Tag Archives: Elderly

Does Pet Ownership Make Us Healthier?

Like many of us, I love animals, and am crazy about both dogs and cats. It is almost hard to describe how much I love them. But is this all very good for me? I mean, dogs can bite, cats scratch, and all animals can transmit infections. On the other hand, they are psychotropic; cuddly, warm and attentive. Some evidence suggests that people who keep pets are healthier than those without.

However, a rather dismal paper in the BMJ puts paid to all of that.[1] According to an analysis of a large cohort study of aging individuals, those who own pets do no better than those who do not. They are no stronger, happier or otherwise healthier than people without pets. Still, I would like to live with a cat or dog.

— Richard Lilford, CLAHRC WM Director


  1. Batty GD, Zaninotto P, Watt RG, Bell S. Associations of pet ownership with biomarkers of ageing: population based cohort study. BMJ. 2017; 359: j5558.

A Heretical Suggestion!

The locus of health care is moving increasingly towards the community. In high-income countries (HIC) the greatest burden of health falls to frail elderly people with multiple chronic diseases. Hospital is often bad news for such people, both from a psychological and physical point of view.[1] There are good arguments for avoidance of admissions, and for increasing care provision in the community in HICs. In low- and middle-income countries (LMICs) there are also good arguments for community care. The WHO estimates that over three-quarters of all care could be most appropriately delivered in the community. The Declaration of Alma Ata and the Bamako Initiative from the United Nations both support the development of community care for LMICs. In this News Blog I wish to probe this subject more deeply. I will argue that community care is entirely appropriate for preventive outreach care. However, I will argue that we should re-examine the case for promoting community over hospital settings for demand-led care, especially in deprived urban environment.

My re-examination of this subject came about as a result of recent tours of eight slums within Nigeria, Kenya, Pakistan and Bangladesh. While all of these areas have a strong need for supply-side preventive care in the community, I have come to question the wisdom of trying to develop demand-led care within slum localities. My misgivings are based on a number of personal observations and from a reading of the relevant literature.

On site observations suggest that local residents prefer to use hospital facilities, even when this is less convenient than a more accessible community clinic. Some, but not all, slums are reasonably well supplied by local clinics. These clinics are usually staffed by medical officers or nurses rather than doctors. In many cases they have been provided by NGOs. I have observed that these clinics do not have many clients. When I draw attention to this, I am often told that this is because I have come at a quiet period. However, when I probe more deeply, I learn that the outpatients departments of nearby hospitals receive the bulk of the patients. Certainly that is my impression on visits to hospitals in LMICs where outpatient departments ‘heave’ with patients. This finding triangulates with work that colleagues and I have carried out in India under MRC sponsorship.

Not only do local residents seem to prefer hospital-based outpatient’s care, but my reading of the literature suggests that they are right to do so. Working with colleagues, I am carrying out a review of the quality of care provided in local settings in LMICs. The literature shows that such care is almost universally of a low standard, irrespective of whether the provider is private or public. Care given by doctors is generally better than that given by non-medical personnel, but even so is of a poor standard when delivered in the community. The quality of care across both settings is a topic of enquiry in the NIHR Unit on Health Service Provision in Slums that I direct. However, I suspect that the hospital will come out on top.

The corollary of the above, rather preliminary findings, is that we should be cautious about wholesale, and perhaps ideologically-driven, policies to deliver demand-based healthcare coverage in community settings  in low-income urban environments. Pending further research I hypothesise that it may be better to improve access and quality in hospital settings, at least in the first instance. Before taking fixed positions on these important issues we need to understand more about access to healthcare at the demand-side, the quality of such healthcare, and the most-cost effective approaches to driving up the quality of health care.

Please note that all of the above remarks apply to healthcare at the demand-side. That is to say, where a person has sought care for a perceived health problem. We fully support outreach primary preventive services to ensure vaccination, detect malnutrition, and ensure that people stick to their HIV and other treatment regimes.

Box A. Section VI of the Declaration of Alma-Ata

Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community [emphasis added] through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of selfreliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.”

— Richard Lilford, CLAHRC WM Director


  1. Lilford RJ. Intensive Care Harmful in Elderly Patients. NIHR CLAHRC West Midlands News Blog. 7 December 2017.

Corroboration of Previous Reports on Vitamin D and on Coffee

In recent News Blogs we have provided evidence that vitamin D and calcium are useless in preventing osteoporotic fractures in elderly people with no obvious risk factors.[1] [2] This is now powerfully corroborated in a paper in JAMA by Zhao, et al.,[3] who carried out a systematic review and meta-analysis involving over 50,000 participants. They found absolutely no beneficial or harmful effects of either vitamin D or calcium or a combination of the two compared to placebo in reducing the risk of either vertebral hip or other non-vertebral fractures. The absolute risk difference was zero with an upper confidence limit of 0.01. Hopefully this puts the matter to bed once and forever.

