SocPop and VLE Flashcards
What are differences between illness, disease and sickness?
Illness - subjective, personal feeling
Disease - pathological process confirmed by signs and investigations
Sickness - social role adopted or assigned to ill people
How can normality be determined?
Statistically
Optimal health
Social norm basis
What is the WHO definition of health?
A state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity
What are the two models of health?
Medical and social
What is the medical model of health?
Health is the absence of disease
Disease caused by pathological changes with specific aetiology
Causes of ill health can be identified by signs and symptoms and the process of diagnosis
Medicine’s role is cure or treat to lessen effects or make comfortable
What is the social model of health?
Health is socially constructed; it is varied, uncertain and diverse
Ill health caused by social/cultural factors not only biological factors
Lay beliefs important, people have own ideas about causes of ill-health
May consider themselves ill but not seek help
Concerned with people’s lives and experiences, and how people themselves define health
Can have a disease or an impairment but still consider oneself healthy
What are criticisms of the medical model of health?
Majority of power is in the hands of the medical profession not patients
Shift to chronic/degenerative conditions (often multi-factorial and multi-dimensional in nature) which are not associated with a simple biological cause or amenable to medical cure
In what 4 ways do people think about their health?
Absence of illness
Functional ability
Equilibrium
Freedom to do
What are the three aspects of ethical reasoning?
Principles - professional codes, moral theories
Particulars - context, case comparison, consistency of judgement
Perspectives - patient, HCP, family, society
What professional codes underpin ethical principles?
Hippocratic oath
Declaration of Helsinki
Declaration of Geneva
GMC doctors duties
What 3 moral theories underpin ethical reasoning?
Deontology- duty
Utilitarianism - consequences
Virtue ethics - character
What is deontology?
Rules based: the morally right thing to do is to obey the moral rule/law
Do not kill, Do not lie, Keep promises
Examples of application to health care: Duty of care, Duty of confidentiality
What is utilitarianism?
The morally right thing to do depends on the consequences, maximising the overall good
Relevance to health care: Best interests principle (beneficence), Resource allocation (quality Adjusted Life Years)
What is virtue ethics?
The morally right action is achieved by exercising the relevant virtues
Virtues are developed by practice, Virtues are developed by learning from those who possess them
Relevance to health care: The ‘good’ doctor, Apprenticeship, mentoring, the hidden curriculum
What are incidence and prevalence?
Prevalence – how many people are ill right now?
Incidence – how many new cases are appearing right now?
What is a confidence interval?
How do we sensibly express our uncertainty in the estimates we find?
What 3 types of prevalence are there?
Point - eg flu during winter
Period - eg flu each year
Lifetime - eg Cancer over a lifetime
How do we calculate incidence?
New cases observed / people observed x years observed
What is mortality rate useful for looking at?
Recognising epidemic outbreaks, effectiveness of new treatment/risks inherent in exposure to new influences
Give an example of a condition with high prevalence but low incidence
Type II diabetes
Give an example of an issue with a low prevalence but high incidence
Nose bleed
Give an example of a disease with low prevalence and low incidence
Pancreatic cancer
Give an example of a condition with high prevalence and incidence
Common cold
How do you minimise sampling variation in a study?
Ask more people
How do you calculate a 95% confidence interval?
p - 1.96 x SE, p + 1.96 x SE
How do you interpret a confidence interval?
95% of confidence intervals we create will contain the true value
What are 3 sources of demographic information in the UK?
UK census
Birth/death registration
Population estimates and projections
What is demography?
The study of the size, structure, dispersement, and development of human populations
What do demographic studies allow us to collect statistics on?
Population size and distribution
Birth and death rates
Life expectancy
Migration
What data is gathered from the census?
Age and sex Ethnicity and religion Employment, home ownership and car ownership Health, long term illness, unpaid care Workplace
What method can be used for assessing the quality of health information?
CART Completeness Accuracy Representativeness and relevance Timeliness (Accessibility)
What are some weaknesses of the UK census?
Completeness - low enumeration of some groups
Accuracy - self reported
Representativeness - low enumeration of some groups
Timeliness - 10 years, takes time for release
Accessibility - confidential for 100yrs
What useful information does the census tell health workers?
Population structure - what service needs are required
Base population - determine rates of illness
Material deprivation - target inequalities
What are measures of fertility?
