HaDSoc Flashcards
What is the function of the national tariff?
Incentivising efficiency and rewarding the best practice
What can the CQC do if a trust is not up to standards?
Can impose conditions of registration, issue warning notices, fines, prosecution, restriction on activity and close the trust
What are the components of a clinical audit?
Setting standards, measuring current practice, comparing results with standards (against the criteria), changing practice and improving practice
What is quality improvement in the healthcare setting?
Systematic efforts to make changes that lead to better patient experiences and outcomes as well as system performance improvements and professional development
Define clinical governance
Framework through which the NHS trusts are required to continuously improve quality of care. NHS trusts therefore have a legal duty to put systems in place to monitor and ensure quality care.
What was Cochrane’s role in the rise of evidence-based medicine?
He criticised the medical profession for failing to incorporate research into their practice. He called for a register of all randomised control trials.
What was Iain Chalmers role in the development of evidence based medicine?
Produced a register of all RCTs in obs and gynae and generated systematic reviews and meta-analyses of this data. This became the first Cochrane Centre.
What is evidence based practice?
Integration of individual clinical expertise with the best available external clinical evidence from systematic reviews.
What is the function of CQUIN?
CQUIN (commissioning for quality innovation) is a financial incentive. 1.5% of a trusts income depends on achieving measurable goals in three areas: safety, effectiveness and patient experience
Why are systematic reviews important?
Quality of the research is variable, helps address clinical uncertainty, can highlight gaps in research or poor quality research, offers quality control, offer generalisable and up to date conclusions, saves times for clinicians, help prevent biased views and are easily convertible into guidelines and recommendations
State some practical criticisms of evidence based practice
Hard to create and maintain systematic reviews across all specialities, expenses, RCTs aren’t always feasible, choice of outcomes are often biochemical thus limiting which interventions are trialled and funded and it also requires good faith in the pharmaceutical companies
State some philosophical criticisms of evidence based medicine
Doesn’t align with most doctors’ way of thinking, population level interventions might not be suited to individual problems, EBM could create unbreakable rules and thus unreflective rule followers, could undermine the patient-doctor relationship and removes professional autonomy and responsibility
State some of the problems in getting evidence based medicine into practice
Doctors being unaware of the evidence, doctors knowing about the evidence but not following it, organisational systems not being able to support innovative procedures, commissioning decisions, resource allocation issues and reluctance to fund things if the evidence is poor
Describe quantitative methods of research
Collection of numerical data. Begins with an idea/hypothesis and draws conclusions through deduction. It is repeatable and reliable.
Briefly state some advantages and disadvantages of quantitative research
Good at describing, measuring, finding relationships between things and therefore allowing comparisons to be made. Bad because it can force people into categories, doesn’t allow freedom of expression, may not access all the important information and might not be effective in establishing causality
Give examples of quantitative research designs
Experimental study designs (e.g. RCTs), cohort studies, case-control studies, cross-sectional surveys, secondary analysis of data from other sources and questionnaires.
Describe qualitative research
Aims to make sense of phenomena in terms of meanings people bring to them. Emphasises meaning, experience and views of the respondents. Analysis emphasises the researchers interpretations.
State some advantages and disadvantages of qualitative research designs
Can provide insight to behaviour, helps understanding perspectives and allows access to information not revealed in quantitative methods, explains relationships between variables. A major disadvantage is that they are not generalisable. They are also prone to bias and therefore make it hard to implement changes. It is also a labour intensive process
State some qualitative research methods
Observation and ethnography, interviews, focus groups and documentary/media style analysis
What is the function of the critical appraisal skills programme?
CASP offers a tool to appraise qualitative research; offers critical appraisal skills training, workshops and tools which help in reading and checking health resources for trustworthiness, results and relevance
Distinguish between inequality and inequity
Inequality - when things are different either in a group or between groups. Inequity - inequalities within a group of people that’s unfair and avoidable.
Describe the relationship between health and socioeconomic position
Generally poorer socioeconomic groups have poorer health. Can be measured by the NS-SEC which is calculated from census data.
What are the domains in the Index of Multiple Deprivation?
