HaDSoc Flashcards
1
Q
What is equity?
A
The idea that everyone with the same need should get the same care
(Different to equality)
2
Q
What is an adverse event?
A
An injury caused by medical management rather than underlying disease
May be unavoidable (eg px being prescribed a drug for first time and having a reaction)
Or may be preventable (eg administering wrong dosage, operating in wrong part of body)
3
Q
In James Reasons Framework of Error, what are active failures and latent conditions?
A
- active failures are acts that lead directly to the patient being harmed
- latent conditions are predisposing conditions that make active failures more likely
4
Q
What are examples of active failures?
A
Administering wrong drug dosage
5
Q
What are some examples of latent conditions?
A
Too few staff
Poor training
Poor syringe design
Poor supervision
6
Q
What is the Swiss cheese model?
A
Some holes are due to active failures and some holes are latent conditions. The holes are hazards and if they line up something can slip through and lead to a loss. The more layers of cheese (ie more safe guarding, defences and barriers) = less chance of hazards lining up
7
Q
What is clinical governance?
A
The fact that NHS organisations are accountable to continuously improve the quality of their services and safeguard high standards of care by creating an environment in which clinical care can flourish.
8
Q
What are some examples of how clinical governance is carried out?
A
NICE quality standards
CCGs
Financial incentives (both to penalise and reward)
QOF points in primary care
Disclosure of information to the public
Registration and inspection by Care Quality Commission
Junior docs carry out clinical audits and quality improvements
9
Q
What is an audit?
A
Quality improvement process that aims to improve patient care by systematic review of care against criteria, and implementation of change
10
Q
What is the national tariff?
A
Scheme so that for each HRG, a set fee is paid from commissioners to providers.
The tariffs are based on typical costs, so efficient trusts can make a surplus but inefficient trusts can make a loss.
Never-events receive no payment.
11
Q
What are some critiques of evidence based practice?
A
- RCTs not always possible (ethical grounds)
- impossible to collate and maintain so much data
- creates ‘followers’ out of clinicians when it may be more appropriate for them to use their initiative
- requires good faith of pharmaceutical companies (publication bias, rare to see negative studies)
- may be challenging and expensive to implement findings
- inhibits autonomy of clinicians
12
Q
What issues may arise when bringing EBP into practice?
A
- clinicians may not be aware of changes
- clinicians may be used to habits
- trusts may not have resources to implement changes (eg time, staff, money)
13
Q
What is quantitative research?
A
Numerical data
Begin with hypothesis and allows conclusions to be drawn with relationships between variables
14
Q
What are some examples of qualitative research?
A
Questionnaires
RCTs
Cohort studies
Case control studies
15
Q
What is meant by a questionnaire being valid and reliable?
A
- valid measures what it is supposed to
- reliable measures consistently
16
Q
What is qualitative research?
A
Good to describe perspectives and explain relationships and make sense of phenomena in terms of meaning people bring to them
17
Q
What are different types of qualitative research?
A
- observation and ethnography
- interviews
- focus groups
- documentary and media analysis
18
Q
What is observational studies and ethnography?
A
Observations studies can be participant or non-participant
Ethnography is observing people in their natural habitat
✅ valuable insight ❌ labour-intensive
19
Q
How should interviews be conducted?
A
Have an agenda of what to cover, but remain conversational in style and focus on the participants perspective
20
Q
What are positives and negatives of focus groups?
A
✅ quick
❌ not good for sensitive topics, not good for individual experience and deviant views may be inhibited, hard to arrange, need a good facilitator, need a fairly homogenous group (so there’s no hierarchy)
21
Q
What are examples of documentary data collected?
A
Using medical records and patient diaries
✅ can be historical, good for subjects difficult to investigate
❌ labour intensive
22
Q
What does the social patterning of health describe?
A
That the more deprived a person is, the larger the proportion of their life will be spent in ill health, and the more likely they will die at a young age
23
Q
What is the black report?
A
A landmark text by the department on health in 1980 that came up with different explanations for inequalities in health care
24
Q
What explanations for inequalities in health care did the black report come up with?
A
- artefact explanation
- social selection explanation
- behavioural cultural explanation
- materialistic explanation
25
Which two other explanations are there for inequalities in healthcare, that aren't from the black report?
- psychosocial explanation
| - income distribution
26
Which is the most plausible explanation for inequalities in healthcare?
The materialistic explanation
27
What is the artefact explanation?
Idea that health inequalities is due to the way statistics are collected (ie measurements of class)
28
What is the social selection explanation?
The idea that ill health causes people to move to a lower social position, whereas healthy people move up the social hierarchy
29
What is the the behavioural cultural explanation?
