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

Charles Alessi

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Mark Masselli: This is Conversations on Health Care I’m Mark Masselli.

Margaret Flinter: I’m Margaret Flinter.

Mark Masselli: Well, Margaret congress pass a fiscal spending bill last week and the
president signed it. While the government won’t shut down there will be some changes
health care funding moving forward. The CDC and the National Institute of Health will
receive more funding, but congress fail to act on stabilizing the insurance markets under
the Affordable Care Act and that means ra tes are almost guaranteed to go up on the
insurance market places next yea.

Margaret Flinter: Since congress fail to include stabilization measures in the budget
omnibus, rates may now be going up they say by as much as 2000% by next year
which seems almo st unbelievable and this is going to be particularly true for older
Americans with more complex health histories.

Mark Masselli: The insurance market stabilization subsides were an integral part of the
Affordable Care Act to help insurers offer customers lower rates on the insurance
exchanges. The Trump Administration fail to renew those subsidies and insurer say
they will have no choice but to raise rates for 2019. As you Margaret this will impact
older health consumers who often have more expensive pre existing conditions.

Margaret Flinter: All of this dovetails to our guest today Dr. Charles Alessi is a primary
care physician with the National Health Service in England. He’ll be talking about the
impact on population health when an entire country has access to primary care.

Mark Masselli: He will also talk about a health issue that is of great concern all around
the world. The expected increase in the number of people being diagnosed with some
form of dementia. He develop some very interesting preve ntion strategies that are
being deployed in the UK, really looking forward to that conversation Margaret.

Margaret Flinter: Lori Robertson will stop by the m anaging editor of FactCheck.org, but
not matter what the topic you can hear all of our shows by go ing to chcradio.com.

Mark Masselli: As always if you have comments please email us at
[email protected] or find us on Facebook or Twitter, we love hearing from you.

Margaret Flinter: We’ll get to our interview wit h Dr. Charles Alessi of Public Health
England in just a moment.

Mark Masselli: First here is our producer Marianne O’Hare with this week’s headline
news.

Charles Alessi

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Marianne O’Hare: I’m Marianne O’Hare with these health care headlines. Winners and
losers i n the congressional budget deal sign by President Trump which keeps the
federal government afloat while securing more money for things like the opioid epidemic
and mental health services. The overall budget for the department of health and human
services increased by 10 billion dollars overall. Congress approves 3.6 billion dollars to
help battle the opioid addiction crisis with. The NIH did well, their budget of 37 billion
dollar showed three billion more than last year with money year mark for Alzheime r’s
research as well as a quest for universal flu vaccine. Noticeably absent from the billings
was the plan to stabilize the insurance market. After the Trump Administration have
removed the Affordable Care Act subsides to ensures to help them keep rates down on
the individual market. The congressional budget office and a number of independent
analyst predict it’s going to mean much higher insurance rates for folks in 2019.

US news and world report has launched its first official rankings of the nation’s
healthiest cities with tiny two mile square town of Falls Church, Virginia taking the
number one spot. The rankings done in partnership with the Aetna Foundation were
complied based on a number of criteria population health overall, equity, education,
ec onomy, housing quality and healthy food and nutrition. The rankings release Monday
the top five communities were Falls Church City, Virginia. Douglas County, Colorado,
Broomfield County, Colorado, Los Aalamos County, New Mexico, and Dukes County,
Massach usetts.

He’s been confirmed, Dr. Robert Redfield the new director of the Centers for Disease
Control and Prevention. The long time researcher rose to prominence in the world of
HIV/AIDS discoveries , he’s also been a long time advocate of drug addiction tr eatment
to reduce the rate of HIV infection which is much higher among IV drug users. Recent
CDC Director Dr. Brenda Fitzgerald, Donald Trump’s first pick resigned over financial
conflicts of interest. I’m Marianne O’Hare with these health care headlines .

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Mark Masselli: We’re speaking today with Dr. Charles Alessi, Senior Advisor for
Dementia Prevention at Public Health England, the United Kingdom’s Public Health
Agency dedicated to protecting and improving population health. Dr. Alessi is a long
time primary care physic ian with a focusing on strategies that can prevent the onset of
dementia. He has served as chairman of the National Association for Primary Care in
the UK. He’s currently a professor in the MBA in Health Innovation Program as well as
Professor of Clinical Neuroscience at Western Ontario University in Canada. Dr. Alessi,
welcome to Conversations on Health Care.