Crude birth rate - live births / 1000
General fertility rate - live births / 1000 in women age 15-44
Total fertility rate - number of children that would be born to a woman if she were to live to the end of her child bearing years and bear
children in accordance with current age-specificfertility rates
What are strengths and weaknesses of mortality data?
Strengths - complete coverage in UK
Weaknesses - Accuracy e.g. underlying cause of death subject to diagnostic uncertainty, coding issues and variable quality, Not reliable as picture of morbidity, Ethnicity not collected, Derivation of socio-economic status - posthumous inflation of status
What are population estimates used for?
Used for planning services / resource allocation
How are population estimates calculated?
Census baseline + births – deaths + migration
What are strengths and weaknesses of population estimates?
Strengths – more up to date than the census, more accurate than projections
Weaknesses - less reliable with time from census, poor information on migration, says nothing about the future
What are strengths and weaknesses of population projections?
Strengths – Can be used for longer term planning
Weaknesses - less accurate the further ahead, unforeseen changes of past trends can invalidate projections
What are sources of mobidity data?
Cancer registration system
Notifications of infectious diseases
NHS activity data
What are Cancer registration data used for?
Evaluation of screening programmes
Clinical (treatment) & epidemiological (causes) research
Planning services for prevention and care
What are strengths and weaknesses of cancer registration data?
Strengths: Detailed information updated over time, Record linkage to cancer deaths (ONS)
Weaknesses: - Expensive, Access is difficult due to confidentiality
How many cancer registries are there?
12
How many notifiable diseases are there in England and Wales?
31
Who collects data about infectious diseases?
Public health England
What are the uses of surveillance of infectious diseases?
Action to prevent further infection
Identify outbreak
Monitor trends
What are strengths and weaknesses of notification of infectious diseases?
STRENGTHS
Timeliness – weekly report by PHE
Representative - Routine national data
Linked to other data to improve accuracy e.g. lab reports
WEAKNESSES
Poor or variable completeness for some diseases e.g.not all food poisoning notified, some treated at home
Accuracy can be questionable due to diagnostic uncertainty, as asked to notify ‘suspected’ cases, although increasingly linked to lab reports
What NHS activity data is collected?
Hospital episode statistics
Quality outcomes framework
What sort of information do hospital episode statistics include?
Personal information eg. age, gender
Clinical information - diagnoses and operations
Administrative data e.g. date of admission, discharge
Geographical information - where treated & lives
What two main clinical classifications are currently used in hospital episode statistics?
ICD-10 (International Classification of Diseases, 10th Revision)
Describes conditions treated or investigated, e.g. myocardial infarction, fractured skull
OPCS-4 (OPCS Classification of Surgical Operationsand Procedures, 4th Revision)
Records details of operations e.g. hip replacement
What are strengths and weaknesses of hospital episode statistics?
STRENGTHS
Completeness – as covers all hospital activity
Accuracy – standard codes used
Representative - Routine national data
WEAKNESSES
Accuracy – differences between individuals / hospitals in coding to diagnosis / surgical procedure
Accessibility – to individual data
What are the 4 domains of the QOF that are measured?
Clinical (20 areas) – managing common chronic diseases
Public Health Domain & additional services
Quality and productivity e.g. care pathways, avoidable admissions
Patient experience at the practice
What are strengths and weaknesses of the QOF?
Completeness - almost 100% response
Accuracy - difficult to tell for individual practices
Relevance - representative of population, data at surgery, CCG and national levels, however no age or sex breakdown
Timeliness - updated annually
Access - online, aggregated data only
What are problems with surveys for assessing information?
Responder bias -i.e. survey of childhood obesity -non-responders more likely to be obese than responders
Reporting bias - i.e. if height and weight are self-reported, more likely to increased height and decreased weight
Describe the health survey for England
Annual
Multi-stage stratified random sampling - ‘nationally representative’
75% to 85% response rate
Questionnaires, physical measures, blood sample
Self reported health (e.g. diabetes) & behaviours
Used to monitor targets e.g. obesity, smoking
National data only, not large enough to disaggregate
What are key components of person centred care?
Seeing patient as a person - person’s own experiences are valued
Putting the person’s needs and preferences first and above those as identified by clinicians
Shared decision making: patients and doctors as partners
Recognising the person’s strengths in self-care and management of their condition
All interactions underpinned by values of compassion, dignity and respect
Patient and public involvement in design and delivery of services: co-production of health
What is the co production of health?
