Robot hearts: medicines new frontier

The long read: From bovine valves to electrical motors and 3-D printed hearts, cardiologists are forging ahead with techologies once dismissed as crazy ideas

On a cold, bright January morning I walked south across Westminster Bridge to St Thomas Hospital, an institution with a proud tradition of innovation: I was there to observe a procedure generally regarded as the greatest advance in cardiac surgery since the turn of the millennium and one that can be performed without a surgeon.

The patient was a man in his 80s with aortic stenosis, a narrowed valve which was restricting outflow from the left ventricle into the aorta. His heart struggled to pump sufficient blood through the reduced aperture, and the muscle of the affected ventricle had thickened as the organ tried to compensate. If left unchecked, this would eventually lead to heart failure. For a healthier patient the solution would be simple: an operation to remove the diseased valve and replace it with a prosthesis. But the mans age and a long list of other medical conditions made open-heart surgery out of the question. Happily, for the last few years, another option has been available for such high-risk patients: transcatheter aortic valve implantation, known as TAVI for short.

This is a non-invasive procedure, and takes place not in an operating theatre but in the catheterisation laboratory, known as the cath lab. When I got there, wearing a heavy lead gown to protect me from X-rays, the patient was already lying on the table. He would remain awake throughout the procedure, receiving only a sedative and a powerful analgesic. I was shown the valve to be implanted, three leaflets fashioned from bovine pericardium (a tough membrane from around the heart of a cow), fixed inside a collapsible metal stent. After being soaked in saline it was crimped on to a balloon catheter and squeezed, from the size and shape of a lipstick, into a long, thin object like a pencil.

The consultant cardiologist, Bernard Prendergast, had already threaded a guidewire through an incision in the patients groin, entering the femoral artery and then the aorta, until the tip of the wire had arrived at the diseased aortic valve. The catheter, with its precious cargo, was then placed over the guidewire and pushed gently up the aorta. When it reached the upper part of the vessel we could track its progress on one of the large X-ray screens above the table. We watched intently as the metal stent described a slow curve around the aortic arch before coming to rest just above the heart.

There was a pause as the team checked everything was ready, while on the screen the silhouette of the furled valve oscillated gently as it was buffeted by pulses of high-pressure arterial blood. When Prendergast was satisfied that the catheter was precisely aligned with the aortic valve, he pressed a button to inflate the tiny balloon. As it expanded it forced the metal stent outwards and back to its normal diameter, and on the X-ray monitor it suddenly snapped into position, firmly anchored at the top of the ventricle. For a second or two the patient became agitated as the balloon obstructed the aorta and stopped the flow of blood to his brain; but as soon as it was deflated he became calm again.

Prendergast and his colleagues peered at the monitors to check the positioning of the device. In a conventional operation the diseased valve would be excised before the prosthesis was sewn in; during a TAVI procedure the old valve is left untouched and the new one simply placed inside it. This makes correct placement vital, since unless the device fits snugly there may be a leak around its edge. The X-ray picture showed that the new valve was securely anchored and moving in unison with the heart. Satisfied that everything had gone according to plan, Prendergast removed the catheter and announced the good news in a voice that was probably audible on the other side of the river. Just minutes after being given a new heart valve, the patient raised an arm from under the drapes and shook the cardiologists hand warmly. The entire procedure had taken less than an hour.

According to many experts, this is what the future will look like. Though available for little more than a decade, TAVI is already having a dramatic impact on surgical practice: in Germany the majority of aortic valve replacements, more than 10,000 a year, are now performed using the catheter rather than the scalpel.

In the UK, the figure is much lower, since the procedure is still significantly more expensive than surgery this is largely down to the cost of the valve itself, which can be as much as 20,000 for a single device. But as the manufacturers recoup their initial outlay on research and development, it is likely to become more affordable and its advantages are numerous. Early results suggest that it is every bit as effective as open-heart surgery, without many of surgerys undesirable aspects: the large chest incision, the heart-lung machine, the long period of post-operative recovery.

The essential idea of TAVI was first suggested more than half a century ago. In 1965, Hywel Davies, a cardiologist at Guys Hospital in London, was mulling over the problem of aortic regurgitation, in which blood flows backwards from the aorta into the heart. He was looking for a short-term therapy for patients too sick for immediate surgery something that would allow them to recover for a few days or weeks, until they were strong enough to undergo an operation. He hit upon the idea of a temporary device that could be inserted through a blood vessel, and designed a simple artificial valve resembling a conical parachute. Because it was made from fabric, it could be collapsed and mounted on to a catheter. It was inserted with the top of the parachute uppermost, so that any backwards flow would be caught by its inside surface like air hitting the underside of a real parachute canopy. As the fabric filled with blood it would balloon outwards, sealing the vessel and stopping most of the anomalous blood flow.

This was a truly imaginative suggestion, made at a time when catheter therapies had barely been conceived of, let alone tested. But, in tests on dogs, Davies found that his prototype tended to provoke blood clots and he was never able to use it on a patient.

Doctors perform minimally invasive heart surgery on a patient. Photograph: Steve Russell/Toronto Star via Getty Images

Another two decades passed before anybody considered anything similar. That moment came in 1988, when a trainee cardiologist from Denmark, Henning Rud Andersen, was at a conference in Arizona, attending a lecture about coronary artery stenting. It was the first he had heard of the technique, which at the time had been used in only a few dozen patients, and as he sat in the auditorium he had a thought, which at first he dismissed as ridiculous: why not make a bigger stent, put a valve in the middle of it, and implant it into the heart via a catheter? On reflection, he realised that this was not such an absurd idea, and when he returned home to Denmark he visited a local butcher to buy a supply of pig hearts. Working in a pokey room in the basement of his hospital with basic tools obtained from a local DIY warehouse, Andersen constructed his first experimental prototypes. He began by cutting out the aortic valves from the pig hearts, mounted each inside a home-made metal lattice then compressed the whole contraption around a balloon.

Within a few months Andersen was ready to test the device in animals, and on 1 May 1989 he implanted the first in a pig. It thrived with its prosthesis, and Andersen assumed that his colleagues would be excited by his works obvious clinical potential. But nobody was prepared to take the concept seriously folding up a valve and then unfurling it inside the heart seemed wilfully eccentric and it took him several years to find a journal willing to publish his research.

When his paper was finally published in 1992, none of the major biotechnology firms showed any interest in developing the device. Andersens crazy idea worked, but still it sank without trace.

Andersen sold his patent and moved on to other things. But at the turn of the century there was a sudden explosion of interest in the idea of valve implantation via catheter. In 2000, a heart specialist in London, Philipp Bonhoeffer, replaced the diseased pulmonary valve of a 12-year-old boy, using a valve taken from a cows jugular vein, which had been mounted in a stent and put in position using a balloon catheter.

In France, another cardiologist was already working on doing the same for the aortic valve. Alain Cribier had been developing novel catheter therapies for years; it was his company that bought Andersens patent in 1995, and Cribier had persisted with the idea even after one potential investor told him that TAVI was the most stupid project ever heard of.

Eventually, Cribier managed to raise the necessary funds for development and long-term testing, and by 2000 had a working prototype. Rather than use an entire valve cut from a dead heart, as Andersen had, Cribier built one from bovine pericardium, mounted in a collapsible stainless-steel stent. Prototypes were implanted in sheep to test their durability: after two-and-a-half years, during which they opened and closed more than 100m times, the valves still worked perfectly.

Cribier was ready to test the device in humans, but his first patient could not be eligible for conventional surgical valve replacement, which is safe and highly effective: to test an unproven new procedure on such a patient would be to expose them to unnecessary risk.

In early 2002, he was introduced to a 57-year-old man who was, in surgical terms, a hopeless case. He had catastrophic aortic stenosis which had so weakened his heart that with each stroke it could pump less than a quarter of the normal volume of blood; in addition, the blood vessels of his extremities were ravaged by atherosclerosis, and he had chronic pancreatitis and lung cancer. Several surgeons had declined to operate on him, and his referral to Cribiers clinic in Rouen was a final roll of the dice. An initial attempt to open the stenotic valve using a simple balloon catheter failed, and a week after this treatment Cribier recorded in his notes that his patient was near death, with his heart barely functioning. The mans family agreed that an experimental treatment was preferable to none at all, and on 16 April he became the first person to receive a new aortic valve without open-heart surgery.

Over the next couple of days the patients condition improved dramatically: he was able to get out of bed, and the signs of heart failure began to retreat. But shortly afterwards complications arose, most seriously a deterioration in the condition of the blood vessels in his right leg, which had to be amputated 10 weeks later. Infection set in, and four months after the operation, he died.

He had not lived long nobody expected him to but the episode had proved the feasibility of the approach, with clear short-term benefit to the patient. When Cribier presented a video of the operation to colleagues they sat in stupefied silence, realising that they were watching something that would change the nature of heart surgery.

