Health and Disease in Society Flashcards
1
Q
What features do we use to define healthcare quality?
A
Safe Effective Patient-centered Timely Efficient Equitable
2
Q
What is an adverse event?
A
Injury caused by medical management that prolongs the hospitalization of a patient and/or produces a disability.
3
Q
What is a preventable event?
A
An adverse event that could be prevented given the current state of medical knowledge.
4
Q
What are human factors?
A
Human factors involve psychological responses that are predictable and poor reliability of systems that can contribute to a problem- made up of active failures and latent conditions.
5
Q
What is the difference between an active failure and a latent condition?
A
An active failure is an act that leads directly to the harm of a patient whereas a latent condition is a predisposing condition that increases the likelihood of an active failure occurring.
6
Q
What is meant by the ‘Swiss cheese model’?
A
Successive layers of defenses, barriers and safeguards with holes due to active failures and latent conditions. When these holes align this can lead to adverse or preventable events.
7
Q
How can we remove latent conditions and avoid adverse events?
A
Avoid reliance on memory and decrease reliance on vigilance
Make things visible
Review and simplify processes
Standardize common procedures and processes
Routinely use checklists
8
Q
What is meant by clinical governance?
A
A framework through which NHS organisations are accountable for continuous improvement of services and safeguarding high standards of care.
9
Q
What quality improvement mechanisms exist in the NHS?
A
Standard setting e.g. NICE
Commissioning
Financial incentives
Disclosure
Regulation- registration and inspection by GMC
Data gathering and feedback
Clinical audits- both at national and local levels
10
Q
What is the role of NICE?
A
NICE sets quality standards based on the best available evidence, produced collaboratively with the NHS and service users.
11
Q
What is the role of a clinical commissioning group?
A
CCGs are responsible for commissioning services for their local populations and driving quality by acting in the best interests of the consumer.
12
Q
What is a QOF in primary care?
A
QOF- quality outcomes framework.
Sets national quality standards with indicators so that practices can score ‘points’ and payments can be calculated.
13
Q
What is the National Tariff?
A
The national tariff is set by the Department of Health and provides a consistent basis/payment for commissioning particular services in order to incentivise efficiency and drive quality.
14
Q
What is the role of the Care Quality Commission?
A
The CQC can impose “conditions of registration”, make visits, issue warnings and fines and in extreme cases prosecute NHS trusts.
15
Q
What are the phases of a clinical audit?
A
Choose topic Criteria and standards set First evaluation e.g. questionnaire Implement change as a result of analysis Second evaluation to observe result of the change
16
Q
What is meant by quality improvement?
A
Systematic changes that will lead to better patient experiences and outcomes, system performance and professional development.
PLAN-DO-STUDY-ACT
17
Q
What is meant by evidence-based practice?
A
The integration of individual clinical expertise with the best available external clinical evidence from systematic research.
18
Q
Why do we use systematic reviews?
A
To highlight gaps in research or poor quality research
Offers quality control
Easily converted into guidelines
19
Q
What practical criticisms are there of evidence-based practice?
A
Difficult to create and maintain systematic reviews across all specialties
Challenging and difficult to disseminate findings
RCTs are not always feasible or desirable
Requires good faith on the part of pharmaceutical companies
20
Q
What philosophical criticisms are there of evidence-based practice?
A
Does not align with most doctor’s methods of reasoning
Aggregate population-level outcomes don’t mean that a particular intervention will work for an individual
Creates ‘unreflective rule followers’
Acts as a means of legitimizing rationing
May compromise professional responsibility/autonomy
21
Q
What problems are associated with getting evidence into practice?
A
Doctors may not know about the evidence
Organisational systems do not support innovation
Commissioning decisions reflect different priorities
Resources may not be available to implement the change
22
Q
What is meant by qualitative research methods?
A
Aim to make sense of phenomena in terms of the meanings that people bring to them and offers insights into people’s behavior.
23
Q
What is meant by quantitative research methods?
