Block 33 H&S Flashcards
Sources of funding for the NHS?
- taxation: compulory taxation e.g. income or sales - often on ability to pay and tends to be redistrubutive
- statutory insurance: customers eligible for services depending on their insurance cover
- out of pocket - private payment at the point of receiving services e.g. dentist, pharmacy
- private insurance
Entitlement to the NHS?
- visitors may not be entitled to HC or have to make additional payments
regulation of the NHS?
- quality of care comission
- Govs regulate healthcare financing, provision and entitlement
- ensures quality and necessity of provision
Idea of a NHS was opposed by
- Churchill and the BMA
- doctors feared it would take their independence and privilege
Who was in support of the NHS?
- women (and the silent majority) alonsgide younger medical professionals were more supportive
NHS largely suceeded due to?
- labour MP Nye Bevan
- underpinned by socialist ideas
- before the NHS ppl lived in fear of getting sick and not being able to work
NHS is based on the principles of?
- cradle to grave - HC is comprehensive and universal
- collectivism - all UK citizens pay taxes
- free at the point of entry
primary care services in the development of the NHS?
- uneven distribution of primary care services was a key problem at the formation of the NHS
- some areas were underdoctored - inverse care law
- 1950 - ministry of health commisoned a review of GPs
How was the primary care problem fixed?
- 1950 - ministry of health commisoned a review of GPs
- lead to provision of interest free loans for practice premises and control of geographical dist of GPs
Abortion act?
- 1967
- legalised abortions upto 28 wks gestation for all women
- prev was only legal when life of mother was in danger
- all of britain except NI
black report?
- 1980
- shows inequalities exist but also that the gap is widening
winter of discontent?
- 1978
- NHS financial problems worsen during winter of ‘78 to 79 bc of oil crisis
- widespread strikes across birtain following attempts to impose a pay freeze to control inflation
NHS reorganisation in 1990
the white paper?
- promoting better health
- suggests improvements in patient choice and widening of services provided by pharmacists and nurses
what did the white paper set out?
- quality and financial incentives to improve processes of delivery care
- extra pay for underraking health promotion and screening
- attempts to introduce medical audit into hosp and primary care
NICE?
- 1998
- to reduce variations in HC
Smoking ban?
- 2007
- in nearly all enclosed work places and public places in england
care quality comission?
- 2009
england
when was PHE set up?
2011
2016?
- junior doctors strike
- promoted by unsuccessful contract negotiations
- first doctors strike in 40 yrs
- withdrew from emergency and routine care
2018?
- Theresa May annouced that the nHS will receive a yearly inc of 3.4% in spending for the next 5 yrs - prev was 1%
- announcement of the 10 yr plan for the NHS
2019?
- NHS england publishes the LTP
- goals to reduce avoidable deaths
- local health and social care services to come together as intergrated care systems
2022 health and care act?
% of GDP spent on NHS post covid?
12
funding of NHS?
- General taxation with some from NI contributions
- used for day to day expenditure like salaries and medicine
social care funding?
– sep to NHS
- managed by LAs
other funding for the NHS?
- small amount from patient costs e.g. prescriptions or dentistry
budget for NHS?
2023-24: £187 B
how does the funding work?
- funds go to NHSE and NHSI
- they are resp for delivering the NHS LTP
- NHSE oversses comissioning of NHS services
NHS E allocates funds to?
- clinical comissioning groups which have been merged into intergrated care systems
the NHS LTP
ICS?
- STPs have changed into ICSs
- partnerships between hospitals, GPs, community services and other organisations
- aims to provide more joined up care provision
ICS means?
- gps coming together as PCNs
- LA areas collaborations between H&S care organisations including charity
ICP?
- Int care partnership
- each ICS has a committee resp for strategy in that area
ICB?
- Statutory NHS organisation resp for meeting population health needs and managing budget for services
roles of ICS
- reduce inequalities
- improve population health
- improve prevention
- support ppt w long term conditions/ MH issues
Challenges to the NHS?
- winter pressure - resp illnesses, ‘war rooms’
- workforcre shortages
- waiting lists
- cost of living crisis
Public statisfaction w the NHS?
- lowest since 1997
- key issue is access to services
alcohol health promotion?
- alcohol campaigns e/g/ Dry January which involves people stopping drinking for one month
- alcohol awareness week
- Drinkaware’s no more excuses
- alcoholics anonymous, narcotics anonymous
- drinkaware app
drug misuse health promotion?