When surgeons and cardiologists overcame their initial scepticism about TAVI they quickly realised that it opened up a vista of exciting new surgical possibilities. As well as replacing diseased valves it is now also possible to repair them, using clever imitations of the techniques used by surgeons. The technology is still in its infancy, but many experts believe that this will eventually become the default option for valvular disease, making surgery increasingly rare.

While TAVI is impressive, there is one even more spectacular example of the capabilities of the catheter. Paediatric cardiologists at a few specialist centres have recently started using it to break the last taboo of heart surgery operating on an unborn child. Nowhere is the progress of cardiac surgery more stunning than in the field of congenital heart disease. Malformations of the heart are the most common form of birth defect, with as many as 5% of all babies born with some sort of cardiac anomaly though most of these will cause no serious, lasting problems. The heart is especially prone to abnormal development in the womb, with a myriad of possible ways in which its structures can be distorted or transposed. Over several decades, specialists have managed to find ways of taming most; but one that remains a significant challenge to even the best surgeon is hypoplastic left heart syndrome (HLHS), in which the entire left side of the heart fails to develop properly. The ventricle and aorta are much smaller than they should be, and the mitral valve is either absent or undersized. Until the early 1980s this was a defect that killed babies within days of birth, but a sequence of complex palliative operations now makes it possible for many to live into adulthood.

Because their left ventricle is incapable of propelling oxygenated blood into the body, babies born with HLHS can only survive if there is some communication between the pulmonary and systemic circulations, allowing the right ventricle to pump blood both to the lungs and to the rest of the body. Some children with HLHS also have an atrial septal defect (ASD), a persistent hole in the tissue between the atria of the heart which improves their chances of survival by increasing the amount of oxygenated blood that reaches the sole functioning pumping chamber. When surgeons realised that this defect conferred a survival benefit in babies with HLHS, they began to create one artificially in those with an intact septum, usually a few hours after birth. But it was already too late: elevated blood pressure was causing permanent damage to the delicate vessels of the lungs while these babies still in the womb.

A prototype of a fully implantable artificial heart, as presented by the French heart specialist Alain Carpentier. Photograph: Jacques Brinon/AP

The logical albeit risky response was to intervene even earlier. In 2000, a team at Boston Childrens Hospital adopted a new procedure to create an ASD during the final trimester of pregnancy: they would deliberately create one heart defect in order to treat another. A needle was passed through the wall of the uterus and into the babys heart, and a balloon catheter used to create a hole between the left and right atria. This reduced the pressures in the pulmonary circulation and hence limited the damage to the lungs; but the tissues of a growing foetus have a remarkable ability to repair themselves, and the artificially created hole would often heal within a few weeks. Cardiologists needed to find a way of keeping it open until birth, when surgeons would be able to perform a more comprehensive repair.

In September 2005 a couple from Virginia, Angela and Jay VanDerwerken, visited their local hospital for a routine antenatal scan. They were devastated to learn that their unborn child had HLHS, and the prognosis was poor. The ultrasound pictures revealed an intact septum, making it likely that even before birth her lungs would be damaged beyond repair. They were told that they could either terminate the pregnancy or accept that their daughter would have to undergo open-heart surgery within hours of her birth, with only a 20% chance that she would survive.

Devastated, the VanDerwerkens returned home, where Angela researched the condition online. Although few hospitals offered any treatment for HLHS, she found several references to the Boston foetal cardiac intervention programme, the team of doctors that had pioneered the use of the balloon catheter during pregnancy.

They arranged an appointment with Wayne Tworetzky, the director of foetal cardiology at Boston Childrens Hospital, who performed a scan and confirmed that their unborn childs condition was treatable. A greying, softly spoken South African, Tworetzky explained that his team had recently developed a new procedure, but that it had never been tested on a patient. It would mean not just making a hole in the septum, but also inserting a device to prevent it from closing. The VanDerwerkens had few qualms about accepting the opportunity: the alternatives gave their daughter a negligible chance of life.

The procedure took place at Brigham and Womens Hospital in Boston on 7 November 2005, 30 weeks into the pregnancy, in a crowded operating theatre. Sixteen doctors, with a range of specialisms, took part: cardiologists, surgeons, and four anaesthetists two to look after the mother, two for her unborn child. Mother and child needed to be completely immobilised during a delicate procedure lasting several hours, so both were given a general anaesthetic. The team watched on the screen of an ultrasound scanner as a thin needle was guided through the wall of the uterus, then the foetuss chest and finally into her heart an object the size of a grape.

A guidewire was placed in the cardiac chambers, then a tiny balloon catheter was inserted and used to create an opening in the atrial septum. This had all been done before; but now the cardiologists added a refinement. The balloon was withdrawn, then returned to the heart, this time loaded with a 2.5 millimetre stent that was set in the opening between the left and right atria. There was a charged silence as the balloon was inflated to expand the stent; then, as the team saw on the monitor that blood was flowing freely through the aperture, the room erupted in cheers.

Grace VanDerwerken was born in early January after a normal labour, and shortly afterwards underwent open-heart surgery. After a fortnight she was allowed home, her healthy pink complexion proving that the interventions had succeeded in producing a functional circulation.

But just when she seemed to be out of danger, Grace died suddenly at the age of 36 days not as a consequence of the surgery, but from a rare arrhythmia, a complication of HLHS that occurs in just 5%. This was the cruellest luck, when she had seemingly overcome the grim odds against her. Her death was a tragic loss, but her parents courage had brought about a new era in foetal surgery.

Much of the most exciting contemporary research focuses on the greatest, most fundamental cardiac question of all: what can the surgeon do about the failing heart? Half a century after Christiaan Barnard performed the first human heart transplant, transplantation remains the gold standard of care for patients in irreversible heart failure once drugs have ceased to be effective. It is an excellent operation, too, with patients surviving an average of 15 years. But it will never be the panacea that many predicted, because there just arent enough donor hearts to go round.

With too few organs available, surgeons have had to think laterally. As a result, a new generation of artificial hearts is now in development. Several companies are now working on artificial hearts with tiny rotary electrical motors. In addition to being much smaller and more efficient than pneumatic pumps, these devices are far more durable, since the rotors that impel the blood are suspended magnetically and are not subject to the wear and tear caused by friction. Animal trials have shown promising results, but, as yet, none of these have been implanted in a patient.

Another type of total artificial heart, as such devices are known, has, however, recently been tested in humans. Alain Carpentier, an eminent French surgeon still active in his ninth decade, has collaborated with engineers from the French aeronautical firm Airbus to design a pulsatile, hydraulically powered device whose unique feature is the use of bioprosthetic materials both organic and synthetic matter. Unlike earlier artificial hearts, its design mimics the shape of the natural organ; the internal surfaces are lined with preserved bovine pericardial tissue, a biological surface far kinder to the red blood cells than the polymers previously used. Carpentiers artificial heart was first implanted in December 2013. Although the first four patients have since died two following component failures the results were encouraging, and a larger clinical trial is now under way.

Christiaan Barnard having dinner in Monte Carlo with Princess Grace of Monaco. Photograph: AP

One drawback to the artificial heart still leads many surgeons to dismiss the entire concept out of hand: the price tag. These high-precision devices cost in excess of 100,000 each, and no healthcare service in the world, publicly or privately funded, could afford to provide them to everybody in need of one. And there is one still more tantalising notion: that we will one day be able to engineer spare parts for the heart, or even an entire organ, in the laboratory.

In the 1980s, surgeons began to fabricate artificial skin for burns patients, seeding sheets of collagen or polymer with specialised cells in the hope that they would multiply and form a skin-like protective layer. But researchers had loftier ambitions, and a new field tissue engineering began to emerge.

High on the list of priorities for tissue engineers was the creation of artificial blood vessels, which would have applications across the full range of surgical specialisms. In 1999 surgeons in Tokyo performed a remarkable operation in which they gave a four-year-old girl a new artery grown from cells taken from elsewhere in her body. She had been born with a rare congenital defect which had completely obliterated the right branch of her pulmonary artery, the vessel conveying blood to the right lung. A short section of vein was excised from her leg, and cells from its inside wall were removed in the laboratory. They were then left to multiply in a bioreactor, a vessel that bathed them in a warm nutrient broth, simulating conditions inside the body.

After eight weeks, they had increased in number to more than 12m, and were used to seed the inside of a polymer tube which functioned as a scaffold for the new vessel. The tissue was allowed to continue growing for 10 days, and then the graft was transplanted. Two months later the polymer scaffold around the tissue, designed to break down inside the body, had completely dissolved, leaving only new tissue that would it was hoped grow with the patient.

