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Mine ESA 4 > Health and Disease in Society > Flashcards

Health and Disease in Society Flashcards

1
Q

Preventable?

A

An adverse event that could be prevented given the current state of medical knowledge

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2
Q

Clinical governance?

A

A framework through which NHS organisations are held accountable by continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish
- all doctors work under this duty

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3
Q

Examples of preventable events:

A
  • operations performed on the wrong part of the body
  • retained objects
  • wrong dose/type of medication given
  • failure to rescue
  • some kind of infections
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4
Q

The swiss cheese model/james reasons framework of error?

A

consists of active failure and latent failure both of which lead to the occurrence of preventable events

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5
Q

Active failures?

A

are acts that lead directly to the patient being harmed e.g. baby has a seizure as a result of a drug overdose

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6
Q

Latent failures?

A

= accidents waiting to happen
- any aspect of context that means active failures are more likely to occue such as poor training, poor supervision, poor design of syringes, too few staff

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7
Q

Why patient safety problems occur?

A
  1. poorly designed systems that do not take into account human factors
  2. culture and behaviour
  3. over reliance of individual responsibility
  4. either system or individual (careless/incompetent) can be at fault
  5. human factors
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8
Q

How can we avoid the effects of human factors?

A
  • avoid reliance on memory
  • make things visible
  • review and simplify processes
  • standardise common procedures and processes
  • decrease the reliance on vigilance
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9
Q

Ensuring quality was done in the health and social care act in 2010…

A
  • need continuous improvement in the quality of services provided to individuals
  • effectiveness of services
  • safety of services
  • quality of the experience undergone by patients
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10
Q

What are the NHS quality improvement mechanisms?

A
  1. standard setting: done by NICE aim to define what high quality care should look like
  2. Commissioning: by CCGs, commission services for local population
  3. Financial incentives: QOF, CQUIN (quality and outcomes framework, commissioning for quality and innovation)
  4. Disclosure: of evidence about performance on an organisational and trust level, focus on safety, effectiveness and experience of patients
  5. regulation, registration and inspection: care quality commission registers and licenses providers of care services, monitors services to ensure that they meet the standard, can also make unannounced visits, can issue warning notices, fines, prosecution, restriction on activities and closure
  6. data gathering and feedback
  7. clinical audit (local and national/ professional regulation)
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11
Q

Define the audit cycle

A

Choose topic -> criteria and standards (using research evidence) -> first evaluation -> implement change -> second evaluation -> etc

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12
Q

Clinical audit:

A

a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against criteria and change

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13
Q

Definition of evidence based medicine:

A
  • involves the integration of individual clinical practice with its best available external clinical evidence from systematic reviews
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14
Q

Origins of evidence based healthcare…

A

The argument that….

  • health service delivery should be based on the best available evidence
  • bets evidence os findings of rigorously conducted research
  • look at evidence of effectiveness (drugs practices, interventions) and cost effectiveness (in a system with finite resources)
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15
Q

Why do we need systematic reviews?

A
  • traditional narrative literature may be biased and subjective
  • not easy to see ho studies were identified for review
  • quality of studies reviewed variable and sometimes poor
  • used to help address clinical uncertainty
  • can highlight gaps in research/poor quality research
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16
Q

Why are systematic reviews useful to clinicians?

A
  • by appraising and integrating findings they offer quality control and increased certainty
  • offer authoritative, generalisable and up to date conclusions
  • save clinicians form having to locate and appraise the studies for themselves
  • may reduce delay between research discoveries and implementation
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17
Q

What are practical criticisms of evidence based medicine?

A
  • impossible task to create and maintain systematic reviews across all specialities
  • challenging and expensive to disseminate and implement findings
  • methodological arguments about meta analyses and systematic reviews
  • RCTs not always feasible/necessary/desirable (due to ethical considerations)
  • choice of outcomes are often very biomedical
  • some groups may not be well served such as minority ethnic groups
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18
Q

What are the philosophical critiques of the evidence based practice movement?

A
  • does not align with most doctors mode of reasoning
  • aggregate, population level outcomes don’t mean that it will work for the individual
  • potential of EBN to create unreflective rule followers out of professionals and possible more work for explaining why they have not followed guidelines
  • might be understood as a means of legitimising rationing
  • doctors may lose their autonomy and could become more like accountants than doctors
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19
Q

What are the difficulties in getting evidence into practice?

A
  • evidence exists but doctors do not know about it?
  • doctors know about the evidence but do not sue it due to habit
  • organisational systems cannot support innovation
  • commissioning decision reflects different priorities i.e. what if patients want something else
  • resources not avaliable to implement the change
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20
Q

What are complementary therapies?

A

The practice of complementary therapies or alternative medicine involves and medical system based in a theory of disease or method treatment other than the orthodox method of science as taught in medical schools

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21
Q

examples of complementary therapies?

A
  • osteopathy, chiropractor, acupuncture, indian head massage, hypnotherapy, bach flower remedy
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22
Q

Why do people use complementary therapies?

