HaDSoc Flashcards
1
Q
Explain what clinical governance means and its implications for the work of doctors
A
A framework through which NHS organisations are accountable for continuously improving the quality and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish
The Health and Social Care Act 2012 means that doctors need to strive for continuous improvement in:
- The effectiveness of services
- The Safety of services
- The quality of the patient experience
2
Q
Describe evidence demonstrating problems of quality and safety in healthcare
A
- Variations in healthcare suggest not everyone is getting the best care
- Over-reliance on individual responsibility
- System failures
- Not enough or not right defences built in
3
Q
What is an adverse event and a preventable adverse event?
A
Adverse event = an injury that is caused by medical management and that prolongs the hospitilisation and/or produces a disability (allergic reaction to drug)
Preventable adverse event = an adverse event that could be prevented given the current state of medical knowledge (operation on wrong side of body)
4
Q
Describe the 3 different types of error
A
- Slips/lapses = error of action
- Giving 0.5mg when meaning to give 0.05mg
- Mistake = error of knowledge
- Misdiagnosing
- Violation = intentional deviations from protocol
- Not using aseptic technique when inserting a catheter
5
Q
Describe a way to conceptualise quality in healthcare
A
Swiss Cheese Model
- Successive layers of defences
- Hazards can penetrate through defences due to:
- Active failures = acts that lead directly to the patient being harmed (wrong dose given)
- Latent conditions = predisposing conditions that increase the likelihood of active failures to occur (poor training)
6
Q
Explain how a systems-based approach can promote quality in health care
A
Remove the human factors:
- Avoid reliance on memory
- Make things visible
- Simplify and standardise processes and procesdures
- Routinely use checklists
- Decrease reliance on vigilance
7
Q
Describe some policies and organisations that encourage quality in the NHS
A
- Standard setting by NICE
- Commissioning - CCG commission service for local populations through contracts
- Financial incentives
- Quality and Outcomes Framework - points generate income
- Discolsure of information about performance
- Registration with Care Quality Commission
- Inspection by CQC
- Clinical audit = quality improvement process that improves patient care through systematic review against criteria
- Professional regulation (doctors must prove they are fit to practice)
8
Q
Describe a range of social science methods for investigating health and illness
A
Social research allows questions about social life to be answered.
- Quantitative - collection of numerical data
- Qualitative - understanding perspective of the situation
9
Q
Describe quantitative research methods and include some examples
A
- Collection of numerical data
- Begins with an idea/hypothesis
- Allows conclusions to be drawn about relationships between variables
- Allows for repeatability and reliability
- Some examples include questionnaires, RCTs, cohort study, case-control study
10
Q
Why are questionnaires a good research method?
A
- Measure exposure to risk factors and effects of lifestyle
- Learn about differing knowledge and attitudes
- Ask about satisfaction with the health service
11
Q
What is the difference between valid and reliable?
A
Valid = measure what they’re supposed to measure
Reliable = measure things consistently (differences should come from difference between participants only)
12
Q
What are the positives and negatives of quantitative research methods?
A
Positives:
- Good at describing and measuring
- Finds relationships between variables
- Good at comparisons
Negatives:
- Can force people into inappropriate categories
- Doesn’t allow choice of expression
- Sometimes cannot establish causality
13
Q
Describe qualitative research methods
A
- Makes sense of phenomina in terms of meanings people bring to them
- Understanding of perspective
- Based on researchers interpretation
- Can provide insights into behaviours
14
Q
Describe the different types of qualitative research methods
A
- Ethnography = studying human behaviour in a natural context
- Participant/non-participant observation
- Interviews
- Clear agenda of topics but in a conversational style
- Participants provide their perspective
- Focus groups
- Accessing a collective understanding
- Not useful for individual views
- Requires a fairly homogenous group
- Documentary and media analysis
- Independent evidence (medical records)
- Provides a historical context
15
Q
What are the positives and negatives of qualitative research methods?
A
Positives:
- Understanding perspective
- Accessive information not revealed in a quantitative approach
- Explaining relationships between variables
Negatives:
- Less good for finding consistent relationships between variables
- Not good for generalisability
16
Q
What is evidence-based practice?