At the turn of the millennium, a new world of possibility opened up when researchers gained a powerful new tool: stem cell technology. Stem cells are not specialised to one function but have the potential to develop into many different tissue types. One type of stem cell is found in growing embryos, and another in parts of the adult body, including the bone marrow (where they generate the cells of the blood and immune system) and skin. In 1998 James Thomson, a biologist at the University of Wisconsin, succeeded in isolating stem cells from human embryos and growing them in the laboratory.

But an arguably even more important breakthrough came nine years later, when Shinya Yamanaka, a researcher at Kyoto University, showed that it was possible to genetically reprogram skin cells and convert them into stem cells. The implications were enormous. In theory, it would now be possible to harvest mature, specialised cells from a patient, reprogram them as stem cells, then choose which type of tissue they would become.

Sanjay Sinha, a cardiologist at the University of Cambridge, is attempting to grow a patch of artificial myocardium (heart muscle tissue) in the laboratory for later implantation in the operating theatre. His technique starts with undifferentiated stem cells, which are then encouraged to develop into several types of specialised cell. These are then seeded on to a scaffold made from collagen, a tough protein found in connective tissue. The presence of several different cell types means that when they have had time to proliferate, the new tissue will develop its own blood supply.

Clinical trials are still some years away, but Sinha hopes that one day it will be possible to repair a damaged heart by sewing one of these patches over areas of muscle scarred by a heart attack.

Using advanced tissue-engineering techniques, researchers have already succeeded in creating replacement valves from the patients own tissue. This can be done by harvesting cells from elsewhere in the body (usually the blood vessels) and breeding them in a bioreactor, before seeding them on to a biodegradable polymer scaffold designed in the shape of a valve. Once the cells are in place they are allowed to proliferate before implantation, after which the scaffold melts away, leaving nothing but new tissue. The one major disadvantage of this approach is that each valve has to be tailor-made for a specific patient, a process that takes weeks. In the last couple of years, a group in Berlin has refined the process by tissue-engineering a valve and then stripping it of cellular material, leaving behind just the extracellular matrix the structure that holds the cells in position.

The end result is therefore not quite a valve, but a skeleton on which the body lays down new tissue. Valves manufactured in this way can be implanted, via catheter, in anybody; moreover, unlike conventional prosthetic devices, if the recipient is a child the new valve should grow with them.

If it is possible to tissue-engineer a valve, then why not an entire heart? For many researchers this has come to be the ultimate prize, and the idea is not necessarily as fanciful as it first appears.

In 2008, a team led by Doris Taylor, a scientist at the University of Minnesota, announced the creation of the worlds first bioartificial heart composed of both living and manufactured parts. They began by pumping detergents through hearts excised from rats. This removed all the cellular tissue from them, leaving a ghostly heart-shaped skeleton of extracellular matrix and connective fibre, which was used as a scaffold onto which cardiac or blood-vessel cells were seeded. The organ was then cultured in a bioreactor to encourage cell multiplication, with blood constantly perfused through the coronary arteries. After four days, it was possible to see the new tissue contracting, and after a week the heart was even capable of pumping blood though only 2% of its normal volume.

This was a brilliant achievement, but scaling the procedure up to generate a human-sized heart is made far more difficult by the much greater number of cells required. Surgeons in Heidelberg have since applied similar techniques to generate a human-sized cardiac scaffold covered in living tissue. The original heart came from a pig, and after it had been decellularised it was populated with human vascular cells and cardiac cells harvested from a newborn rat. After 10 days the walls of the organ had become lined with new myocardium which even showed signs of electrical activity. As a proof of concept, the experiment was a success, though after three weeks of culture the organ could neither contract nor pump blood.

A surgeon using a catheter during an operation. Photograph: Kent Nishimura/Denver Post via Getty Images

Growing tissues and organs in a bioreactor is a laborious business, but recent improvements in 3D printing offer the tantalising possibility of manufacturing a new heart rapidly and to order. 3D printers work by breaking down a three-dimensional object into a series of thin, two-dimensional slices, which are laid down one on top of another. The technology has already been employed to manufacture complex engineering components out of metal or plastic, but it is now being used to generate tissues in the laboratory. To make an aortic valve, researchers at Cornell University took a pigs valve and X-rayed it in a high-resolution CT scanner. This gave them a precise map of its internal structure which could be used as a template. Using the data from the scan, the printer extruded thin jets of a hydrogel, a water-absorbent polymer that mimics natural tissue, gradually building up a duplicate of the pig valve layer by layer. This scaffold could then be seeded with living cells and incubated in the normal way.

Pushing the technology further, Adam Feinberg, a materials scientist at Carnegie Mellon University in Pittsburgh, recently succeeded in fabricating the first anatomically accurate 3D-printed heart. This facsimile was made of hydrogel and contained no tissue, but it did show a remarkable fidelity to the original organ. Since then, Feinberg has used natural proteins such as fibrin and collagen to 3D-print hearts. For many researchers in this field, a fully tissue-engineered heart is the ultimate prize.

We are left with several competing visions of the future. Within a few decades it is possible that we will be breeding transgenic pigs in vast sterile farms and harvesting their hearts to implant in sick patients. Or that new organs will be 3D-printed to order in factories, before being dispatched in drones to wherever they are needed. Or maybe an unexpected breakthrough in energy technology will make it possible to develop a fully implantable, permanent mechanical heart.

Whatever the future holds, it is worth reflecting on how much has been achieved in so little time. Speaking in 1902, six years after Ludwig Rehn became the first person to perform cardiac surgery, Harry Sherman remarked that the road to the heart is only two or three centimetres in a direct line, but it has taken surgery nearly 2,400 years to travel it. Overcoming centuries of cultural and medical prejudice required a degree of courage and vision still difficult to appreciate today. Even after that first step had been taken, another 50 years elapsed before surgeons began to make any real progress. Then, in a dizzying period of three decades, they learned how to open the heart, repair and even replace it. In most fields, an era of such fundamental discoveries happens only once if at all and it is unlikely that cardiac surgeons will ever again captivate the world as Christiaan Barnard and his colleagues did in 1967. But the history of heart surgery is littered with breakthroughs nobody saw coming, and as long as there are surgeons of talent and imagination, and a determination to do better for their patients, there is every chance that they will continue to surprise us.

Main photograph: Getty Images

This is an adapted extract from The Matter of the Heart by Thomas Morris, published by the Bodley Head

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General election 2017: The people behind the parties – BBC News

The party leaders will be inescapable until 8 June as they are photographed non-stop on the campaign trail, kissing babies and knocking on doors. But who are the strategists plotting behind the scenes?

Sir Lynton Crosby

The strategist cut his teeth working for the right-wing Liberal party in his native Australia, helping John Howard to successive victories between 1996 and 2004.

Back then he carried a business card bearing the words of the Ancient Greek philosopher Solon: “When you give advice seek to help, not to please.”

This has certainly been true of his career on the British political scene, which began when he became one of the top advisers to Conservative leader Michael Howard in the 2005 election campaign.

The campaign was ultimately unsuccessful, but it bore the hallmarks of his approach, which helped Boris Johnson to victory as London mayor in 2008 and 2012.

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Image caption Boris Johnson’s mayoral election campaigns were masterminded by Crosby

He placed an emphasis on targeting strategic seats – in the case of the mayoral elections, prioritising suburban London over Labour’s traditional inner-city strongholds in what became known as “the doughnut strategy”.

He earned a reputation for pushing subliminal messages on issues such as immigration, decried by opponents as “dog-whistle” politics.

For Michael Howard, this found expression in the slogan, “Are you thinking what we’re thinking?”

Image copyright Alamy

He joined Conservative HQ as a part-time consultant at the beginning of 2012, stepping up his involvement before the 2015 general election.

During that period, Labour claimed his background as a lobbyist for tobacco giant Philip Morris was influencing the government’s public health policies, which he denied.

He was also criticised by some in the Conservative Party who felt he was too right-wing to appeal to more moderate British voters, but the then chairman Grant Shapps described him as “a serious campaigner” with “the kind of focus that’s required”.

His services come with a hefty price tag, it’s been suggested. Mr Johnson advised David Cameron to “break the piggy bank” to get him on board for the 2015 general election.

It was worth it, in the eyes of many Conservatives, as he helped deliver their unexpected Commons majority two years ago.

He was given a knighthood in the 2016 New Year honours, a move condemned by Labour as “outrageous”.

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Image caption Sir Lynton was knighted in 2016

He declined an offer of 2m to work for one of the No campaigns in the EU referendum – but he’s now back on the scene running the Conservative Party’s election campaign with his agency CrosbyTextor.

His presence is likely to be as controversial as ever, with some linking his appointment to the departure of other members of Theresa May’s staff. For others, he remains the “alpha male” the party needs.