A
  • if they have persistent symptoms that have not been relieved with conventional treatment
  • real or perceived adverse effects of conventional treatment
  • may feel they receive more time and attention (paying!)
  • have a preference for a more holistic approach to the problem
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23
Q

What is the doctors perspective on complementary therapies?

A
  • believe some established forms maybe of benefit
    But concerns include:
  • practitioners maybe unqualified and unregulated
  • may risk missed or delayed diagnosis as could go to complementary therapies first
  • may refuse conventional treatment
  • may waste money on ineffective treatment
  • the mechanism of some complementary treatments is so implausible it cannot work
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24
Q

What is the evidence base idea for complimentary therapies?

A
  • should meet the same standards of any other treatment
  • issues in assessing the effectiveness in ways consistent with EBM principles
  • is EBM relevant and applicable to complementary therapies
  • should be judged by biomedical rules
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25
Q

What are the challenges in conducting trials?

A
  • resources
  • trial of single intervention may not reflect reality due to co morbities
  • multifaceted intervention trial is very complex
  • have to agreement for randomisation
  • finding placebos and shams can be challenging especially in complementary therapies
  • difficult to make double blind
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26
Q

What are the argument for NICE evaluating complementary therapies?

A
  • high public interest
  • half GP provide access
  • address inequalities in access/opportunity
  • should apply same standards to everything
  • stimulate more high quality reserach
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27
Q

Arguments against NICE evaluating complementary therapies?

A
  • money is limited in NHS
  • NHS has higher priorities
  • poor quality evidence in these ares i.e. small number, poorly powered studies, poor methodology
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28
Q

What is the traditional model of professional self regulation?

A
  • 1858 medical act gave power to the GMC over registration of doctors
  • it was seen that the interests of the profession would be the best guarantee of the interests of the public
  • heavily dependant upon professional norms
  • relies on individuals internalising and cooperating with the collective norms of the professional group and aligning their conduct with the professions standards
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29
Q

What is a profession?

A

is a type of occupation able to make distinct claims about its works practices and status.

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30
Q

What is professionalisation?

A

Describes the social and historical process that result in an occupation becoming a profession

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31
Q

How does an occupation become a profession?

A
  • asserting exclusive claim over a body of knowledge or expertise
  • establishing control over market competitors
  • establishing control over professional work practices
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32
Q

What is professional socialisation?

A

the process through which new entrants acquire the professional identities/turning lay persons into professionals by..
formal curriculum: knowledge tested through exams and acquisition of technical knowledge
informal curriculum: attitudes and beliefs that are performance noted but are not formally examined

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33
Q

What are the critisms of self regulation?

A
  • an attempt to collect monopoly rents
  • claims of virtue as self deceiving vision of the objectivity and reliability of its members
  • bad apples e.g. bristol inquiry, Harold shipman
  • common theory in reports of those in positions of authority in the NHS, its regulators, failure to detect signs of unacceptable or incompetent professional behaviour and to take effective and timely action action to protect patients for example staff who were informed found it difficult to act, patients who were told health professional often greeted with disbelief or discredited, whistle blowers are not always believed, NHS disciplinary procedures are cumbersome, costly and inhibiting
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34
Q

What are the rules of professional propriety?

A
  • doctors discouraged from raising concerns about each other
  • etiquette rules forbid close monitoring of other doctors
  • hist costs associated with sanctioning
  • problems of quality of evidence, absence of supportive process
  • credibility gap
  • shared sense of personal vulnerability
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35
Q

What was the end of self regulation and the regulatory reform

A
  • GMC was given parity of lay and professional members
  • there was a move away from the self regulatory model, this was overseen by the professional standards authority for health and social care
  • the powers of setting standards, monitoring practice and conduct and management relocated from inside the profession
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36
Q

Fitness to practice questions?

A
  • if concerned then referred to medical tribunals service
    reasons include - misconduct, poor performance, criminal conviction or caution, physical/mental illness, failure to listen to concerns
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37
Q

What actions can be taken by the GMC?

A
  • agree undertaking with the doctor
  • place conditions on their registration
  • suspend their registration
  • remove them from the medical register
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38
Q

What is revalidation?

A

a local evaluation of a doctors practice through annual appraisals that consider the whole of their practice.

  1. participate in annual appraisal that have a GMP at their core
  2. maintain a portfolio of supporting information to bring their appraisals as a basis for discussion
  3. have a positive recommendation from a responsible officer
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39
Q

What is the rise of mangerialism?

A
  • gone from administrations (facilitating the work of professionals) to management (control over the work of professionals)
  • now appoint consultants, allocate clinical excellence awards, agree detailed job descriptions, assist in implementation of government policies, expect to ensure compliance with guidelines and clinical governance
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40
Q

What are the two forms of rationing?

A

Explicit rationing = care is limited but is based on defined rules of entitlement i.e. the reasoning behind decisions is explicit
Implicit rationing = is the allocation of resources though individual clinical decisions but the decisions, nor the bases of these decisions is clearly expressed

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41
Q

When was implicit rationing used?

A
  • before 1990 reforms of NHS
  • patients believes that care with offered or withheld on the basis of clinical need
  • however this was open to abuse, could lead to inequalities and discrimination, decisions based on social deservingness, doctor appeared increasingly unwilling to do it
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42
Q

In explicit rationing there are..