Income, employment, health and disability, education skills and training, barriers to housing and services, living environment and crime
Describe the relationship between health and ethnicity
Different ethnicities are at risk of different diseases. Also racial bias can play a role in treatment
Describe the relationship between health and gender
Men have a higher mortality rate, more suicides and more violent deaths. Women have a higher life expectancy, higher reported poor mental health and higher rates of disabilities and long standing illness. Gender is prescribed by social factors whereas biological sex is defined by hormonal and reproductive differences
Explain the artefact explanation about inequality and inequity within healthcare services
Health inequalities are evident due to the way stats are collected. Mostly discredited because data problems can lead to underestimation of inequalities
Explain social selection in terms of inequality and inequity within healthcare services
Direction of causation is from health to social position; sick people move down whereas healthy people move up. It is a plausible theory however most studies suggest that it only makes a minor contribution to differentials in health and morality
Explain the behavioural-cultural explanation about inequality and inequity within healthcare services
Ill health is due to people’s choices, decisions, knowledge and goals. States that people with a disadvantaged background are more likely to engage in health-damaging behaviours and vice versa. Limitations of this approach: behaviours are outcomes of societal pressures and not just individual choices and ‘good’ choices might be impossible to carry out
Explain the materialist explanation in terms of inequality and inequity within healthcare services
Inequalities in health arise from differential access to material resources e.g. low income, work environments etc. These factors then accumulate over life. Limitation of this approach is that further research is needed as to the precise methods through which ill health is caused by material deprivation
Explain the psychological explanations in terms of inequality and inequity within healthcare services
Psychological pathways act in addition to direct effects of absolute material living standards. There’s a social gradient of psychological factors. Stressors can impact health directly or indirectly
What is the function of the critical appraisal skills programme?
CASP offers a tool to appraise qualitative research; offers critical appraisal skills training, workshops and tools which help in reading and checking health resources for trustworthiness, results and relevance
Distinguish between inequality and inequity
Inequality - when things are different either in a group or between groups. Inequity - inequalities within a group of people that’s unfair and avoidable.
Describe the relationship between health and socioeconomic position
Generally poorer socioeconomic groups have poorer health. Can be measured by the NS-SEC which is calculated from census data.
What are the domains in the Index of Multiple Deprivation?
Income, employment, health and disability, education skills and training, barriers to housing and services, living environment and crime
Describe the relationship between health and ethnicity
Different ethnicities are at risk of different diseases. Also racial bias can play a role in treatment
Describe the relationship between health and gender
Men have a higher mortality rate, more suicides and more violent deaths. Women have a higher life expectancy, higher reported poor mental health and higher rates of disabilities and long standing illness. Gender is prescribed by social factors whereas biological sex is defined by hormonal and reproductive differences
Explain the artefact explanation about inequality and inequity within healthcare services
Health inequalities are evident due to the way stats are collected. Mostly discredited because data problems can lead to underestimation of inequalities
Explain social selection in terms of inequality and inequity within healthcare services
Direction of causation is from health to social position; sick people move down whereas healthy people move up. It is a plausible theory however most studies suggest that it only makes a minor contribution to differentials in health and morality
Explain the behavioural-cultural explanation about inequality and inequity within healthcare services
Ill health is due to people’s choices, decisions, knowledge and goals. States that people with a disadvantaged background are more likely to engage in health-damaging behaviours and vice versa. Limitations of this approach: behaviours are outcomes of societal pressures and not just individual choices and ‘good’ choices might be impossible to carry out
Explain the materialist explanation in terms of inequality and inequity within healthcare services
Inequalities in health arise from differential access to material resources e.g. low income, work environments etc. These factors then accumulate over life. Limitation of this approach is that further research is needed as to the precise methods through which ill health is caused by material deprivation
Explain the psychological explanations in terms of inequality and inequity within healthcare services
Psychological pathways act in addition to direct effects of absolute material living standards. There’s a social gradient of psychological factors. Stressors can impact health directly or indirectly
Explain income distribution and its effect on inequality and inequity within healthcare services
Relative income distribution effects health - countries with greater income inequalities have greater health inequalities. The psychosocial element associated with this is as follows: greater social-evaluative threat, greater stress and therefore poorer health.
Suggest why deprived groups might have higher rates of GP use and emergency services as opposed to preventative and specialist services
Tendency for them to manage health as a series of crises. They may have normalised ill health. They may not want to present unless there is an obvious symptom. Might not have access or be aware that they have access to health services
Why is it important to understand lay beliefs?