- Frank - helpline for people concerned abt drug or solvent misuse
- addaction - helpline for those in need of addiction support for their families
- educational websites e.g. NHS inform
- cocaine anonmyous
3 elements of stigma?
- stereotypes
- prejudice
- discrimination
stereotypes?
assoc w misinfo/ lack of info
prejudice =
provlem of attitudes, exp negative feelings
discrimination?
comes from prejudice
public stigma?
- the way society faces the person with mental illness
- assoc w sterotypes and negative expectations such as incomptence, lack of character
how does public stigma affect ppl?
- often limits job opportunties, indep life of education to ppl w mental illness creating obtacles to well being, health and QOL
self stigma?
- leads to self depreciation and low self esteem
- leads to giving up on personal goals in education, relationships bc they believe they can’t correspond to the society’s expectations
self stigma also discourages the person from..
also discourages the person from seeking and adhering to treatment, inhibing will to recover
AQ-27 questionnaire?
- 9 dimensions of stigma
AQ-27 questionnaire - responsibility?
people withmental illnesscan control their
symptoms and are responsible for having the illness
AQ-27 questionnaire - pity?
people withmental illnessare overtaken by their own disorder and therefore deserve concern and pity
AQ-27 - anger?
people withmental illnessare blamed for having the
illness and provoke wrath and rage
AQ-27 questionnaire - dangerousness?
people withmental illnessare not safe); Fear
(people withmental illnessare dangerous)
AQ-27 questionnaire - help?
Ppl w mental illness need assistance
AQ-27 - coercion?
people withmental illnesshave to participate in treatment management
AQ-27 questionnaire - segregation?
people withmental illnessare sent to institutions separated from the community
AQ-27 questionnaire - avoidance?
patients withmental illnessdo not live in society
Stigma of mental illness - where does it come from?
- media portrayls- stigmatization or trivialization
- mental health and violence in media
Portrayal of schizophrenia?
- Characters with
schizophrenia are presented as “homicidal
maniacs” in “slasher” or “psycho killer” movies - overemphasis of positive symptoms
Trivialization of mental illness by the media?
- promoting MI as not being severe or as being less severe than it really is
- e.g. anorexia nervosa
over-simplification of MI by the media?
- e.g. OCD
- cleanliness and perfectionism
- symptoms portrayed as beneficial
Prev of a MH problem in 1 yr?
1 in 4 people in one year
schiz prev?
1%
Victimisation of the mentally ill?
- Patients with severe mental illness constitute a high-risk group vulnerable to fall victims to violence in the community.
- past traumatic and victimisation experiences have been found to be sig associated w patients symptom severity and illness course
consequences of stigma - life expectancy?
People with a diagnosis of severe
mental illness die on average 15-25
years before those without—largely
from preventable physical diseases
such as heart disease and diabetes.
Diagnostic overshadowing?
- evid that ppl w mental illness have poorer acces to physical healthcare and receice worse Tx for physical disorders when comp to general population
- Medical staff tend to treat physical illnesses of people withmental illnessless thoroughly and less effectively.
Parity =
- equal respect and hope when
dealing with difficult prognoses - lack of parity in those w severe, chronic schiz
psychiatric problems in medical professionals?
- delayed seeking mH Tx
- often only in a crisis situation
- fear of exposure to stigmatization from peers
4 main barriers to medical students seeking MH support?
- fear of repercussions
- med student expectations
- judgement
- lack of support
5 principles of mental capacity?
- A person must be assumed to have capacity unless it is established that he/she lacks capacity.
- A person is not to be treated as unable to make a decision unless all practicable steps to help him/her to doso have been
taken without success. - A person is not to be treated as unable to make a decision merely because he/she makes an unwise decision.
- An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his/ her best interests.
- Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as
effectively achieved in a way that is less restrictive of the person’s rights and freedom of action
capacity =
Capacityis related to a specific decision and if not a global impression of a person’s ability to make any or all decision
critria for capacity?
- ppt understands the info relevant to the decision
- ppt can retain the info
- ppt is able to weigh info as part of the process of making a decision
- ppt able to communicate his/ her decision - talking/ sign language
When a ppt is treated against their will for a physical health cause this must be done under
the capacity act
mental health act vs capacity act?