The idea that ill health is due to people's decisions, knowledge and goals
(Ie people from disadvantaged backgrounds tend to engage in more health-damaging behaviours and vice versa)
But... Too simplistic, not everyone has 'choices' when there's a lack of resources, behaviour is due to social processes and not simply individual choice
30
What is the materialistic explanation?
Health inequalities are due to differential access to material resources
(Idea that low income allows less money to be spent on health, and that more deprived areas are prone to more hazards eg poor water)
31
What is the psychosocial explanation?
That health inequalities are due to psychosocial pathways acting in addition to the effects of material living standards
Eg stress impacts health in different ways, direct: physiologically, immune system, indirect: mental health, stress behaviours etc)
32
What is the income distribution explanation?
The idea that the degree of income inequality is the main determinant of health
(So it is not the richest, but the most egalitarian societies that have the best health)
33
What do utilisation studies measure?
The receipt of healthcare services, but it is still difficult to measure those who can't access a service
34
What is the difference between inequality and inequity?
Inequality is when things are different. Inequity is inequalities that are unfair and unavoidable
35
What are lay beliefs?
How lay people understand and make sense of health and illness
36
What are the different perceptions of health?
Negative: health equates to absence of illness
Functional: health is ability to do certain things
Positive: health is a state of well being and fitness (so can be worked towards)
37
What is the sick role?
Formal response to symptoms, seeking formal help and acting as a patient
38
What is illness behaviour?
Activity of an ill persons to define their illness and seek help
39
How does social class affect perception of health?
Higher social class is more likely to have a positive definition of health so are incentivised to remain healthy
40
What is the illness iceberg?
Describes the fact that only a small property of symptoms are actually acted on, most symptoms never even get to a doctor
41
What is lay referral?
Most lay people discuss their symptoms with another lay persons, prior to, or instead of, seeking advice from a healthcare professional.
42
What is symptom evaluation?
Influences how quickly medical advice is sought
Eg how severe the pain is, it is normalised, how long symptoms persist (eg tipping point if remaining after X days), idea of candidacy (wont happen to me)
43
How can lay beliefs affect adherence?
- deniers and distancers: believe I don't have x, or it's not proper x therefore have poor adherence
- acceptors: accept diagnosis with no stigma and so have good adherence
- pragmatists: eg only use inhaler if symptoms are bad (will treat but not prevent)
44
What are determinants of health?
A range of factors that influence and individuals health eg media, relationships, culture.
45
What are the different health promotion prevention strategies?
Primary: aims to prevent the onset of disease eg smoking cessation
Secondary: aims to detect and treat disease at an early stage eg cancer screening, BP monitoring
Tertiary: aims to minimise effects of established disease eg by transplants, steroids
46
What are the principles of health promotion strategies?
- equitable
- sustainable (can persist once funding has ended)
- empowering (gives individuals power to change)
- holistic (encompasses their physical, mental, social and spiritual health)
- participatory (involve everyone at all stages)
- intersectoral (collaboration of all relevant sectors)
47
What are some problems with health promotion techniques?
- nanny state (too much interference)
- victim blaming (plays down influence from socioeconomic and environmental health determinants)
- fallacy of empowerment (giving people info doesn't necessarily lead to power)
- unequal responsibility (as implementation of healthy behaviours is usually left to mothers)
- can reinforce negative stereotypes (eg HIV in gays)
- the prevention paradox
48
What does the prevention paradox describe?
The fact that interventions that make a difference at a population level might not have much effect on an individual
Eg national reduction in BP may appear successful at a population level, but there wouldn't be much noticeable effect on those who weren't a risky level just having it lowered more
49
What are some difficulties when evaluation the use of health promotion techniques?
- possible lag time to effect (delay to decay)
- design of intervention (eg was it leaflets or videos that had the effect)
- large chance of confiding factors
- large cost of evaluation research
50
What is an illness narrative?
A type of qualitative interviewing used to get a story telling narrative of someone's experience with illness
51
What is he illness work in a chronic condition?
Having to cope with the diagnosis and symptoms, self management of condition
52
What is the everyday work of chronic illness?
Coping (cognitive) and strategies (actions) to deal with the illness
Can adapt to a new style of living, or normalise to attempt to retain their pre-illness lifestyle
53
What is the emotional work of chronic illness?
Protecting the emotional well being of others eg by maintaining cheery self
Idea of dependency impacting their role eg if there were breadwinner/ mother
54
What is the biographical work of chronic illness?
Loss of self and self value
| Reconstruction of their biography
55
What is a stigma?