A
Collections of numerical data that begin with an idea/hypothesis and by deduction allows the establishment of associations/relationships.
24
Q
What are the advantages of quantitative methods?
A
Quick and cheap
They are good at establishing relationships
Allow comparisons
Describe and measure
25
What are the disadvantages of quantitative methods?
May force people into inappropriate categories
Do not allow personal expression
Not effective in establishing causality
26
What is ethnography?
Studying human behavior in its natural context, e.g. participant observation to allow knowledge of behaviors that people are unaware of.
27
What are focus groups?
Flexible method for assessing a group-based collective understanding of a topic or issue. Membership is ideally homogeneous and a good facilitator is required.
28
What are the advantages of qualitative methods?
Help to understand perspectives
| Explain relationships
29
What are the disadvantages of qualitative methods?
Cannot establish relationships
They are not generalisable
Are highly labor-intensive
30
What is the social selection explanation for health inequalities?
Direction of causation is from health to social position, therefore the chronically ill and disabled are more likely to be disadvantaged.
31
What is the behavioral-cultural explanation for health inequalities?
Ill health is due to people's choices and decisions, knowledge and goals e.g. people from more disadvantaged backgrounds are more likely to engage in more health-damaging behaviors.
However "choices" and behaviors are often outcomes of social processes and may be difficult to exercise in adverse conditions.
32
What is the psycho-social explanation for health inequalities?
Psycho-social factors act in addition to the direct effects of absolute material living standards and stresses are distributed on a social gradient e.g. negative life events, social support, autonomy.
33
What is the income distribution explanation for health inequalities?
Relative (not average) income affects health, therefore countries with greater income inequalities have greater health inequalities.
Re-distributive policies reduce income inequality in a society in order to improve social well being.
34
What is the difference between inequality and inequity?
Inequality is when services are not equal and inequity refers to inequalities that are unfair and avoidable.
35
What other factors besides socio-economic status can affect access to health services?
Ethnicity
Gender
Health exposures
36
What are lay beliefs?
How people understand and make sense of health and illness with no specialized knowledge, so evidence is drawn from embedded beliefs and social sources.
37
What is the negative definition of health?
Defined as the absence of illness/symptoms.
38
What is the functional definition of health?
Ability to do certain things/activities and continue with daily life activities.
39
What is the positive definition of health?
Health is a state of wellbeing and fitness- proactive approach.
40
What is meant by health behavior?
A health behavior is an activity undertaken for the purpose of maintaining health.
41
What is illness behavior?
The activities undertaken by an ill person to define their illness and seek solution.
42
What is sick role behavior?
The formal response to symptoms including seeking formal help etc.
43
What is meant by the lay referral system?
Chain of advice seeking contacts which the sick individual makes with other lay people prior to seeking help. This may encourage or discourage the individual to seek professional help.
44
What are the three lay approaches to symptom evaluation?
Deniers- claim symptoms do not interfere with daily activity
Acceptors- control illness with medication and adhere to treatment
Pragmatists- use medication when they feel it necessary but may downplay illness severity
45
What is meant by health promotion?
The process of enabling people to increase control over and improve their health. Health promotion combines health education and public policy.
46
What features are seen in good health promotion?
Empowerment
Participatory
Holistic
Intersectoral (collaboration of agencies)
Sustainable- aims to bring about maintainable change
Multi-strategy
47
What is Public Health England?
A group that brings together agencies with the aim to empower communities, enable professional freedoms and unleash new evidence-based ideas.
48
What are the structural critiques of health promotion?
Focus too much on individual responsibility/victim blaming
| Ignores the factors that material conditions play in ill health
49
What are the surveillance critiques of health promotion?
Health promotion results in monitoring and regulating the population
50
What are the consumption critiques of health promotion?
Lifestyle choices are not only seen as 'health risks' but play a part in identity
51
What is primary prevention?
Prevention of the onset of disease by reducing exposure to risk factors e.g. immunisation
52
What is secondary prevention?