A way of working whereby service providers and users work together to create a decision or a service which works for them all
Value-driven and built on the principle that those who are affected by a service are best placed to help design it
Why is person centred care good?
Evidence of positive outcomes for patients
Social and political drivers
Concurs with ethical principles underpinning duties of a doctor
What are social and political drivers in the demand for person centred care?
Wider society: less hierarchical relationships, more critical and questioning public → patients want to be involved
Patient dissatisfaction with the NHS: evidence from surveys
Spiralling economic cost of NHS: better outcomes for patients may control costs
Recent reports on appalling care standards at Mid Staffordshire NHS Trust (Francis report in 2013) and Serious care review of Winterbourne View Hospital (2012)
Together these have increased health policy focus on:
Delivering safe, dignified and compassionate care
Putting the person at the centre of their own care
Patient and public involvement in service planning
What is respect?
Due regard for the feelings, wishes, or rights of others
Treating people as ends and not simply as means
Recognising the moral value of a person as an autonomous being
What is autonomy?
The capacity to be one’s own person, to live one’s life according to reasons and motives that are taken as one’s own and not the product of manipulative or distorting external forces
What are 3 common conditions of autonomy?
Capacity (age 16 and over assume capacity)
Freedom (requires freedom from interference and opportunities for choices)
Authenticity (consistent with personal identity and values)
What is dignity?
A state, quality or manner worthy of esteem or respect and self respect Dignity in care, which supports and promotes, and does not undermine, a person’s self-respect regardless of any difference
Being treated like I was somebody
What are 5 elements of dignity?
Respect Privacy Self esteem Freedom from unnecessary pain Autonomy
What is care?
Beneficence
Best interests
An ethic of care (relationships and responsibility)
What are consequences of person centred care?
Better patient outcomes
Less complaints
Less risk of litigation
Increased trust in the medical profession
What are the two functions of the Calgary Cambridge model?
Build relationship
Provide structure
What is the consequentialist argument about confidentiality?
Harm of breaching confidentiality normally outweighs benefit
Impact on individual patient: loss of trust, refusal to share information, less effective patient care
Impact on wider population: loss of public trust in health profession, less effective health care
When is self determination constrained?
When it’s exercise places others at risk of harm
When may an individual breach of confidentiality be favoured?
Utilitarian approach
Either avoid harm to others or to generate benefit to others
What does law say about confidentiality?
Statutory obligation to disclose in some circumstances
There is a public interest in maintaining patient confidentiality that must be weighed against any public interest argument for breaching it
Which laws may include statutory disclosure statements?
Police and criminal evidence Act 1984
Serious organised crime and police Act 2005
Public Health (Control of Disease) Act 1984 and
Public Health (Infectious Diseases) Regulations 1988
Abortion Regulations 1991
Births and Deaths Registration Act 1953
Road Traffic Act 1988
Children Act 1989
Human Fertilisation and Embryology Act 1990 (2008)
When may information be disclosed without a patients consent?
Patient lacks capacity (adult) - best interests
Patient lacks capacity (child) - parental consent
Legally required
Public interest
What are examples of Inadvertent breaches of confidentiality?
Conversations in hospital lifts or corridors
Use of coloured wrist bands to indicate certain conditions
Barrier nursing signs on patients’ rooms
Information sharing within the wider health care team (including receptionists, ward clerks, porters etc)
Teaching
Electronic communication
What are Current framework of guidance on confidentiality?
Maintaining patient confidentiality is core duty
Disclosing information without consent should only occur if there is a statutory duty or if it is in the public interest.
Patient should be informed before disclosure without consent
Assumption of implied consent for sharing of information within the health care team if it is necessary to provide care for the patient
Information should be available to patients about the need for information sharing and the extent to which this may happen in order to justify implied consent
Information should only be disclosed to an appropriate person
What does the GMC say about deciding if a patient is fit to drive?
Explain to the patient: The condition may affect their ability to drive, they have a legal duty to inform the DVLA
If they refuse to accept your assessment, suggest they seek a second opinion and arrange this
If they continue to drive, make reasonable effort to persuade them to stop
If you cannot persuade them to stop you should contact the DVLA immediately and disclose any relevant information to the medical advisor and inform the patient about the disclosure
What things require consent?
Treatment Investigation Examination Disclosure of information Research Education
What does the law say about battery?
To avoid a charge of battery a doctor must have a valid consent.