There can be a gap between lay concepts and medical knowledge which a practitioner should notice and fill in. Lay beliefs impact adherence and compliance with treatments and can change the way a patient understands medical advice or explanations
Define the negative definition of health
Health equates to absence of illness. This view is commonly held by those from lower socioeconomic groups
Define the functional definition of health
Health is the ability to do certain things; these things vary from person to person. This view is commonly held by the elderly population
Define the positive definition of health
Health is a state of wellbeing and fitness. This view is usually held by those in higher socioeconomic groups
State some factors that influence illness behaviours
Cultural attitudes, visibility of symptoms, extent to which symptoms disrupt life, frequency and persistence of symptoms, tolerance threshold, information available, resources available and lay referral
What is lay referral and why is it important?
Lay referral is the action of a patient asking a lay person (family, friend etc) if they should go to the doctors. It’s important because it helps in understanding why people may delay seeking help, our role as doctors, use of health services and medication and use of alternative medications
Explain the relevance of lay beliefs to health promotion
Medical information might be rejected if it doesn’t align with the patients lay beliefs (e.g. lay understandings of inheritance often differ to the medical understanding)
What two concepts is lay epidemiology based on?
Understanding why and how illness affects people
Understanding why it happened to a particular person at a particular time
Why might lay epidemiology be problematic?
Because it is based on observations from collective experiences. This means that if there are exceptions to a rule then patients can justify poor health related behaviours by using these examples e.g. smokers living a long time and not getting cancer
Define health behaviours
Activities undertaken for the purpose of maintaining health and preventing illness
Define illness behaviours
Activity of an ill person to define illness and seek a solution
Define sick role behaviour
Formal response to symptoms (including seeking help formally and acting as a patient)
Define lay beliefs
How people understand and make sense of illness
Explain what the illness/symptom iceberg is
The fact that most symptoms are never presented to a doctor. A study showed that only 12% of symptomatic patients presented to their GP!
What is the lay referral system?
Chain of advice-seeking contacts which the sick make with other lay people prior to - or instead of - seeking help from health care professionals
Explain what is meant by the term ‘determinant of health’
Determinants of health are a range of factors that have a powerful and cumulative effect on the health of populations, communities and individuals. Includes physical, social and economic environment, genetics, characteristics, behaviours etc. Individuals are unlikely to be able to directly control many of the determinants of their health
Define health promotion
Process of enabling people to increase control over and improve their health. Aims to protect and improve the nation’s health and wellbeing and reduce health inequalities. Meant to empower local communities, enable professional freedom and unleash new evidence- based ideas
What are the main principles of health promotion?
Empowerment, participation, holistic, intersectoral, equitable, sustainable and multi-strategy
What is the difference between public health and health promotion?
Public health places more emphasis on the ends whereas health promotion focuses on the means used
What are the three levels of prevention?
Primary prevention (aims to prevent onset of disease), secondary prevention (aim to detect and treat a disease) and tertiary prevention (aims to minimise the effects of established diseases)
State the five approaches to health promotion
Medical/preventative, behavioural changes, educational, empowerment and social change
Illustrate some of the dilemmas raised by health promotion
‘Big brother’ effect, victim blaming, fallacy of empowerment, reinforcing negative stereotypes, unequal distribution of responsibility and the prevention paradox
Why is evaluation of health promotion techniques important?
To make sure that the evidence matches current practice, assessment of the accountability of interventions, ethics and programme management and development
Explain the three ways in which health promotion can be assessed
Process (focus on assessing the process of programme implementation), impact (measures the immediate effects) and outcome (measures more long-term consequences)
What are the difficulties in evaluating outcomes of health promotion?
Hard to demonstrate an attributable effect. This can be due to: design of the intervention, possible lag time to effect, potential intervening or concurrent confounding factors and high cost of evaluation research
What is an illness narrative?
Story-telling and accounting practices that occur in the face of illness; most sociological research into chronic illnesses is based on the illness narrative of patients
Describe ‘illness work’
Illness work refers to the things associated with becoming ill e.g. getting the diagnosis, managing symptoms and managing treatments
Describe ‘everyday life work’
This refers to the coping and strategy involved in the management of long term illnesses and usually involves normalisation of the disease
Describe ‘emotional work’
This refers to work people do to protect the emotional wellbeing of others. This might involve downplaying symptoms, appearing happy when they aren’t etc.
Describe ‘biographical work’
This refers to the feeling of loss of self; chronic illnesses can damage how the patient views themselves, where they come from and where they’re headed. Can lead to a constant struggle to lead a meaningful life.