When both the capacity act and the mental health act can be used, that is criteria are met,mental health act will take
precedenceas the patient is then provided with the statutory safeguards provided by the act
MCA deprivation of liberty?
- MCA states thatif a ppt lacks capacity to make a decision abt medical treatment, the decision should be made on their behalf acting in their best interests
Restraints under the MCA?
- Under the MCA, restrictions and restraint, including restraint that restricts the person’s freedom of movement, are lawful
(under s. 6), provided that it is believed to be both ‘necessary’, and that it is “proportionate” to risk and severity of harm
what can effective leadership do?
- improve clinical outcomes e.g. mortality rates
- improve ppt exp and satisfaction
- imp staff exp
- improve ppt safety
Poor leadership report?
- Ockenden report
- highligjts that if Shewbury and Telford NHS trust had provided better care the deaths of 201 babies could have been avoided
what is leadership?
- A process whereby an individual
influences a group of individuals to achieve a common goal. - influencing indiv to contribute to gr goals and co-ordinating the pursuit of those goals
Direct leadership?
leader influences followers through direct communication w them
indirect leadership?
- cascading through hierachy
- influencing organisational culture
- developing structures and processes
Layers of healthcare leadership - macro?
- setting global/ national healthcare policy
- co-ordinating lobal response to health issues
Meso leadership?
- leadership of healthcare organisation e.g. chief exec
- resp for community level HC e.g. director of PH
Micro leadership?
- leadership of clinical area
- indiv HC teams
Leadership vs management - what they produce
- leadership produces change and movement
- management produces order and const
Leadership - 3 key elements?
- establishing direction
- aligning ppl
- motivating and inspiring
Management - 3 key elements?
- planning and budgeting
- organising and staffing
- control and problem solving
(WHO) - in healthcare leaders set the…
strategic vision and mobilize efforts towards its realization
(WHO) - managers ensure…
effective
organization and utilization
of resources to achieve
results and meet the aims.
What are teams?
set of indiv working together towards a shared outcome
How do teams differ from co-acting./ pseudo-teams?
the latter may simply be working in close proximity
characteristics of healthcare teams?
- differentiated skill levels due to MDTs
- differentiated authority levels and involvement in DM
- high prev of short lived teams
Fundamentals of effective teamwork?
- compelling direction
- strong structure
- supportive context
- shared mindset
assessing leadership - self assessment?
- imp element of leadership development but weakness such as
- incomplete info - one source
- overestimation of effectiveness - dunning kruger
- underestimation- imposter syndrome
performance appraisal?
- usually one type of feedback
- may perpetuate culture of the organisation
- may be too focused on organisational goals
Multi-source/ 360 feedback?
- process in which leaders receive feedback from at least 2 rating sources
- collects data on perceived behaviours
- analyses and compares data across ppl and time
Steps in learning abt leadership - experiental learning?
- conc experience
- reflective observation
- abstract conceptualisation
- active experimentation
concrete exp?
learning through actual encounters with the phenomena abt which learning is taking place
reflective observation?
reflecting on a phenomenon in order to learn more abbt it
abstract conceptualisation?
using experience and knowledge to develop ideas and theories
active experimentation?
applying what u know abt leadership and testing this in practice
GMP - working w colleagues?
You must not demonstrate uninvited or unwelcome behaviour
that can be reasonably interpreted as sexual and that offends,
embarrasses, humiliates, intimidates, or otherwise harms an
individual or group
GMP - domain 1
Knowledge, skills and performance
- responding positively to the learning process
- reflecting abt study and clinical work
- working within the limits of competency
- consent
GMP - Domain 2 - Safety and quality
- being open and honest if something goes wrong
- raising concerns including peers and staff
- having insight into your own health and following medical advice
GMP - communication, partnership and teamwork?
- communicate effectively
- maintaining confidentiality
- polite to patients and respect their dignitiy and privacy
GMP - domain 4 - maintaining trust?
- not pursuing relationships w patients
- respecting patients beliefs and lifestyle choices
- not discriminating
- acting w honesty
The MHA only authorises detention for the…
assessment or treatment of a mental disorder
Key features of the liberty protection safeguards:
- apply to those 16+
- deprivations of liberty have to be authorised in advance by the responsible body
For the responsible body to authorise any deprivation of liberty it needs to be clear that:
- the person lacks capacity to consent
- the person has a mental disorder
- the arrangements are necessary to prevent harm to the person
Deprivation of liberty can be for a maximum of…
- 1 yr initially
- under LPS can be renewed intially for 1 year but subsequent to that for up to 3
Safeguards once a DoL is authorised?
