National Access to Primary Care and Minister of Loneliness: Dr. Charles Alessi on the UK’s Approach to Population Health and Dementia Prevention

Dr. Charles Alessi

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Mar garet Flin ter : Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter , a show where we speak to the top thought leaders
in health innovation, health policy, care delivery , and the great minds
who are shaping the health c are of the future. This week , Mark and
Margaret speak with Dr. Charl es Alessi , senior advisor for dementia
prevention at Public Health England. Dr. Alessi talk s about the
benefits of the UK ' s health system and its lack of barriers to primary
care as well a s the nation's commitment to addressing loneliness as a
key health concern, especially for the elderly.

Lori Robertson also checks in , the managing editor of FactCheck .org ,
l ooks at misstatements spoken about health policy in the public
domain, separating the fake from the facts.

We end with a bright idea that ' s improving health and well - being in
everyday li ves . If you have comments , please email us at
[email protected] or find us on Facebook , or Twitter, iTunes , o r
wherever you listen to podcast s . You can also hear us by asking Alexa
to play the program, Conversations on Health Care .

Now , stay tuned for our interview with Dr. Charles Alessi of Public
Health England on Conversations on Health Care .

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Mark Mas selli: We 're speaking today with Dr. Charles Alessi, senior advisor for
dementia prevention at the Public Health England, the United
Kingdom's Public Health Agency , dedicated to protecting and
improving population health and reduci ng public health inequiti es. Dr.
Alessi is a long time primary care physician with a focus ing on
strategies that can prevent the onset of dementia. He has served as
chairman of the National Association for Primary Care in the UK at the
National Health Service, the NHS . Dr. Alessi is currently a professor in
the MBA in health innovation program as well as professor of clinical
neuroscience at Western O ntario University in Canada.

Dr. Alessi, welcome to Conversations on Health Care .

Dr. Charles Alessi: Thank you.

Mark Massel l i: Yeah . As a primary care clinician with a long history working with the
NHS, England's National System , responsible for delivering health care
to all residents in the country , t here are some similarities , but also
vast differences between our respective health systems. I'm
wondering if you could share with our listeners how the National
Health Service functions and how Public Health England is able to

Dr. Charles Alessi

better partner with NHS to advance health initiatives that impact
population health.

Dr. Charles Alessi: The NHS is an organization , which was set up just after the Second
World War . Basically , it delivers health care free at the point of
delivery to the population of England , and it delivers that irrespective
of the ability of people to pay for the service. It deli vers health care on
the basis of clinical need rather than ability to pay. It's paid for out of
the taxes of each individual associated with the way we pay tax in the
United Kingdom.

The NHS is open to everybody. Classically , what tends to happen is the
m oment somebody is born, they tend to register or rather the ir
parents tend to register them with a general practitioner who holds
that clinical record . The clinical record is held by th at general
practitioner for the whole of that individual. Only one reco rd is kept
for an individual and there is only one practitioner which is
responsible for that care . This has significant advantages because
what tends to develop is a very long standing relationship, a lifelong
relationship between an individual and the ir clinician. Primary care is
the fir st port of call . Actually 90% of all clinical episo des take place in
primary care . Only about 10% take place in hospitals.

Mar garet Flinter : Many organizations that we partner with are on the front lines of
serving a popul ation , which many would call underserved in the
United States . Many of them have really traditionally been locked out
of access to most primary care services outside of community health
centers until the passage of the Affordable Care Act. We have always
b een so intrigued to talk with our British counterparts about the
sense of everyone having access to comprehensive primary care and
not just primary care , but all services with little or no out - of - pocket
costs. What happens to population health in the prese nce of this
national access to primary care ?

Dr. Charles Alessi: Well, I wish I could say that the solution is purely around access to
primary care . We still have levels of inequality within our system ,
which are associated with lower soci o economic groups, which despite
the fact that they have access to primary care facilities often choose
not to access them , despite the fact that they are not charged any
money to access them at all . I think we can learn from other countries
in terms of the way we manage di sease and the way people think of
disease themselves.

If you look to some jurisdictions, places like Singapore where people
have a real understanding associated with sense of community and
sense of belonging to a community. I think part of that is also ou r
responsibilit y as clinicians because we tend to practice some , what I

Dr. Charles Alessi

call , [inaudible 00:05:18] body part rather than really deal with people
quite as comprehensive ly as we could do.

