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Abstract:This article discusses the energy and aggressiveness of the campaigns against mitigating transmission of Covid-19 during the pandemic, and especially against vaccination. These campaigns have brought anti-vaxx sentiments into the limelight with a vengeance. The aim of the article is to seek a better understanding of the forms that the contemporary anti-vaxx movements can take and what is fuelling them. It has three parts. The first describes recent anti-vaxxer actions in the UK, France, Austria and Canada, highlighting the siege of Ottawa. The second part draws on the history of anti-vaxx movements in the UK and the USA for insights into their militancy; and in the third part there is an exploration of ideas about what makes anti-vaxx platforms so attractive and who is drawn towards them. Countering anti-vaxxer propaganda requires an understanding of the pathways by which the information spreads. False narratives will move from anti-vaccine echo chambers to mass audiences via social-media sharing, as well as coverage in local and mainstream media. Countering this misinformation all along the pathway requires a whole-of-society effort that is multifaceted, tolerant of short-term setbacks, and persistent even in challenging conditions. The NHS faces the whole of society. Could it, in its present state, be the vehicle for engaging the anti-vaxxer movements?

Abstract:Drawing on insights from psychology, psychoanalysis, cultural studies, health economics and medical ethics, this article explores two linked aspects of the management of the Covid-19 pandemic during its first and second waves in the UK. The first aspect is the range of cognitive and emotional responses to the imminent collapse of authority early in the crisis, and how these played out in public and private. Ultimately, the NHS fallback response was the 'Rule of Rescue', the requirement to rescue identifiable individuals in immediate peril, regardless of the cost. The second aspect is the meaning of heroism in the context of this pandemic. This includes the Clap for Carers initiative-and its function as an endorsement of others' deeds; the use of war imagery and war resources in mobilising against the infection; and the possibilities for different objects of applause to appear when seen from different standpoints. Linking these two aspects together we argue that the potential collapse of authority helps explain responses that seek heroes in the war against the virus and see war strategy and tactics as deserving of our support. We also ask what will remain of the pandemic in public memory.

Background: Frailty is a state of increased vulnerability to poor resolution of homeostasis as a consequence of age-related decreased physiological reserves. Although physical frailty and cognitive impairment have been shown to be associated, evidence on the prevalence of frailty in Alzheimer's disease is scarce. Objective: To conduct a systematic review on the prevalence of frailty and to combine the data to synthesize the pooled prevalence of physical frailty among patients with Alzheimer's disease. Method: Five electronic databases (Embase, MEDLINE, CINAHL Plus, PsycINFO, and the Cochrane Library) were searched for studies providing cross-sectional data on physical frailty among patients with Alzheimer's disease published from 2000 to January 2016. Results: Of 2,564 studies identified through the systematic review, five studies incorporating 534 patients with Alzheimer's disease were included for the meta-analysis. The prevalence of frailty varied with a wide range from 11.1% to 50.0% and the pooled prevalence was 31.9% (five studies, 95% confidence interval (CI)=15.7%-48.5%). The high degree of heterogeneity was observed in all analyses. A borderline publication bias was detected. Conclusion: The current study showed that frailty is highly prevalent in older patients with Alzheimer's disease in the community with the pooled prevalence of 31.9%. The true prevalence may be much higher given that end-stage patients may not be included. This information is important for clinicians and researchers.

Japan's population is aging more rapidly than that of any other country. Frailty has recently been recognized as an important priority. Understanding the basic epidemiology of frailty in Japan, which is an example of a rapidly aging society, will be beneficial for Japan as well as other countries expecting an aging population. A systematic literature search of 11 electronic databases was conducted in March 2016 using a comprehensive set of Medical Subject Heading and text terms for any studies published in 2000 or later that report the prevalence of frailty among Japanese community-dwelling older people aged 65 years or older. A total of 1529 studies were identified in the systematic search, of which five studies were included in this review. The pooled prevalence of frailty, prefrailty, and robustness was 7.4% (95% confidence interval [CI], 6.1%–9.0%), 48.1% (95% CI, 41.6%–54.8%), and 44.4% (95% CI, 37.2%–51.7%), respectively. A significant degree of heterogeneity was observed. There was no evidence of publication bias. Age-stratified meta-analyses of four studies showed the pooled prevalence of frailty was 1.9%, 3.8%, 10.0%, 20.4%, and 35.1% for those aged 65–69, 70–74, 75–79, 80–84, and ≥85 years, respectively. Pooled prevalence of frailty was 8.1% for women and 7.6% for men. This review showed an overall pooled prevalence of frailty among Japanese community-dwelling older people of 7.4%. The age-stratified analysis suggested that Japanese older people are less frail before their late 70's but frailer in later life than older people in other countries. These findings provide important basic information for all parties involved in Japanese frailty research.