A negatively defined condition, attribute, trait or behaviour conferring 'deviant' status
56
What is the difference between discreditable vs discrediting stigma?
Discreditable: no physical signs, but stigma may occur if people found out eg HIV/ mental illness
Discrediting: physically visible/ well known stigma eg disability, known suicide attempt
57
What is the difference between enacted and felt stigma?
Enacted stigma is real experience of prejudice or discrimination
Felt stigma is the fear of enacted stigma
58
What is the difference between the medical and social model of disability?
Medical model sees disability as a result of physical impairment to the patients body
Social model sees disability as the way that society is organised
59
How can health be measured?
Mortality, morbidity and patient based outcomes (PROMs)
60
What are PROMs and what can they be used for?
Patient reported outcome measures
Currently covers hip replacements, knee replacements, groin hernia and abdominal pain
Collected by all providers of NHS care and made publicly available
Assess health directly from the patients point of view, unlike morbidity and mortality
Can be used to improve clinical management of patients
Can compare between providers
61
What is health related quality of life?
The functional effect of an illness, as perceived by the patient
62
How can HRQoL be measured?
Either by quantitative or qualitative measures
Qualitative methods are useful but resource demanding and difficult to evaluate
Quantitative methods involve the use of instruments/ scales and can be generic (cover the whole population) or specific (to a certain disease/ site)
63
What are some examples of specific and generic measure of HRQoL?
General: SF36, EuroQoL 5D
Specific: to site eg Oxford hip score, to disease eg asthma QoL questionnaire, to dimension eg Beck depression inventory
64
What are some positives and negatives of specific instruments to measure HRQoL?
✅ relevant and sensitive
| ❌ limited comparison, can't use on people who don't have the disease
65
What is SF-36?
Generic instrument to measure HRQoL
Short form 36-item questionnaire
Uses a 4 week recall period to score in 8 dimensions, then gives a score for each dimension (but cannot add up dimensions to give an overall score)
✅quick, easy to evaluate, population comparable
❌doesn't produce a single index value
66
What is EuroQoL 5D?
Generates a single index value for health status (unlike SF-36)
Full health is assigned a value of 1
Death is assigned a value of 0
Measures 5 dimensions, with 3 levels per dimension and the patient ticks the most appropriate box for each dimension
✅ very quick, reliable, valid, good population date
67
What is screening?
Attempt to detect an unrecognised condition to distinguish between apparently well people who probably have a disease and those who probably do not.
68
What are the 5 areas of criteria for screening?
1. Condition (well understood, all cost effective primary prevention interventions implemented)
2. Test (simple, safe, validated, accepted cut off, agreed policy on those who test +ve)
3. Intervention (must be evidence intervention at pre-symptomatic stage leads to better outcomes than at symptomatic stage)
4. Screening programme (proven reduction in morbidity and mortality, benefit outweigh harms, economically balanced)
5. Implementation (adequate staffing and facilities, scientifically justifiable to public, quality assurance, informed choice for public)
69
What types of bias could screening lead to?
Lead time bias
Length time bias
Selection bias
70
What is lead time bias?
When early diagnosis falsely appears to prolong survival, when in fact px just knows they have disease for longer
71
What is length time bias?
That screening is better at picking up slow growing cases rather than fast growing ones
These diseases detected are more likely to have a favourable prognosis and may never have caused a problem
72
What is selection bias in screening?
The idea that screening studies are skewed by a "healthy volunteer" effect, because those who attend screening are more likely to follow health promoting behaviours eg good diet, exercise.
73
What are some sociological critiques of screening?
- nanny state idea that has to much focus on surveillance
- victim blaming
- feminism arguments (screening mostly aimed at women's bodies so creates the impression that a woman's body is inferior)
- moral obligation (people have reported HCPs treating them as deviant if they refuse screening)
74
What is sensitivity of a screening method looking at?
The proportion of people with the disease who test positive aka the detection rate
(The probability that a case will test positive)
75
How can the sensitivity of a screening method be calculated?
= a / (a+c)
76
What is the specificity of a screening method looking at?
The proportion of people without the disease who test negative (probability a non case tests negative)
77
How is specificity of a screening method calculated?
= d /(b+d)
78
If the same screening method is applied in the same way but in different populations, what effect will this have on its sensitivity and specificity?
They will not change (as they are characteristics of the test, not of the population)
79
What is the positive predictive value (PPV)?
Probability of someone who tests positive actually having the disease
80
What is positive predictive value strongly influenced by?
The prevalence of the disease
81
What is the negative predictive value?
The proportion of people who are test negative who actually do not have the disease
82
How is negative predictive value calculated?
=d / (c+d)
83
What are the implications of a false positive result?
