My notes Block 15 Flashcards
The equality act 2010 offers protection to what 9 characteristics?
Age Race Sex Gender reassignment status Disability Religion or belief Sexual orientation Marriage and civil partnership status Pregnancy and maternity
What is direct age discrimination?
occurs when a direct difference in treatment based on age cannot be justified. A direct difference in treatment is a situation in which a person is, was or could be treated in a less favourable manner than another person in a comparable situation based on his/her age.
What is indirect discrimination?
occurs when a seemingly neutral provision, measure or practice has harmful repercussions on a person (…or group of persons)
What does the GMC say about age discrimination?
“You must not unfairly discriminate against patients or colleagues by allowing your personal viewsto affect your professional relationships or the treatment you provide or arrange…
This includes your views about a patient’s or colleague’s lifestyle, culture or their social or economic status, as well as the characteristics protected bylegislation: age, disability, gender reassignment, race, marriage and civil partnership, pregnancy or maternity, religion or belief, sex and sexual orientation.”
What is a QALY and how do we calculate them?
QALY-based assessments involve assigning a utility value (between zero and one) to a state of health and then multiplying that value by the number of years expected to be lived in that state.
e.g. Smith: 5 (yrs) x 0.5 QALY points = 2.5 QALYs
Jones: 5 (yrs) x 0.8 QALY points = 4.0 QALYs
The total value helps determine resource distribution.
What are some objections to QALY based assessments?
Difficulties relating to measurement and bias “pharmaceutical company funded studies were eight times less likely to reach unfavourable qualitative conclusions about drugs under investigation than comparable non-profit-funded studies”
Some object QALY-based assessments are unjust
Double-jeopardy objection
Does end of life care lose out??
Favours life years over individual lives
What is the case for QALY based assessments?
Addresses primary purpose of healthcare, which is about maximising welfare (=combination of quality and quantity of life).
Also might seem to be motivated at the individual patient level
QALY-based assessments are already utilised widely, including by NICE
How is the NHS funded?
80% general taxation
15% National Insurance
The rest from payments like for the dentist or prescriptions
What condition gets the most funding from the NHS proportionally?
Mental health
How is general practice funded?
In principle
Contractual arrangements between GPs and the NHS
Basis for payments:
Capitation – (weighted head count)
QOF (Quality Outcomes Framework – ‘points mean prizes’)
Enhanced services (e.g. vaccination)
How else could we fund a National Health service?
Out-of-pocket payments Social Insurance ‘European Model’ Required – earnings-related if in work Costs fall mainly on employment sector Private Insurance ‘US model’ May be paid by employers Otherwise met by patient Mixtures
Why is it good to get health insurance?
Health costs are unpredictable and potentially high
In the absence of perfect knowledge – spread the risk
What are the problems with insurance models?
Adverse selection- Private health insurance tends to be more expensive the more likely you are to need healthcare.
Moral hazard- A process whereby ‘insulating’ consumers from consequences of their actions increases demand.
Consumer moral hazard: taking extra risks as don’t pay for the consequence
Provider moral hazard: carry out un-needed work as will be paid anyway
How do we respond to issues with insurance models?
Adverse Selection
Universal insurance
Safety-nets
Moral hazard
Co-payments (for patients)
Guidelines
What is the definition of efficacy?
does the intervention work in a randomised controlled trial (RCT)?
What is the definition of effectiveness?
does it work in usual practice?
What is technical efficiency?
maximise production of goods or servicesmaximise production of goods or services
What is allocative efficiency?
production of most desired/worthwhile goods and services at least cost
What is opportunity cost?
Opportunity cost represents the benefit foregone by making the choice to use resources as you do.
What is a market?
Meeting point between potential consumers and providers
What are some reasons for market failure?
Don’t provide the efficiency we hoped for
Information asymmetry-supplier-induced demand
Monopolies and limited market entrants
Transaction costs- the costs of ‘doing business’
Externalities
Also can fail as markets may not provide fair allocations- as seen with Wales health care differences with England
What are some responses the the reasons behind market failure?
Information asymmetry- Try and ‘empower’ and inform the consumer -Regulate
Monopolies and limited market entrants - ‘Any willing provider’ - Subsidise new entrants
Transaction costs - try to minimise complexity
Externalities
What is economic evaluation?
Deals with inputs and outputs (costs and consequences)
Concerned with choices – resources are scarce so decisions have to be made
Evaluations aim to make these
choices explicit
What are the basic steps of economic evaluation?
Identify
Measure
Value
Compare
What is involved in an evidence based approach?
Question formulation
Literature search
Appraisal of evidence
Clinical decision
What are some examples of decision and diagnostic support systems?
Reminder systems
Decision systems
Prescribing support
Condition Management
What are some examples of reminder systems?