A
Integrates the best external evidence with individual clinical expertise and patients’ choice
- Not a ‘cookbook’ approach
- Clinical evidence should inform but not replace individual clinical expertise
17
Q
What are the origins of evidenc-based practice?
A
- Health service should be based on best available evidence via rigorously conducted research
- Ineffective/inappropriate interventions waste resources
- Variations in treatment create equities
- Previous practice influenced by professional opinion, clinical fashion and historical practice
- Not research
- Cochrane called for a register of all RCTs in Obs and Gynae
18
Q
Why are systematic reviews needed?
A
- Traditional literature reviews may be biased and subjective
- Variable quality of studies reviewed
- Highlights gaps in research
- Offer authoritative, generalisable and up-to-date conclusions
- Can reduce delay between research discoveries and clinical implementation
19
Q
List some practical criticisms of evidence-based practice
A
- Difficult to create and maintain systematic reviews across all specialities
- Challenging and expensive to implement findings
- Requires ‘good faith’ towards pharmaceutical companies
- RCTs are not always feasible or necessary
20
Q
List some philosophical criticisms with evidence-based practice
A
- May not work for individual patients
- Potential to create ‘unreflective rule followers’
- Increased paperwork if not followed
- ‘Cookbook’ medicine
- Professional responsibility/autonomy
21
Q
Describe some problems with implementing evidence-based practice
A
- Evidence exists but doctors are unaware
- Not incentivised to keep up to date
- Doctors are aware of evidence but don’t use it
- Organisational systems cannot support innovation
- Managers lack authority to invoke change
- Resources not available
- Financial or human
- Commissioning decisions reflect different priorities
22
Q
Describe the relationship between health and social class, ethnicity and gender
A
- The more deprived a population, the lower their life-expectancy and disability-free life expectancy
- Ethnicity varies:
- Cardiovascular risk increases is south asians
- Cancer risk decreases in blacks
- Infant mortality increases in Pakistani and black Caribbean
- Gender varies due to hormonal and reproductive differences and social factors (roles/norm)
23
Q
List some explanations for inequalities in health
A
Black report:
- Artefact explanation
- Social selection
- Behavioural-cultural
- Materialist explanation
Others:
- Psychosocial explanation
- Income distribution
24
Q
Describe the artefact explanation to inequalities in health
A
Health inequalities are evident due to the way statistics are collected
- Discredited theory
- Concerns about quality of data and methods of measurement
25
Describe the social selection explanation to inequalities in health
Direction of causation is from health status to social position
* Sick individuals move down social hierachy
* Chronically ill and disabled more disadvantaged
* Makes only minor contribution to socioeconomic differentials
26
Describe the behavioural-cultural explanation to inequalities in health and include some limitations
Ill health is due to people's decisions/choices, knowledge and goals
* People from lower socioeconomic classes tend to engage more in unhealthy behaviours
* Possibly to due to poorer health education
Limitations of theory:
* Behaviours are outcomes of social processes, not individual choice
* Choice can be difficult to exercise in adverse conditions/lack of resources
27
Describe the materialist explanation to inequalities in health, including limitations
Inequalities arise from differential access to material resources (e.g. Low income/poor housing/unemployment)
* Lack of choice to exposure to hazards
* Most plausible theory
Limitations:
* More research needed into specific into precise routes
28
Describe the psychosocial explanation to inequalities in health
* Some stressors are distributed on a social gradient
* Impact of stress on health
* Inequalities in society lead to further stress and inequalities in health
29
Describe the income distribution explanation to inequalities in health
Relative income affects health
* Countries with greater income inequalities have greater health inequalities
* Egalitarian countries have better health
* Health effects due to increased stress
* Social cohesion is important in health
30
What is the difference between inequality and inequity?
