BackgroundThe objective of this study was to assess the responsiveness of the Minimum Data Set Activities of Daily Living (MDS-ADL) Scale to change over time by examining the change in physical function in adults with moderate to severe dementia with no comorbid illness who had been resident in a nursing home for over 90 days.MethodsLongitudinal data were collected on nursing home residents with moderate (n = 7001) or severe (n = 4616) dementia in one US state from the US national Minimum Data Set (MDS). Severity of dementia was determined by the MDS Cognitive Performance Scale (CPS). Physical function was assessed by summing the seven items (bed mobility, transfer, locomotion, dressing, eating, toilet use, personal hygiene) on the MDS activities of daily living (ADL) Long Form scale. Mean change over time of MDS-ADL scores were estimated at three and six months for residents with moderate (CPS score of 3) and severe (CPS score of 4 or 5) dementia.ResultsPhysical function in residents with moderate cognitive impairment deteriorated over six months by an average of 1.78 points on the MDS-ADL Long Form scale, while those with severe cognitive impairment declined by an average of 1.70 points. Approximately one quarter of residents in both groups showed some improvement in physical function over the six month period. Residents with moderate cognitive impairment experienced the greatest deterioration in early-loss and mid-loss ADL items (personal hygiene, dressing, toilet use) and residents with severe cognitive impairment showed the greatest deterioration in activities related to eating, a late loss ADL.ConclusionThe MDS-ADL Long Form scale detected clinically meaningful change in physical function in a large cohort of long-stay nursing home residents with moderate to severe dementia, supporting its use as a research tool in future studies.

Governments face pressures to improve services and (at the same time) to contain taxes and to ensure that their decisions are accountable to increasingly well-informed and challenging citizens. The dilemma of "squaring the welfare circle" confronts New Labour in a particularly acute form, since the party has set ambitious targets for improvements in the NHS, education and elsewhere, and is also committed to economic prudence and transparency. This article uses new data from a major national survey to investigate knowledge and beliefs in the main policy areas. It shows that most people are generally strikingly well-informed in some areas and ill-informed in others. A government which wishes to pursue a progressive direction in redistribution, increasing taxation of the better-off, or expanding provision for those on low incomes, faces real difficulties because many people hold inaccurate beliefs about policy impact and the policy context in these areas. However, NHS costs are more accurately perceived across the population, and the proposed expansion is likely to create less controversy. Current high-profile policies appear to follow the contours of public knowledge reasonably accurately, but further policy development will require positive efforts to lead debates and improve public knowledge. The Need to Explain Policy Choices to CitizensFor reasons beyond their control, to do with economic globalization, changes in labour markets and shifts in population structure, governments in welfare states face increasing pressure on public spending. These constraints are growing stricter at a time when commentators detect an increasingly querulous and challenging stance among citizens. The New Labour government in the UK faces particular problems. It comes from a political tradition that

Welfare spending in the UK is too low to provide services at the level to which most citizens aspire. The problem is that, although most people state in surveys that they would like to pay higher taxes for better services, politicians from all the main parties generally do not believe that they would put their vote where their mouth is. Advocates of higher spending increasingly retreat to a position of promoting ear-marked taxes for specific, highly favoured services, as in the 2002 Budget plan to finance the cost of improvements in the highly valued NHS through increased National Insurance Contributions. Recent theoretical work further undermines arguments for higher state spending: an important strand in political science argues that trust in state institutions is in decline, and work in sociology claims that citizens are becoming more independent, reflexive and keen to take responsibility for meeting their own needs. This paper uses data from a recent ESRC-financed national survey to examine these arguments. It shows real support for hypothecated taxes for the NHS, and more generalised support for higher taxes for welfare provision. Such support is not undermined by a decline in citizen trust in the welfare state or by a rejection of collective solutions. However, there is little endorsement of hypothecated taxation in other areas, and the use of such measures may encourage citizens in a pick-and-mix approach to welfare services.

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