Describe ‘identity work’
When a patients condition changes the way they see themselves and the way others see them. Illnesses can become the defining feature about their identity even if they don’t want it to be
Define stigma
A negatively defined condition, attribute, trait or behaviour conferring a ‘deviant’ status
Explain the difference between discreditable and discredited stigma
Discreditable - nothing is seen but there is stigma is something is found out (e.g. HIV, mental health problems etc.). Discredited - physically visible characteristic or well-known stigma
What three concepts does the international classification of impairments, disabilities or handicaps offer as consequences of disease?
Impairment (concerned with abnormalities in the structure or function of the body), disability (concerned with performance of activities) and handicap (concerned with the broader psychosocial consequences of living with an impairment or disability).
Suggest some criticisms for the international classification of impairments, disabilities or handicaps as a model
Uses the problematic term ‘handicap’, implies that problems are intrinsic or inevitable and embodies a lot of the features of the medical model
What is WHO’s framework for measuring health and disabilities?
International classification of functions, disability and health
What are the key components to the international classification of functions, disability and health?
Body structures and functions (and impairments thereof), activities undertaken by the individual and participation or involvement in life situations
State some reasons why we need to measure health
To have an indication of the need for healthcare, target resources, assess effectiveness of interventions, evaluate quality of health services and to monitor patients’ progress
What three commonly used measures when looking at health?
Mortality, morbidity and patient-based outcomes
What are patient-reported outcome measures and how do they work?
PROMs are measures of health that come straight from the patients. Work by comparing scores before and after treatment
Which four procedures does the PROMs programme currently cover?
Hip replacements, knee replacement, groin hernia and varicose veins
Define quality of life
An individual’s sense of social, emotional and physical wellbeing which influences the extent they can achieve personal satisfaction - represents the functional effect of an illness and is therapy on the patient
State some of the factors that contribute to health-related quality of life
Physical function, symptoms, global judgements of health, social wellbeing, cognitive function, personal constructs and satisfaction with care
Explain what is meant by reliable and valid in relation to PROM
Reliable - the instrument is accurate overtime and is internally consistent
Valid - does the instrument measure what it is intended to measure?
Explain why general instruments are used to measure quality of life
Can be used with any population, generally cover perceptions of overall health, questions emotional, social and physical functioning, pain and self-care. Short-form-36 item questionnaire (SF-36) and the EuroQoL (EQ-50)
Explain why specific instruments are used to measure quality of life
Evaluates a series of health dimensions specific to a disease, site or dimension
State some advantages and disadvantages of using generic instruments to measure quality of life
Advantages - broad range, enables comparisons between groups, can detect positive/negative effects of an intervention and can be used to assess health of populations
Disadvantages - less detailed, too general (loss of relevance?), less sensitive to changes that occur as a result of an intervention and might be less acceptable to patients
State some advantages and disadvantages of using specific instruments to measure quality of life
Advantages - detailed, patients are likely to want to do it because of it’s obvious relevance, sensitive to change
Disadvantages - can’t be used on people without the disease, comparison is limited and it might not detect unexpected effects
What are the 8 dimensions involved in the SF-36 questionnaire?
Physical functioning, social functioning, role functioning, bodily pain, vitality, general health and mental health
What are the 5 dimensions involved in the EQ-50?
Mobility, self-care, usual activities, pain/discomfort and anxiety/depression
Define screening
Rapid and systematic approach to detecting undiagnosed conditions by the application of tests, examinations or other procedures. Can be applied rapidly to distinguish between apparently well people who probably don’t have the disease and those who probably do
How does the disease/condition being screened for effect the implementation of a screening programme?
It must be an important health problem with an understood natural history and epidemiology. Must be detectable at an early-stage and should be cost-effective. Primary prevention interventions should be implemented where possible
How does the test being used effect the implementation of a screening programme?
It should be simple, safe, precise and valid. Should be acceptable to the population as a whole. Agreed cut-off must be defined with an agreed policy in regards to which patients need further investigations
How do treatments offered effect the implementation of a screening programme?
Early treatment should be advantageous with an agreed policy on who to treat. Clinical management of the patient and their outcomes should be optimised by health care providers
How does the programme offered effect the implementation of a screening programme?
There should be proven effectiveness (preferably RCT). The whole programme should be quality assured and alternative options should be available. Decisions about the parameters should be justifiable to the public. Benefits should outweigh potential harm
What is sensitivity?
Proportion of people with the disease who test positive are actually positive (true positive)
What is specificity?
Proportion of people without the disease who test negative (true negatives)
What makes a test sensitive?