Screening Vaccination Testing Medication use To ID risky behaviour
How do diagnostic systems work?
Model individual patients against epidemiological data
Can match patient signs and symptoms to database
Can provide hypotheses or estimates of probability of different diagnoses
E.g. Ottawa ankle rules
E.g. Decision support for VTE
What may hinder the use of computerised support systems?
Earlier negative experience of IT
Potential harm to doctor- patient relationship
Obscured responsibilities
Reminders increase workload
What may help the use of computerised support systems in practice?
Self control of the system
If the clinician notices it helps during their practice
What is the link between 5 a day advice and cancer?
Found increased cancer risk if eat less than 200g of fruit or veg per day, but no extra cancer protection after 400g per day. So based on a portion of 80g that gives 5 portions a day
What are some problems with trying to measure diet?
Random error as peoples diets vary
Bias
Confounding
Homogeneity of exposure
What is weird about beta carotene?
As a substance of its own it increases cancer risk but if consumed in a vegetable then the protective benefit of the vegetable outweighs the risk of that
What are some health promotion messages relevant to cancer?
Increase level of exercise Dont gain weight in adulthood Aim for healthy BMI Maintain safe alcohol intake Eat at least 400g of fruit and veg per day Limit intake or red or processed meat
What are some explanations for the higher alcohol mortality amongst lower socio-economic groups even though they consume less alcohol?
Lower resilience or confounding factors
Possibly more binge drinking
Difference in drinking histories
Differential access to health services
How can alcohol harm others?
Physically threatened Kept awake due to noise Emotionally hurt Serious argument Looking after someone harmed by alcohol
What are some policy ideas to reduce alcohol related harm?
Reduce affordability of alcohol
Marketing regulations
Reducing hours alcohol is available
Why are brief interventions regarding peoples alcohol use not really done much in primary care?
Time Attitudes Impact on patient relationship Skills and training Links to community support services
What is an outbreak defined as?
An incident where 2 or more people thought to have a common exposure experience a similar illness or proven infection
The public health act allows exclusions from work of people who pose increased risk of GI infection spread, who does this refer to?
People with doubtful personal hygiene
People who work in food preparation
Health care workers who work with vulnerable people
Children in nursery or pre school
The food safety act refers to what?
A place selling any food substance, even if have no dietary value e.g. chewing gum
What is hazard analysis critical control point- HACCP?
Compulsory procedure within GMP covering all aspects of food production, distribution and storage. It looks at areas where possible food hazards could occur and implementing effective control procedures at each place to ensure food safety.
What are some types of economic evaluation?
Cost effectiveness- benefit in natural units- life years
Cost utility- benefit in utility values- QALYs
Cost benefit- benefit in monetary values
What does cost minimisation analysis involve?
Not a full form of economic evaluation
Know (or assume) health effects to be equal
Two possibilities:
Evidence suggests there is no difference in outcomes
Prior view that health effects are equal
Then we choose the least cost option
What is cost effectiveness analysis?
Effects are measured in terms of the most appropriate
uni-dimensional natural unit.
Cost per unit effect
Examples:
Renal failure - cost per life saved
Screening for Down’s syndrome - cost per Down’s syndrome foetus detected
Straight forward to carry out. But hard to compare different things.
What is cost utility analysis?
Effects are multi-dimensional
Combines life years gained with some judgment (or value or preferences) on the quality of those life years
Most popular measure:
quality adjusted life years (QALYs)CUA enables comparison of interventions that would be measured using different clinical outcomes
Enables a global health budget to be allocated more efficiently across different clinical areas
BUT
Is heavily reliant on the Quality Adjusted Life Year
What is cost benefit analysis?
CBA the most comprehensive form of evaluation
Takes a societal perspective
All costs and outcomes are included
All costs and outcomes are measured in monetary units
Controversial – how do we assign money values to health outcomes?
How much is a life or outcome worth?
Needs a uniform value across all options for efficient allocation of resources
Results presented as an overall + or - £ or $ etc
Allows comparison across programmes with different health outcomes
Allows comparisons with non-health care interventions, so can be used to allocate a global budget
What are some problems with cost benefit analysis?
How do we value a life?
How do we value a health outcome?
How do we value other societal costs e.g. time?
Difficulties mean very few CBAs are undertaken
What type of food poisoning is caused by a gram -ve bacteria with a transmission period of 12-72 hours?
Salmonella
What bacteria causes symptoms within 2-2 hours after eating and produces a toxin that is acid and heat stable?
Staph Aureus
What type of fooding poisoning would you be worried about if someone had got back from abroad 4 days ago and was having watery and mucus diarrhoea?
Cryptosporidum protozoa
What is the most common cause of food poisoning and caused by eating undercooked meat or unpasteurised dairy?
Camplylobacter