Dr. Charles Alessi: Thank you for having me.

Charles Alessi

Mark Masselli: Yeah, and as a primary care clinician with a long history working with
the NHS Englan d’s national system there 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 in delivering care across the UK?

Dr. Charles Al essi: The NHS was set up just after the Second World War, and basically
it delivers health care free at the point of delivery to the population of England
irrespective of the ability of people to pay for the service. It delivers health care on the
basis of clinical need, in other words the single insurer and that single insurer is
government, it’s paid for out of a taxes associated with the way we pay tax in the United
Kingdom. The NHS is open to everybody and classically what tends to happen is the
mome nt somebody’s born they tend to register or rather their parents tend to register
them with a general practitioner who holds their clinical record. That clinical record is
held by that general practitioner for the whole of the individual’s life. That doe sn’t mean
of course that the individual can’t change general practitioner, they choose to change
their practitioner but only one record is kept for an individual and there is only one
practitioner which is responsible for their care, the registered list is the way we describe
that. This has significant advantages because what tends to develop is a very long
standing relationship, a lifelong relationship between an individual and their clinician.
Actually 90% of all clinical episodes take place in primary care, only about 10% take
place in hospitals.

Margaret Flinter: We have always been 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 cost, something that eliminate
so many barriers for people. What is your analysis of what happens to population
health to the health of your country and the population in general in the presence of this
national access to primar y 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 the lower socioeconomic 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, people choose not to access them
despite the fact that we have services which are open to everybody. I thi nk we can
learn from other countries in terms of the way we manage disease. If you look to some
jurisdiction, this is like Singapore where people have a real understanding associated
with sense of community and sense of belonging to a community. People t end to
access services better than perhaps we do in the west, and I think part of that is also
our responsibility as clinicians because we tends to practice what I call mixing by body
parts.

Charles Alessi

One lesson I think we need to learn is primary care services are incredibly important of
course because it’s the only way you can manage a population. You can’t really
eliminate clinical risk from individual by each individual going to the hospital when they
need to. It just doesn’t work like that, and then we have ve ry good examples of how it
doesn’t work, particularly in terms of the amounts of money it cost to exclude on this
without getting clinical benefits associated with it. What is important in a primary care
environment needs to be sensitive to their culture, needs to be sensitive to their needs
and preferably be needs to be delivered by people who are amongst them. In other
words having neighborhoods arrangement is probably the best way to deliver services
and that’s certainly been the experience of a lot of middle income countries that have
developed primary care services, 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 Eng land and that’s the prevention of dementia. Our
health system as well as yours is bracing for what’s been referred to as a Silver
Tsunami with millions of Americans as well as Britain’s already diagnosed with some
form of dementia. I’m wondering if you c ould again share with our listeners some of the
strategies for dementia preventions being deployed under your direction.

Dr. Charles Alessi: Thank you, well I mean the key messages of what’s good for your
heart is good for your brain. Dementia is not an inevitable, a normal part of aging is one
of the risk factors associated with dementia. There are ways to reduce the risk of
developing dementia and many of these are common to what reducing called the
vascular risk, these are taking regular exercise, thi s is particularly important, not
smoking this is extremely important. Healthy balance diet, maintaining a healthy weight,
and keeping socially and mentally active, social engagement is really important and
education is also really important. Really manag ing to try to remain engaged and
involved with your community is of extreme importance. This also includes ensuring
you manage risk factors like blood pressure, ensuring you manage that your diabetes is
particularly well, if you are a diabetic. Then ensu ring that if you have something like a
defibrillation which is a condition associated within a regular heart beat, that is properly
treated. The science isn’t quite as good as it could be, we’re not sure exactly why
there’s an association between pollutio n for example and particulates. There’s another
association between hearing loss perhaps is associated with social isolation, and it
certainly an association with depression.

Margaret Flinter: Well, Dr. Alessi you’ve said that the problems of aging are n ot going
to be solved just by the medical community, but by a greater understanding of activity
within the community. You’ve noted that sometimes interventions as simple as a
national walking program which is understand has proven successful in the UK to help
treat depression is to get people more active. These things both have a significant

Charles Alessi

impact, but we know in health care that behavior change can be a heavy lift and maybe
you could talk with us a bit about some the community base initiatives of the Na tional
Health Service maybe engaged in, but that are really being carried out at the community
level.