Inequality = when things are different and not equal
Inequity = inequalities that are unfair and avoidable
Inequality can exist without inequity
31
Describe the link between socioeconomic status and inequalities in health care
More deprived groups have higher rates of GP and emergency services and underuse of preventative and specialist services
* Manage health as a series of crises
* Normalisation of ill health
* Difficulty marshalling the resources needed
* Reflects lack of cultural alignment between health services and lower SES
32
How can ethnicity affect healthcare?
* Potential discrimination in service provision
* Language barrier
* Genetic factors
* Cultural norms may prevent access to healthcare (e.g. mental health)
* Stigmitisation and stereotyping
33
Explain why understanding lay beliefs is important in medical practice
Lay beliefs impact on:
* Health behaviour = activity undertaken for purpose of maintaining health and preventing illness
* Illness behaviour = Activity of ill person to define illness and seek solution
* Sick role behaviour = formal response to symptoms including seeking formal help
* Adherence with medication
34
What is the lay referral system?
The chain of advice-seeking contacts which the sick make with other lay people prior to/instead of seeking professional help
* Explains delay in seeking help
* Symptom evaluation by themselves and others influences how quickly advice is sought
35
Describe the 3 different definitions of health
* Negative definition = health equates to absence of illness
* Functional definition = health is the ability to do certain things
* Positive definition = health is a state of wellbeing and fitness
* More likely to engage in health promotion activities
* Higher SES
36
Describe the different patterns of adherence to treatment
* Deniers/distancers = deny having condition at all or deny having 'proper' form of condition
* Claims symptoms do not interfere with everyday life
* Doesn't take medication or attend appointments
* Acceptors = accept diagnosis and doctors advice completely
* Pragmatists = accept diagnosis but see condition as mild or acute
* Only takes medication in acute episodes
37
Discuss from a global perspective the determinants of health and disease
* Socioeconomic status
* Poor housing
* Poor health systems
* Genetics
* Behaviour
38
Distinguish between primary, secondary and tertiary prevention
* Primary = prevent onset of disease by reducing exposure to risk factors
* Immunisation, changing behaviour etc
* Secondary = detecting and treating a disease at an early stage to prevent progression and complications
* Screening, treating BP etc
* Tertiary = Minimising the effects of an established disease
* Transplants, maximise remaining capabilities
39
List some health promotion strategies
* Medical/preventative
* Behaviour change
* Educational
* Empowerment
* Social change
40
Illustrate some of the dilemmas raised by health promotion
* Ethics of interfering in people's lives
* Psychological impact of health promotion
* Victim blaming
* Reinforcing negative stereotypes
* 'Fallacy of empowerment'
* Giving people information may not give them the power to change
* Unequal distribution of responsibility
* Change in family left to women
* Prevention paradox
* Interventions that make a difference at population level may not have an effect on the individual
41
Explain the relevance of lay beliefs to health promotion interventions
* Candidacy - if people don't see themselves as a candidate or 'typical victim' of a disease they may not follow health promotion messages
* Awareness of anomalies and randomness of disease may discourage participation also
42
Describe the different types of health promotion evaluation?
* Process = assesses process of programme implementation
* Impact = assesses immediate effects of intervention
* Outcome = measures long-term consequences and what is achieved
* Timing is important
* Delay = takes a long time to have an effect
* Decay = wears off rapidly
43
Describe some difficulties in evaluating health promotion
* Design of intervention
* Possible lag time to effect
* Potential intervening or concurrent confounding factors
* TV adverts/programmes
* High cost
* Studies are usually large scale and long term
44
What is illness narrative?