A
  • technical processes e.g. assessments of efficiency and equity
  • political processes e.g. lay participation
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43
Q

What are the advantages to explicit rationing?

A
  • transparent and accountable
  • opportunity for debate
  • uses EBM
  • more opportunities for equity in decision making
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44
Q

What are the disadvantages to explicit rationing?

A
  • very complex
  • heterogeneity of patients and illnesses
  • patient and professional hostility
  • threat to clinical freedom
  • evidence of patient distress
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45
Q

Technical efficiency?

A
  • you are interested in the most efficient way of meeting a need
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46
Q

Allocative efficiency?

A
  • you are choosing between the many needs to be met
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47
Q

What are the range of opportunities to resource allocation in healthcare?

A
  • NICE: gives guidelines, directions are binding, replaces local recommendations, has to approve significant new drugs and devices, has a controversial role in expensive treatment,
  • Tariffs: payments by results, diagnosis treatment etc are recorded and coded so if efficient enough then a tariff is paid hence trusts can make money or if never events occur then no payment is made to the hospital
  • could let the public decide
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48
Q

What are the issues in letting the public decide in resource allocation?

A
  • consultation can be problematic
  • resistant to rationing
  • majority think that everyone should have the healthcare they need regardless of cost
  • tend to value heroic interventions higher and particular patient groups too
  • have a preference for treating patients with dependants
  • a willingness to discriminate against those who were partially responsible for their health e.g. smokers
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49
Q

What is opportunity cost?

A
  • this is the idea that choosing to use resources in one way forgoes the opportunity to use them in other ways, this is measured in terms of benefits foregone
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50
Q

What is economic evaluation?

A

is the comparison of resource implications and benefits of alternative ways of delivering healthcare

  • can facilitate decisions so that they are more transparent and fair
  • is underpinned by the concepts of scarcity/sacrifice, efficiency, utility and opportunity costs
  • is a system in which competing programmes are evaluated in terms of their cost and consequence
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51
Q

What are costs in economical evaluation?

A
  • medical e.g. treatment, health professional visits

- non medical e.g. time off work, travel costs

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52
Q

What are the benefits in economic evaluation?

A
  • survival
  • monetary
  • clinical criteria
  • quality of life
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53
Q

What is cost minimisation analysis?

A

This is were outcomes are assumed to be equivalent and are compared on their inputs i.e. cost
- this is not relevant as it is rare that outcome are equivalent

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54
Q

What is cost-effective analysis?

A

this is used to compare drugs or interventions which a have a common health outcome such as lowering blood pressure. The interventions are compared in terms of cost per unit outcome such as a 5mmHg drop in BP.
But if costs are higher in one treatment but benefits are too then need to calculate how much extra benefit do you get for the extra cost?
- uses a cost effectiveness plane

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55
Q

What is cost benefit analysis?

A

This is were all inputs and outputs are compared in monetary terms and hence allows comparisons for interventions outside of healthcare but methodological issues include putting value on non-monetary benefits such as lives saved.
willingness to pay is problematic here e.g. how much is a life worth?

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56
Q

What is cost utility analysis (the one we use!)

A

is a particular type of cost effectiveness analysis that focuses on the quality of health outcomes produced or foregone
- most frequently used measure if quality adjusted life years, QALYs (which is a composite of survival and quality of life) where interventions are compared in cost per QALY

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57
Q

What are problems with QALYs?

A 
RCT evidence: 
- comparison therapies may differ
- length of follow up 
- atypical care
- atypical patients 
- limited generalisability 
- sample sizes 
however statical modelling can address some of these problems and areas of uncertainty
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58
Q

What are the criticisms of QALYs?

A
  • do not distribute resources according to need but according to benefits gained per unit of cost
  • technical problems with calculations
  • may not embrace all dimensions of benefits
  • controversy about the values that they embody
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59
Q

What are the advantages to QALYs?

A
  • effective measure that can be used in a wide range of settings
  • allows broad comparisons across differing programmes
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60
Q

What are the founding principles of the NHS?

A
  • universal (covering everyone)
  • comprehensive (covering all health needs)
  • free at the point of delivery

Now there is continual change due to pressures such as ageing population, shifting burden of disease, new technologies, increasing expectations, financial austerity

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61
Q

At the top of the NHS….

A
  • secretary of state for health = overall accountability for NHS
  • department of health = sets national standards, shapes direction of NHS and social care services
  • NHS England = authorises clinical commissioning groups, supports, develops and performance manages commissioning, comssion general primary care services
  • CCGs = crucial bodies in new organisation of the NHS that bring together GPs, nurse, specialists, public health, patient, public and other to commission secondary and community healthcare services, 65% of NHS budget, local authorities now responsible for public health
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62
Q

Service provision..

A

CCGs and NHS England commission providers to provide care for populations that they serve. Can put contracts with private or volunatry sectors

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63
Q

NHS providers of care…

A

e.g. acute hospital trusts, community health services trust, ambulance service trust, GP practices
Earn money through reaching targets and if can earn money via greater function and managerial activity if gain foundation trust status
Can also earn money through undergraduate and postgraduate teaching

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64
Q

What are the management skills needed by doctors?