Dr. Charles Alessi: Yes thank you, I mean I think this is really important giving people
meaning and purpose in life is a 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
embroilments in other words being connected with the people around you, knowing who
your neighbors are, helping your neighbors, trying to learn something every day. This is
all parts of giving people meaning and purpose. I think a lot of what 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 talk to each other which was particularly helpful
because it started to engage people with their neighbors. While they were doing that
they were als o improving their step count which we know is of value anyway, so you’re
killing two birds with one stone. The most important thing is to remain connected. Now
if you do that through work or you do that through hobbies, or you do that through
helping peo ple I don’t think it really matters as long as you feel you have meaning and
purpose in your life. If you don’t, then life doesn’t stops to be worth living and that we
see the effect of that really quite readily in how long it takes for people to die. Pe ople
tend to die relatively quickly when they lose meaning and purpose in life.

Mark Masselli: We’re speaking today with Dr. Charles Alessi senior advisor for
dementia prevention at Public Health England, the UK’s Public Health Agency
dedicated to protect and improving population health and reducing public health and
equities. Dr. Alessi is a long time primary care physician with a focus set on strategies
that can prevent the onset of dementia. Dr. Alessi you always – I hear the new axiom in
the public health space such as sitting is the new smoking which is 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 especially among seniors
and that the affects from such isolation are just as damaging to health and longevity of
sitting or smoking . I’m thinking about the work of Dr. Robert Putnam here in the United
States wrote Bowling Alone. Your country has adopted a novel approach, I’m
wondering if you could talk about your new minister of loneliness in the UK and how will
the person be addres sing these newly recognized public health challenges of chronic
loneliness?

Dr. Charles Alessi: We’re very aware of the dangers of loneliness. I mean the dangers
of social isolation are very well described in the literature. The moment somebody
become s ocially isolated on retirement, the health effects of that sort of equivalent to
them taking up smoking on retirements. I mean it really does have a significant affects
upon one’s life. It’s really quite important to think in terms of ways in which one

Charles Alessi

m anages the situation, of course this is not something which is terribly common when
we lived in small villages and knew each other, but it’s becoming much more common
th
as the old family values which existed in the middle of the 20 century become less
st
prev alent in the 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 governments and local government is
around loneliness is ensuring that we develop things like befriending services, and we
work very closely with our voluntary agencies, the equivalent of AARP and various other
charities to ensure that we develop services that befriend people, that try to introduce
adult learning all sorts of mechanisms. The walking initiative was just one of the m,
ensuring that people feel there’s somebody cares about them, and ensuring that it’s
possible people care about somebody else. We know those two things really make a
difference to outcomes. They also make difference if you have a long term condition
wh ich some people leads you remain lying in bed all day but if you have a particular
interest you may actually be able to live with that condition for longer, because your life
is more important, you’re busy. I think this is a sense of trying to ensure peop le retain
meaning and that’s why loneliness is something and social isolation is something we’re
attacking with quite a significance amounts of resource in England.

Margaret Flinter: Dr. Alessi you obviously bring a depth and richness of the years of
bein g a physician or primary care provider and a leader in the United Kingdom’s primary
care system. You’re also an educator and you’ve noted that health systems are at a
dramatic turning point and therefore the way we teach and the way we train needs to be
a t a turning point. How has this change the way that you and your colleagues are
training this next generation of clinicians?

Dr. Charles Alessi: We have a lot of work to do around training physicians because the
world is changing more rapidly than we can change the curricular 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 win [inaudible 00:17:09 ] to people. Basically
we told people what to do, and what ha ppen now with the digital revolution is that
information is available to everybody. The ability of information immediately it is really
important that clinicians understand that their role is changing to one where they have to
accompany people and one whe re they don’t need to tell people what to do but they
need to guide people around what they advice people to do.

I think that’s a fundamental difference to the way I was trained as a physician in the
1970s. Now I think it’s more about the company of someb ody on a life journey around
their non - communicable diseases and being somebody who they can turn to and
somebody who can help them make decisions that was also changes the
personalization of health care. People are behaving far more like consumers, and I
think that’s not necessarily a bad thing, because I think we need to understand that the

Charles Alessi

system is changing and health care needs to change like everything else has changed
st
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 irrelevant, we can start delivering these cares by Skype and we have to
really reform our system and leverage these technological adva nces. Where do you
see the greatest promise for disruption and improvement with these technological
changes advancing?