The storytelling and accounting practices that occur in the face of illness
* Offers a way of making sense of the illness
45
List the 5 different types of work of chronic illness
* Illness work - managing the symptoms
* Everyday life work - coping and strategic management
* Emotional work - protecting emotional wellbeing
* Biographical work - loss and reconstruction of self
* Identity work - maintaining an acceptable identity
46
Describe illness work
* Managing the symptoms
* Dealing with the physical manifestations of illness
* Bodily changes = changes in self conception (eg. weight gain)
47
Describe everyday life work
* Coping = cognitive processes involved in dealing with illness
* Strategy = processes involved in managing the condition and impact
* Decisions about mobilisation of resources and how to balance demands on others
* Remaining independent
* Keep pre-illness identity intact by disguising symptoms or redesignate new life as normal
48
Describe emotional work
* Managing own and others emotions
* Maintaining normal activities
* Downplaying pain/symptoms
* Presenting 'cherry' self
* Impact on role and dependency
49
Describe biographical work
* Struggle to maintain positive definitions of self
* Consciousness of body and fragility of life
* Focus on physical discomfort can overlook broader suffering
* Attempt to 'reconstruct' self
50
Describe identity work
* Maintaining an acceptable identity
* Illness becomes defining aspect of identity
* Loss of self produces:
* Scrutiny of others reactions for signs of discreditation
* Fostering dependence on others
* Relationships harder to maintain
51
What is a stigma? Name some different types
Negatively defined condition/trait/behaviour that confers a deviant status
* Discreditable = not physically visible (mental illness)
* Discredited = physically visible (physical disability)
* Enacted = real experience of prejudice, discrimination and disadvantage as a consequence of the condition
* Felt = fear of enacted stigma
* Leads to selective concealment
52
What is a narrative reconstruction?
The process by which the shattered self is reconstructed in ways that explain the appearance of illness
* Desire to create a sense of coherence, stability and order in the aftermath of biographical disruption
53
Explain different ways of conceptualising disability
* Medical model = disability is a deviation from the medical norm
* Needs medical intervention to cure or help
* Model has lack of recognition of social and psychological factors and may use stereotyping and stigmatising language
* Social model = problems are a product of environment and failure of environment to adjust
* Disability is a form os social oppression
* Political/social change is needed
* Model fails to recognise body realities
54
Name a tool that is used to classify disability
International Classification of Impairments, Disabilities or Handicaps (ICIDH) classifies consequence of disease
* Body structure and function (impairment)
* Activities and any difficulties or limitations
* Participation in life situations and any restrictions
* Integrates the medical and social models of diability to recognise the significance of wider environment
55
Discuss reasons for the rise of patient-based measures as outcomes of healthcare
A patient-based outcome attempts to assess well-being from the patients point of view
* Aim is managing rather than just curing
* Biomedical tests just one part of the picture
* Pay attention to iatrogenic effects of care
* Measure health status of the population
* Assess benefits in relation to cost
* Comparison of hospitals
56
Why is the measurement of health-related quality of life (HRQoL)is seen as interesting and necessary?
HRQoL = the functional effect of an illness and its consequent therapy upon a patient, as perceived by the patient
* Multi-dimensional - physical, psychological, social, cognitive, satisfaction with care etc
* Emphasis on patient's own views
* Emphasis on therapy as well as illness
* Emphasis on functional effects
57
Describe some approaches to, and difficulties, in measuring health-related quality of care
* Qualitative methods
* Gives access to parts other methods can't reach
* Resource-hungry (training, time)
* Good for initial look at dimensions
* Not easy to use in evaluation
* Quantitative methods
* Questionnaires - instruments or scales
58
Describe the different instruments used when measuring quality of life
* Generic instruments
* Used within any population
* Enable comparisons across treatment groups
* Covers social, emotional and physical health
* Can be too generic - loss of relevance and detail
* Specific instruments
* Evaluates a series of health dimensions specific to a diseases, site or dimension
* Sensitive to change
* Comparison is limited
* May not detect unexpected events
59
Describe 2 examples of generic instruments
* Short form 36 item questionnaire (SF-36) = covers 8 dimensions which gives a measure of general health
* Scores within each dimension are added up to give a score from 0-100
* Dimension scores cannot be added together - difficulty in interpretation
* EuroQol EQ-5D = generates a single index value from o-1 by asking about 5 dimensions
* 3 levels for each dimension - no problems, moderate problems, severe problems
* Good in economic evaluations
60
Name 3 examples of specific instruments
* Disease specific - Arthritis Measurement Scale
* Site specific - Oxford Hip Score
* Dimension specific - McGill Pain Questionnaire
61
Assess the suitability and value of HRQoL instruments in a range of areas
* Is there published work showing established validity and reliability?