A

Strategic: ability to analyse, plan, make decisions
Financial: ability to set priorities and manage a budget
Operational: ability to run things, execute plans
Human resources: ability to manage people and teams

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65
Q

What are the management roles for doctors?

A
  • medical director, clinical director, consultant, GP
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66
Q

What is the clinical directors role?

A

To manage his or her directorate as a whole e.g. radiology, cardiology

  • provide continuing medical education and training
  • design and implement policies on junior doctors hours of work, supervision, tasks and responsibilities
  • ensure that clinical audit is carried out and results are translated into improvements
  • develop management guidelines and protocols for clinical procedures
  • induction of new doctors
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67
Q

What is the medical directors role?

A
  • responsible for the quality of medical care i.e. care provided by doctors at hospital
  • communicates between the board and medical staff
  • leadership of medical staff: sets out strategy, exemplifies positive values, helps to implement change
  • leads on organisations clinical policy and clinical standards
  • associate or deputy medical directors may have responsibility for particular functions such as patient safety and clinical governance
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68
Q

Adverse Event?

A

An injury that is caused by medical management rather than underlying disease and prolongs both the hospitalisation, produces a disability or both

69
Q

What are Quantitative research methods?

A
  • collection of numerical data that begins with an idea/hypothesis and by deduction allows conclusions to be drawn
70
Q

What are the advantages to quantitative methods?

A

good at…

  • describing and measuring
  • finding relationships between things
  • allows comparisons
  • reliability and repeatability
  • can include large numbers of people
  • can use existing questionaries which have demonstrated reliability and repeatability
  • can establish validity by comparing with other measures
71
Q

What are the disadvantages to quantitative research methods?

A
  • may force people into inappropriate categories
  • doesn’t allow people to express things in the way that they want
  • may not access all important information
  • may not be effective in establishing causality
72
Q

An example of quantitative research method….

A

Questionaire

  • should be valid (measure what supposed to measure)
  • should be reliable (measure things consistently, differences in results come from difference between participants not from inconsistencies in how items are understood or in how responses are interpreted
73
Q

What can a Questionaire measure?

A
  • measure exposure to risk factors, effect of lifestyle, dietary factors or particular conditions
  • knowledge and attitudes
  • satisifcation with health services
74
Q

What types of question are in a questionnaire?

A
  • mainly closed questions
  • can offer other or please specify option
  • can have open ended questions, with free text bokx at end of questionnaire
  • either self completed, done via telephone, interview,
75
Q

What are qualitative research methods?

A
  • aims to make sense of phenomena in terms of meanings that people bring to them e.g. why don’t people give up smoking
  • needs to listen to what people have to say, understand their perspective
  • emphasises meaning, experience and views of respondents
  • analysis emphasises the researchers interpretation not measurement
  • can provide insights into peoples behaviour
  • the analysis is an ongoing process and is very labour intensive
  • is often and indicative process, not testing hypothesis, broad area meaured
76
Q

How can we go about qualitative data collection?

A
  • observation and ethnography
    observe what people do either as a participant or a non participant (i.e. not normally there)
    + gains access to individuals behaviour that they may be biased towards or not think to mention and allows researchers to record the mundane and unremarkable features of everyday life
  • labour intensive and is normally combined with formal interviews and other sources of data
  • interviews
    Are semi structured, prompted by a prompt guide, clear agenda of topics, emphasis on participant giving their perspective with the interviewer facilitating this .
    gives detailed focused accounts relating to an issue of interest but is someones professed views or explanation of the issue itself, so not unproblematic description of the issue itself.
  • focus groups
    + are a flexible method, quick for establishing parameter or for accessing group based, collective understanding of the issue.
    Disadvantages = not useful for individual experience, may encourage people not to participate, some topics may be too sensitive for focus groups and deviant views could be inhibited as feel marginalised, not the easiest option to mediate/needs a good facilitator, have to consider group membership e.g. consultants with HCA
  • document and media analysis
    Uses independent evidence such as medical records or patient diaries so must always be authored by someone, may provide historical context and is useful for subjects that are difficult to investigate
77
Q

What are qualitative methods good for?

A
  • understanding the perspective of those in the situation
  • accessing information not revealed by quantitative approaches
  • explaining relationships between variables
78
Q

What are qualitative methods less good at?

A
  • finding consistent relationships between variables
  • generalisability, qualitative methods may be good at identifying a range of views on an issue but it would be dangerous to suggest that views for a small sample are statistically representative
79
Q

How do we choose research methods?

A
  1. topic under investigation and research question
  2. research teams perspective and capacity
  3. cost and money available
  4. finding of evidence, what do they want from it
80
Q

When do we use quantitative date?

A
  • numbers
  • point of view of researchers
  • research distant
  • theory testing
  • static
  • structures
  • generalisation
  • behaviour
  • causality
81
Q

When do we use qualitative data?