For a patient to give a valid consent he/she must understand the broad nature of the procedure
The patient need not be harmed by the procedure to claim damages if battery is proved
What forms of consent exist?
Explicit - written, verbal
Implicit - implied
What are 3 requirements for consent?
Capacity
Information
Voluntariness
What is capacity?
Capacity is function/decision specific
Capacity can fluctuate
There is an assumption of capacity in adults
An imprudent decision is not grounds for deciding someone lacks capacity
Assessment of capacity is ultimately a legal decision
What does the mental capacity act say about a person who would be deemed unable to give a valid consent?
Unable to give consent if they are unable to:
Understand the information relevant to the decision
Retain that information
Use or weigh that information as part of the process of making the decision
Communicate his decision (whether by talking, using sign language or any other means)
What information is required in order for a person to give informed consent?
Broad nature of treatment (defence against battery)
Information about risks, benefits, alternatives
Level of information required relates to standard of care, may be challenged in allegation of negligence
What factors may influence a persons voluntariness to make a decision?
Explicit coercion
Implicit coercion
Power differentials in the patient/doctor relationship
Pressure from family
Who can make an advance refusal of treatment, or appoint a proxy decision maker (LPA)?
Competent adult patient over 18
An over 16 year old patient is what in terms of consent?
Assumed competent unless shown to lack capacity
Who owns a body?
A property right in a body is not recognised in law
There is a right to bodily integrity (battery)
Right to possession of a dead body – Anyone with duty to bury the person, A hospital in which the person has died (until released to the person burying the body), A coroner where an inquest takes place
Which Values frameworks are involved in dealing with human tissue?
Respect
Dignity
Autonomy
What does the human tissue act 2004 say about use of human tissue?
Framework for regulating storage and use of human organs and tissue from the living, and removal, storage and use of tissue and organs from the deceased, for specified health-related purposes and public display
Extends to England, Wales and Northern Ireland.
Created a new offence of DNA “theft” that applies throughout the UK
What does the human tissue act do?
Makes consent fundamental principle underpinning lawful retention and use of tissue from living or deceased for specified health-related purposes and public display
Covers the removal of such material from deceased but not from living – common law on consent
Gametes excluded as regulated under HFEA
Established Human Tissue Authority to advise and oversee compliance with the Act, issue codes of practice, license and inspect post mortem activities for hospitals and coroners, anatomical examinations, public display of human remains and storage of human tissue
Makes it an offence to have human tissue with the intention of DNA being analysed without consent of the individual from whom the tissue came, or of those close to them if they have died
Makes it lawful to take minimum steps to preserve organs of deceased person while consent is sought from next-of-kin to removing them for transplantation
Gives specified museums in England power to move human remains out of collections, if remains are reasonably believed to be those of a person who died less than 1000 years before date that the relevant provision of the Act comes into force
What are Human Tissue Act 2004 scheduled purposes?
Generally requiring consent where tissue is from the living or deceased:
Anatomical examination - requires witnessed consent in writing before death
Determining the cause of death - exception where a post mortem is ordered by a Coroner
Establishing after a person’s death the efficacy of any drug or other treatment administered eg hospital post mortem
Obtaining medical information about a living or deceased person which may be relevant to any other person (including a future person) - eg
genetic information
Public display - requires witnessed consent in writing before death
Research in connection with disorders or functioning of human body
Transplantation - includes all bodily material such as blood, bone marrow, skin, tissue and organs
Clinical audit
Education or training relating to human health
Performance assessment - eg testing medical devices
Public health monitoring
Quality assurance
Human Tissue Act 2004, Who can give consent?
Competent adult, or child willing to make a decision- His/her consent
Child (incompetent, or competent but unwilling to decide)-Consent of a person with parental responsibility
Deceased adult: His/her consent before death, if not, consent of a nominated representative (LPA), if not, consent of a qualifying relative
What licences are required by the human tissue authority?
Use, storage, and disposal of a deceased human body or human tissue for scheduled purposes other than transplantation
Carrying out of anatomical examination
Post mortem examination
What does the human tissue authority say on people responsible for maintaining licences?
Each licensed establishment has to nominate a person, Designated Individual, who supervises activities being carried out
They have primary (legal) responsibility under Section18 of Human Tissue Act to ensure: suitable practices are used in undertaking the
licensed activity; other persons working under the licence are
suitable; conditions of the licence are complied with
What are punishments for non compliance with laws on use of human tissue?