* And successful use of the instrument?
* Is it suitable for your area of interest?
* Adequately reflect patients concerns in this area?
* Sensitive to change?
* Easy to administer and analyse?
62
Define screening
A systematic attempt to detect an unrecognised condition by the application of tests and examinations to distinguish between apparently healthy people who probably or probably do not have a disease
63
Describe different ways of detecting disease
* Spontaneous presentation = person presents with symptoms
* Opportunistic case finding = GP checks for other diseass after a person presents with unrelated symptoms
* Screening
64
List and describe the criteria of screening programmes
* Disease - must be an important health problem
* Early detectable stage
* With cost-effective primary preventions
* Test - simple, safe, precise, valid
* Acceptable to the population
* Treatment - effective and evidence-based
* Early treatment must be advantageous
* Programme - proven effectiveness
* Quality assurance for whole programme
* Facilities for counselling, diagnosis and treatment
* Benefit should outweigh harm
65
Describe some errors that occur in screening programmes
* False positives = people without the disease that test positive
* Undergo invasive diagnostic testing for a disease they don't have
* Turned into 'patients'
* False negatives = people with the disease that test negative
* False reassurance
66
Describe the different ways of testing for validity of screening programmes
* Sensitivity = proportion of people with the diease who test positive (detection rate)
* High sensitivity is ideal
* Specificity = proportion of people without the disease who test negative
* High specificity is ideal
* Positive Predictive Value = probability that someone who has tested psitive actually has the disease
* Low prevalence = low PPV
* Negative Predictive Value = probability that someone who has tested negative does not have the disease
67
Describe how to calculate the different ways of testing for vailidity in screening programmes
* Sensitivity = a / a+c
* Specificity = d / b+d
* PPV = a / a+b
* NPV = d / c+d
* Prevalence = a+c / a+b+c+d
68
Describe the advantages and disadvantages of screening
69
List some issues raised by screening
1. Alteration of usual doctor-patient contract
2. Complexity of screening programmes
3. Evaluating screening programmes
4. Limitations of screening
5. Sociological critiques
70
Describe how the alteration of usual doctor-patient contract raises issues with screening
* Screening targets apparently healthy people who have not sought help of the health service
* Something they may not have thought about
71
Describe how the complexity of screening programme raises issues with screening
* Not screening young people due to increased number of false positives
* Not all abnormalities require furhter investigation
* Could regress spontaneously
* Has screening actually causes a reduction in mortality?
* Has screening lead to over treatment?
72
Describe how the evaluation raises issues with screening
* Lead time bias = early diagnosis falsely appears to prolong survival
* Longer time knowing they have the disease
* Length time bias = screening is better at picking up slow growing, unaggressive cases which will have a more favourable prognosis anyway
* False conclusion that screening lengthens lives
* Selection bias = 'healthy volunteer' effect - those who have regular screening usually do other things to protect their health and are likely to be healthier
73
Describe how the limitations raises issues with screening
* Screening carries potential for harm
* Need to encourage informed choice based on evidence
* Eg. For every life saved through breast cancer screening, 3 women are treated unnecessarily
* Communicating harms and risks can be challenging
74
Describe the sociological critiques of screening
* Structural critiques:
* Victim blaming = individuals encouraged to take responsibility for their own health
* Indivualising pathology = does not address underlying material causes of disease
* Surveillance critiques = prevention part of wider apparatus of social control
* Expectation of acceptance
* Social constructionist = health practices can be seen as moral and given meaning through particular social relationships
* Feminist critique = more women screened?