Likewise a recent umbrella review in the BMJ [4] corroborated previous news blogs on the generally health promoting effects of coffee.[5] It would appear that these benefits are also seen in equal measure with de-caffeinated coffee, suggesting that it is the other components of coffee that benefit health.

— Richard Lilford, CLAHRC WM Director


  1. Lilford RJ. Effects of Vitamin D Supplements. NIHR CLAHRC West Midlands News Blog. 24 March 2017.
  2. Lilford RJ. Yet Another Null Result on Vitamin D and Calcium Supplementation in Older Women. NIHR CLAHRC West Midlands News Blog. 5 May 2017.
  3. Zhao J-G, Zeng X-T, Wang J, et al. Association Between Calcium or Vitamin D Supplementation and Fracture Incidence in Community-Dwelling Older Adults: A Systematic Review and Meta-analysis. JAMA. 2017; 318(24): 2466-82.
  4. Poole R, Kennedy OJ, Roderick P, Fallowfield JA, Hayes PC, Parkes J. Coffee consumption and health: umbrella review of meta-analyses of multiple health outcomes. BMJ. 2017; 359: j5024.
  5. Lilford RJ. Should You Keep Drinking Coffee? NIHR CLAHRC West Midlands News Blog. 1 September 2017.

A Calming Scent

In a previous News Blog we looked at a study investigating associations between body odour and attractiveness to strangers.[1] But what about the smell of someone we already love? A recent study randomly assigned 96 women to smell the scent of either their partner, a stranger, or a neutral unworn shirt, before exposing them to stress through a standardised mock job interview and an unanticipated mental arithmetic task.[2] The results found that women exposed to their partner’s scent perceived lower levels of stress both before and after the stressor task (though not during). Further women exposed to a stranger’s scent had higher levels of cortisol throughout the study, which is released in response to stress.

Perhaps providing worn clothing from a loved one could be a useful coping strategy for people who have been separated, for example, in elderly patients in care homes.

— Peter Chilton, Research Fellow


  1. Lilford RJ. The Scent of a Woman – Not as Important as Once Thought. NIHR CLAHRC West Midlands News Blog. 24 November 2017.
  2. Hofer MK, Collins HK, Whillans AV, Chen FS. Olfactory Cues From Romantic Partners and Strangers Influence Women’s Responses to Stress. J Person Soc Psychol. 2018; 114(1): 1-9.

Intensive Care Harmful in Elderly Patients

An intervention to promote use of intensive care in elderly patients (over age 75) was evaluated in a cluster RCT of 20 French hospitals.[1] The intervention worked in the narrow sense that it did increase the rate of admission to the intensive care unit (ICU) (by nearly 70%). But did this result in improved survival? Not at all – in fact there was a statistically significant increase in death rates in the hospitals randomised to have lower thresholds for ICU care; both in hospital (18% increase) and at 6 months (16% increase). So a conservative policy dominates – it is both less expensive and more effective in old people. But this paper should make one think – how effective is ICU for other groups of patients? Apart from looking after people who need a breathing machine, is ICU really an effective treatment at all? It is highly invasive and intrusive. I am not a therapeutic nihilist, but one does have to wonder. Perhaps we should design a less intensive form of intensive care? Such an approach could be evaluated in RCTs before advocating global use of the current standard ICU model in high-income countries. Let me annoy my colleagues by proposing a hypothesis. ICU types think that it is the monitoring and fiddling with vital signs that saves lives. I think the main effect is better diagnosis – because patients are scrutinised carefully by highly trained people, conditions are spotted that would otherwise be missed. Just a thought!

I would like to thank News Blog reader Gus Hamilton for drawing my attention to this article.

— Richard Lilford, CLAHRC WM Director


  1. Guidet B, Leblanc G, Simon T, et al. Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France: A Randomized Clinical Trial. JAMA. 2017; 318(15): 1450-9.