SummaryPersonal health budgets (PHBs) were piloted in the National Health Service (NHS) in England between 2009 and 2012 and were found to have greater positive effects on quality of life and psychological well-being for those with mental health problems than commissioned service, as well as reducing their use of unplanned care. The government intends to extend PHBs in England for long-term conditions, including mental health, from April 2015. Given the importance of engaging clinicians in the next phase of PHB development, we provide an overview of the approach, synthesise the evidence from the national pilot and debate some of the opportunities and challenges. Balancing individual choice and recovery with concerns for risk, equity and the sustainability of existing community services is the central tension underpinning this innovation in mental health service delivery.

Personal health budgets (PHBs) were piloted in the National Health Service (NHS) in England between 2009 and 2012 and were found to have greater positive effects on quality of life and psychological well-being for those with mental health problems than commissioned service, as well as reducing their use of unplanned care. The government intends to extend PHBs in England for long-term conditions, including mental health, from April 2015. Given the importance of engaging clinicians in the next phase of PHB development, we provide an overview of the approach, synthesise the evidence from the national pilot and debate some of the opportunities and challenges. Balancing individual choice and recovery with concerns for risk, equity and the sustainability of existing community services is the central tension underpinning this innovation in mental health service delivery.

Frailty is the most problematic expression of population ageing. It is a state of vulnerability to poor resolution of homoeostasis after a stressor event and is a consequence of cumulative decline in many physiological systems during a lifetime. This cumulative decline depletes homoeostatic reserves until minor stressor events trigger disproportionate changes in health status. In landmark studies, investigators have developed valid models of frailty and these models have allowed epidemiological investigations that show the association between frailty and adverse health outcomes. We need to develop more efficient methods to detect frailty and measure its severity in routine clinical practice, especially methods that are useful for primary care. Such progress would greatly inform the appropriate selection of elderly people for invasive procedures or drug treatments and would be the basis for a shift in the care of frail elderly people towards more appropriate goal-directed care.

Study aims:To discover the current level of nurse-led involvement in activity promotion for older people in primary care and to explore the knowledge and attitudes of primary care nurses about health benefits of activity promotion for older people.Background:The importance of improving and maintaining activity levels in later life is well established. However, intervention studies show that the uptake of and adherence to physical activity programmes by older people are highly variable. The optimal approach to activity promotion for older people is not well understood. Although many activity promotion schemes and evaluations assume that specialist exercise trainers are needed, it remains unclear who is best placed to facilitate activity promotion for older people, and if this is something in which existing primary care practitioners (specifically nurses) could and should take a leading role.Methods:This study surveyed all nurses and health visitors working in five primary care organizations in an inner city area. A semi-structured postal questionnaire asked about their knowledge and attitudes to the benefits of exercise in later life, their current levels of involvement in promoting physical activity with older people, and their personal activity levels.Findings:The overall response rate was 54% (n=521). The responses of 391 district nurses and practice nurses are presented here. Nurses had the commitment and (depending on the focus of their work) different opportunities to promote physical activity with older patients. There were organizational and individual constraints on their ability to be involved in this aspect of health promotion work themselves, or to refer older people to local activity promotion schemes. Nurses did not have a structured approach when promoting physical activity with older people and had only a partial awareness of the limitations of their knowledge or skills when promoting activity with older people.Conclusions:For promotion of physical activity by older people to be meaningfully incorporated into primary care nursing work there is a need to develop a more strategic approach that can optimize the opportunities and interest of primary care nurses and develop the knowledge and skills of the workforce in this area of nursing work.