A
  • words and artefacts
  • discussing things
  • interacted in point of view of participant
  • research close
  • theory emergent
  • long process rather than quickly done
  • less structures
  • contextual understanding
  • small number of people but in lots of details
82
Q

What are the possible explanation and which ones are form the black report?

A
  1. artefact BR
  2. social selection BR
  3. behavioural cultural BR
  4. materialist BR
  5. psychosocial explanation
  6. income distribution and psychonarrative pathway
83
Q

What is the artefact explanation?

A

The existence of health inequalities is due to the way that statistics are collected and in particular to problems with the measurement of social class

  • concerns about the quality of data and method of measurement
  • data problems in anything actually lead to an underestimation of equality
  • mostly discredited
84
Q

What is the social selection explanation

A

Direction of causation is from health to social position
i.e. sick individuals move down social hierarchy and healthy individuals move up so chronically ill and disabled people are more likely to be disadvantaged

problems = studies suggest that social selection only makes a minor contribution to SE difference in health and mortality

85
Q

What is the behavioural-cultural explanation?

A

Ill health is due to people’s choices, decisions, knowledge and goals

  • people form disadvantaged backgrounds tend to engage in more health damaging behaviours
  • people from advantaged backgrounds tend to engage in more health promoting behaviours

problems = contributes but is not the sole explanation, not always simply an option of individual choice i.e. cost of healthier food, lack of easier access to healthy affordable food, learn to cook in certain ways, difficult to do choices in adverse conditions,

86
Q

What is the materialist explanation?

A

Inequalities in health arise from differential access to material resources such as low income, unemployment, work environment, low control over job, poor housing condition. People in low socioeconomic groups lack choice in exposure to hazards and adverse conditions and there is an accumulation of factors across life course.

problems = most convincing but further research is needed to understand the precise routes through which material deprivation causes ill health

87
Q

What is the psychosocial explanation?

A
  • psychosocial pathways in addition to direct effects of absolute material living standards, some stressors are distributed on a social gradient and stress can have a direct i.e. physiological and indirect i.e. mental health and behaviours
88
Q

What is the income distrubition/wilkinson theory?

A
  • relative not average income that affects health, so the countries with the greater health inequalities have greater health inequalities. Therefore it is the most egalitarian societies that have the best health. so social cohesion is n important part of health
89
Q

What is the difference between health inequality or inequity?

A 
Inequality = when things are different/not equal 
Inequity = inequalities that are unfair/avoidable
90
Q

Socioeconomic groups and patterns of access to health care…

A

Utilisation studies measure the receipt of services.
Find that more deprived groups seem to have…
- higher rates of use of GP services
- more use of emergency services
- under use of preventative services i.e. screening
- under use of specialist services

91
Q

What are the explanations behind deprived groups pattern of access?

A
  • tendency to manage health as a series of crises
  • normalisation of ill health
  • event based consulting may be required to legitimise consultations
  • difficulty marshalling the resources needs for negotiation and engagement with health services
  • tendency to use poor porous services
  • may reflect lack of culture alignment between health services and lower SES
92
Q

Further patterns of access

A
  • minority ethnic groups = some patterns i.e. higher primary care use in some BME (black and minority ethnic) groups, evidence of lower receipt of some specialist services
  • vulnerable groups show different patterns of use/different ways of engaging in health behaviour
  • gender, highest primary care use in women
93
Q

What is the explanations behind diversity and access?

A
  • language, social networks, alienation by culturally discordant organisations, stigmatisation, stereotyping
  • associated with SES
  • cultural expectation i.e. gender
  • differing needs of different groups
  • variations between and within minority groups, be careful ot avoid simplistic classifications
94
Q

What are lay beliefs?

A
  • how people understand and make sense of illness
  • constructed by people about areas in their lives about which they have no specialised knowledge
  • not a watered down version of medical knowledge
  • socially embedded
  • complex = drawn from may different sources
95
Q

Why are lay beliefs important?

A
  • impact on health behaviour
  • impact on illness behaviour
  • impact on compliance/non compliance (adherence) with treatment
96
Q

What is a negative definition on health?

A

health equated to the absence of illness

97
Q

What is a functional definition of health?

A
  • health is the ability to do certain things
98
Q

What is a positive definition of health?

A

Health is a state of wellbeing and fitness

99
Q

What is health behaviour?

A

activity undertaken for the purpose of maintenance of health and prevents illness

  • higher social class have a more positive definition of health
  • people focus on long term concepts
  • incentives are less clear to disadvantaged groups i.e. smoking is a coping mechanism
100
Q

What is illness behaviour?

A

Activity of a person to define illness, seek solution, what they decide to do about it

101
Q

What is the illness iceberg?

A
  • most symptoms will never get to a doctor i.e. some will do nothing, other will self treat, some will consult doctor
    Like an iceberg proportion of people who do not get seen by health care professional
102
Q

What influences illness behaviour?

A
  • culture e.g. stoical attitude
  • visibility or salience of symptoms
  • extent to which symptoms disrupt life
  • frequency and persistence of symptoms
  • tolerance threshold
  • information and understanding
  • availability of resources
  • lay referral
103
Q

What is sick role behaviour?

A

The formal response to symptoms including seeking formal help and action of person as patient

104
Q

What is the lay referral system?