Treating disease at an early stage e.g. screening
53
What is tertiary prevention?
Minimizing the effects of established diseases e.g. maximizing the remaining capabilities of a disabled person
54
What is the 'fallacy of empowerment'?
Unhealthy lifestyles are not a product of ignorance and may be outside of the patient's control.
55
What is the 'prevention paradox'?
Interventions that make a difference at a population level may have little effect on an individual.
56
What is process evaluation?
Assesses the process of programme implementation by qualitative methods.
57
What is impact evaluation?
Assesses the immediate effect of an intervention.
58
What is outcome evaluation?
Assesses the long-term consequences and measures what is achieved by the programme.
59
What is meant by delay and decay in terms of health promotion programmes?
Delay- some interventions have a long time to take an effect.
Decay- some interventions wear off rapidly and the changes made are not sustainable.
60
What are some problems with evaluation of health promotion programmes?
Design problems
Lag time to effect
Confounding factors
High cost
61
What is meant by 'negotiated reality' in terms of chronic illness?
The experiences and meaning of chronic illness that vary from person to person, how people manage and negotiate chronic illness in every day life.
62
What is an 'illness narrative'?
Illness narratives refer to the story-telling and accounting practices that occur in the face of illness.
63
What are the features of illness work?
Getting a diagnosis
Managing symptoms (must be done before coping with social relationships)
Self-management (optimum is difficult to achieve)
64
What is the Expert Patient Programme?
A programme that aims to help patients better self-manage their condition and learn coping mechanisms to help them improve their general well being and adherence to treatments.
65
What are the advantages of the Expert Patient Programme?
Coping management
Reduced hospital admissions due to better self-care
Patient-centred
66
What are the disadvantages of the Expert Patient Programme?
Responsiblity for care is put on very ill patients
| There is little evidence of efficiency savings
67
What are the features of everyday life work?
Coping- cognitive processes of dealing with an illness
Strategy- actions involved in managing the condition
Normalisation- keeping pre-illness lifestyle or identity/designating the new life as 'normal'
68
What is emotional work?
Work done to protect the emotional wellbeing of others, may include conscious maintenance of normal activities or strategic withdrawal.
69
What is biographical work?
Loss of self and former image without the development of an equally valued new one resulting in difficulty to achieve a positive view of self.
70
What is meant by biographical disruption?
Disruptive experience that threatens the sense of the 'taken-for-granted' world resulting in grief for a former life.
71
What is identity work?
Idea that different conditions can affect how people see themselves and how others see them- changing roles and relationships.
72
What is a stigma?
A negatively defined condition, attribute or trait/behavior that confers deviant status.
73
What is meant by a discreditable condition?
There are no outward signs of the condition but if it was discovered that the individual had the condition there would be judgement from peers.
74
What is meant by a discredited condition?
Physically visible characteristics set the individual apart from peers.
75
What is meant by enacted stigma?
The real experience of prejudice, discrimination and disadvantage as a consequence of having a particular condition.
76
What is felt stigma?
Fear of enacted stigma.
77
What is the medical definition of disability?
Disability is deviation from medical norm, disadvantages are a direct consequence of the impairment and it requires medical intervention to help.
78
What is the social definition of disability?
Problems are a product of failure of the environment to adjust to the individual and disability is a form of social oppression requiring political action and social change.
79
What are the criticisms of the medical definition of disability?
Does not recognise the impact of social and psychological factors
Stereotyping and stigmatising language
80
What are the criticisms of the social definition of disability?
Lacks recognition of the impact of the body
| Has an 'all-powerful' view of society and fails to recognise how solvable these problems may be socially
81
What is the ICF?
International Classification of Functions, Disability and Health- aims to integrate the medical and social models of disability and recognise the impact of the wider environment.
82
What are Patient Based Outcomes?
PBO assess wellbeing from the patient's point of view using patient-reported outcome measures (PROMs) that work by comparing scores over time or after an intervention.