75
Give examples of screening programmes in the UK
* Abdominal aortic aneurysm
* Bowel/breast/cervical cancer
* Diabetic retinopathy
* Foetal anomalies
* Sickle cell anaemia/thalassaemia
76
Describe a brief history of the NHS
* Created in 1948
* Initially centrally run by Department of Health
* 3 principles
* Universal (for everyone)
* Comprehensive (all health needs covered)
* Free at point of delivery
* Increasing role for managers through time
* Health and Social Care Act 2012 = devolves power to GPs and primary care
77
Describe the current structure of the NHS
* Secretary of State - overall accountability
* Department of Health - sets national standards and shapes services
* Also sets 'national tariff'
* NHS England - supports, develops and performance-manages CCGs
* Clinical Commissioning Groups - responsible for the flow of the NHS budget
* Commissions primary, secondary and community services
* Providers (hospitals, GPs, community services etc)
* Opportunity for competition
78
Describe the role of a medical director
* Responsible for quality of medical care
* Communicates between the board of directors and medical staff
* Leadership of medical staff
* Interview panels and job descriptions
* Decisions about clinical policy and standards
79
Describe the role of a clinical director
* Leads each directorate (speciality)
* Education and training
* Design and implement policies on junior doctors working hours, supervision, tasks and responsiblities
* Develop guidelines and protocols for clinical procedures
* Implementation of clinical audit
* Induction of new doctors
80
List some factors involved in clinical governance
* Patient involvement
* Risk management
* Complaints procedure
* Incident reporting
* Clincal audit
* Set standards of care
* Observe current practive and compare with standard
* Implement
* Staffing and management
* Education and training
81
Why set priorities in healthcare
* Changing demographic - ageing population
* Expenditure and demand is rising
* Resources are scarce - demand outstrips supply
* Technology is increasing
* Expensive and expand pool of candidates
* It is clear and explicit who benefits from public expenditure
82
What are the 5 Ds or rationing in the NHS?
1. Deterrent - demands for healthcare are obstructed (prescriptions, dental etc)
2. Delay - waiting lists
3. Deflection - GPs deflect demand away from secondary care
4. Dilution - fewer tests, cheaper drugs etc
5. Denial - certain services denied to certain patients
83
Describe explicit rationing including advantages and disadvantages
Use of institutional procesdures for the systematic allocation of resources within the healthcare system
* Reasoning behind limitations are explicit and can be debated
* Assesses equity and efficiency of each intervention
* Transparent, accountable and equitable
* Use of evidence-based practice
* Very complex - heterogeneity of patients and illness
* Threat to clinical freedom
84
Describe implicit rationing
The allocation of resources through individual clinical decisions without explicit criteria
* Can lead to inequities and discrimination
* Decisions based on perceptions of 'social deservingness'
* Patients believe care was offered on basis of clinical need
85
Describe different levels of rationing in the NHS
* Rationing to NHS from Government
* To different departments/specialities
* To different interventions within the departments
* To different patients of the same group
* Ration the amount of the intervention given to the patient
86
What is NICE? Describe its function
National Institute for Health and Care Excellence
* Provides guidance on whether treatments can be recommended for use in the NHS
* Appraise new drugs and devices based on cost and clinical benefit to ensure cost-effectiveness
* While being appraised, NHS organisations make decisions on its use locally
87
What is a Healthcare Resource Group?
Standard groupings of clinically similar treatments which use common levels of resource
* Unit of currency = equitable reinbursement for care services delivered by providers
* Tariff paid when a hospital diagnoses and treats a patient
* Incentive to become more efficient
* Avoiding complications and never events produced more HRGs (tariffs) so more money
88
Why is difficult to consult the public about rationing in the NHS?
* Resistance to inevitability of rationing
* Tend to value heroic interventions and particular patient groups (children over elderly)
* Discrimination against those responsible for illness
* May go against cost-effectiveness data
89
Why is health economics important?
* Shows the net benefits of a new intervention
* Allocates resources in an effeicient and equitable way
* Exposes opportunity costs of new interventions
* Directs innovation into areas regarded as priorities
90
What are the basic concepts of health economics?
* Scarcity - need outstrips resources
* Efficiency - getting the most out of limited resources
* Equity - distribution of resources is fair
* Effectiveness - if desired outcomes are produced
* Utility - the value placed on a state of health
91
What is an opportunity cost?
The value of the next best alternative use of resources, when spending them on a new treatment
* Measured in benefits foregone
92
Describe the different types of efficiency
* Technical = the most efficient way of meeting a need
* Allocative = choosing between the many needs to be met
93
What is economic evaluation?