A
  • chain of advice seeking contacts which the sick make with other people prior to or instead of seeking help from health care professionals
105
Q

Why is the lay referral system important?

A
  • explains why people delay seeking help
  • how, why and when people contact the doctor
  • your role as a doctor in health, it is not just you advising them
  • use of health services and medication
  • use of alternative medication
106
Q

What is symptom evaluation?

A

Key factor in influencing how quickly medical advie is sought

107
Q

How lay beliefs can affect adherence, what are the categories?

A
  1. deniers and distancers
    - deny have condition
    - do not have proper condition (distancers)
    - claim symptoms do not interfere with everyday life, will use complex strategies to hide it, do not take medication or attend clinics
  2. acceptors
    - accept diagnosis and doctors advice, normal life involves having control over symptoms through use of medication. Do not stigmatise condition
  3. Pragmatics
    - do not use preventer medication only use when symptoms are bad, see condition as a mild illness and only take medication when needed but do accept diagnosis
108
Q

What is health promotion?

A

The process of enabling people to increase control and improve their health. Health is a positive concept that empathises social and personal resources as well as physical capabilities.

109
Q

What are the principles of health promotion?

A
  • empowering, participatory, holistic, intersectoral, equitable, sustainable, multi strategy
110
Q

What are the main health promotion strategies?

A
  1. medical or preventive e.g. encourage smokers to stop
  2. behavioural change e.g. persuasive campaigns
  3. educational e.g. effects of diet
  4. empowerment e.g. patient centred
  5. social change e.g. pubs becoming smoking free
111
Q

What is primary prevention?

A

Aims to prevent onset of disease or injury by reducing exposure to risk factor e.g. immunisation, prevent contact with environment, take precautions over communicable diseases, reduce risk factors for health related behaviours

112
Q

What is secondary prevention?

A

Aims to detect and treat a disease or its risk factors at an early stage i.e. prevent progression
e.g. screen for cervical cancer, monitoring bP, screening for glaucoma

113
Q

What is tertiary prevention?

A

Aims to minimise effects of established disease

e.g. renal transplants, steroids to prevent asthma attacks

114
Q

What are the dilemmas raised from health promotion?

A
  • ethics of interfering in peoples lives
  • victim blaming
  • fallacy of empowerment
  • reinforcing negative stereotypes e.g. leaflets about HIV and recreational drug users
  • unequal distribution of responsibility e.g. often left to women
  • prevention paradox i.e. intervention that works at the population level may not have an effect at the individual level, links with lay beliefs if people do not see themselves at risk of a disease then will not take part in the health promotion
115
Q

Define evaulation

A

The rigorous & systematic collection of data to asses the effectiveness of a programme in achieving pre-determined objectives

116
Q

Why do we need to evaluate health promotions?

A
  • need for evidence based interventions
  • accountability - evidence gives legitimacy to intervention and gains political support
  • ethical obligation i.e. no direct or indirect harm
  • programme management and development
117
Q

What are the types of health promotion evaluation?

A 
Process = the process of programme implementation 
Impact = what effect did it have 
Outcome = what has it achieved in the long term?
118
Q

What are the difficulties with health promotion intervention?

A
  1. design of the intervention (complex?)
  2. timing of evaluation can influence the outcome due to delay (some interventions might take a long time to have and effect) and decay (intervention may wear off)
  3. many potential intervening or concurrent confounding factors
  4. high cost of evaluation research i.e. studies are likely to be large scale and long term
119
Q

What is the work of chronic illness?

A
  • illness work = dealing with management of illness e.g. symptoms
  • everyday life work = coping (cognitive processes involved in dealing with illness) and strategic management (action and process involved in managing the condition and its impact) so ordinary tasks of daily living
  • emotional work = work that is done to manage own emotions and emotions of others
  • biographical work = loss of self, biographical disruption (shift of life projectory due to illness)
  • identity work - affects how people se themselves and how other see them and how concerned other may seem them, work to maintain an acceptable identity
120
Q

What is the illness narrative?

A

Refers to the story telling and accountability practice that occur in the face of illness

121
Q

What is narrative reconstruction?

A

Process by which the shattered self is reconstructed in way that explain the appearance of illness

122
Q

What is stigma?

A

Is a negatively defined condition, attribute, trait or a behaviour conferring deviant status

123
Q

What is discreditable stigma?

A
  • nothing seen/immediate apparent but if found out one may be treated differently e.g. mental illness, HIV positive
124
Q

What is discredited stigma?

A

physically visible characteristic or well know stigma that sets them apart e.g. physical disability, known suicide attempt

125
Q

what is enacted stigma?

A

The real experience of prejudice discrimination and disadvantage as the consequence of a condition

126
Q

What is felt stigma?

A

Fear of enacted stigma, also encompasses a feeling of shame associated with having a condition.
- Might lead to selective concealment of condition e.g. diabetics not injecting themselves in public

127
Q

What is the medical model of disability?

A
  • disability is the deviation from medical norms
  • disadvantages are a direct consequence of impairment and disabilities
  • needs medical intervention to help or cure
128
Q

What are the critiques of the medical model of disability?

