce in the construction industry, then pay them low wages. It's appalling. And the only people who benefit are the companies."

Corbyn also said that a government led by him "would guarantee the right of EU nationals to remain here, including a right of family reunion" and would hope for a reciprocal arrangement from the EU for British citizens abroad. 

Matt Holehouse, the UK/EU correspondent for MLex, said Corbyn's phrasing was "Ukippy". 

Asked by Andrew Marr if he had sympathy with Eurosceptics - having voted against previous EU treaties such as Maastricht - Corbyn clarified his stance on the EU. He was against a "deregulated free market across Europe", he said, but supported the "social" aspects of the EU, such as workers' rights. However, he did not like its opposition to state subsidy of industry.

On student fees, Corbyn was asked "What did you mean by 'I will deal with it'?". He said "recognised" that graduates faced a huge burden from paying off their fees but did not make a manifesto commitment to forgive the debt from previous years. However, Labour would abolish student debt from the time it was elected. Had it won the 2017 election, students in the 2017/18 intake would not pay fees (or these would be refunded). 

The interview also covered the BBC gender pay gap. Corbyn said that Labour would look at a gender pay audit in every company, and a pay ratio - no one could receive more than 20 times the salary of the lowest paid employee. "The BBC needs to look at itself . . . the pay gap is astronomical," he added. 

He added that he did not think it was "sustainable" for the government to give the DUP £1.5bn and was looking forward to another election.

Helen Lewis is deputy editor of the New Statesman. She has presented BBC Radio 4’s Week in Westminster and is a regular panellist on BBC1’s Sunday Politics.