The comparison of resource implications and benefits of alternative delivery of healthcare
* Evaluated in terms of cost and consequences
* Decides which intervention represents best value for investment
Input → Intervention → Output
94
Describe the different ways of comparing cost and benefit?
* Cost Minimilisation Analysis = focus on measurement is on costs
* Choose cheapest input if outcomes are the same
* Cost Effectiveness Analysis = compare interventions which have a common health outcome
* Calculate how much extra benefit obtained for extra cost
* Cost Benefit Analysis = all inputs and outputs value in monetary terms
* Methodological difficulties
* Cost Utility Analysis = focuses on quality of health outcomes
* Cost compared using QALY measurement
95
What is a QALY?
Quality Adjusted Life Years
* Compositie of survival and quaity of life
* Use cost-effectiveness as a guide to decision making
* 1 year of perfect health = 1 QALY
* 10 years of 0.1% of perfect health = 1 QALY
* Measured using the generic HR-QoL measurement
* EQ-5D
96
List some criticisms of using QALYs
* Does not distribute resources according to need
* Only according to cost-effectiveness
* Technical problems with calculations
* May not embrance all dimensions of benefit
* RCT evidence is not always perfect
97
How does NICE decide whether to approve new interventions?
* Integration of QALY score with treatment price using Incremental Cost-Effectiveness Ratio (ICER)
* * £20-£30k needs further judgement (adds demonstratable and distinctive benefits not shown by QALY)
* \>£30k needs an increasingly stronger case
98
Describe how to calculate a QALY
Person with peptic ulcer disease expected to live for 23 years with a QoL of 0.7.
Treatment A is £50 per annum and produces 0.95 QoL
* QALYs without treatment = 23 x 0.7 = 16.1
* QALYs with treatment = 23 x 0.95 - 21.85
* QALYs gained = 21.85 - 16.1 = 5.75
* Total cost of treatment = £50 x 23 years = £1150
* Cost per QALY gained = £1150 / 5.75 = £200
99
Describe the policy background to the growth of interest in patients’ views of health services
* NHS Patient Prospectus (2000) - annual account of patients view and action taken
* NHS Outcomes Framework (2012/13) - ensuring a positive experience of care
* NHS Act (2006) - involve and consult patients about the way services are provided
100
Describe some ways of indirectly investigating patients' views
* Patient Advice and Liason Services (PALs)
* Listens to patients concerns, suggestions and experiences
* Provide information about complaints procedure
* On the spot help about health services
* Parliamentary and Health Service Ombudsman - understakes independent investigations into complaints that the NHS has not acted properly on
101
Describe some ways of directly investigating patients' views
* Qualitative - identifies patient priorities
* Interviews
* Focus groups
* Observation
* Quantitative - cheap, easy, anonymous
* National patient surveys
102
Name some causes of dissatisfaction in healthcare
* Poor interpersonal skills
* Inappropriate advice
* Do not take full histories
* Not reassuring
* Content of health care
* Invonvenience, access, continuity
* Hygeine
* Waiting times
* Unsatisfactory health outcomes
103
What is the Local HealthWatch?