A
  • lack of recognition of social and psychological factors

- stereotyping and stigmatising language

129
Q

What is the social model of disability?

A
  • problems are a product of environment and failure of environment to adjust
  • disability is the form of social oppression
  • political action and social change is needed
    i. e. disability is a function of society which fails to take account of people with impairment, people are special needs only in certain context
130
Q

What are the critiques of the social model of diasbility?

A
  • body left out
  • overly drawn view of society
  • failure to recognise bodily realities and extent to which these are socially solvable
131
Q

How self management impact on LTC management?

A

optimum self management is difficult to achieve…
- poor rates of adherence to treatment
- reduced quality of life
- poor psychological well being
can do brief interventions to improve such a telephone/see in person, but vary in quality and effectiveness

132
Q

What are the advantages and disadvantages to self management?

A

+ coping and condition management skills
+ aims to decrease hospital admissions
+ patient centred
- responsibility for own care placed on patient
- needs understanding
- little evidence of efficacy and savings

133
Q

What are patient based outcomes?

A
  • attempts to assess well being from patients point of view
    e. g. HRQoL, health status, functional abilities, patient report outcome measures (PROMs) measures of health that come directly from patients
134
Q

Why do we use patient based outcomes?

A
  • increase in conditions where aim is to manage rather than cure
  • biomedical tests just seen one part of picture
  • need to focus on patients concerns
  • need to pay attention to iatrogenic effects of care
135
Q

What can they be used for?

A
  • clinically
  • assess benefits in relation to cost
  • clinical audit
  • measure health status of population
  • measure service equality/compare trusts
  • used to compare interventions in a clinical trial
  • results can be published
  • results allows patients to make informed decisions
136
Q

What is health related quality of life?

A

Quality of life in clinical medicine represents the functional effect of an illness and its consequent therapy upon a patient as perceived by the patient.

  • emphases patients own views
  • emphasis on functional effects
  • emphasis on therapy as well as illness
137
Q

HRQoL is multidimensional….

A

Physical function = mobility, dexterity, physical activity, activities of daily living
Symptoms = pain, nausea, appetite, energy, vitality, fatigue, sleep, rest
Global judgments of health = differences in how people expect quality of life to be
Psychological well being = anxiety, depression, coping, positive well being and adjustment, sense of control/self esteem
Social wellbeing = family and intimate relations, social contact, integration, social opportunities, leisure activities, sexual activities and satisfaction
Cognitive Functioning = cognition, alertness, concentration, memory, confusion, ability to communicate
Personal constructs = satisfaction with bodily appearance, stigma, life satisfaction, spirituality
Satisfaction with care

138
Q

What are the two different types of quantitative quality of life measures?

A

Generic = can be used with nay population, they generally cover perceptions of overall health and also questions on social, emotional, physical functioning, pain and self care e.g. short form 36 item questionnaire/SF-36 or the euroQoL/EQ-5D

Specific = This types of instrument evaluates a series of health dimensions specific to a disease, site or dimension
e.g. asthma QoL questionnaire, oxford hip score, beck depression inventory

139
Q

What are the advantages to generic instrutments?

A
  • can be used for a broad range of health problems
  • can be used if no disease-specific instrument
  • enable comparisons across treatment for groups of patients
  • can be used to assess health of populations
  • can be used to detect unexpected positive or negative effects of an intervention
140
Q

What are the disadvantages to generic instruments?

A
  • loss of detail
  • loss of relevance
  • may be less sensitive to changes that occur as a result of an intervention
  • maybe less acceptable
141
Q

What are the advantages to specific instruments?

A
  • very relevant context
  • sensitive to change
  • acceptable to patients
142
Q

What are the disadvantages to specific instruments?

A
  • can’t use them with people who don’t have the disease
  • comparison is limited
  • may not detect unexpected effects
143
Q

What should be considered when selecting a questionnaire?

A
  • is there published work showing established reliability and validity
  • is there published studies that have used this instrument successfully
  • is it suitable for your area of interest
  • does it adequately reflect patients concerns in this area
  • is the instrument acceptable to patients
  • is it sensitive to change
  • is it easy to administer and analyse
144
Q

Describe how qualitative methods are used in measuring HRQoL?

A
  • relatively uncommon but gives you access to parts that other methods do not reach (+)
    + good at for initial look at dimensions for HRQoL
  • very resource hungry as needs training and time
  • not easy to sue in evaluation of RCTs
145
Q

What is screening?

A

A systematic attempt to detect an unrecognised condition by the application of a test, examination of other procedures which can be applied rapidly and cheaply to distinguish between apparently well persons who probably have a disease or its precursor and those who probably do not

146
Q

The screening process…

A
  • following screening a person is labelled screen positive or negative
  • further test are required before the diagnosis of the disease is made
  • treatment will only be given once a definitive diagnosis is made
147
Q

What is the purpose of screening?

A
  • to give better outcomes compared with finding something in the usual way i.e. having symptoms and self reporting to health services
  • if treatment can wait until there is symptoms then no point in screening
  • not simply finding a disease earlier
148
Q

Errors of screening programmes….