Dr. Charles Alessi: I think digital health is going to revolutionize medicine because the
fact that information is going to be availabl e to everybody readily is going to potentially
reduce the qualities we’ve been talking about. People would be able to do much more
for themselves, self - care will become much commoner and together with initiatives
which will arise artificial intelligence, physicians that are actually – not physicians but
chat box. Physicians that are really decision aids will be able to actually help us
manage our health care and make decisions better. Of course there always will be the
need for a physician, and I think t he big challenge really is where the digital world hits
the old fashioned personal world. I think managing that interface is going to be the
biggest challenge. Either all the people in the world will change or it’s up to medical
system to change, and I w ould suggest it’s up to the medical system to change because
it’s not very likely the whole world will change. Really the big change is around the
metrics of drive our systems, at the moment a lot of health systems we have are driven
around activity. I t hink they need to move and turn to be driven by wellness, we pay our
physicians when we’re sick, I recon we should pay them when we’re well, that change
of mindset is really what’s going to drive the new world and the new way of thinking.

Margaret Flinter: We’ve been speaking today with Dr. Charles Alessi the Senior Advisor
for Dementia Prevention at Public Health England. You can learn more about their work
by going to gov.uk/government/organization/Public Health England or follow them on
Twitter @PHE_UK #Dr. Charles Alessi. Dr. Alessi we wanted to thank you so much for
the important work that you are doing and for joining us on Conversations on Health
Care Today.

Dr. Charles Alessi: Thank you.

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Mark Masselli: At Conversations on Health C are, 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?

Charles Alessi

Lori Robertson: Several readers have asked us about a popular Facebook post that
claims President Donald Trump quote, “Signed an executive order allowing our vetera ns
to get a 100% medical bills paid at hospitals other than a VA hospital.” No such
executive order was ever signed. We could find no evidence to support the post in
either news reports or White House statements. What Trump has done is continue the
Vete rans Choice Program, a program started in 2014 following a scandal overweight
times at Veterans Affairs facilities. A bipartisan bill that was signed by President Barack
Obama, the Veterans Choice Program allows some veterans who experienced difficulty
ob taining care from a Veterans Affairs medical facility to seek care elsewhere. Veterans
must be enrolled in the VA health care system and demonstrate that they faced barriers
to using the VA system. Last year Trump signed a bill that eliminated the progra ms
exploration date and twice signed legislation that authorized continued funding for the
program. Under the Veterans Choice Program care isn’t necessarily free, veterans
might have co - payments depending on their financial status. While Trump has
extend ed this Obama era program that covers some medical care for a certain eligible
veterans outside the VA system, he has not signed any executive order that would allow
veterans to get free care at any hospital as this post spread through Facebook says.
That ’s my fact check for this week, I’m Lori Robertson Managing Editor of
FactCheck.org.

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 at
CHCradio.com we ’ ll have FactCheck.org’s, Lori Robertson, check it out for you, here on
Conversations on Healthcare.

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Margaret Flinter: Each week Conversations highl ights a bright idea about how to make
wellness a part of our communities and to everyday lives. Health care providers are
forever on the lookout for that magic Elixer that can cure a host of chronic ills in one
step. In the case of obesity, depression, a nxiety and stress that Elixer could be a
number of steps as in taking a hike. A large study conducted by several institutions
including the University of Michigan and Edge Hill University in the UK looked at the
medicinal benefits derive from regular grou p hikes conducted in nature. Researchers
evaluated some 2000 participants in a program called Walking for Health in England or
sponsor some 3000 walks per week across the country.

Dr. Sarah Warber : This is a national study in the UK, there was investment in this
walking group.

Charles Alessi

Margaret Flinter: Dr. Sarah Warber, Professor of Family Medicine at the University of
Michigan School of Medicine said the study showed a dramatic improvement in the
mental wellbeing of participants.

Dr. Sarah Warber: Depression w as reduced, perceived stress was reduced and that
people experience more positive feelings or positive emotions. We have less negative
emotions when we’re out in nature, and when we’re out in nature in group.

Margaret Flinter: Dr. Warber says this is th e first study that revealed the added benefits
of group hikes in nature and significant mitigation of depression. Walk for Health, a
simple guided group nature hike program which incentives folks suffering from
depression and anxiety to step into the fres h air with others, improving their mood,
reducing their depression, now that’s a bright idea.

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Margaret Flinter: This is Conversations on Health Care I’m Margaret Flinter.

Mark Masselli: I’m Mark Masselli, peace and health.

Conversations on Health C are broadcast from WESU at Wesleyan University,
streaming live at www.wesufm.org and brought to you by the Community Health Center.