Antioxidants and Age-Related Macular Degeneration

It is estimated that around 5% of the general population suffer from age-related macular degeneration (AMD),[1] where extracellular material known as drusen accumulate under the retina at the back of the eye and which can eventually lead to blurred or a loss of vision. It has been suggested that antioxidants may help prevent or delay development of AMD in people who do not suffer the condition by protecting the retina against oxidative stress, but it is unclear as to whether this is the case.

A systematic review in the Cochrane Database by Evans and Lawrenson looked at the effectiveness of antioxidant supplements as treatment in people who already had AMD,[2] and found that taking a multivitamin antioxidant vitamin may delay the progression of AMD when compared to a placebo or no treatment (odds ratio 0.72, 95% CI 0.58-0.90). The authors also conducted a systematic review looking at whether there was an association between taking antioxidant vitamins (carotenoids, vitamin C, vitamin E) or minerals (selenium, zinc) and the development of AMD in people without AMD.[3] Five RCTs were included, with a total of 76,756 individuals without AMD. These studies all looked at the use of various supplements against placebo. Generally, the various studies found that there was no effect of supplements on development of AMD, while in some cases there was evidence of an increased risk (see table below).

Comparison No. of studies Disease Risk Ratio (95% Confidence Interval)
Vitamin E vs. placebo 4 AMD 0.97 (0.90-1.06)
Late-stage AMD 1.22 (0.89-1.67)
Beta-carotene vs. placebo 2 AMD 1.00 (0.88-1.14)
Late-stage AMD 0.90 (0.65-1.24)
Vitamin C vs. placebo 1 AMD 0.96 (0.79-1.18)
Late-stage AMD 0.94 (0.61-1.46)
Multivitamin vs. placebo 1 AMD 1.21 (1.02-1.43)
Late-stage AMD 1.22 (0.88-1.69)

— Peter Chilton, Research Fellow


  1. Owen CG, Jarrar Z, Wormald R, Cook DG, Fletcher AE, Rudnicka AR. The estimated prevalence and incidence of late stage age related macular degeneration in the UK. Br J Ophthalmol. 2012; 96(5): 752-6.
  2. Evans JR, Lawrenson JG. Antioxidant vitamin and mineral supplements for slowing the progression of age-related macular degeneration. Cochrane Database Sys Rev. 2017; 7: CD000254.
  3. Evans JR, Lawrenson JG. Antioxidant vitamin and mineral supplements for preventing age-related macular degeneration. Cochrane Database Sys Rev. 2017; 7: CD000253.

Sniffing Out Trouble

The scent of freshly baked bread; the smell of a recently-mown lawn on a summer’s breeze; the aroma of an open bottle of wine – people often take particular delight in smell. But as we get older our olfactory function starts to decline. Interestingly, previous research has shown that adults with dementia have more difficulty distinguishing smells, compared to adults without dementia. However, we do not know whether this olfactory dysfunction is predictive of subsequent dementia.

A longitudinal study of 2,906 US adults aged 57-85 measured their ability to identify five odours (rose, leather, orange, fish and peppermint) using a validated test, then looked at the incidence of dementia five years later.[1] They found that adults who had difficulty identifying the smells at baseline were more than twice as likely to have developed dementia by the five year follow up (odds ratio = 2.13, 95% CI 1.32-3.43). This was after controlling for age, sex, race and ethnicity, education, comorbidities, and cognition at baseline. Further, more errors in identification was associated with greater probability of dementia diagnosis (p=0.04). Unfortunately, as the authors admit, they did not control for confounders already associated with olfactory function, such as smoking or depression.

It is hoped that using such an odour identification test will be an efficient and cost-effective addition to current examinations that assess an individual’s risk of dementia, thereby allowing early interventions and give individuals more time to plan for their future. It may also be a useful tool for early diagnosis of Parkinson’s disease, which is also associated with olfactory dysfunction.

— Peter Chilton, Research Fellow


  1. Adams DR, Kern DW, Wroblewski KE, McClintock MK, Dale W, Pinto JM. Olfactory Dysfunction Predicts Subsequent Dementia in Older U.S. Adults. J Am Geriatr Soc. 2017.