The party’s relentless focus on one or two simple slogans – “strong and stable leadership” being the most obvious one – coupled with robust attacks on the character of its opponent, in this case Jeremy Corbyn, are hallmarks of the no-holds-barred Crosby campaigning style.

Who else?

Image copyright PA
Image caption Nick Timothy and Fiona Hill

Just as important is Lord Gilbert, a stalwart of Conservative central office, who is running a tightly controlled strategy with its sights on taking seats the Conservatives have not won for years and Theresa May at its centre. He’s seen as returning the party to an older and more traditional version of itself after the perceived slick “posh boy” image of David Cameron and George Osborne.

Former campaign manager for Barack Obama Jim Messina and his team have returned after an advisory role with the Conservatives in 2015. Mrs May’s trusted lieutenants Fiona Hill and Nick Timothy are key figures in shaping how the prime minister approaches the campaign, while Tom Edmonds and Craig Elder are leading the way on digital campaigning, as they did in 2015.

Seumas Milne

In some ways, Labour’s director of communications could not be more different from Sir Lynton, with his roots firmly in the British establishment.

His father was the former BBC director general Alasdair Milne, and he attended Winchester College and Balliol College, Oxford before going into journalism.

He started out on a small Communist-backed paper, Straight Left, and spent three years at The Economist before joining the Guardian in 1984.

He wrote extensively on industrial issues for the Guardian, being promoted to labour editor and later comment editor, and represented the paper in the National Union of Journalists.

His tenure as comment editor in the early 2000s grated with some of his fellow journalists, with colleagues complaining he was too ready to defend Hugo Chavez and Vladimir Putin, and that he commissioned too many pieces on Palestine.

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But none of that prepared the industry for the announcement in late 2015 that he would take a “leave of absence” to work for the newly elected leader of the Labour Party, Jeremy Corbyn.

He remained officially on staff until January 2017, a source of concern for some at the Guardian, who felt it might inhibit criticism of the Labour leader.

Like Sir Lynton, he has proved to be a divisive choice as strategist.

There have been numerous criticisms of his past opinions including allegations of justifying Russian actions in Ukraine and for describing the murder of Lee Rigby as not “terrorism in the normal sense of an indiscriminate attack on civilians”.

His detractors say he is too far to the left, too dogmatic and unwilling to co-operate with the demands of the 24-hour news cycle. Some have also suggested he appears to exercise too much control over Mr Corbyn at times. Some within the party accused him of “sabotaging” Labour’s remain campaign.

Others say he’s had to maintain a tough stance to counter “annoying” leaks from sections of the Labour Party who disagree with Mr Corbyn. They praise his calm manner as a welcome change from the bullish style of Labour spin doctors past.

He enjoys the advantage, from his supporters’ point of view, of being an experienced journalist as well as being very close politically to the party leader.

Image copyright Getty Images

He’s also seen by his allies as a quick and reflective thinker with strong principles, and a compelling writer who’s effective at capturing the best of Mr Corbyn.

The recent departure of campaigns director Simon Fletcher from Mr Corbyn’s top team has been interpreted by Labour-watchers as a sign of Mr Milne taking a tighter grip on the reins ahead of the election.

And with speculation rife that Mr Corbyn could stay on as leader even if Labour loses – or make way for an ally – Mr Milne may be an important figure in the party for some time to come.

Who else?

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Image caption Andrew Gwynne formerly worked with Ed Balls

Seumas Milne will be aided by deputy Steve Howell, from the PR firm Freshwater, and policy director Andrew Fisher, who wrote the Labour manifesto. In charge of Mr Corbyn’s office is former Unison official Karie Murphy, who was caught up in the vote-rigging row at the 2013 Falkirk by-election. The two former MPs running the party’s national campaign are Andrew Gwynne, former parliamentary private secretary to Ed Balls, and Ian Lavery, an ex-miner and champion of the trade unions.

Liberal Democrats

Communications consultant James Gurling has been brought back into the party as campaign chief from lobbying firm MHP, having previously chaired the Lib Dem campaigns and communications committee.

He was a press aide to former leader Paddy Ashdown in 1997 and leadership election agent to Charles Kennedy, who was his brother-in-law, as well as a councillor for the Lib Dems in Southwark.

Another returning activist is Phil Reilly, director of communications, a former aide to Nick Clegg as deputy prime minister and devout West Ham fan.

Two other influential figures are Lib Dem leader in the Lords, Lord Newby, who chaired the party’s manifesto group, and party leader Tim Farron’s chief of staff Ben Williams, who was in charge of the whips’ office during the coalition, described by one insider as “the power behind the throne”.


The SNP’s campaign manager is MSP Derek Mackay, the party’s business convener (chair) and finance secretary. He got involved in politics at an early age, first becoming a councillor at 21 after dropping out of university. He has since risen through the ranks to become one of Holyrood’s most prominent figures.

He’s seen as a steady hand and close ally of First Minister Nicola Sturgeon in the Holyrood group.

He’ll be able to draw on the experience of former campaign managers Angus Robertson, the SNP leader at Westminster, who has his hands full defending his Moray seat, and John Swinney, who is under fire in his role as education secretary.

Peter Murrell, the party’s chief executive and Nicola Sturgeon’s husband, remains a force to be reckoned with at the top of the SNP. The Scotsman has described him as “a supreme political tactician who is one of the unsung heroes of the SNP’s rise to power”.

Unlike in Westminster, where advisers quit their day jobs to focus on party politics, the Scottish Parliament continues to sit and aides to the first minister such as Liz Lloyd and spokesman Stuart Nicolson will stay in their roles.


This time around MEP and former Daily Express journalist Patrick O’Flynn is set to be an influential figure within UKIP’s campaign. He ran former councillor Lisa Duffy’s leadership bid, which focused heavily on an anti-multicultural message. He is close to the leader, Paul Nuttall, and is thought to have worked on the manifesto alongside party deputy chair Suzanne Evans.

Green Party of England and Wales

The Greens’ campaign will be led by Nick Martin, chief executive of the party, who has previously stood as a candidate in Southwark and headed several legal practices before that. He has also overseen the manifesto-writing committee, which is made up of the party’s co-leaders, and policy leads Sam Riches and Sam Pancheri. The Greens stress that policies are consulted on widely among members.

Plaid Cymru

Adam Price, AM and ex-MP for Carmarthen, is coordinating the general election campaign for Plaid Cymru, with an emphasis on speaking for Wales in the Brexit process. The party is counting on some unpredictable multiparty races in a number of Welsh seats. Gareth Clubb, a former director of Friends of the Earth Cymru, remains chief executive.

Northern Irish parties

There’s an issue of strained resources for the Northern Irish parties represented at Westminster, as they have only just fought an assembly election and there could be another one this year, pending the outcome of talks on restoring devolved government. Timothy Johnston, long regarded as one of the most significant officials within the DUP, will be in charge for the largest Northern Irish party at Westminster.

But the electoral maths will be difficult for any strategist to calculate this time, with pacts between the DUP and UUP in two seats, Traditional Ulster Voice fielding only one candidate, and Sinn Fein enjoying improved fortunes since the renewable heating scandal.

Profiles by Esther Webber. Illustrations by Gerry Fletcher.

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Report: Big Cuts To Medicaid Coming In Trump Budget This Week

U.S. President Donald Trumps budget proposal, set to be unveiled on Tuesday, will include cuts to Medicaid and propose changes to other assistance programs for low-income citizens, the Washington Post reported on Sunday.

The White House did not immediately respond to a request for comment.

Trumps proposal follows on a Republican healthcare bill that passed the U.S. House of Representatives in early May that seeks to overhaul the national healthcare system and cut more than $800 billion over the next 10 years from Medicaid, the government health insurance program for the poor and disabled.

The healthcare bill faces a difficult time in the Senate, where Democrats and some Republicans worry about its impact on costs for low-income Americans, among other issues.

The report said the White House will also give individual U.S. states more autonomy over a variety of anti-poverty poverty programs including the Supplemental Nutrition Assistance Program (SNAP), the largest U.S. anti-hunger program which was formerly called the food stamp program.

More than 44 million Americans received benefits from the SNAP program in February according to the U.S. Department of Agriculture.

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Trump’s doublespeak in Saudi Arabia

(CNN)If there’s one thing we’ve learned about Donald Trump, it is that he has no qualms about contradicting himself to get what he wants. In Saudi Arabia, he wanted a $110 billion arms deal — not to promote peace and tolerance, as he later proclaimed in his Sunday speech.