83
Why do we use PROMs clinically?
```
To assess benefit vs cost
For clinical audit
Comparison of services/interventions
Improve clinical management
Comparison of service providers
```
84
What are the existing NHS PROM programmes?
Hip and knee replacement
Groin hernia
Varicose veins
85
What are the challenges to PROMs?
Cost of data collection and analysis
Achieving high rates of patient participation
Avoiding misuse
Expanding into other areas
86
What is Health-related Quality of Life?
In clinical medicine HRQoL represents the functional effect of an illness and its consequences, including physical function, symptoms, psychological and social wellbeing, personal constructs and satisfaction of care.
87
Give some examples of generic instruments used to measure HRQoL:
SF-36
| EuroQol EQ-5D
88
Give examples of some specific instruments used to measure HRQoL:
Oxford Hip Score
| McGill Pain Questionnaire
89
What are the ideal features of an instrument?
```
Established reliability and validity
Published (ensures above)
Suitability to your area of interest
Adequately reflects patient concerns (so is acceptable)
Sensitive to change
Easy to use
```
90
What is a diagnosis?
Definitive identification of a suspected disease by applications of investigations and tests to label people has having or not having a disease.
91
What is screening?
An attempt to detect unrecognised conditions by application of rapid and cheap tests to distinguish between apparently well people who probably have the disease and those who probably do not.
92
What criteria are there for screening?
Important health problem
Early detectable stage- gives better outcome compared with spontaneous self-preservation
Cost-effective primary prevention interventions already in place
Test is simple, safe, precise and valid
Test is acceptable to the population
Effective evidence-based treatment must be available
Clinical management should be optimum
Proven effectiveness (RCT data) exists for the screening programme
93
What is meant by false positives?
People who test positive for the disease but do not actually have the disease.
94
What is meant by false negatives?
People who test negative for the disease but actually do have the disease.
95
What is meant by sensitivity?
The probability that a case (actually has the disease) will test positive.
96
What is meant by specificity?
The probability that a non-case (does not have the disease) will test negative.
97
What is the PPV?
The risk that if you tested positive you actually have the disease. (Value is affected by prevalence i.e. a low prevalence condition will have a lower PPV meaning more false positive results)
98
What is the NPV?
The proportion of people who are test negative and do not actually have the disease.
99
What is lead time bias?
Early diagnosis falsely appears to prolong survival; patients life the same length of time as they would without screening but know they have the disease for longer.
100
What is length time bias?
Screening is better at picking up slow-growing cases and diseases that are detectable in this way are therefore more likely to have better prognoses- this leads to the false conclusion that screening is beneficial in lengthening lives.
101
What is the 'healthy volunteer' effect?
Those who participate in screening are more likely to do other things to protect them from disease, resulting in a selection bias.
102
What are some of the sociological critiques of screening?
Victim blaming
Individualising pathology
Populations subject to surveillance
May be targeted more at women than men
103
What are the 3 core principles of the NHS?
Universal
Comprehensive
Free at the point of delivery
104
When was the NHS founded?
1948
105
What were the main features of the Griffiths Report (1983)?
Increased managerial and strategic roles
Increased marketisation of provision
Commissioners act as customers to choose between providers on patient's behalf
106
What are the main features of 2012 Health and Social Care Act?
Secretary State of Health now responsible for promotion and not provision of the NHS
Structural change
Increased use of markets including 'social enterprises'
Required efficiency savings of £20bn per annum
107
What is the role of NHS England?
Authorises CCGs, supports, develops and performance-manages commissioning and commissions services.
108
What is the role of CCGs?
Bring together nurses, GPs and public health to commission secondary and community healthcare services.
109
What is meant by FT status?
Foundation trust stats can be earned by high-performing trusts (provide services and undergraduate/postgraduate education) to allow them greater financial and managerial authority.
110
What is the role of the Clinical Director?