Effects of Vitamin D Supplements

Bolland and colleagues have written a lovely summary of the evidence on the effects of vitamin D supplements, with or without calcium, on health.[1] Their careful and comprehensive systematic overview based on a large sample, and providing narrow confidence limits, finds that there is no evidence that vitamin D, with or without calcium, reduces the risk of fractures in elderly people with no known bone disease. It is, as expected, efficacious in people with established osteomalacia. Systematic reviews of lower quality or based on per protocol analyses, tend to find the more optimistic results, but the data, taken in the round, yield a null result. The reviewers find that additional research is unlikely to further clarify the issue, as an effect of more than a 10% reduction in fracture has been ‘excluded’ by the existing studies. From a Bayesian perspective, further data are unlikely to have much effect on credible limits. The studies do not find any evidence that calcium plus vitamin D have either harmful or beneficial effects on the other (non-skeletal) outcomes, such as cancer or heart disease. Perhaps this is an example of the horizon of science; science cannot prove a null result, merely exclude a positive or negative effect beyond certain limits. We will never know everything, but let’s just forget about the use of vitamin D and calcium as prophylaxis in healthy people as any benefit must be nugatory – less than 10% relative risk reduction, which equates to a very small absolute reduction.

— Richard Lilford, CLAHRC WM Director


  1. Bolland MJ, Leung W, Tai V, et al. Calcium intake and risk of fracture: systematic review. BMJ. 2015; 350: h4580.


Future Trends in NHS

The future of health care is often conceptualised in terms of improved treatments emerging from the bio-medical science base – for instance increasing the precision with which particular therapies can be targeted. Many of these advances in the effectiveness of care will have supply side consequences in terms of cost and some will require service re-configuration – regenerative medicine and bed-side diagnostics, for example. However the larger challenges are likely to originate from increased demand. The service will have to adapt to these supply and demand side changes. This blog considers the role of applied research in informing these adaptations in order to improve the overall effectiveness and efficiency of services.

We discern three trends which, absent a major perturbation such as international conflict, will alter demand over the medium to long term. The time horizon for our analysis is the next quarter century, given that the longer the time horizon the wider the variance in any predictions.

The trends are as follows:

  1. The population demographic will continue towards higher proportions of elderly people.
  2. The dependency ratio (ratio of working age to young and retired people) will become increasingly adverse.
  3. Demand for services per capita will increase.

None of these assumptions is unarguable as they involve outcomes that have not yet been observed. They are ordered from least to most contentious.

  1. That the population will continue to age is almost a given, but the rate at which it will do is less certain. Some predict that over a third of children alive now will reach a century. However, the rate of increase in life expectancy may slow as the large reductions in smoking related deaths are absorbed into the base-line. Immigration could affect population projections in ways that are hard to predict. The recent sudden increase in mortality among white middle-aged males in the USA,[1] but improvement in survival of low socio-economic group children in the same country,[2] shows how difficult projections can be. A recent demonstration of trends over two decades suggests that age-specific prevalence of dementias are reducing, arguably because risk factors for cardiovascular disease are also risk factors for dementia. This will not reduce the total prevalence of dementia, of course, if life expectancy continues to increase.[3] [4]
  2. The worsening of the dependency ratio is almost a corollary of an ageing society, but again the extent to which this happens is less certain as the work force gradually internalises the notion that 65 years of age is not a biological watershed but a social convention.[5] But delayed retirement will not solve the problem of a deteriorating dependency ratio; absent a method to delay ageing, many types of work, such as aviation and mining, are simply not suitable for older people. In addition, as people work longer at the end of life; so policies are encouraging longer leaves of absence from work outside the home to care for young children. So, all things considered, the dependency ratio will become more adverse as a function of increased longevity. Note, Britain appears to be at an earlier stage in this transition than many other high-income countries, such as Japan and Germany, and the opportunity for immigration to mitigate the tendency is likely to be accentuated given recent events.
  3. Demand for services contingent on an ageing population is somewhat controversial. A reasonable planning assumption is that people will be healthier at a given age but this will not completely mitigate the frailty of older people at a given age. In that case we must assume a rise in demand as the population ages, even if age-specific morbidity declines to some extent.

Implications for the NHS flow from the above. Demand for services will increase relative to resources. That is to say there will be more old people relative to working age people and there will be more frail people relative to the population and demand will outpace economic growth. All of this may be compounded by a tendency for old people to live in remote areas at a distance from major conurbations where health services are concentrated. However, this problem will be less acute than in most other countries.

There are many possible mitigations and the NIHR has a role in all of them; these are listed in the table below.

Factors to help the service cope with increasing demand.