Primary care services are incredibly important, of course, because it 's
the only w ay you can manage a population. You can't really eliminate
clinical risk from every individual by each individual going to hospital
when they need to. It just doesn't work like that. We have very good
examples of how it doesn't work, particula rly in terms of the amount
of money it costs to exclude illness without getting clinical benefits
associated with it. What is important is the services that are available
to people in a primary care environment needs to be sensitive to that
culture, needs to be sensitive to their needs, and preferably needs to
be delivered by people who are amongst them. In other words, ha ving
neighborhood arrangement s is probably the best way to deliver
services. That's certainly been the experience of a lot of middle
inco me countries I have developed primary care services , and some of
which have really quite excellent health services in general.

Mark Masselli: Let's take a closer look at your specific areas of expertise in your
ongoing work at Public Health England. That's the prevention of
dementia . Our health system as well as yours is bracing for what's
being referred to as a Silver Tsunami with millions of Americans as
well as Britain's already diagnosed with some form of dementia that
I 'm wonder ing if you could again s hare with our listeners some o f the
strategies for dementia p revention s being deployed under your
direction.

Dr. Charles Alessi: Thank you. Well, the key messag e is of what's good for your heart is
good for your brain. Dementia is not an inevitable and nor mal part of
aging, even though aging is one of the risk factors associated with
dementia . There are ways to reduce the risk of developing dementia.
Many of these are common to reducing cardiovascular risk. There are
actions that we all can take to reduce t he risk of developing dementia.
These are taking regular exercise. This is particularly important . Not
smoking . This is extremely important . A healthy balanced diet,
maintaining a healthy weight, no t drinking too much, and keeping
socially and mentally act ive.

Social engagement is really important and education is also really
important. Really managing to try to remain engaged and involved
with your community is of extreme importance as well as this also
includes ensuring you manage risk factors like blood pressure ,
ensuring you manage your diabetes particularly well if you are
diabetic , and ensuring that if you have something like atrial
fibrillation, which is a condition associated with an irregular
heartbeat , that is properly treated .

Dr. Charles Alessi

The science isn't quite as good as it could be yet. We're not sure
exactly why there's an association between pollution, for example,
and particulates . There's another association between hearing loss .
Perhaps it's associated with social isolation and certainly an
associati on with depression.

Margaret Flinter: Well , Dr . Alessi , you've said that the problems of aging are not going
to be solved just by the medical community, but by a greater
understanding of activity within the community . You've noted that
sometimes interventi ons as simple as a national walking program,
which I understand has proven successful in the UK to help treat
depression , is to get people more active. These things both have a
significant impact and I think equally importantly, they don't always
require t he intervention of a health professional . We know in health
care that behavior change can be a heavy lift and , g osh, we certainly
see this around diet and eating , and getting people to think about a
different approach.

Maybe you could talk with us a bit a bout some of the community -
based initiatives th at the National Health Service may be engaged in,
but that are really being carried out at the community level that are
filling an important role in chronic disease prevention in the UK.

Dr. Charles Alessi: Ye s, thank you. I t hink this is really important . G iving people meaning
and purpose in life is of fundamental importance. What would I do if I
woke up every morning and I didn't know why I was here , what I was
going to do today? Being in employment, in other words, being
connected with the people around you, being conscious of your
environment, knowing who your neighbors are , helping your
neighbors, trying to learn something every day , this is all part of giving
people meaning and purpose . I think a lot of wh at we're trying to do is
to ensure we give people meaning and purpose.

The walking program was a mechanism because , one, it got people to
talk to each other, which was particularly helpful because it started to
engage people with their neighbors . While th ey were doing that, they
were also improving their step counts, which we know is of value
anyway. You're killing two birds with one stone . In essence, the most
important thing is to remain connected.

Now, if you do that through work , or you do that throug h hobbies , or
you do that through helping people, I don't think it really m atters , a s
long as you feel you have meaning and purpose in your life. If you
don't, then life doesn't stop to be worth living . We see the effect of
that really quite readily in how long it takes for people to die. People
tend to die relatively quickly when they lose meaning and purpose in
life.

Dr. Charles Alessi

Mark Masselli: We're speaking tod ay with Dr. Charles Alessi , senior advisor for
dementia prevention at Public Health England , t he UK ' s Publi c Health
Agency , dedicated to protecting and improving population health and
reducing public health inequities. Dr Alessi is a long time primary care
physician with a focus ing on strategies that can pre vent the onset of
dementia.