Many practitioners will sympathise with Claire Hilton’s views of the National Dementia Strategy. However, implementation of healthcare policies is frequently a long drawn out and messy process. There is no guarantee that its proposals will be implemented, given the vagaries of economies and the frailty of political will, but all of them could be. We should aim for gradual changes that produce qualitative shifts in the standards of dementia care.

Background and aims: In clinical practice, the status of living alone is often used as the only measure describing an older person’s social network. We evaluated whether additional use of a brief social network measure provides relevant additional information in relation to social support and engagement. Methods: Cross-sectional survey of 6982 community-dwelling adults 65 years or older living in London, UK; Hamburg, Germany; and Solothurn, Switzerland. Data were collected using the self-administered multidimensional Health Risk Appraisal Questionnaire. Multivariate models were used to analyse adjusted correlations between the two measures of social network (living alone status, risk for social isolation with marginal family and friend network subscales) and potential consequences of inadequate social network (marginal emotional or instrumental support, lack of social engagement). Results: Living alone status was more strongly associated with marginal instrumental support [OR=7.6 (95% CI 6.3, 9.1)] than with marginal emotional support [OR=4.2 (95% CI 3.4, 5.1)], and showed no statistically significant association with lack of social engagement [OR=0.9 (95% CI 0.8, 1.0)]. Risk of social isolation was more strongly related to marginal emotional support [OR=6.6 (95% CI 5.4, 8.0)] than to marginal instrumental support [OR=3.3 (95% CI 2.8, 4.0)], and was moderately related to lack of social engagement [OR=2.9 (95% CI 2.5, 3.4]. Marginal family and friend network subscales showed consistent and unique associations with social support and social engagement. Conclusion: Findings suggest that living alone status and a brief measure of social network identifies distinctive at-risk groups and potential pathways for intervention. Geriatric assessment programs including both social network measures may provide useful information about potentially modifiable social network risks in older persons.

The theme of this article is the recognition of and response to dementia in general practice. Its aim is to clarify the tasks of diagnosing dementia, to advise on the use of cognitive function tests, to suggest ways of establishing the subtype of dementia where possible and to assist general practitioners in talking about dementia with their patients and their families.

This second of two articles on the recognition of and response to dementia syndrome in general practice focuses on the long-term support of patients and their families. It includes guidance on the use of cholinesterase inhibitors, the role of psychosocial interventions and the need to organize systematic follow-up. Sources of support for meeting carers' needs are discussed, including ways of managing behavioural and psychological symptoms that appear in the middle phase of the disease trajectory. Discussion of the issues underlying relocation to a care home, and the practicalities of end-of-life care, lead into ways of assessing the quality of care provided in general practice.

The promotion of health and independence for older people through preventative strategies is rising up the public health agenda in many countries and has been made a government policy objective in the UK. Despite forty years of experimentation, community nursing and general practice involvement in this field has been characterized by a lack of evidence to support broad screening and surveillance programmes and a failure to reach consensus on the most effective approaches to health promotion in later life. One initiative brought together community nursing, general practice and the voluntary social welfare sector in an inner urban setting to proactively identify and address unmet need and promote health through short term case management in an older population. This paper reports on the ability of the primary care teams to identify ‘at risk’ groups in the older population, which can then be targeted for comprehensive assessment.