Independent network of groups or individuals that ensure that services reflect the needs and wishes of local people
* Influence how services are designed, set up and delivered
* Makes recommendations to those who plan and run services
104
Comment on the advantages and disadvantages of using patient-based outcomes to assess doctors’ performance
Advantages:
* Ultimately care is provided to patients, so they should feel it is adequate
Disadvantages:
* May not provide an objective opinion
* Focussed on own individual needs
* Not applicable nationally
105
List the different sociological approaches to the patient-professional relationship and distinguish between the explanatory and aspirational models
* Functional approach - explanatory
* Conflict approach - explanatory
* Interpretative/interactionalist approach - explanatory
* Patient-centred models - aspirational
106
Describe the functionalist approach to the patient-professional relationship
* How an asymmetrical relationship can function so well
* Taboos must be broken for relationship to work
* Trust based on codes of conduct
* Patients adopt the 'sick role'
* Don't have technical competence
* Freed of social responsibilities but expected to seek the technical help to recover
* Doctors take on powerful role
* Act for welfare of patients - objective and non-discriminatory
* Granted intimate access to patients
107
Describe some criticisms to the functionalist approach
* Chronic illness cannot get better
* Some patients illegitimately occupy sick role
* Assumes incompetence of patients
* Assumes rationality and beneficence of medicine
* Doesn't explain why things go wrong
108
Describe the conflict approach to the patient-professional relationship
* Doctors hold bureaucratic power - 'gatekeeper'
* Doctors have a monopoly on defining health which they can exploit
* Patients must submit to dominance of doctor
* Lay ideas are marginalised and discounted
* Cultural iatrogenesis - people become dependent on medicine, lost self-reliance and become sick again
* Medicalisation of childbirth etc loses control for patients
109
Describe some criticisms of the conflict approach
* Doctors and patients aren't inevitably in conflict
* Patients not always passive
* Non-adherence
* Complementary therapy
* Patients can also medicalise issues
* ME
* PTSD
110
Describe the interpretive/interactionalist approach to the patient-professional relationship
* Focusses on the meanings that both parties give to the encounter
* Governed by informal, unwritten rules
* Doctor and patients avoid all matters “not fitting” with the ideal of patient and doctor
* Each party orients to an idealised conception of the encounter
111
Describe the patient-centred models in the patient-professional relationship
Relationship could be less hierachical and more cooperative if patients' views were taken more seriously
* Emphasis on more egalitarian relationship
* Concordance - mutually agree on management
* Enhances prevention and health promotion
* Understanding of emotional needs and life issues
* Patients contribute their concerns, priorities and personal perceptions about problems, cost and treatment
112
Suggest reasons for the increased interest in complementary therapies
* Persistent symptoms not relieved with conventional treatment
* Real/percieved adverse effects of conventional treatment
* Prefer a more holistic approach
* More patient-centred?
* Feel they receive more time and attention
* Paying for it
113
Describe some doctors perspectives of complementary therapy
* Some forms may be beneficial
* Concern about:
* Unqualified/unregulated practioners
* Risk of delayed/missed diagnosis
* Patients may refuse conventional treatment
* Waste of money
114
List some arguments for and against NICE evaluating complementary therapies
115
Describe the theory and practices underlying aromatherapy
* Controlled use of essential oils which have therapeutic properties
* Relieve stress
* Ease tension
* Promote wellbeing
* Stimulates the limbic system of the midbrain to release hormones and influence mood
* Oils can be used topically with massage or inhaled
116
What is a profession? What the criteria for a profession?
A type of occupation able to make distinctive claims about its work practices and statuses
* Asserting an exclusive claim over a body of knowledge
* Establish control over the market and exclusion of competitors
* Establishing control over professional work practice
117
What is professional socialisation?
The process through which new entrants gain their professional identities
* Formal curriculum - knowledge
* Informal curriculum - attitudes and beliefs
Based on learning from others and aligning ones own conduct with the professions standards
118
Why was the medical profession self-regulated in the beginning?
* Non-professionals are not equipped with the skill and knowledge to evaluate or regulate the profession
* Professionals are responsible enough to regulate other professionals
* The profession should be trusted to undertake proper regulatory action
119
What are the arguments against self-regulation in the medical profession?
* Bad apple inquiries (Bristol etc) show those in positions of authority fail to detect signs of unacceptable conduct or to take effective action against it
* Etiquette between doctors about raising concerns
* Control is mostly through quiet chats
* NHS disciplinary action costly and inhibiting so problem is usually relocated
* Patients/whistleblowers not always believed
120
Name some changes to the the regulation of the medical profession
* GMC now has mixture of lay persons and medicall professionals
* Publication of Tomorrow's Doctors
* Revalidation of doctors every 5 years
* Establishment of Responsible Officers - doctors who will be responsible for dealing with local performance and conduct issues with the GMC
121
Why are doctors revalidated?
* Positive affirmation to patients
* Maintain and improve practice
* Identify concerns at an early stage
* Encourage patient feedback