- reg reviews by the resp body
- right to an independent MC advocate
if a ppt has not been detained under the mental health act, ? applies
If a patient has not been detained under the Mental Health Act,
consent, capacity and best interests applies, even if the proposed
treatment is for a mental disorder.
what cannot be authorised by the MHA?
- medical treatment for conditions unconnected to the medical disorder
once a patient is detained under the MHA,
consent is not required
for the administration of psychiatric treatment.
Second opinion approved doctors?
- SOAD will speak to the patients consultant, nurse and an allied HP
- will authorise the Tx if satisfied
- consultant psychiatrist visiting hospital where they don’t normally work
what requires referral to SOAD?
ECT w/o capacity
Patient has capacity to decide:
- Patient consents: Informal admission
- Patient does not consent: Consider MHA
Patient lacks capacity to decide and patient does not object:
- Admit under MCA
- Patient objects: Consider MHA
section 2?
- detains for up to 28 days for the purpose of assessment
criteria for a s2 detention?
- mental disorder
- warrants detention for assessment
- in the interests of the patients health or safety
detention under s2 cannot be extended beyond…
- 28 days
- once this period ends ppts must either be discharged or remain as a voluntary ppt or be detained under s3
s3 detainment =
- detained for the purpose of Tx
S3 - detainment criteria also involves that
- necessary treatment can’t be provided unless they’re detained if community based possible do that)
- appropriate medical treatment is available
s3 admission can be renewed if after ? months the ppt still meets criteria for detention
6
Who can detain ppts?
- 2 doctors needed for a s2 or s3
- one of the doctors must have prior approval under s12 MHA
- AMHP who is not a doctor must meet the ppt and discuss case w nearest relative
sectioning - if AMHP accepts the 2 medical recommendations for admission they can
apply for the ppt to be admitted and convey them to hosp
section 4?
- cases of urgent necessity
- an AMHP can make an emergency application for admission under only one medical recommendation
- which must be made by a s12 approved doctor
section 4 lasts for…
- lasts 72 hrs
- enables ppt to be admitted to MH unit whilst arrangements for assessment or detention being made
section 5?
If a patient has already been admitted to hospital informally but then withdraws consent or, if they lack capacity, shows signs of objection
section 5 provides?
emergency holding powers which justify restraining the
patient from leaving, enabling time for a full assessment for
detention under s2 or s3
S5-2 doctors holding powers?
authorise the hospital to detain the
patient for up to 72 hours
S5 (4) - nurses holding power?
authorise the hospital to detain the
patient for up to six hours
section 136?
- police
- detain in place of safety for upto 24 hrs - extendable to 36 hrs by a doctor
- person must be in a public place
under what circumstances does the mental health act take precedence over the MCA?
When the patient has a mental disorder and requires
treatment for this mental disorder.
statutory resp =
- agencies that have a legal right to intervene in child abuse is suspected are: social services, police, National Society for the Prevention of Cruelty to Children (NSPCC)
roles of social workers?
- The job of the social worker is to safeguard and promote the welfare of children.
- They work with families/carers and with other professionals to keep children safe and healthy.
when may social workers become involved w a family?
- They may become involved with families/carers due to poverty, child abuse, mental health problems, disabilities or conditions such as ADHD
police?
- identifying if there is a history of unlawful Tx and drugs or alcohol
- history of violence including domestic abuse, sexual offences and any other matter relevant to the welfare of the child
NSPCC?
- This is a voluntary organisation with a statutory right to apply for a court order to safeguard children. It has a team of social workers who work together with local social workers.
- Its goal is to prevent abuse and it works with those children who are most vulnerable
statutory duties?
- all organisations that work with children share a commitment to safeguard and promote welfare - statutory duties
contributions to personality development?
- genetic influence - twin studies
- some evidence for inheritance - cluster B, familial relationship between schizotypical and schizophrenia, bipolar, affective disorders
- adverse intrauterine and perinatal and postnatal experience - affects neurodevelopment
Illness behaviour =
- the ways in which given symptoms may be differentially perceived, evaluated, and acted (or not acted) upon by different kinds of persons.“
what is disease?
disorder due to organic pathology.
what is illness?
the state experienced by a person who perceives him or herself as suffering from ill-health.
the sick role?