The emerging UK national research network in neurodegenerative diseases and dementias aims to promote large-scale community-based studies of therapeutic interventions, based in primary care. However, trials in primary care settings can be problematic, a common difficulty being the recruitment of a large enough sample. The article discusses recruitment issues in a multi-centre randomized controlled trial of differing educational approaches to improving dementia care in general practice. Sample size calculations based on community studies of prevalence may be misleading in intervention trials which may recruit practices with atypical demography. Recruitment rates for practitioners in this study were lower than expected. Professionals excluded themselves from the study mainly due to pressures of time and staff shortages, and we detected both ambivalent attitudes to primary care research and a perception that research into dementia care was not a high priority. Evaluation of the quality of care may be perceived as criticism of clinical practice, at a time when general practice is undergoing major administrative and contractual changes. Variations in Research Ethics Committee conditions for approval led to different methods of recruitment of patients and carers into the study, a factor which may have contributed to disparate levels of recruitment across study sites. Patient and carer levels of recruitment were lower than expected and were affected partly by carers' time pressures and other family commitments, but largely by problems in identifying patients and carers in the practices. The development of research potential in primary care is at an early stage and studies reliant on patient recruitment in general practice must allow for multiple obstacles to enrollment. This is particularly relevant for studies of dementia care, where the prevalence of dementia in a demographically average population is low and the incidence very low, compared with other disabilities. Professionals may give dementia low priority in allocating practice time for research projects, and strategies to address this problem are needed.

OBJECTIVE: To test the effectiveness of educational interventions in improving detection rates and management of dementia in primary care. Design Unblinded, cluster randomised, before and after controlled study. Setting General practices in the United Kingdom (central Scotland and London) between 1999 and 2002. Interventions Three educational interventions: an electronic tutorial carried on a CD Rom; decision support software built into the electronic medical record; and practice based workshops. Participants 36 practices participated in the study. Eight practices were randomly assigned to the electronic tutorial; eight to decision support software; 10 to practice based workshops; and 10 to control. Electronic and manual searches yielded 450 valid and usable medical records. MAIN OUTCOME MEASURES: Rates of detection of dementia and the extent to which medical records showed evidence of improved concordance with guidelines regarding diagnosis and management. RESULTS: Decision support software (P = 0.01) and practice based workshops (P = 0.01) both significantly improved rates of detection compared with control. There were no significant differences by intervention in the measures of concordance with guidelines. CONCLUSIONS: Decision support systems and practice based workshops are effective educational approaches in improving detection rates in dementia.

This article introduces findings from the first phase of a randomized controlled trial of educational interventions in primary care. The focus of the article is the knowledge, attitudes and confidence of primary care nursing staff to the diagnosis and ongoing management of dementia. A total of 78 nurses with a mean age of 46.4 years and a mean time since qualification of 23.0 years were recruited in 36 practices in central Scotland and in London. Disciplines represented by this sample were predominantly district nurses, health visitors, practice nurses and community staff nurses. Each practitioner was administered an extensive self-completion questionnaire before the educational interventions were introduced to measure baseline knowledge, confidence and perceived difficulties in dementia care management and attitudes. Results from the quiz indicate lower levels of knowledge about epidemiology and diagnosis, but slightly higher levels about management strategies. Self-reported ratings of confidence were also low and were directly related to ratings of difficulty in identifying dementia and dealing with coexisting behavioural and mental health problems. Lower scores on all domains were recorded for practice nurses than for district nurses or health visitors.

The aim of this study was to explore the perspectives of primary care practitioners on the early diagnosis of dementia.

Community-oriented primary care (COPC), a 50-year-old widely applied innovative approach to primary care development, seems to be the same combination of public health and general practice perspectives currently sought in the formation of primary care trusts in Britain's NHS. The article reviews the experience of implementing COPC methods, the outcomes, and the applicability to and implications for primary care policy, taking the current British reforms as an example. The COPC model has been developed mainly in underserved populations to integrate public health objectives and primary care through interdisciplinary approaches, with active involvement of the target population. COPC methods are time consuming, can create problems with professional boundaries, and are vulnerable to socioeconomic changes. They can also deliver complex packages of care for target populations, particularly in poor areas underserved by traditional medical services. British primary care reforms may be seen as an unplanned, uncontrolled, nationwide experiment in applying COPC methods. They differ from COPC as applied elsewhere because change has been introduced from above rather than below, into a well-developed primary care system rather than underserved communities. International experience suggests the need for attention to factors promoting and impeding success and to reliable outcome measures. If this experiment succeeds, COPC methodology may facilitate similar changes in other health care systems.