Dr. Alessi , you always he ar the new axiom in the public health space ,
such as sitting is the new smoking , which has led to a lot of innovative
approaches to address our sedentary lifestyle . We 're really taken by
the recent revelations that there's also an epidemic of loneliness,
e specially among seniors , and that the effects from such isolation are
just as damaging to health and longevity as sitting or smok ing . I'm
thi nking about the work of Dr. Robert Putnam here in the United
States, who wrote Bowling Alone, the work of Nick Chri stakis at MIT ,
l ooking at the issues around social isolation. These are very important
issues within our country as well . Your country has adopted a novel
approach.

I wonder if you could talk about your new minister of loneliness in the
UK and how will th at person be addressing these newly recognized
public health challenges of chronic loneliness.

Dr. Charles Alessi: We are v ery aware of the danger s of loneliness , the dangers the social
isolation , very well described in the literature. The moment somebody
become s socially isolated on retirement, the health effect of that are
equivalent to them taking up smoking on retirement. It really does
have a significant effect upon one's life. It does have a physical effect
at all. It's really quite important to think in terms of ways in which one
manages the situation. Of course, this is not something which is
terribly common when we lived in small villages and knew each other .
It's becoming much more common as the old family values which
th
existed in the middle of the 20 century become less prevalent in the
st
21 , and also with city dwelling where many of us don't even know
who our neighbors are .

A lot of what the work of government and local government is around
l oneliness is ensuring that we'd develop things like be friending
services . We work very clos ely with our voluntary agencies , the
equivalent of A ARP , and then various other charities to ensure tha t
we develop services that befriend people , that try to introduce a dult
[ PH 00:13:12] learning all sorts of mechanis ms . The walking i nitiative
was just one of them.

In essence, they all are pointing in exactly the same place, ensuring
that people feel that somebody who cares about them , and ensuring
that i f possible , p eople care about somebody else. We know those

Dr. Charles Alessi

two t hings really make a difference to outcomes. They also make a
difference if you have a long - term condition, which in some people
leads you to remain lying in bed all day . If you have a particular
interest, you may actually be able to live with that conditio n for
longer because your life is more important. You're busy . I think this is
the sense of trying to ensure people retain meaning . That's why
loneliness is s omething and social isolation is something we're
attacking with quite a significant amount of reso urce i n England.

Margaret Flinter: Dr. Alessi , you obviously bring a depth and richness of the years of
being a physician, a primary care provider , and a leader in the United
Kingdom's primary care system . You're also an educator and a
professor charged wi th teaching a new generation of health
practitioners , of training this next generation . You've noted that
health systems are at a dramatic turning point . Therefore , the way we
teach and the way we train needs to be at a turning point where we
embed all of our new health care professionals in understanding
these upstream causes of poor population health.

How has this changed the way that you and your colleagues , and your
education and training systems are training this next generation of
clinicians? What do you see as some of the seminal changes there?

Dr. Charles Alessi: We have a lot of work to do where I'm training the physicians because
the world is changing more rapidly than we can change the curricul ar
of medical schools. People like me were trained in a period when we
accumulate a whole series of levels of information and knowledge to
be able to [inaudible 00:15:10] those t w o people. Basically , we told
people what to do . We were not particularly good at listening to
people perhaps as well as we could d o.

What's happened now with the digital revolution is that information is
available to everybody . With the digital revolution, the smartphone,
the availability of information immediately , i t is really important that
clinicians understand that their role i s changing to one where they
have to accompany people and one where they don't need to tell
people what to do, but they need to guide people around what they
advise people to do.

I think that's a fundamental difference to the way I was t rained as a
physic ian in the 1970s . Now , I think it's more about ac company ing
somebody on thei r life journey around their non - communicable
diseases , and being somebody who they can turn to and somebody
who can help them make decisions , but b as ically, the decisions are
their s . What's also change d is the personalization of health care .
People are behaving far more like consumers. I think that's not
necessarily a bad thing. I think that's okay because I think we need to

Dr. Charles Alessi

understand that the system is changing and health care nee ds to
st
change l ike everything else has changed in the 21 century.

Mark Masselli: Dr. Alessi , let me pull the thread on that transformation that you've
been talking about in the health system . You've talked very
passionately about, make geography irrelevan t . We can start
deliver ing these cares by Skype . We have to really reform our system
and leverage these technological advances. Maybe share with us ,
w here do you see the greatest promise for disruption and
improvement with these technological changes a dvan cing?

Dr. Charles Alessi: I think digital health is going to revolutionize medicine because the
fact that information is going to be available to everybody readily is
going to potentially reduce the inequalities we've been talking about
and people would be able to do much more for themselves. Sel f care
will become much common. Together with initiatives which will arise
out of artificial intelligence and other technological advances,
physicians that are actually not physici ans , but chatbots, physicians
th at are really decision aids will be able to actually help us manage
our health care and make decisions.