                  Mitigating factor How it might work Caveats Potential impact
Major technical advances that might affect demand. A ‘cure’ or prevention for dementia would both improve the economy (and hence supply) while supressing demand. Probably lies outside our 25 year time horizon. Will prolong life and hence increase the proportion of frail elderly people. Potentially very high but out of scope. Medical advances more generally likely to increase demand by increasing longevity.
Self-care An ‘extreme’ form of skill substitution. Unlike other mitigations there is an extensive research literature. Beneficial for capable patients minimal impact on global demand. The correct answer to improving care, reducing demand will require development of interventions and further research.
Information technology Can make care safer and supply more efficient. Full electronic notes disrupt patient communication in their current form. A lot more needs to be learned about the design and implementation of this deceptively complex technology. Huge benefits in prospect but the socio-technical aspects require extensive development and research.
Robotics May substitute for expensive/scarce human resources.[6] Humans require the care and attention of other humans. Moderate. Likely to assist rather than replace clinical input.
Skill substitution Less expensive staff (physician’s assistants) substitute for more expensive (doctors). Increasingly feasible as health care increasingly codified. Limited by the complexity of decision making in patients with many diseases. Very hard to say without more research. May be modest.
Pro-active community services Prevent deterioration to improve health and decrease admissions. Existing research disappointing – may actually increase demand by identifying self- correcting illness. Potentially great but we are in the foothills of discovery.

Mitigating demand is not easy in the face of the demographic factors mentioned above. It is often argued, even in official enquiries, that prevention is the key to reducing demand. While prevention may reduce demand arising from particular diseases, such as diabetes, survivors go on to develop further diseases on their trajectory to death.[7] It is therefore not at all clear that prevention will reduce total demand and it may even be the case that deferred demand is augmented demand. There are some potential mitigating possibilities. A prevention or cure for Alzheimer’s disease would make a massive difference. Less distant is an ‘artificial pancreas’ that might massively simplify diabetes care. Methods to make people independent, such as home telemetry, have had nugatory impact on demand to date,[8] but this may change in the future. Patient self-care is beneficial in improving healthcare and satisfaction,[9] but effects on total demand have been modest.

If supply side measures might help services cope with the consequences and demand continues to rise, then two points should be noticed. First, efficiency gains are notoriously difficult to achieve in service industries. Second, the likely increasingly adverse dependency ratio is likely to limit expansion in skilled staff. Partial solutions may lie in manufacturing, including robotics and information technology. Skill substitution is a future area where it may be possible to improve efficiency.[10] In particular, physicians assistants may reduce costs overall.[11] The research for skills or system substitution is not entirely positive – for example, substituting nurses for doctors may not improve efficiency because consultation times had to increase.[12] There is an international trend to provide more care at ‘grass roots’ by means of Community Health Workers (CHWs) – an area where high-income countries are learning from low- and middle-income countries.[13] CHWs have a large potential role in improving care – helping patients to adhere to medications, providing preventative services, identifying deteriorating patients. Their effect on reducing demand is less certain, and on occasion they may actually increase it.[14]

Readers may think that the CLAHRC WM Director can be rather pessimistic, even nihilistic. Not so, CLAHRC WM has recently conducted an overview (umbrella review) across 50 systematic reviews of different methods to integrate care across hospitals and communities.[15] Discharge planning with post-discharge support is highly effective. Multi-skill teams are much more effective if they include hospital outreach than if they are entirely community-based. Self-management is effective but mainly for single diseases. Case management is of minimal value. Across all intervention types, length of stay was reduced in over half, emergency admissions were reduced in half, and readmissions were reduced in nearly half. In almost no case did the intervention make any of the above outcomes worse. Costs to the service were reduced in over a third of intervention types, but the quality of evidence is poor on this point – a topic that is being addressed across all CLAHRCs. And here is the CLAHRC WM Director’s point; there are no quick wins and no silver bullets. And the solutions are not self-evident. Only by patiently trying out new things and evaluating them methodologically can things improve. It may sound self-serving, but that does not mean it is incorrect – CLAHRCs have an immense contribution to make to improve the effectiveness and cost-effectiveness of health services.

— Richard Lilford, CLAHRC WM Director

I acknowledge advice from Prof Peter Jones (University of Cambridge), Director of CLAHRC East of England, but the views expressed are entirely my own.