- role in society occupied by a person who has declared himself as ill, and whose illness has been legitimised by a doctor, or by family or friends
obligations of the sick role?
- The person must want to get well as soon as possible.
- They should seek professional medical advice and cooperate with the doctor.
priv of the sick role?
- The person is allowed (and perhaps expected) to shed some normal responsibilities and activities.
- They are regarded as being in need of care and unable to get better by his/her own will.
abn illness behaviours?
- inappropriately perceiving, evaluating and acting in relation to their health
illness denial?
- Behaviours to avoid the ‘stigma’
- Inability to accept the physical/mental disease
illness affirmation?
- behaviours which inappropriately affirm illness behaviours
- Invalidism
- Disproportionate disability compared to symptoms/signs
types of abn illness behaviour>
- illness affirmation
- illness denial
predisposing factors in somatisation ?
- History of early (chronic) physical illness:family or patient
- Somatic vocabulary
- alexithymia / LD / difficulties establishing mental representations of emotion
- Childhood neglect / abuse
- Early regime: attention for physical illness but not for emotional distress
- central pain mechanisms
- emotional avoidance culture
- absent, insufficient or dismissive communication with significant adults…
- difficulty communicating about problems, concerns and emotions re: stress
MUS - precipitating factors?
- stressful events can often trigger it
- life events - losses, threats, traumatas
- acute disease e.g. viral illness
perpetuating factors in MUS?
- Dilemma / conflict resolution
- Role changes / reduced social responsibility and expectation
- Changing dynamics of relationships
- Physical consequences of illness behaviour
- Iatrogenic harm
- public recognition of suffering
Leventhal suggested that patients?
- organise their understanding of their illness around five areas, called illness representations
- identity
- cause
- consequences
- timeline
- control/cure
Leventhal - identity?
- Symptoms, concrete signs, labels, diagnosis, what they think it is
Leventhal - cause?
- Perceived causes; includes internal and external attributions
Leventhal - consq?
- Perceived physical, social, economic, emotional consequences
leventhal - timelines?
- Perceived timescale for development and duration of illness
leventhal - cure/ control?
- By individual or external means
the illness perception questionnaire (IPQ)?
- Derived from Leventhal’s self regulatory model
- quantitative measure
- provides clinician w qualitative framework for useful discussion w the patient
emotional response to health threat?
- depression and anxiety are twice as common in patients with medical problems than in the general population
- associated w significant morbidity and mortality
- hospital anxiety and depression scale
problem focused coping strategies?
- learning new sklls
- seeking support and information
- developing new interests if previous ones are compromised by illness
- actively participating in Tx
emotion focused coping strategies?
- shared feelings and concerns abt illness
- acknowleding loss
- emotional support through religion
- giving up unrealistic hopes of reovery
- distancing - temporarily closing off emotional worries in order to cope
coping strategies that aren’t helpfiul
- denial - if it prevents the patient from seeing appropriate tx
- Obsessively focusing on minute details of the medical problem
- Preoccupation with medical/health, fringe/alternative websites, leading to over interpretation or misinterpretation of symptoms
- Seeking to blame someone else
Primary prevention for MH?
- targets those individuals vulnerable to developing mental disorders and their consequences because of their bio-psycho-social attributes
- MH awareness programs in schools, and suicide risk prevention programs in the community
Secondary prevention for mH
- LGBTQIA+ support programs, grief and loss groups, single parent support groups, and trauma recovery support
higher rates of alcoholism in:
- urban areas
- divorced/ separated
- those who manufacture, or sell alcohol
- commercial travellers, frequent overseas travellers
- entertainers, doctors, journalists
- North American, Afro-Caribbean, Irish
lower rates of alcoholism in:
- ‘middle’ social groups
- Jewish, Chinese
social effects of alcohol - inc rates of?
- physical / sexual abuse of partner
- divorce
- child abuse
- later alcoholism in children
social effects of alcohol - emp?
- 2 ½ times as many days off work
- decreased productivity
- increased accidents at work
social effects of alc - accidents?
- 80 % of fatal car accidents involve alcohol
- 40 % of casualty trauma involves alcohol
What does it increase ur risk of and suicide rate?
psychiatric complications of alc?