- unecessary stress
- may lead to lower uptake of screening programmes in future
- unecessary use of invade diagnostic testing
84
What are the implications of a false negative result?
- falsely reassured
| - not offered diagnostic testing that they would benefit from
85
What are the three core principles of the NHS?
- universal
- free at the point of use
- comprehensive
86
What change did the 1983 griffiths report bring about for the NHS?
Gave an increasing role doe managers and gave the internal market (competition between hospitals)
87
What does devolution mean?
That Scotland, Wales and Northern Ireland each have a differently organised NHS
88
What is the current structure of the NHS, broadly?
Secretary of State -> department of health -> NHS England -> CCGs -> providers
89
Who is responsible for most of the flow of the NHS budget?
CCGs
90
How do NHS hospital trusts earn their income?
Through services that CCGs commission from them, and from the provision and undergrad and postgrad training
91
What are clinical directorates?
Hospital trusts are organised into clinical directorates based on a speciality/ group of specialities eg radiology, women's health
Each is led by a clinical doctor, as well as a lead nurse and non clinical doctor
92
What is the role of clinical directorates?
To implement audits, protocols and manage medical education for their speciality
93
What is a medical director?
Someone responsible for the quality of medical care, and communicates between the board and medical staff
Involved in approving job description, and carrying out disciplinary processes etc
94
What is a profession?
An occupation able to make distinctive claims about its work practices and status
In healthcare, usually refers to occupations requiring registration
95
What is socialisation?
The process by which professionals assume their professional identity during their education and training
Occurs during interaction with others (formal and informal curriculum)
96
What is the self regulatory model?
Where a profession self regulates by determining who is to be admitted and who should remain licensed
Self regulation for doctors has now come to an end, GMC now controls registers
97
What are the three elements of a profession?
- can assert an exclusive claim over a body of knowledge/ expertise
- establishing control over market and exclusion of competitors
- establishing control over professional work practice
98
What is explicit rationing?
Based on defined rules of entitlement
| Circumstances of who gets treatment is widely expressed
99
What is implicit rationing?
Allocation of clinical resources through individual decisions without the criteria for those decisions being explicit
100
What are some drawbacks of implicit rationing?
Can lead to discrimination and inequalities
Doctors often unwilling to do it
Open to abuse
101
What are some positives and negatives of explicit rationing?
✅ transparent, accountable, evidence based, equitable
❌ complex, assumes heterogeneity of patients and illnesses, impact on clinical freedom, patient distress, patient and professional hostility
102
Which organisation provides guidance on whether treatments have be recommended and approved for use in that NHS?
NICE
| Use evidence to assess clinical AND cost effectiveness
103
What is meant by scarcity?
If demand outstrips resources, prioritisation is inevitable
104
What is meant by efficiency?
Getting the most out of limited resources
105
What is meant by equity?
Distribution of resources is fair
106
What is meant be effectiveness, in terms of healthcare economics?
The extent to which an intervention produces desired outcomes
107
What is meant by utility?
The value an individual places on a health state
108
What is meant by opportunity cost?
Once you have used resources is one way, you no longer have them available to use in another way
Measured in terms of benefits foregone (what would the same pot of money be able to buy, what are we now not able to buy)
109
What is the difference between technical and allocative efficiency?
Technical: interested in the most efficient way of meeting a need
Allocative: choosing between one of the many needs to be met
110
What is cost minimisation analysis?
When all outcomes are assumed to be equivalent, so focus is only on the costs (inputs)
Eg assume all hip prostheses improve mobility equally, so just choose the cheapest
Not often relevant as all outcomes are rarely equivalent
111
What is cost effectiveness analysis?
To compare drugs/ interventions which have a common health outcome, measure in terms of cost per unit outcome eg cost per 5mm/Hg reduction in blood pressure
112
What is cost benefit analysis?
All inputs and outputs are viewed in monetary terms
Can compare with interventions outside health care
But methodological difficulties eg how can you put a value on someone's life
113
What is cost utility analysis?
Focuses on the QUALITY of health outcomes produced/ foregone
| Can compare interventions in QALY terms
114
What is a QALY?
= quality adjusted life year
Uses a single index to incorporate both quality AND quantity of life
1 year of perfect health = 1 QALY, same as 10 years of 0.1 health
115
How is quality of life methods for QALYs?
Uses EQ-5D (a generic instrument to measure HR-QoL
116
For NICE, what value is a QALY under when it is usually approved?
20k per QALY
| >30k would need very strong case
117
What are some criticisms of QALYs?