  1. Deaton A, Lubotsky D. Mortality, inequality and race in American cities and states. Soc Sci Med. 2003;56(6):1139-53.
  2. Chetty R HN, Katz LF. The Effects of Exposure to Better Neighbourhoods on Children: New Evidence from the Moving to Opportunity Experiment. Am Econ Rev. 2016.
  3. Matthews FE, Stephan BC, Robinson L, Jagger C, Barnes LE, Arthur A, Brayne C; Cognitive Function and Ageing Studies (CFAS) Collaboration. A two decade dementia incidence comparison from the Cognitive Function and Ageing Studies I and II. Nat Commun. 2016; 7: 11398.
  4. Matthews FE, Arthur A, Barnes LE, Bond J, Jagger C, Robinson L, Brayne C; Medical Research Council Cognitive Function and Ageing Collaboration. A two-decade comparison of prevalence of dementia in individuals aged 65 years and older from three geographical areas of England: results of the Cognitive Function and Ageing Study I and II. Lancet. 2013; 382(9902): 1405-12.
  5. Lilford R. Robotic hotels today – nursing homes tomorrow? NIHR CLAHRC West Midlands News Blog. March 6 2015.
  6. Lilford R. Medical Technology – Separating the Wheat from the Chaff. NIHR CLAHRC West Midlands News Blog. February 26 2016.
  7. Lilford R. Improving Diabetes Care. NIHR CLAHRC West Midlands News Blog. November 11 2016.
  8. Henderson C, Knapp M, Fernández J-L, Beecham J, Hirani SP, Cartwright M, et al. Cost effectiveness of telehealth for patients with long term conditions (Whole Systems Demonstrator telehealth questionnaire study): nested economic evaluation in a pragmatic, cluster randomised controlled trial. BMJ. 2013; 346: f1035.
  9. Tricco AC, Ivers NM, Grimshaw JM, Moher D, Turner L, Galipeau J, et al. Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis. Lancet. 2012; 379: 2252–61.
  10. Lilford R. The Future of Medicine. NIHR CLAHRC West Midlands News Blog. October 23 2015.
  11. Lilford R. Improving Hospital Care: Not easy when budgets are pressed. NIHR CLAHRC West Midlands News Blog. January 23 2015.
  12. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev. 2005; 2(2).
  13. Lilford R. Lay Community Health Workers. NIHR CLAHRC West Midlands News Blog. April 10 2015.
  14. Roland M, Abel G. Reducing emergency admissions: are we on the right track? BMJ. 2012; 345: e6017.
  15. Damery S, Flanagan S, Combes G. Does integrated care reduce hospital activity for patients with chronic diseases? An umbrella review of systematic reviews. BMJ Open. 2016; 6: e011952.


Bias is something that affects us all; its all-pervasive nature means it influences everything we do from supermarket choices through to study design. But what of perception? Bias might lead the result of our study to be skewed or flawed, but if our perception of where the issue lies is incorrect we may select the wrong thing to study. So, how wrong can our perception be? Well, very, according to IPSOS MORI and their annual Perils of Perception report for 2015.[1]

This report polls members of the public in 33 countries on their understanding of key issues affecting their nation. The results show a significant gap between perception and reality across a number of issues that specifically relate to society and health in Great Britain.

Our perception of the distribution of wealth was one of the most distorted views. When asked what proportion of wealth the top 1% of the population own the guess was 59%, more than twice the true figure, which is 23%.

On immigration the perception of Britons is that 25% of the population are immigrants, nearly double the actual figure of 13%.

We also know we have an ageing population, but perhaps not to the extent we believe. The estimate of the average age of the population was 51 years old, when it is in fact 40.

With regard to obesity we may be complacent; the average estimate of the proportion of people over the age of 20 who are overweight or obese was 44% when it is in fact 62%.

And before you think that the Great British Public are better or worse than elsewhere, we are not. Ranked 16th of 33 countries in IPSOS MORI’s provocatively titled “Index of Ignorance” we are firmly in mid-table. If you are reading the blog from either Ireland or South Korea (ranked 27th and 28th) you potentially have a better perception of issues affecting your nation than if in Mexico, India and Brazil who occupy the top 3 positions. But this is not an issue that is delineated along boundaries of low-, middle- or high-income countries in case you were to infer that from the results: New Zealand is ranked at number 5 and Belgium at number 7.

So this is all good fun, interesting stuff, but what does it mean? Well certainly not that we should quietly reassure ourselves that we would have been much closer to the real figure than most of the population. Bias and perception issues are at their most insidious when we fail to acknowledge that we may be subject to them.

These findings are in fact an endorsement of the way, as CLAHRCs, we structure what we do. By bringing together academics, patients and those involved in delivering care, we challenge each others perceptions of the issues related to service delivery. That way we can work collaboratively to solve that issues that are in fact real issues, rather than those which we perceive to be the issue.

— Paul Bird, CLAHRC WM Head of Programme Delivery (Engagement)


  1. Ipsos MORI. Perils of Perception 2015. 2015.