The current focus on dementia risks eclipsing other mental health problems of later life. While the National Service Framework for Older People (NSF) has highlighted depression as an important disorder meriting special consideration,1 anxiety and psychoses in older people remain difficult problems for practitioners to manage. This paper reviews the prevalence and impact, recognition, complexity and prognosis and treatment for these three clinical problems, and proposes a framework for ‘good enough practice’

The National Service Frameworks for Older People and for Mental Health are setting standards for services in areas where problems are complex and solutions limited. Primary Care Trusts seeking to raise the quality of primary care for older people and commission specialist services rationally face many challenges. Specialists in old age medicine and old age psychiatry will find themselves working closely with primary care practitioners to develop services and extend professional skills, for it is uncertain that specialist services will be able to deal with the scale of the clinical and social problems unaided.

Dementia presents a challenge for primary care and the advent of new therapeutic options has highlighted the need to improve its detection so that early decisions about medication use can be made. Efforts at earlier diagnosis should be targeted at primary care as the gateway to specialist health and social services. There is, however, evidence that dementia remains under-detected and sub-optimally managed in general practice throughout the world. This article reviews the obstacles to early recognition of dementia and the factors causing sub-optimal management in the community, and discusses educational approaches to enhancing professional skills in the recognition of and response to dementia. Three educational interventions with different characteristics and methods of delivery are described.

Dementia presents a challenge for primary care and the advent of new therapeutic options has highlighted the need to improve its detection so that early decisions about medication use can be made. Efforts at earlier diagnosis should be targeted at primary care as the gateway to specialist health and social services. There is, however, evidence that dementia remains under-detected and sub-optimally managed in general practice throughout the world. This article reviews the obstacles to early recognition of dementia and the factors causing sub-optimal management in the community, and discusses educational approaches to enhancing professional skills in the recognition of and response to dementia. Three educational interventions with different characteristics and methods of delivery are described.

The assessments of patients aged 75 years and over that were built into the 1990 contract for general practice have failed to enthuse primary care teams or to make a significant impact on the health of older people. The lack of an evidence base for these checks, and the absence of any training programme for practice staff involved in the assessment of older people, both appear to be important factors contributing to the failure of this approach. Alternative methods for improving the health of older people who are living at home are being sought. This paper describes the use of a model of community-oriented primary care (COPC) to initiate innovative care for older people in four exemplar practices in an inner-city area of London. Pump-priming funding was supplied for a 2-year period by one health authority, with the proviso that all innovation must be self-sustaining. The project was supported by an academic department of primary care, which promoted discussion about objectives and priorities, provided the evidence base for interventions considered by the practices, supported staff and created an evaluation framework, but avoided any prescriptive intervention in the process of innovation. All four practices have successfully identified different problems that need attention in their local populations of older people, and developed different projects focused on particular needs among older people. The effectiveness of the COPC method in promoting change in these practices was sufficient for the health authority to fund a second stage, extending the method to 40 practices over a 2-year period.

The assessments of patients aged 75 years and over that were built into the 1990 contract for general practice have failed to enthuse primary care teams or to make a significant impact on the health of older people. The lack of an evidence base for these checks, and the absence of any training programme for practice staff involved in the assessment of older people, both appear to be important factors contributing to the failure of this approach. Alternative methods for improving the health of older people who are living at home are being sought. This paper describes the use of a model of community-oriented primary care (COPC) to initiate innovative care for older people in four exemplar practices in an inner-city area of London. Pump-priming funding was supplied for a 2-year period by one health authority, with the proviso that all innovation must be self-sustaining. The project was supported by an academic department of primary care, which promoted discussion about objectives and priorities, provided the evidence base for interventions considered by the practices, supported staff and created an evaluation framework, but avoided any prescriptive intervention in the process of innovation. All four practices have successfully identified different problems that need attention in their local populations of older people, and developed different projects focused on particular needs among older people. The effectiveness of the COPC method in promoting change in these practices was sufficient for the health authority to fund a second stage, extending the method to 40 practices over a 2-year period.

Britain's New Labour government has consolidated its reform of the National Health Service with an ambitious NHS Plan that links investment in staff, new buildings, and new technology to delivery of a modernization agenda combining consumerist and public health agendas. The fundamental principles of the NHS are preserved, but within a regulatory structure of a managed market. The author outlines the changes proposed and the possible responses of different stakeholders.