Thus, his speech will not “be remembered as the beginning of peace in the Middle East,” as he loftily put it, but rather a boost to the war that is ravaging it. Nor will Trump’s speech put an end to the Islamophobia and bigotry that he has spent the past two years inciting. After all, he needs scapegoats to blame when the terrorism in the Middle East inevitably reaches the United States.
Given Trump’s opportunistic leadership style — what he calls “principled realism”– we can expect more contradictions between his rhetoric and his actions. Four specific contradictions warrant exploring to predict what is in store for American foreign policy in the Middle East, as well as for the treatment of Muslims in the United States.
    First, Trump preaches peace and prosperity in his speech, but then sells weapons to the Saudis, which will inevitably fuel war. Trump treats terrorism in the Middle East as a business opportunity to create jobs at home and enrich defense industry tycoons.
    While addressing the world’s longest-ruling dictators about terrorism, Trump failed to mention how state violence and repression feeds ISIS and al Qaeda’s propaganda campaigns. Instead, he proclaims the Arab leaders to be defenders of the people’s freedom. As he advised his allies to allow “young Muslim boys and girls (to) be able to grow up free from fear, safe from violence and innocent of hatred,” he disingenuously pretended that the Arab Spring never occurred. The people revolted against their authoritarian governments seeking just those things, but found themselves abandoned by the United States and violently repressed by Arab regimes — which he is once again arming.

      Trump to Muslim world: Drive out terrorists

    Thus, we should not expect any meaningful attempts by the Trump administration to decrease terrorism in the region. Rather, the focus of US counterterrorism strategy will be to geographically contain the violence within the Middle East and prevent it from crossing the Atlantic.
    This brings us to the second of Trump’s contradictions — deliberately disconnecting Islam from terrorism in his speech to his Saudi arms purchasers while bolstering Islamophobia in the United States. Over the past two years, Trump has repeatedly stated that “Islam hates us” and Islam is a “hateful foreign ideology,” a kind of rhetoric that has emboldened his white nationalist supporters to discriminate against and attack Muslims. The growing anti-Muslim bigotry could give his administration free rein to disproportionately target Muslims in counterterrorism investigations, surveillance and prosecutions.
    Third, there is little evidence Trump is willing to participate in the global effort to “counter extremist ideology,” a new term he strategically coined instead of “radical Islamic terrorism” that he’s been peddling to his right-wing base. As Trump announced a “groundbreaking new center (that) represent(ed) a clear declaration that Muslim-majority countries must take the lead in combatting radicalization,” he took no responsibility for his own divisive rhetoric that radicalizes the political right in the United States. Indeed, over the past five years, extremist ideology from the right has risen at troubling levels.
    Accordingly, we should expect the continued use of “radical Islamic terrorism” in his speeches to American audiences and willful blindness to the rise in violence of the alt-right, right-wing militia groups, and the Ku Klux Klan.
    Finally, Trump stated that in “the scenes of destruction, in the wake of terror, we see no signs that those murdered were Jewish or Christian, Shia or Sunni.” Here he intimates sympathy for Muslims, even as his domestic policies single out and discriminate against Muslims. His first executive order barred millions of people from Muslim-majority countries from lawfully entering the United States. The refugee clause in the order applied only to Muslim Syrian refugees while exempting Christian Syrian refugees — as if the lives of the hundreds of thousands of Muslim Syrians killed were of no value. And in all of his speeches warning about terrorism committed by Muslims, he has never acknowledged the rise in hate crimes, mosque vandalizations and bullying suffered by Muslims in the United States. For Trump, there is a major difference between Muslims and everyone else.

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    While citizens in the Middle East and America may find his contradictions repugnant, his audience in Saudi Arabia will not. On the contrary, Middle East authoritarians see Trump as a fellow demagogue who will do whatever it takes to get what he wants. And what he wants has little to do with peace, stability and prosperity for the people of the Middle East.

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    Saudis, UAE pledge $100 million to Ivanka Trump-proposed fund

    (CNN)Just two days into President Donald Trump debut foreign trip, a member of his inner-circle has already reaped benefits to the tune of $100 million.

    In a sunlit ballroom Sunday morning at the Tuwaiq Palace in Saudi Arabia, Ivanka Trump’s proposed Women Entrepreneurs Fund — a concept she first shared during her own inaugural international trip as first daughter last month to Berlin, Germany — was promised a combined $100 million by Saudi Arabia and the United Arab Emirates specifically to help women in the Middle East.
    The fund, which will be run by World Bank, not Ivanka Trump, aims to provide to female entrepreneurs with financial support in the form of capital and access to networking and financial markets, something Trump says she anticipates will be important to the future growth of women.
      But Saudi Arabia places severe restrictions on women’s rights and participation in society, including prohibitions on driving and finances. The creation of a fund that solicits donations from such countries and is championed by Trump’s daughter, one of Trump’s closest advisers, could open the President up to charges of hypocrisy, saying that the concept is not dissimilar to the Clinton Foundation, which he roundly criticized as a candidate.
      The first daughter spoke of the need for transformation at Sunday’s women’s economic empowerment roundtable, which was attended by 15 women, most of them Saudi business and government leaders and entrepreneurs.
      “We are living in a pivotal moment in history for women,” she said. “Around the world, women continue to achieve unprecedented levels of rights and freedoms. Today, you all stand on the front lines of the fight for gender equality. You recognize the indisputable truth that empowering women is key to driving economic transformation.”
      “Yet in every country, including United States, women and girls face unique challenges that hold them back from full and meaningful participation in all parts of society,” added Trump, who wore a powder blue designer suit; the rest of the women in attendance at the roundtable wore traditional Muslim garb, their hair covered in abayas or scarves, according to reporters traveling with the first family.
      Last year, however, Donald Trump bashed the Clinton Foundation for accepting money from countries with human rights issues, implying the move was in direct contrast to the help the foundation was established to provide.
      “Saudi Arabia and many of the countries that gave vast amounts of money to the Clinton Foundation want women as slaves and to kill gays,” Trump wrote on Facebook. “Hillary must return all money from such countries!”
      During his campaign for president, Trump also tweeted about what he claimed was a “pay-for-play” agreement with countries that donated to the Clinton Foundation.
      The White House did not immediately respond to a request for comment Sunday.
      World Bank President Jim Yong Kim, who said he first heard about the Women Entrepreneurs Fund when it was pitched to him by Trump and German Chancellor Angela Merkel, said the program will only expand.
      “We had no idea how quickly this [fund] would build,” said Kim, who added that World Bank would be able to announce at the G-20 summit in July that it has created, with additional donations from the United States and other countries, a fund with a total of $1 billion for women’s economic empowerment. “I really have to say that Ivanka’s leadership has been tremendous.”

      Read more:

      Ebay accused of failing its sellers as fraudulent buyers manipulate the system

      A website built on the premise that most people are honest is struggling. Now at last there is a promise of more protection, as Anna Tims reports

      Last November Clive Rose* sold two handmade Japanese swords on eBay, worth a total of 1,940. The buyer, once he had received them, demanded that the cost of the more expensive sword be slashed. Rose refused to haggle and asked for the items to be returned and a refund issued.

      Eventually a box arrived. We couldnt open it until we had signed for it, says Rose. On the label it said two items were inside. When we had signed and opened it up we found the cheaper 540 sword badly damaged because of poor packaging, and a brick. The other 1,400 sword, for which he had been trying to barter, was not there.

      The buyer claimed Rose had forfeited his rights by signing for the parcel, while eBays response was similar. Although Rose sent photographs and message threads to support his case, eBay took the money from his PayPal account and refunded the buyer for both swords. Rose, who has a 100% satisfaction rating from other buyers, had his account suspended for withholding eBays seller fees and is now threatened with debt collectors because his PayPal account is overdrawn.

      The tale will be familiar to many eBay sellers who have experienced difficulties with problem buyers.

      It was only after The Observer intervened that the auction site examined the history of Roses buyer what the company found was a pattern of suspect behaviour. The buyers account has been suspended and we are happy to issue the seller with a courtesy refund to ensure he is not left out of pocket, eBay says.

      It is a year since The Observer reported that eBay had introduced a pilot programme to address issues around similar problems. At the time, critics claimed its measures to protect buyers from dodgy transactions left sellers at the mercy of fraudsters who can manipulate the system to effectively steal goods.

      Readers related instances where a buyer falsely claimed to have been sent beetroot instead of a mobile phone, while another buyer stuffed an envelope with a used T-shirt instead of a 258 pair of trainers he claimed to be returning. Both were refunded under eBays money back guarantee.

      There is something wrong, eBay admitted last April. The system was built on the premise that most people are honest. It needs to be more intuitive.

      Under the experimental scheme, a seller can ask eBay to intervene before issuing a refund if a buyer returns a damaged or substitute item. Ordinarily, they have a week to resolve the dispute before having to part with their money, but an unscrupulous buyer can ignore contact and open a claim directly with eBay. In many cases it issues an automatic refund without any evidence from the seller being considered.