Provide medical education and training
Design and implement policies on juniors hours of work, supervision, tasks and responsibilities
Clinical audits
Management guidelines and protocols for procedures
Induction of new doctors
111
What is the role of the Medical Director?
Responsible for quality of care
Communicates between board and staff
Approves job descriptions, interview panels and equal opportunities
Leads clinical policy and standards
112
Give examples of management skills that doctors can have:
Strategic- plan and make decisions
Financial- manage budgets
Operational- run things and execute plans
HR- manage people and teams
113
Why is resource allocation necessary?
Changing demography
New technologies
Consumerism
Demand is always greater than supply
114
What is implicit rationing?
Care is limited but neither the decisions nor the basis for them are exposed.
115
What is explicit rationing?
Based on defined rules of entitlement with the use of institutionalized parameters for the systematic allocation of resources.
116
What are the advantages of explicit rationing?
Transparent and accountable
Opportunity for debate
Evidence-based
More opportunity for equity
117
What are the disadvantages of explicit rationing?
Complex
Assumes heterogeneity of patients
Negatively impacts clinical freedoms
Causes patient distress and hostility
118
What are the main features of healthcare economics?
```
Scarcity
Efficiency
Effectiveness
Utility
Opportunity cost
```
119
What is an opportunity cost?
The value of the next best alternative use of those resources, measured in benefits forgone.
120
What is cost minimisation analysis?
Outcomes are assumed to be equal and focus is on the input (resources).
121
What is cost effectiveness analysis?
Compares interventions with a common health outcome in terms of cost-per-unit-outcome.
122
What is cost benefit analysis?
All inputs and outputs valued in monetary terms and allows for comparison of interventions through a 'willingness-to-pay' model.
123
What is cost utility analysis?
Type of cost effectiveness analysis that focuses on the quality of the health outcome produced or forgone, measured in QALYs (Quality adjusted life years).
124
How do we produce a cost-per-QALY figure?
QALY score is calculated and then integrated with the price of treatment using the incremental cost-effectiveness ratio (ICER).
125
List some advantages of QALYs:
Maximises benefits from healthcare spending
Overcomes regional variations in access
Allows direct comparisons of interventions
126
List some disadvantages of QALYs:
Resources not distributed according to need
May disadvantage common conditions
QALYs do not assess impact on carers/family
RCT evidence may be flawed e.g. atypical care or patients
127
What was the outcome of the NHS Plan (2000)?
Organisations were required to publish a patient's prospectus and an annual account of patient's views to set out the range of local services available and their ratings.
128
What was the outcome of the NHS Act (2006)?
Duty was placed on organisations to "involve and consult" patients and the public in planning and developing services and changes.
129
What were the features of the White Paper from 2010?
Set up Healthwatch England
Encouraged use of patient experience surveys
Stated complaints should be a central mechanism for assessing service quality
130
What is the NHS Friends and Family Test?
"How likely would you be to recommend the service to friends and family?"
131
What is Healthwatch England?
The national consumer champion with local authorities that are responsible for seeking the views of local people and passing them onto commissioners and establishing direct relationships through their seat on the Health and Wellbeing Board.
132
What is PALS?
Patient Advice and Liason Services- help with questions and resolving concerns for those who need more information about the NHS, getting involved in their health and complaints procedures.
133
What is the Parliamentary and Health Service Ombudsman?
Undertakes independent investigations into complaints that have not been resolved by NHS England to a satisfactory standard.
134
What problems exist with current complaints procedure?
People lack information on complaining
The system is unnecessarily confusion and complex so support is often needed
People want to know that lessons are learned and changes implemented as a result of their complaint
135
What problems exist to do with responding to complaints?
Patients may not be reasonable or rational
Difficult to locate responsibility for the problem
How many resources should be used to respond to complaints?
How should patient's concerns of clinical competence be considered?
136
Explain the functionalist approach to patient-doctor relationships?
Falling ill is a socio-cultural experience and generally lay people do not have the technical competence to remedy their situation.