Of course , there always will be the need for a physician . I think the big
challenge really is where the digital world hits the old fashion ed, but
s till ve ry relevant, personal wealth . I think managing that interface is
going to be the biggest challenge . I think there are two options that
are open to us. Either all the people in the world w ill change or it's up
to the medical system to change . I would sugges t it's up to the
medical system to change because it's not very likel y the whole world
will change.

Really the big change is around the metrics that drive our systems . At
the moment , a lot of the health systems we have are driven around
activity . I think they need to move and turn to being driven by
wellness. We pay our physicians when we're sick. I reckon we should
pay them when we are well and not when we are sick. That change of
mindset is really what's go ing to drive the new world and the new
way of th inking.

Margaret Flinter: We've been speaki ng today with Dr. Charles Alessi , the senior advisor
for dementia prevention at Public Health England. You can learn more
a bout their work by going to gov.uk/govern ment/organization/public -
health - e ngland , or follo w them on twitter at PHE _uk #Dr. Charles
Alessi .

Dr. Alessi, we want to thank you so much for the important work that
you're doing for your perspectives on the future and for joining us on
Conversations on Health Care today.

Dr. Charles Alessi

Dr. Charles Alessi: Thank you.

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Mark Masselli: At Conversations on Health Care , we want our audience to be truly in
the know when it comes to the facts about health care reform and
policy . Lori Robertson is an award - winning journalist and managing
editor of FactCheck.org, a non - partisan, nonprofit consumer advocate
for voters that aim to reduce the level of deception in U.S. politics.

Lori, what have you got for us this week?

Lori Robertson: President Do nald Trump has repeatedly made the claim that he came
up with " the gr eatest idea for Veterans Choice ", a program that was
launched in 2014 during the Obama Administration . During his
midterm campaign rallies , t he President made the claim several times ,
say ing that we just passed Veteran s Choice to allow veterans to see a
private d octor outside the VA System if they faced a long wait for
care. He told the crowd in Kentucky that it was " the greatest idea I
think I've ever had " .

In fact, the Veterans Choice Program was created by the bipartisan
Veterans ' Access , Choice , and Accountab ility Act signed by President
th
Barrack Obama on August 7 , 2014. The l egislation , which garnered
8 91 to 3 vote in the Senate and a 420 to 5 vote in the house, followed
a scandal over wait t imes at Veterans' Affairs Facilities . Program
allows veterans facin g wait s for appointments of 30 days or more, or
veterans who live more than 40 miles from the closest VA facilit y to
get care from eligible non - VA health care providers .

Since Trump took office , h e has continued the program , signing
legislation to provide funding for it and t o eliminate the expiration
date. In June, Trump signed the bipartisan VA Mission Act to fund the
Veterans Choice Program for one more year and then consolidate it
into a new Veterans Community Care Program , under which a veteran
could go to a private medical provider , including travel distance and
appointment time.

The Government Accountability Office said in a June report that it
wasn't clear whether the choice program had improved the timeliness
of care because of incomplete data . Tr ump has continued the
Veterans Choice Program and the new law could expand eligibility or
change such services, but the choice program has been in existence
since 2014 .

That's my fact check for this week. I'm Lori Robertson, managing
editor of FactCheck .o rg.

Dr. Charles Alessi

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country ' s
major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you 'd
like checked, email us a t chcradio.com . We 'll have FactCheck.org ' s
Lori Robertson check it out for you here on Conversations on Health
Care .

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Margaret Flinter: Each week , Conversations highlights a bright idea about how to make
welln ess a part of our communities and everyday lives. The
prevalence of sexually transmitted diseases has been on the rise in
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Lora Ivanova : One of every two Ame rican today is living with an STI . The vast
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Margaret Flinter: She created my LAB Box , which overnight s the testing kit to your
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Lora Ivanova : Delivering those services and tests to the consumer in a way t hat they
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Margaret Flinter: If someone has a positive result, they're offered a complimentary
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Laura Ivanova: You order it online . It arrives i n your house . Then all you need to do is
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Dr. Charles Alessi

new day and age we live in, but in this day and age, we really need to
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Margaret Flinter: m y LAB Box , a safe, accurate, easy way to test for mor e than a dozen
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Mark Masselli: You 've been listening to Conversations on Health Care . I am Mark
Masselli.

Margaret Flinter: I am Margaret Flinter.

Mark Masselli: Peace and health.

Margaret Flinter : Conversations on Health Care is recorded at WESU at Wesleyan
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