      The seller has no recourse under PayPals seller protection scheme since this is invalidated when a buyer claims directly through eBay. And although eBays own rules require buyers to send disputed items back, refunds are sometimes released before this happens or after damaged or substitute goods have been returned. Even eBay can see the flaw, and in a brainwave that would seem obvious to anyone else the pilot scheme requests photographic evidence when buyers or sellers allege damage or duplicity.

      Twelve months on, has the trial made a difference? Not according to Londoner Catherine Lewis who sold a coat via the website. The buyer claimed that it never arrived and, because Lewis could only provide proof of postage and not of delivery, eBay forced a refund. When I looked at the buyers feedback other sellers all told the same story, she says. The buyer claimed the item didnt arrive but eBay gave a refund, even on items that were signed for. Worse, the buyer has been reported to eBay three times before for this and no action has been taken. They are free to keep buying items and claiming back the money essentially stealing and eBay is not doing anything about it.

      Ebay may have been duped by its own rules which only allow sellers to leave positive ratings for buyers in case, as it admits, criticism puts the latter off future spending.

      The score of warning reviews that Lewis found were all spelled out beneath the obligatory heading of positive. Buyers, on the other hand, can damage a sellers status with negative feedback, posted anonymously, and every case opened against a seller results in a defect against the buyer.

      Its a policy that appears to protect eBays profits at the expense of sellers reputations, as eBays own website explains: Were counting any activities weve found that decrease a buyers likelihood to come back and shop with us again, as defects.

      It only occurred to eBay to read the reviews of Lewiss buyer on its own website after The Observer alerted it to them. It then discovered that the individual was a serial fraudster and suspended their account. This is not good enough on our part, it says. We have a buyer abuse team that uses software to scan the site to spot this behaviour. In this case, this buyer clearly has been abusing the system and it wasnt picked up.

      So anxious is the company to keep buyers spending that it turned a blind eye to a stream of violent threats sent by one to a seller in Australia. The victim made 10 complaints about the abusive messages to eBay which responded by restricting the messages to three a day to each of her three accounts. After her fifth complaint she was advised by customer service to ignore the abuse, which included rape threats. The senders accounts were eventually terminated when The Observer got involved. This behaviour will not be tolerated, says eBay, which had tolerated it for days until a headline loomed.

      According to eBay, it will announce permanent policy changes in the autumn. Learning from the experiences of the 50,000 UK and US sellers in the pilot, we have created a different returns experience, including putting obstacles in the way of suspected fraudsters to prevent refunds, or even blocking a buyer entirely when we suspect fraud before theyve been refunded, it says. Were also giving the sellers who offer free or 30-day returns the ability to allow partial refunds on faulty, damaged and lost item claims so that they can recover costs.

      The extraordinary fact that eBay has only recently put obstacles in the way of fraudsters is no surprise to Dean Marchant* whose business was threatened by the knee-jerk refund policies.

      He sold a 400 turntable to a buyer who requested a return and sent back a different damaged device. Marchant sent photographs of the smashed item to eBay which, nonetheless, refunded the buyer. Because the buyer had contacted eBays dispute resolution service, a defect was recorded against Marchant.

      I had erroneously been issued with two previous defects and this third one put me below standard, excluding me from money-saving promotions, he says. It is crushing my ability to do business.

      Ebay decided to refund him as a goodwill gesture after an Observer investigation, but claimed that since it never gets sight of items it could not judge whether the correct item was returned. Marchant plans to start a lobby group of disaffected sellers to challenge what he sees as bias against sellers. My experience, and that of other sellers I have spoken to, is that buyer-fraud of this kind is rife, he says. Every single seller I spoke to had a tale to tell of at least two incidents in the past year. The simple fact is the eBay policy allows this fraud.

      * Names have been changed

      Read more:

      New Zealand navy paid $700,000 to firm mired in Fat Leonard sex and bribery scandal

      Exclusive: Royal New Zealand Navy says no investigation opened following US military bribery case

      The Royal New Zealand Navy paid hundreds of thousands of dollars over four years to a ship services company run by a man now imprisoned in the US for an enormous corruption and sex scandal, the Guardian has learned.

      US prosecutors say Leonard Glenn Francis, known as Fat Leonard for his wide girth, had cheated its navy out of nearly US $34m mostly through overcharging port services and providing gifts to personnel, including arranging sex parties.

      The New Zealand navy has told the Guardian it paid a total of NZ$710,235.04 (around 370,000) to Francis company, Glenn Defence Marine Asia (GDMA), between May 2007 to December 2011 for specific ship visits in South East Asia.

      The navy told the Guardian in previous correspondence that it had used a range of services in Singapore from bus hire to tug provision.

      Responding to a freedom of information request, it added it had not conducted an investigation into its relationship with GDMA based on the results of the US corruption investigation, nor is there an intention to do so.

      There has been no standing or enduring contract between the Royal New Zealand Navy and GDMA, which the navy said it had contracted in Singapore and Malaysia.

      A three-year US case against Francis has severely and consistently rattled the US military. Rear Adm. Robert Gilbeau, the first US admiral ever convicted of a federal crime while on active duty, was sentenced on Wednesday to 18 months in prison for lying to investigators.

      Francis, who was lured to the US and arrested in a 2013 sting, pleaded guilty in January 2015 and faces a maximum of two decades in prison.

      Twenty current and former Navy officials have been charged so far, while ten have pleaded guilty, mostly for bribes of lavish trips and sex workers in return for routing ships to ports where Francis could overcharge for ship husbandry services.

      One US indictment said Francis once rented the MacArthur Suite at a hotel in the Philippines, where memorabilia of former American five-star General Douglas MacArthur was used for sex acts with prostitutes.

      GDMAs website, now defunct, claimed the company had worked with more than two dozen navies around the world.

      The UK navy did not hold any direct contracts with GDMA. Francis did, however, buy a decommissioned British Armed Forces ship, Sir Lancelot, which had been hit by an bomb that failed to explode during the Falklands war.

      The ship, which Francis bought from a South African company, was renamed Glenn Braveheart, refurbished and reused occasionally as a giant party boat, with sex workers hired to entertain US officers, according to US court statements.

      The defence department in Australia contracted one of Francis Singapore-based companies to provide port services for its vessels in Singapore on two occasions in 2008.

      Australias border protection agency had also contracted Francis local company firm, Glenn Defence Marine (Australia), tender searches show.

      Canadas navy told the Guardian in an email that although had not had any direct dealings with GDMA, it may have received minor support or docking services at various ports.

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      General election 2017: New warning over social care plans – BBC News

      Image copyright Science Photo Library

      Conservative plans to change social care funding in England may be derailed by councils, an ex-minister has warned.

      The party wants to include the value of someone’s home when deciding how much they must pay towards care at home – but allow them to pay after they die.

      The Conservatives say the changes ensure fairness across the generations.

      But Sir Steve Webb, the ex-Lib Dem pensions minister, says there is already a “lottery” in the way councils use existing deferred payment schemes.

      Currently, people living in residential care can ask their local authority to pay their bill and recover the money from the sale of their family home after they die.

      The Conservatives’ plan would extend this right to those receiving care in their own homes, who would have to pay until they were down to their last 100,000.

      But Sir Steve, who is now policy director for pensions specialist Royal London, said Freedom of Information responses showed a wide variation in the number of deferred payment arrangements set up.

      Some councils in England had not signed any agreements to let people defer their payments, while in other areas more than 100 agreements had been signed.

      Sir Steve said: “It is clear that there is already a lottery as to whether people facing significant care costs can exercise their legal right to defer their payments under the existing system.

      “The government will need to investigate very quickly why the present system is not working properly, otherwise there is a danger of building a new system on very shaky foundations.”

      The councils who had entered into the most agreements were Southampton City Council with 331, followed by Essex County Council with 208 and Middlesbrough Council with 165.

      In contrast, 10 authorities – Westminster, Tower Hamlets, Hackney, Kensington and Chelsea, Haringey, Lewisham, Lambeth, Ealing, Blackburn with Darwen, and Luton – said they had not issued any.

      How would the Tory social care plans work?

      Image copyright ForMed Films

      Under the Conservative plans nobody with assets of less than 100,000 would have to pay for social care. Currently anyone with assets of over 23,250 is expected to pay the full cost of their residential care and the value of their home can be taken into account.

      But that is not the case if you receive care in your own home. Under the Tory plans the value of your home may in future be factored in, although the money would not be taken from your estate until after your death.

      This means some people fear they will not be able to pass their homes down to their children.

      Why many will pay more for care

      Work and Pensions Secretary Damian Green said the Tories would not “look again” at the proposed changes, and Foreign Secretary Boris Johnson said the “broad thrust” was right.

      Conservative former business minister Lord Willetts said the plan was “one of the bravest, most serious and most important” features of the Conservative manifesto.