- almost half of alcoholics meet criteria for another psychiatric disorder
- affective disorders - depressive symptoms, contemplation of suicide
- alcoholics have 7x the expected suicide rate
schiz and alc?
- Schizophrenia - schizophrenic symptoms can occasionally be triggered by heavy drinking, which remit when the patient is detoxed
what is MI?
A directive, patient-centred counselling style that aims to help patients explore and resolve their ambivalence about behaviour change.
4 principles of MI?
- empathy
- discrepency
- address resistance
- support self efficacy
MI - empathy?
- Express empathy by using reflective listening to convey understanding of the patient’s point of view and underlying drives
MI - discrepency?
- Develop the discrepancy between the patient’s most deeply held values and their current behaviour (i.e. tease out ways in which current unhealthy behaviours conflict with the wish to ‘be good’ – or to be viewed to be good)
MI - resistance?
- Sidestep resistance by responding with empathy and understanding rather than confrontation
MI - self -efficacy?
- Support self-efficacy by building the patient’s confidence that change is possible
stages of change in the cycle of change model?
PCPAML
pre-contemplation?
- doesn’t recognise the problem
- no reason to change
contemplation stage?
*Ambivalence
*“I might have a problem”
*Apprehension, fear of change.
preparation stage?
ppt ready to engage in change process
action stage?
- noticable change in beh
- re-inforcement and support
- understand factors and strategies supporting the new behaviour
maintenance stage?
- consolidation of change
- skills development
what can be done during the maintenance stage?
- Support and encouragement
- Provision of support systems
- Design of relapse prevention plans
What can be done during the lapse/relapse stage?
- Re-engagement with services and supports available.
- Exploration of reasons for relapse and learn from lapse experience
- Review of relapse prevention plan.
effects on life of drinking?
- relationships
- occupation
- do they currently drive? for work? driving under the influence
impacts of addiction on society
- child neglect
- loss of productivity - days off associated w ill health
- increased crime rates
- substance related conditions e.g. liver disease -> increased healthcare cost
- increased risk of homelessness and provery
impact of addiction on family
- distressing for the family
- child neglect/ abuse
- children may develop addiction at an early age
- increased domestic disputes
envir damage from drugs?
- environmental damage from drugs e.g. methamphetamine or cannabis
impacts of addiction on the indiv?
- health conditions - MH, lung, cardiac etc
- side effects - depression, psychosis
- loss of job
- loss of relationships
- finances - cost of alcohol/ drugs, inability to work
RF for drug taking
- early aggressive factors
- lack of parental supervision
- academic problem
- peer substance use
- drug availability
- child abuse/ neglect
- poverty
social RF for taking drugs?
- peer pressure
- lack of family involvement
- attitudes towards drugs/ alcohol
social and environmental factors for taking drugs?
- poor school achievement, unemployment, social deprivation, history of criminal activity, peer influence, and normalisation of substance misuse in the individual’s culture or peer group.
psych theories of dependence - classical conditoning?
- drinking alcohol is associated with a pleasurable feeling
- triggering craving for the drug
- craving may be triggered by familiar internal states (like anxiety, depression, loneliness) that were previously alleviated by taking drugs.
psych theories of dependence - operant conditioning?
- A person might use a drug for the first time and enjoy the feelings it creates, which is apositive reinforcementfor the behavior.
- negative reinforcement - relief of pain, low, mood, anxiety
psych theories - SLT?
- watching others engaging in the behaviour - modelling
Psych theories of dependence - self medictaion theories?
- The underlying basis for the pain that is being medicated is usually attributed to trauma—adverse childhood experiences (ACES), sexual or violence trauma as an adult, or other experiences associated with post-traumatic stress.
biological theories - dopamine?
- positive reinforcing effect of alcohol comes from the dopaminergic reward pathway in the limbic system
- dopamine is released in the VTA and projects to the NA where it is involved in motivation and reinforcement behaviours - mesolimbic pathway
Psych management of alcohol dependence?
- MI in the initial assessment
- psychological interventions - CBT, behavioural therapies or social network therapies focused on alcohol-related cognitions, behaviour, problems and social networks
what should MI include?