Britain's National Health Service (NHS) has been the subject of unprecedented market reforms, which have failed to solve its problems. The New Labour government elected in 1997 has halted the drive toward the marketization of health care and replaced cost with quality as the central concern of NHS administration and policy. Major changes are occurring in the regulation of professional activity, with profound implications for the medical profession and the health service. The authors discuss these changes and possible future problems for the NHS.

Objective: Primary care occupies a strategic position in the evaluation, treatment, and prevention of the mental disturbances of later life. This article highlights four themes that are crucial to understanding mental disturbances among older adults: 1) subsyndromal depression, 2) coexisting depression and anxiety, 3) comorbidity of depression and chronic medical conditions, and 4) risk factors for cognitive impairment.Method: The literature was selectively reviewed for each theme to ask the central question, “What can primary care physicians learn about mental disturbances of their older patients from epidemiologic and community studies?”Results: The primary care setting itself is an important venue for an examination of aging issues and mental health. Workers in the “middle ground of psychiatric epidemiology”—primary health care—have not yet reached a full appreciation for the value of research in the primary care setting for enhancing our understanding of the mental disturbances of late life, and how these intersect with other salient factors.Conclusions: Primary care physicians and others who work in primary care should advocate for further mental health integration and research in primary care. Research is needed that will lead to new ways of maximizing the health and quality of life of older adults and their families.

Asthma is a chronic disease estimated to affect 6–7% of the total UK population. In addition, a number of studies have shown that asthma has become commoner since the 1970s, especially in children. The diagnosis of asthma can be difficult and its management requires the involvement of patients in a long-term treatment plan, something which general practitioners may be unable to achieve easily in the average 10-min consultation. As a consequence, asthma is underdiagnosed and undertreated. Deaths from the disease are often avoidable with timely and sufficient use of the available medication.(3,4) In order to support this, the British Thoracic Society (BTS) has published guidelines for asthma management based upon a stepwise approach, in which a patient is categorized as being on one of five steps according to the severity of his or her asthma. The guidelines give “rules of thumb” for deciding when the patient should move up or down the steps. The most recent version of the guidelines also included special rules for children.(5,6) Within a recent European Community project on Advanced Informatics in Medicien (AIM), we developed a prototype decision support system for asthma management targeted at the primary care setting and based on the British Thoracic Society guidelines. This paper reports this development, and describes the further work needed on the prototype. Plans for evaluation of the knowledge bases and for future full application production are also described.

The current emphasis on improving the quality of dementia services is welcome, but it treats dementia as if it were separable from complex comorbidities, disability and frailty. As a consequence, dementia can overshadow other problems, from heart failure to multisystem failure at the end of life, which may be poorly managed. Three ways in which old age psychiatrists can reconnect dementia with the diseases and disorders of later life are described in this editorial. The first is to improve skills in general practice so that general practitioners (GPs) can take on the bulk of the clinical work of both diagnosis and management of dementia and its comorbidities, while specialists retain complex decision-making and management tasks. The second is for old age psychiatrists to function as consultants to social enterprises run by GPs for the purpose of managing almost all patients with dementia in general practice. The third is for community geriatricians and old age psychiatrists to work together in integrated organisations that take full clinical responsibility for older people with dementia.

The current emphasis on improving the quality of dementia services is welcome, but it treats dementia as if it were separable from complex comorbidities, disability and frailty. As a consequence, dementia can overshadow other problems, from heart failure to multisystem failure at the end of life, which may be poorly managed. Three ways in which old age psychiatrists can reconnect dementia with the diseases and disorders of later life are described in this editorial. The first is to improve skills in general practice so that general practitioners (GPs) can take on the bulk of the clinical work of both diagnosis and management of dementia and its comorbidities, while specialists retain complex decision-making and management tasks. The second is for old age psychiatrists to function as consultants to social enterprises run by GPs for the purpose of managing almost all patients with dementia in general practice. The third is for community geriatricians and old age psychiatrists to work together in integrated organisations that take full clinical responsibility for older people with dementia.