      He told Westminster Hour on BBC Radio 4 the proposal meant social care for older people would be financed by pensioners with “substantial assets” instead of younger people “struggling to make ends meet”.

      Labour leader Jeremy Corbyn has accused the Conservatives of “forcing those who need social care to pay for it with their homes,” labelling the policy a “dementia tax”.

      Lord Wood, former adviser to Ed Miliband, said the problem with the Tory plan is that “it’s not a long term system solution because it abandons the principle of social insurance”.

      The Lib Dems, meanwhile, said nine out of 10 homes would be eligible to be sold under the new regime, citing Land Registry house sale figures.

      Calling for a “national movement” against the policy, Lib Dem leader Tim Farron said: “Every elderly person that needs care should receive it in the best place for them and not be fearful of those mounting, limitless costs.”

      Related Topics

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      Can Donald Trump solve the Israeli-Palestinian conflict?

      (CNN)Jerusalem: US President Donald Trump arrives in Israel Monday in search of what he has called “the ultimate deal”.

      But like so many US presidents who have believed it their duty to bring peace to the region, Trump will face a series of challenges, which have grown increasingly insurmountable.
      Seven years on since Abbas and Israeli Prime Minister Benjamin Netanyahu last held talks, the same issues remain — disagreements over borders, security, Jerusalem, a right of return for refugees and mutual recognition are no closer to being solved.
      “Everybody wants peace, they just want it on their terms,” Senator George Mitchell who worked on peace talks between the Israelis and Palestinians in 2010, told CNN.
      “I don’t think it’s a case of finding people who want to make peace. If you said to everyone: ‘do you want peace?’ then of course they’ll say they want peace. But they define peace differently and want it according to their definition, not the other side’s definition.”


      One of the most difficult challenges facing Trump is trust between the two parties involved, according to former US Envoy to the Middle East, Dennis Ross.
      Ross, a William Davidson distinguished fellow and counselor at the Washington Institute, helped establish the 1995 Interim Agreement between Israel and the Palestinians as well as the 1997 Hebron Accord.
      A part of both the George H.W. Bush and Clinton administrations, Ross says the challenges are as much psychological as they are practical.
      “The level of disbelief between the Israelis and Palestinians, not just the leadership, but also the public, has never been wider,” Ross told CNN.
        “You have to somehow recreate a sense of possibility which has been completely lost.”
        It’s nearly seven years since Netanyahu and Abbas took part in a trilateral meeting with then US President Barack Obama in New York in September 2009. Obama — working with both Secretary of State Hillary Clinton in his first term and Secretary of State John Kerry in his second — tried to advance the peace process in two rounds of negotiations.
        The most recent negotiations fell apart in April 2014 after nine months of talks, with both sides blaming each other. Two months later, the Gaza war started, causing a further deterioration in relations between the Israeli and Palestinian leadership.

          Mahmoud Abbas ‘very hopeful’ about Trump

        David Makovsky, a Ziegler distinguished fellow at The Washington Institute and director of the Project on the Middle East Peace Process, who was involved in those talks, said a failure to agree over the five core issues (borders, security issues, Jerusalem, refugees and mutual recognition) was the reason for the breakdown.
        “We couldn’t create that diagram where they all overlapped on these five issues,” Makovsky told CNN
        “Ultimately the status quo that they knew was more, and I hesitate to use this word, appealing, than taking a leap into the unknown.”
        Makovksy says Trump’s wish for peace is genuine, though he cannot see a grand deal in the offing.
        “There are no shortcuts and you have to do the heavy lifting on those five core issues,” Makovsky added. “I don’t see the parties or him about to be on the cusp of doing that heavy lifting.”
          For Mitchell, the challenges of brokering a major peace deal are well known. One of the leading figures in the 1998 Good Friday Agreement, which ushered in a new chapter for Northern Ireland, he was brought in facilitate between the Israelis and Palestinians in 2010.
          “There’s such a high level of mistrust on both sides between both the public and leaders themselves that it’s very hard to get them to genuinely listen to the point of view or narrative of the other side,” Mitchell told CNN.
          “In Northern Ireland it took years. Netanyahu and Abbas have known each other for many years but unfortunately the context they’ve had has tended to validate their mistrust and suspicion and I think that is and will continue to be one of the problems in the Middle East that has to be overcome.”

          One State vs Two State solution

          US foreign policy has held for decades that the only solution to the Israeli-Palestinian conflict is a two-state solution: an Israeli state living side-by-side in peace and security with a Palestinian state.

            What’s the Israeli-Palestinian two-state solution?

          Trump threatened to upend that framework at his first press conference with Netanyahu in mid-February when he said he would be OK with a one-state or two-state solution.
          But since then, Trump seems to have has fallen in line with traditional US policy.
          “One thing I know is that a one state outcome is not a solution, it’s a prescription for an enduring war,” Ross said.
          “Because you have two national identities, they won’t co-exist in one state. You will have one, which will inevitably dominate the other and by the way, look at the Middle East.”
          Convinced he can find a solution, Trump has been intent on restarting dialogue between the Israelis and Palestinians.
          His special envoy for international negotiations, Jason Greenblatt, has met with Israeli, Palestinian, and Arab leaders, to restart momentum for negotiations.
          Trump is determined to keep that momentum going. Before his trip to Israel and the West Bank, Trump is set to meet with Abbas and other Arab leaders in Saudi Arabia, setting up a regional Arab consensus on a need for a peace agreement with Israel.


            Jerusalem is one of the most sensitive issues in the Israeli-Palestinian conflict.
            Under the 1947 UN Partition Plan, Jerusalem was supposed to be an international city, but that goal was never realized as war broke out between the fledgling state of Israel and its Arab neighbors. From 1948 to 1967, West Jerusalem remained under Israeli control, while East Jerusalem was held by the Jordanians.
            Following the 1967 Six-Day War, Israel occupied East Jerusalem and the West Bank. For the first time in modern history, all of Jerusalem came under Israel’s governance. Israel claims the entire city as its united capital, but no country recognizes this decision. The Palestinians claim East Jerusalem as the capital of a future Palestinian state.
            “Addressing East Jerusalem means addressing occupied territories,” Hanan Ashrawi, a member of the Palestinian Liberation Organization’s Executive Committee, said.
            “If you want to change the status of Jerusalem you have to address both sides – East and West Jerusalem. You can’t accept an illegal reality that was imposed by an occupying power.”
            Israel’s position has always been — and perhaps will always be — different.
            “There’s no distinction between East and West Jerusalem,” said MK Michael Oren. “In July of 1967 after the Six-Day War, Israel liberated the eastern part of Jerusalem, the Israeli government made all of Jerusalem one sovereign Israeli city and our capital.”
            “That is actually Israeli policy. It’s not a position. It’s Israeli law.”
              The right of return stipulates that Palestinians who fled their land seized by Israel in 1948 and 1967 will be allowed to return home. With millions of refugees living in neighboring countries and around the world, Israel fears any return could tip the demographic balance where Jews become a minority. Palestinians claim it’s their inherent right to return home.
              “People’s rights can’t be negated. International law shouldn’t be violated by agreements,” explains Ashrawi. “But at the same time, once you recognize the rights we can discuss different ways of implementation.”
              But Oren says there is “no wiggle room” for Israel on the right of return.
              “The Palestinian demand for refugee return is an existential threat to this country,” he said.
              “It’s not about spirituality, it’s not about national pride. It’s about our national existence. Israel is the nation-state of the Jewish people. Any attempt to erode the Jewish majority of this state is an existential threat.”
              No American administration has definitively weighed in on Jerusalem, leaving the final status of the city open to negotiations between Israelis and Palestinians as part of a two-state solution. The US has never recognized Jerusalem as the capital of Israel, and the US embassy to Israel sits in Tel Aviv.
              Like other presidential candidates before him, Trump made a campaign promise to recognize a united Jerusalem as the capital of Israel and to move the embassy. But Trump has since demurred on the embassy move, walking back the promise as he attempts to reignite a peace process between Israelis and Palestinians.
              The issue of refugees and Jerusalem remain two of the most contentious with neither side appearing likely to cede ground.

              Palestinian skepticism

              While expectations ahead of Trump’s visit may be low, there is some cautious optimism.
              Only last month, Abbas heaped praise onto Trump during their press conference in Washington. He finished by telling Trump in English, “Now, Mr. President, with you we have hope.”