A
  1. going to refer well people for further investigation = put them through unnecessary stress, anxiety, inconvenience, direct cost, opportunity cost
  2. going to fail to refer people who do actually have an early form of the disease e.g. inappropriate reassurance, possible delay presentation with symptoms
149
Q

What is the disease/condition criteria for screening programmes?

A
  • must be an important health problem
  • epidemiology and natural history must be well understood
  • must have an early detectable stage
  • cost effective primary prevention interventions must have been considered and where possible implemented
150
Q

What is the test criteria for screening programme?

A
  • simple and safe
  • precise and valid
  • acceptable to the population
  • distribution of test values within the population must be known
  • an agreed cut off level must be defined
  • must be an agreed policy on who to investigate further
  • expansion
151
Q

What is the treatment criteria for screening programmes?

A
  • effective evidence based treatment must be available
  • early treatment must be advantageous, cannot just bring date of diagnosis forward
  • need an agreed policy on who to treat
  • clinical management of the condition and patient outcomes should be optimised in healthcare providers before participation in screening programme
152
Q

What is the programme criteria for screening?

A
  • proven effectiveness with RCT data
  • quality assurance for whole programme not just the test
  • facilities for diagnosis, counselling and treatment
  • other options should have be considered such as improving treatment
  • decisions about parameters should be scientifically justifiable to the public
  • benefits should outweigh physiological and psychological harm
  • opportunity costs
153
Q

What are the features of test validity?

A
  • sensitivity (detection rate)
  • specificity
  • positive predictive value
  • negative predictive value
154
Q

Sensitivity?

A

Proportion of people with the disease who test positive i.e. true positives/ (false negatives + true positives)

i. e. probability a case will test positive
- want this to be high!

155
Q

Specificity?

A

Is the proportion of the people without the disease who test negative/ people without the disease who are correctly identified as not having the disease by the test
= true negatives/ (false positives + true negatives)
- want this to be high

156
Q

Remember that for sensitivity and specificity…

A

They are functions of the characteristics of the test so when the same test is applied in the same way to different populations these values are the same

157
Q

Positive predictive value?

A

Probability that someone who tests positive actually has the disease
= true positive /(false + true positives)
- is influenced by the prevalence of the disease in a population

158
Q

Negative predictive value?

A

Is the proportion of people who are test negative and who actually do not have the disease
= true negatives/ (false + true negatives)

159
Q

What are the issues raised by screening?

A
  1. alteration of usual doctor-patient relationship

2. complexity of screening programmes, who do you screen/what ages,

160
Q

What are the difficulties in evaluating screening?

A
  1. lead time bias, falsely appears to prolong survival in screened patient by earlier diagnosis
  2. length time bias, screening programmes are better at picking up slow growing unthreatening cases than the aggressive faster growing ones and the slow growing ones are more likely to have a favourable prognosis and might have never have caused a problem, Curing people that do not need curing
  3. selection bias, studies of screening skewed by healthy volunteer effect, i.e. those who attend regular screening are likely to do other things to protect them from the disease. An RCT can deal with this bias but might not be ethical to conduct
161
Q

What are the sociological critiques of health promotion and screening?

A

Structural critiques = victim blaming, individualising pathology
Surveillance critiques = individuals and populations increasingly coming subjective to surveillance
Social constructionist = health and illness practices can be seen as moral given meaning through particular social relationships
Feminist critiques = screening targeted more at women that men? policing women’s bodies

162
Q

What are the options for assessing patients views on healthcare?

A
  • NHS friends and family test
  • NHS choices website feedback
  • range of other non-NHS websites and forums
  • local health watch
  • patient advice and liaison service
  • parliamentary and health service ombudsman
  • NHS hospital complaints system
163
Q

What are the things that cause dissatisfaction in healthcare?

A
  • interpersonal skills (patient not allowed to express their concerns fully, do not take full history of problem, no reassurance conveyed, do not provide appropriate advice)
  • content of health care (waiting times, inconsistency, competence, culturally inappropriate care)
164
Q

What is the aspirational model?

A
  • how doctor patient model should be
  • involves patient in role of management and shared decision making
  • patient centred model
165
Q

What is the explanatory model?

A

explains how doctor patient relationship works and what can go wrong
- functionalism, conflict, interpretive/interactionist approach

166
Q

Functionalism?

A
  • sick role and doctor role
  • medical restores people to good health and hence erstores social equilibrium
  • assumes people are incompetent/have a passive role, sick role not good as some patients do not get better, assumes rationing and beneficence of medicine
167
Q

Conflict approach?

A
  • medical dominance so suppressed conflict
  • medicine now involved in areas previously thought to be areas of lay public
  • people become dependant on medicine, lose self reliance
  • e.g. medicalisation of childbirth
168
Q

Interpretive/interactionist approach

A
  • focus on meaning that both parties bring to the encounter
  • how does order emerge from interaction
  • informal, unwritten rules govern almost every aspect of social life
169
Q

Patient centred model?

A
  • patient centred consultation
  • shared decision making
  • challenges to this method
  • patients contribute concerns, priorities, personal perception of cost and benefits

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