- helping people to recognise problems or potential problems related to their drinking
- helping to resolve ambivalence and encourage positive change and belief in the ability to change
- adopting a persuasive and supportive rather than an argumentative and confrontational position.
how does co-working with other NHS specialities maintain high qual patient care?
- collaborative approach - combined expertise
- seamless care
- improvement in decision making
- working with local authorities - supported employment
- better targeting of resources
- better prevention
capacity is the ability to:
—Receive and retain relevant information
—Balance costs benefit.
—Communicate decision
adults w capacity can refuse treatment unless
the treatment is for mental disorder when treated under the mental health act
core principles of the MCA 2005?
1.Adults are assumed to have capacity. A lack of capacity has to be clearly demonstrated.
2. No-one should be treated as unable to make a decision unless all practicable steps to help them have been exhausted and shown not to work.
3. A person can make an unwise decision.
4. If it is decided that a person lacks capacity then any decision taken on their behalf must be in their best interests.
5. Any decision should show that the least restrictive option or intervention is achieved.
what is required in order for conset to be valid?
- Have Capacity
- Act under free will (not pressurised)
- Provided with enough information.
role of psychiatry?
- work as part of the community team
- diagnose and treat mental illness
- assess risk
- offer advice on medication
role of community nursing?
- advice and support on:
- Your mental health
- Your physical health e.g. health screening and promotion
- Epilepsy and seizures
role of social care nursing?
- assessment needs - talking to the person and their carers to decice what support they need
- making sure they get the support e.g. residental housing or respite or day services
speech and language therapy?
- looks at total communication
- communication books or aids w pictures or symbols
- looks at ppls eating drinking and swallowing skills
- looks at how much ppl understand
role pf physiotherapy?
- help w mobility/ exercise
- assist at wheelchair and orthotics clinics
- help w 24hr postural management
role of OT?
- Help w everyday tasks like:
- domestic activities
- help w finding: easier way of doing things
- help to learn new skills and be more independent
health inequalities faced by ppl w LDs?
- people w IDs enjoy less good health and are less likely to attend GP
- less likely to be invited for screening
- much more likely to die young
additional health needs for those with learning difficulties?
- 25% hearing or visual impairment, epilepsy
- 5x increased risk of sudden death in epilepsy
- upto 20% have mental health problems
barriers to healthcare w LDs?
- not understanding letters
- phone system
- touch screen system
- not being able to read badges
- confusion between diff roles e.g. psychiatrist, nephrologist
- using big words
- talking to carers instead of them
improving care for those w LDs?
- transforming care partnerships
- community Tx reviews
- LD mortality review
- annual healchecks
- hospital passports/ flagging systems
community treatment reviewS?
- community treatment reviews - called when someone is admitted to hospital
- expert and senior member of commissioning group which try and find altns to hospital admission
LD mortality review?
- Learning disabilitity mortality review - anyone who dies w a LD is reported to this body, tasked w investigating the death to see if anything could ahve been done to prevent it
flagging system?
- hospital passports/ flagging systems - identifies key details abt the person so the team caring for them know how to support them
acute liason nurses?
to ensure they recieve the same outcome as other ppl
green light toolkit?
- green light toolkit - ensures ppl w LDs are not disadvantaged when they access MH services
reasonable adjustments for LDs?
- easy read letters
- longer appts
- awareness training
- flagging system
- quieter areas to wait, not having to wait
- visit to a department to look round prior to appt
MDT members in a community LD team?
- MDT: psychiatrist, psychology, nursing, OT. physio, AHP (social care)
- reasaonable adjustments made to meet the health needs of ppl w LDs
co-morbities w LD?
- ADHD is the most common co-morbidities
- anxiety, mood disorder, language disorder
What is diagnostic overshadowing?
- Diagnostic overshadowing occurs when a health professional makes the assumption that a person with learning disabilities’ behaviour is a part of their disability without exploring other factors such as biological determinants
- Attributing all other problems to the learning disability
when can diagnostic overshadowing occur?
- Diagnostic overshadowing can occur during an assessment, such as when a health professional interprets a person with a learning disability rubbing their heads as a behaviour linked to their learning disability and fails to investigate any possible underlying health cause
people with learning disabilities have worse health outcomes than the general population. These include:
- reduced access to and less likely to receive interventions for their obesity
- greater risk of death from avoidable causes
- low take up of national cancer screening programmes
- low uptake of vaccinations
- increased risk of death due to resp infection - one of the highest causes of amenable death
how can diagnostic overshadowing be avoided?