Proportion of people with the disease who test positive are actually positive (true positive)
Define positive predictive value (PPV)
Probability that someone who has tested positive actually has the disease
Define negative predictive value (NPV)
Proportion of people that will test negative who don’t have the disease
State the disadvantages of false positives
Patients will be offered a diagnostic test for a condition they don’t have, ca lead to lower uptake of screening in the future, if PPV is low then there will be a lot of people who undergo unnecessary stress and anxiety
State the disadvantages of false negatives
People won’t be offered a diagnostic test when they need it. Could lead to false reassurance and delay presentation
Describe lead time bias
Early diagnosis falsely appears to prolong survival; screened patients appear to live longer when in reality they just know about their illness for longer
Describe length time bias
Screening programmes are better at picking up slow-growing, unthreatening cases. Diseases that are detectable through screening might not have needed curing
Describe selection bias
People who get screened are more likely to be doing other things that protect them from the disease
What are some of the issues that are raised by screening?
Alteration of the doctor-patient relationship, complexity of screening programmes, evaluation of screening programmes, limitations of screening and sociological critiques
Give examples of screening programmes in the UK
Cervical cancer screening, breast cancer screening, foetal anomaly screening programme and foecal occult blood test
State the sociological critiques of screening
Victim blaming, individualising pathology, surveillance critiques, social constructionist critique and the feminist critique
What three principles was the NHS founded on?
It should be universal, comprehensive and free at the point of delivery
What are commissioners?
Commissioners are essentially consumers and choose between different care providers on behalf of patients
What do clinical commissioning groups do?
Bring together GPs, nurses, public health, patients, public and others to commissions secondary and community healthcare services
Describe the current structure of the NHS in England
Secretary of State for Health –> national board –> 4 regional hubs –> 50 local offices of the board –> 240 clinical commissioning groups –> trusts –> patients
Where do NHS hospital trusts earn most of the their income from?
Through services that CCGs and NHS England commission from them. Also get income from the provision of undergraduate and postgraduate training. High-performing trusts can get more by gaining foundation trust status
Give some examples of managerial activities and functions undertaken by doctors in the NHS
Medical directors, clinical directors and general practitioners
Describe a directorate
Based on speciality or group of specialities. Led by a clinical director, alongside a nurse and a general non-clinical manager as well.
Describe the role of a clinical director
Continuation of medical education and training, in charge of policies effecting junior doctors’ hours of work, supervision, tasks and responsibilities, audits, developing guidelines and inducting new doctors
Describe the role of a medical director
Recruitment of staff, disciplinary processes, leading the clinical policy and standards, strategic overview of medical staff’s role and sitting in the organisation’s Board of Directors
Give examples of management skills
Strategic skills (e.g. analysing, planning and making decisions), financial skills (e.g. setting priorities and managing a budget), operational skills (e.g. running things and executing plans) and human resources (e.g. managing people and teams)
Why is health economics useful?
Exposes the opportunity costs of new interventions and enables consistency in investment (and disinvestment) decisions. Helps direct innovation towards health system priorities
What are the basic concepts that health economics is based on?
Scarcity, efficiency, equity, utility and opportunity costs
Why is priority-setting inescapable in the NHS?
Demands on the NHS are greater than the supply; demand is therefore driven by demographics. Also new technology usually costs a lot
Explain the difference between implicit and explicit rationing in relation to resource allocation
Explicit - based on rules of entitlement and generally done by overseeing bodies, implicit - care limited and is usually done by healthcare professionals
What are the advantages and disadvantages of implicit rationing?
Advantages - expenditure matches healthcare needs. Disadvantages - can lead to discrimination, inequity and the decisions are based on social deservingness
What are the advantages and disadvantages of explicit rationing?
Advantages - transparent, accountable, based on evidence and provides more equitable healthcare
Disadvantages - complex, heterogeneity of patients, patient/professional hostility and loss of clinical autonomy
Define economic evaluation
Comparison of resource implications and benefits of alternative ways of delivering healthcare
What does an economic analysis entail?
Comparison of the input and outputs of alternative interventions and therefore allows better decisions to be made
What are the problems with economic evaluation and how can they be overcome?
Assumptions might influence conclusions, this can be overcome by sensitivity analysis. Some health benefits aren’t felt for some time this can be overcome by discounting
Describe cost effective analysis
Compares drugs/interventions which have a common health outcome. This is done by comparing the cost per unit with the outcome. Key question: is the extra benefit worth the cost?