- assumes everyone has same perceptions of QoL
- doesn't take into consideration carers/ partners
- evidence on costs is difficult to find and interpret
- RCT evidence is not always perfect (eg length of follow up, sample size, atypical care, atypical patients)
- problems at treatments aimed for conditions that affect older people as they have less years on average to live so QALYs will be less than treatments aimed at younger individuals, regardless of effectiveness of treatment
118
If a female was expected to live for 23 years of 0.7 QoL without treatment
Tx A offers 23 years of 0.95 QoL at cost of £50 p/a
Tx B offers 23 years of 0.7 QoL at cost of £30 p/a
Which treatment is more cost effective?
Without tx: 16.1 QALYs
Tx A: gained 5.75 QALYs at cost of £200 per QALY
Tx B: gained 2.3 QALYs at cost of £300 per QALY
So Tx A more cost effective
119
What are some ways that patients can give feedback?
NHS friends and family test
NHS choices website
Non-NHS forums
PALS service in hospitals
120
What is the role of the health service ombudsman?
Undertake independent investigations into complaints and provides and independent review on what has happened
121
What is the functionalist approach of the patient-professional relationship?
Idea that the ill patient is placed in a position of helplessness and the doctor has power to is expected to use their skills to restore people to good health to restore social equilibrium
122
What are some criticisms of the functionalist approach?
- assumes patient is incompetent
- doesn't explain why things can go wrong
- assumes beneficence of medicine
- sick role not well thought out, eg px with chronic illness can't get better
123
What is the conflict approach for patient professional relationships?
Elliot Freidson's theory that the doctor holds bureaucratic power and the patient has little choice but to submit to the dominance of the doctor. Lay ideas are marginalised and discounted.
124
What are some criticisms of the conflict approach?
- patients are not always passive eg non-adherence
- assumes the patient has legitimate views
- patient and doctor are not always in conflict
125
What is the interpretative/ interaction its approach to patient professional relationships?
Focus on the meanings that both parties gives to the encounter
Interested in patterns of order
Informal rules govern almost every aspect of conduct of all parties
126
What is the patient centred approach for patient professional relationships?
Aspiration for patient professional relationship to be less hierarchical and more cooperative
Shift away from traditional professional centred model, towards patient centred model
Emphasis on egalitarian relationship (patient and professional as equals)
Underpins many recent policy initiatives
Both agree on a management plan
Enhances health prevention and promotion
127
What is the difference between explanatory and aspirational models of the Doctor-patient relationship?
Explanatory approaches try to explain how doctor-patient relationships can work, and how they can go wrong
Aspirational approaches describe how the doctor-patient relationship should ideally be
128
What is meant by the formal and informal curriculum through which socialisation into the medical profession involves?
Formal refers to technical knowledge that can be tested in examinations
Informal refers to attitudes and beliefs that are typically not formally examined
129
What is the illness work of chronic illness?
Coping with their diagnosis and managing their treatment
130
What is everyday life work of chronic illness?
Coping with the illness and a strategy to manage it (normalisation to maintain pre-illness self)
131
What is the emotional work of chronic illness?
Maintaining "cheery self" to downplay symptoms and protect the emotion well being of others (may impact their role as bread winner, mother etc)
132
What is the biographical work of chronic illness?
Loss of self, from perceived normal to abnormal, recognition of fragility of life
133
What is the identity work of chronic illness?
Different conditions have different connotations, affects how people see themselves and how others see them
Eg would have different ideas of a schizophrenic patient compared to a breast cancer patient
134
What criteria should a screening TEST fulfil before it can be carried out as a screening programme?
- simple and safe
- precise and valid (high specificity and sensitivity)
- agreed cut off levels
- acceptable to the population
- agreed policy on who to investigate further
135
What criteria should a screening CONDITION fulfil before it can be carried out as a screening programme?
- well understood and important health problem
| - all cost effective primary prevention intervention methods implanted as far as practicable
136
What criteria should a screening programme fulfil before it is carried out an a large scale?
- proven ability to reduce morbidity and mortality
- must be clinically, socially and ethically acceptable
- it's opportunity cost should be economically balanced
- benefit gained from individuals should outweigh any harms (eg from overdiagnosis, over treatments, false positives, complications)
137
What is a clinical audit?
A quality improvement process that aims to improve patient care and outcome, by a systematic review against criteria and implementation of change
138
Why is it important for doctors to have a good understanding of lay beliefs?
- lay beliefs may influence health behaviour
- they may influence illness behaviour
- can help understands compliance and non compliance
139
What is a systems based approach to health care?
Suggest things go wrong due to multiple errors occurring (Swiss cheese) rather than the fault of the individual so it refers systems in place to promote "no blame" and discourage latent errors