Failure to comply with licensing requirements – Loss of license
Failure to obtain appropriate consent– Up to 3 years imprisonment or fine
What do human tissue authorities say on the use of photographs of human tissue?
Making and displaying of images (inc. photographs, films and electronic images) falls outside scope of HT Act. However, HTA requires DIs (designated individuals) put systems in place to ensure suitable practices are carried out
Ensure suitable practice where licensed activities concerned, includes DI ensuring dignity of deceased people is maintained. DIs need to put in place systems to prevent inappropriate use of images
What does GMC say on the making and use of images?
If you wish to make recordings of the body, organs or tissue during a post-mortem examination, for a secondary purpose such as teaching or research, you should seek consent at the same time as you seek consent to undertake the examination
What are values?
Motivations for action
Important and lasting beliefs or ideals shared by members of a culture about what is good or bad and desirable or undesirable
What is morality?
Study of what is morally right and what is morally wrong (critical approach, based on rational argument)
What is ethics?
A system of accepted beliefs which control behaviour (agreed and taught moral systems)
What is law?
A system of rules, a form of command authority, a means of achieving justice, a way of mediating interests, or whatever we predict the
judges will do
A form of constraint with direct, practical consequences
What are approaches to the relationship between law and ethics?
Separatist approach – courts of law not arbiter of morals
Assimilative approach – if it’s legal it’s moral
Integrated approach – Not every moral obligation involves a legal duty, but every legal duty is founded on a moral obligation
Law is the “hard edge” of ethics
What is the virtuous circle of VLE?
Moral code: hippocractic oath, non maleficence, beneficence Medical ethics: professional guidance Medical law: cases and statutes Professional practice: consent Public policy
What is the meaning of medical and health care law?
Medical law focusses on a relationship between doctors and patients remains a creature of private law
Health care law located in public law. Doctors shifted to margins of debate. Needs and rights of individual patients must be viewed in wider context of protecting health and promoting public goods
What is common law?
Deriving from decisions of judges
What is statute law?
Laid down in Acts of Parliament
What is European law?
A body of treaties, legislation and court decisions
What are advantages of common law?
Slow changes
Fits with other law
Sensitive issues considered outside political arena
What are disadvantages of common law?
Piece-meal - cases must arise - no “grand scheme”, small scale Conservative Retrospective, based on previous cases No community consultation Uncertain standard, “reasonable”
What is The doctrine of ‘precedent’?
Previous decisions of courts are a fundamental source of law
Reasoning by courts in earlier cases is normally binding on courts subsequently hearing similar cases (stare decisis: let decision stand)
Reasoning of courts higher up hierarchy must be followed, but things said ‘by the way’ might be followed
What are the advantages of statute law?
Paramount - overrides common law Clear and conclusive Prospective Carefully planned - systematic Public – participatory Reflects community attitudes
What are disadvantages to statute law?
Inflexible
Difficult to change
Hard for rapid change areas like biotechnology
What are the 2 basic rules on statutory interpretation?
Literal rule – accords word of a statute its every day meaning, unless result is patently absurd or illogical
Golden (purposive) rule – seeks to discover purpose of legislation
What are advantages of European law?
Embeds ethical principles
Avoids conflict between domestic and international law
Enforcement of individual human rights
Better policy outcomes
What are disadvantages of European law?
Too much power to judges
Only imposed against government and public authorities
Subject to Parliamentary sovereignty
What are absolute and qualified rights?
Absolute rights: right to life, right to be free from torture and inhuman and degrading treatment
Qualified (derogable) rights: right to privacy
What is the primacy of values?
Human right is a higher law, affects all other laws by subjecting them to a set of basic values, e.g. right to life
Courts in this country are obliged interpret law in a way that is compatible with Convention rights
Places an obligation on public authorities to act compatibly with Convention rights
What does the equality act say on healthcare?
Key values: equality and diversity
Legal protection from discrimination in workplace and wider society
Every patient treated as an individual with respect and dignity
Fair treatment and non-discrimination in access to health/social care
What is the difference between direct and indirect discrimination?
Direct discrimination - 1 person recieves less favourable treatment by virture of characteristic they posess
Indirect - condition or rule that applies to everybody but disadvantages one particular group
What are the 6 key values of the NHS constitution?
Patients come first Every person is respected and their dignity valued Commitment to quality of care Compassion central to the care provided The improvement of health and wellbeing Everyone counts