- don’t make assumptions
- always communicating with the patient directly
- Assess people’s health and wellbeing so that any changes in behaviour that may signify changes in condition or an illness are not attributed to their learning disability
- pay attention to non verbal communication e.g. body position, painm anx
- seek help from patient’s family/ carers to get to know the person better
how can psychiatric disorders present in LDs?
- response to frustration - impulsive, stubborn, aggressive
- passitivity, withdrawal, compliance
- poor frustration tolerance can cause aggression towards caregivers or self-injurious behaviour
- challenging behaviour may be a way of asking for somthing - to be stopped, or for attention e.g.
Assessing suicide risk?
*What taken/done
*How much
*When
*What with – alcohol/drugs
*Where
*Anyone present
- How/when obtained
*Did they tell anybody afterwards?
*Delay in seeking help?
*How came to hospital?
*How long thinking about?
*How often – how intrusive?
*Degree of planning?
*saving or purchasing in advance
*were they expecting to be found
concealment/timing
self harm assessment - prepatory acts?
- affairs – bills etc
- will
- pets
- turning off services
- visit to significant others beforehand
- note ??
other things to ask in a self harm assessment?
- past history of SH
- past psych history
- current psych history
DSH or failed suicide
self harm assessment - screening for social stresses?
*relationships
*housing
*employment
*debt
- criminal proceedings
section 2?
- Detain inpatient 72 hours – for assessment to be made with a view to an application for admission being made -
- mental disorder
- risks
- unwilling to remain informally
- Does not authorise treatment
- Start MHA assessment process
who can place a patient under a section 2?
*Doctor in charge of treatment or nominated deputy
*If no current psychiatric involvement - consultant medic/surgeon…
*If patient open to psych -medic or psychiatrist
RF for self harm?
- Socio-economic disadvantage.
- Socialisolation.
- Stressful life events, for example relationship difficulties,
- Bereavement by suicide.
- Mental health problems
- Chronic physical health problems.
- Alcohol and/or drug misuse.
- Involvement with the criminal justice system (with people in prison being at particular risk).
self harm rates peak in which age gr?
- 16 to 24 women
- 25 to 34-year-old men.
suicide rates peak in the ? age
- Suicide rates are highest in both men and women aged 45–49 years.
RF for suicide?
- Male
- Older
- Widowed/separated/single
- Living alone/social isolation
- Low income/unemployed
- Certain occupation (e.g. doctor, farmer)
- Family history of suicide
epidemiology of self harm and suicide?
- 1:10 young ppl
- F>M 1.5-2.2:1
- age
groups of people more likely to self harm?
- divorced people more likely to self harm
- adversity
- substance misuse
- childhood abuse
- gay and bisexual
suicide rates after self harming?
- 50X higher suicide rates within 5-10 yrs
- higher suicide rate in men and higher self harm rates for women
commonest form of self harm?
- overdose - 80%
- cutting
- RF for later cutting
management of Self harm?
- CBT or problem solving therapy that is spec tailored for self harming - ASAP
- dialectical behaviour therapy adapted for adolescents - DBT-A for young ppl and children
creating a safety plan for self harm?
- establish the means of self-harm
- recognise the triggers and warning signs of increased distress, further self-harm or a suicidal crisis
- identify individualised coping strategies, including problem solving any factors that may act as a barrier
- identify social contacts and social settings as a means of distraction from suicidal thoughts or escalating crisis
- identify family members or friends to provide support and/or help resolve the crisis
- include contact details for the mental health service, including out‑of‑hours services and emergency contact details
- keep the environment safe by working collaboratively to remove or restrict lethal means of suicide.
harm minimisation - self harm?
- distraction techniques or coping strategies
- approaches to self care
- wound hygiene and aftercare
- providing factual information on the potential complications of self-harm
- the impact of alcohol and recreational drugs on the urge to self-harm.
when should a person be referred to MH services (community mental health teams and liason psychiatry teams)?
- The person’s levels of concern or distress are rising, high or sustained.
- The frequency or degree of self-harm or suicidal intent is increasing.
- The person providing assessment in primary care is concerned.
- The person asks for further support from mental health services.
- Levels of distress in family members or carers of children, young people and adults are rising, high or sustained, despite attempts to help.