                Hamas leader: Trump has ‘historic opportunity’

              But back in the West Bank and in Gaza, many Palestinian leaders view the new US President skeptically. During the election campaign, they saw then candidate Trump pledge his unwavering support for Israel and after winning, nominate a new US ambassador to Israel, David Friedman, who is considered to be on the far right even by Israeli standards.
              “He has been extremely pro-Zionist. David Friedman is known for being an extreme supporter of the most hardline policies of Israel, including settlements which are illegal,” Hanan Ashrawi, a member of the Palestinian Liberation Organization’s Executive Committee, said.
              “On the other hand we know he isn’t beholden to the pro-Israel lobby in many ways. He is not really an ideologue, he is not really a party man. That gives him some leeway and freedom.”
              But any sort of peace deal will have to start within the Palestinian community itself with the rift between Hamas, which controls Gaza, and Fatah, which is led Abbas, growing deeper in recent months.
              The situation in Gaza has become desperate with the United Nations cautioning that it may become unlivable by 2020.
              “In the short term, progress in Gaza seems to be the hardest issue,” Natan Sachs, director at the center for Middle East policy at Brookings, told CNN.
              “Both the Israelis and Palestinians know that the current situation is not good for anyone. It’s bad for Israelis and awful for those in Gaza. That’s where I’d start if I was Trump.”


              The threat of a nuclear Iran remains one of Netanyahu’s major talking points, and it was at the top of the agenda when Israeli Defense Minister Avigdor Liberman met Secretary of Defense James Mattis in both Washington and Tel Aviv.

                The Trump effect on Iran’s election

              Netanyahu was perhaps the most outspoken critic of the Iran nuclear deal, lobbying against the deal up until the moment it was signed.
              He toned down his criticism following the finalization of the deal, but saw the election of Trump as a chance to reignite opposition to the deal.
              So far though, Trump has not made any changes to the deal, and key figures in Trump’s administration have indicated that the Iran deal will remain in place, at least for the time being.
              But the administration’s concerns about Iran remain. In February, Mattis labeled the country as “the single biggest state sponsor of terrorism in the world.”
              That has encouraged a number of Arab countries to seek co-operation with Israel on Iran, according to former US ambassador Shapiro, former US ambassador under Obama.
              He says the new found co-operation could help advance the peace process with the Arab states keen to work with a new US President at a time where the threat of Iran is perhaps a more worrisome prospect.
              “There is definitely more of a recognition that Israel is a strategic partner against Iran, ISIS and other strategic threats,” Shapiro, senior visiting fellow at the Institute for National Security Studies in Tel Aviv, told CNN.
              “That strategic co-operation at a level of intelligence, security co-ordination is very strong and very real.”
              He believes Arab states can help provide cover for Abbas who would face criticism from the Palestinian public, particularly from Hamas.
              “He needs a cover where there is a shared responsibility which makes it easier for him to take steps otherwise it might be impossible,” Shapiro added.

              Trump’s Leverage

              If Trump wants to pressure the Israelis or Palestinians to make concessions, he has different ways of doing so for each party.
              Early in his term, Trump is off to a strong start in his relations with the Sunni Arab states, including Egypt, Saudi Arabia, and Jordan. Together with those countries, he could pressure the Palestinians into making concessions on certain issues.
              The US also provides $440 million per year in foreign aid to the Palestinians. Offering an increase in that aid, possibly combined with an economic incentives package, could make compromise easier.
              Trump has even more options for negotiating with Israel, both financially and politically. If Trump offers to recognize Israeli sovereignty over the occupied Golan Heights or release Jonathan Pollard, an American convicted of spying for Israel, from the terms of his probation, it would be a political win for Netanyahu, and it would give the Israeli Prime Minister maneuvering room within Israeli politics.
              Trump could also offer to increase US military aid to Israel from its record level of nearly $4 billion a year. As a last option, Trump can move the embassy to Jerusalem, but such a move would require large concessions to the Palestinians to avoid regional turmoil.

              Temper expectations

              For those who have tried and failed in the past to bring peace to the Middle East, Trump’s visit represents the next chapter.
              For Makovsky, who was part of Kerry’s negotiating team in 2013-14, an incremental approach rather than a traditional all or nothing scenario could work for Trump.
              “I think the most likely prospect you’ll get with the Trump visit is the prospect of possibly renewing talks between Netanyahu and Abbas which would be significant after seven years,” Makovsky said.

                Pres. Carter hopes Trump pushes Mid-East peace

              Ross is also cautious of progress, though he believes there are ways to engage both parties and change their outlook on the possibility of a future deal.
              “If you could persuade Israelis not to build outside the bloc, they could still build inside the bloc, then I think that would be something you could realize,” he said
              “If you could get the Palestinians to stop providing funds to the families of those who kill Israelis or try to kill Israelis or are in prisons because of that, it would send a message to the Israelis that something is changing.
              “You could do things which resonate on each side. When you have disbelief, it’s not like you can suddenly flick a light switch and everything is fine.”

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              Philippines’ Duterte looks to strengthen ties with trip to Moscow

              (CNN)Philippines President Rodrigo Duterte will depart on an official five-day visit to Moscow Monday, as part of an effort to realign his country’s foreign policy away from longtime ally the United States.

              Under Duterte, who took office in June 2016, the Philippines has made overtures toward Beijing and Moscow — seeing the countries as a source of much-needed investment — and away from the US, which, despite a mutual defense treaty, Duterte regards as unreliable and hypocritical.
              Over the weekend, Duterte indicated that one of the top priorities of the trip would be to acquire Russian-made precision armaments, to use against Islamist militants in the Southern Philippines, local media reported.
                “I’ve been scouting around for (a weapon to finish them off)… I’m going to Russia. Same purpose. If they can spare us the precision-guided (bombs)… we have so many smart bombs but not as accurate as the ones guided by laser or satellite,” he said at a Philippine Coast Guard Auxillary national convention, according to the Philstar.
                The trip, alongside recent visits to China, is designed to diversify the Southeast Asian nations’ trade as relations with allies such as the European Union and the US become increasingly chilly.
                Russian President Vladimir Putin extended the invitation on the sidelines of an APEC summit in Peru last November, according to Russia’s Department of Foreign Affairs spokeswoman Maria Natividad.
                The trip sends “a strong message of the Philippines’ commitment to seek new partnerships and strengthen relations with nontraditional partners” such as Russia, Natividad said.

                  Who is Rodrigo Duterte?

                First visit

                The visit to Moscow and St. Petersburg marks the first time Duterte will visit Russia and his administration hopes it will “mark a new chapter in Philippine-Russia relations,” she added.
                It will kick off with a bilateral meeting between Duterte and Prime Minister Dmitry Medvedev, before the Philippines’ president gives a policy speech at the Moscow State Institute of International Relations (MGIMO) on the Philippines’ independent foreign policy and “his ideas on how to achieve peace and security, especially in the Asia Pacific region.”
                He will then meet Russian President Vladimir Putin — who Duterte previously described as his “favorite hero” — before hosting a gathering of expatriate Filipinos who have settled in Russia and surrounding countries.
                The two countries last year marked 40 years of diplomatic relations, but ties remain “best described as cordial albeit modest in scope and depth,” Natividad said at a pre-departure briefing for the press ahead of the trip.
                The trip, which a trade delegation will also attend, is expected to lead to deals in defense, security, legal assistance, tourism, the “peaceful use of nuclear energy” and cultural exchange.
                Bilateral trade in 2016 totaled $226 million, with the Philippines only exporting $49 million worth of goods to Russia, Natividad said.
                Western countries have taken issue with Duterte’s track record on human rights since taking office — his police force has waged a bloody war on drugs over the past year, with extrajudicial killings of dealers and users numbering the thousands.
                Following reports late last year that the US State Department had halted the sale of an estimated 26,000 assault rifles to Philippines police, Duterte suggested that he would look to Russia for arms deals instead.
                “They’re blackmailing me that they won’t sell weapons? We have lots of explosives here,” Duterte said, according to CNN Philippines.
                “I remember what the Russian diplomat said: Come to Russia, we all have here anything you need.”
                The Philippines has also distanced itself from the European Union, recently rejecting an aid package worth around 250 million euros ($278 million) over the next three years, given as it was tied to commitments to improve human rights.
                “We cannot accept aid with conditions,” Foreign Affairs Minister Alan Peter Cayetano said.
                “We’re just telling them very respectfully: we believe in our independence. We know our problems better than you. You are welcome here. Let’s do business but we will not accept aid if there are conditions or you will interfere.”

                  China influence tests US – Philippines alliance


                Duterte has a “very long, complex history of anti-Americanism,” Joshua Kurlantzick, a Southeast Asia fellow at the Council on Foreign Relations told CNN, and his relationship with former President Barack Obama was particularly fractious, with the Filipino leader once calling Trump’s predecessor a “son of a bitch.”
                Kurlantzick suggested that while Duterte is likely to visit Washington he may not want to appear as though he is embracing the US, given how much he has courted China and Russia.
                Trump recently extended a White House invitation to Duterte during a “very friendly conversation,” triggering an avalanche of criticism from human rights groups.

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