The sick person is placed in a state of helplessness and medicine restores the social equilibrium.
137
What is meant by the "sick role"?
Being ill is a legitimate reason to be freed of social responsibilities and obligations and places the individual in a state of dependence. The sick person should want to get well and not abuse their legitimised exemption.
138
What are criticisms of the functionalist approach?
Some people cannot get better
Assumes that patients are incompetent
Assumes the beneficience of medicine
It doesn't explain how things go wrong
139
Explain the conflict approach to patient-doctor relationships?
Doctor's control involves a degree of bureaucratic power and the patient must submit to the institutionalized dominance of the doctor. Results in the medicalisation of processes and supports a dependence on medicine.
140
What is meant by cultural iatrogenesis?
Loss of self reliance and dependence on medicine.
141
What are the criticisms of the conflict approach?
Patients are not always passive
Patients may appear deferential in consultation and assert themselves outside
Patients may seek to medicalise situations
142
Explain the interactionist approach to patient-doctor relationships?
Focuses on the meanings that both parties give to the encounter.
143
Explain the patient-centred approach to patient-doctor relationships?
Focuses on a cooperative, egalitarian approach to the relationship and on the patient's ideas, concerns and expectations.
144
What is a complementary therapy?
Therapeutic and diagnostic disciplines that exist largely outside of institutions where conventional healthcare is provided.
145
Give reasons why patients may be interested in complementary therapies?
```
Dissatisfaction with conventional medicine
Lay referral
Recommended by a clinical professional
Take control of their healthcare
Idea of it being a 'natural' treatment
Reducing symptoms/side effects
```
146
What problems may be associated with complementary therapies?
May stop conventional treatments working
May interact with conventional treatments and produce side effects
No guarantee of safety or effectiveness
May actively cause harm
147
What is a profession?
A type of occupation able to make distinctive claims about its work practices and status.
148
What is meant by professionalization?
Social and historical processes that result in an occupation becoming a profession.
149
What are the stages of professionalization?
1) Asserting an exclusive claim over a body of knowledge/expertise
2) Establishing control over the market and excluding competitors
3) Establishing control over professional work practice
150
Give a brief history of the medical profession:
1518- founded Royal College of Physicians
1815- Apothecaries Act
1858- Medical Act gave GMC powers of registration
151
What is meant by socialization?
Process by which professionals learn during their education and training the attitudes and behaviors necessary to assume their professional role. "Informal and formal curriculum".
152
What are the rights to self-regulation?
Non-professionals not equipped to evaluate or regulate
Professionals are responsible and can be trusted to work conscientiously without supervision
The profession itself can be trusted to undertake the proper regulatory action
153
What critiques are there of professions?
Professions are protected monopolies
Claims of virtue are self-serving and strategic
Professions seek to optimize their own interests
154
What critiques are there of self-regulation?
Promotes a "self-deceiving vision of the objectivity and reliability of its knowledge and the virtue of its members".
Medicine's autonomy has lead to insularity and mistaken arrogance about its mission.
Informal controls do not work on 'bad apples'.
155
What changes to the medical profession have come about from the mid-2000s?
Authority for setting standards, monitoring practice and conduct relocated.
GMC now has parity of lay and professional members and members are appointed independently.
Civil rather than criminal standard of proof is required e.g. Fitness to Practice.
156
What is the purpose of revalidation?
Drives better clinical governance and improving standards of patient care.
157
What are the threats to clinical autonomy?
```
Proliferation of guidelines
Inspection and monitoring
Pay for performance
League tables
Reputational sanctions
```
158
What threats exist to the medical profession?
Diminished professional discretion
External accountability may have unintended consequences
Large administrative overheads
Undermining clinician's roles as patient's advocates
Displacement of professional goals and ethos for organisational ones
159
What are the "three logics"?
Bureaucracy
Markets
Professionalism
160
What is meant by the collective "new professionalism"?
The responsibility of the profession as a whole to act as a force for good.
