Theme C Flashcards
Criteria for sectioning
3 people must agree:
- You are suffering from a mental disorder
- You need to be detained for assessment and treatment
- It is in the patient’s best interests or protects the safety of patients or others
Section 2 Mental health act 1983
Detained in hospital for ASSESSMENT and treatment
Up to 28 days
Can’t renew but can transfer to section 3
Patient CANNOT refuse treatment
Section 3 Mental Health Act 1983
Detained in hospital for TREAMENT
Up to 6 months
Can be renewed - 6m-6m-12m
Patient cannot refuse treatment
Section 4 Mental Health Act 1983
Emergency situations Detained for ASSESSMENT Only needs recommendation of one doctor Up to 72 hours Patient can refuse treatment
Section 5(2) Mental Health Act 1983
Doctors holding power Detained from leaving hospital Must already be in hospital for treatment Up to 72 hours, not renewable Patients can refuse treatment
Section 5(4) Mental Health Act 1983
Nurses holding power Detained from leaving hospital Must already be in hospital for treatment Up to 6hours, not renewable Patients can refuse treatment
Human rights that conflict with mental health act
Article 2 - right to life (authorities must make every protection to protect your life, if death under section = coroner’s report)
Article 3 - Prohibition of torture and inhumane or degrading treatment
If patient disagrees with treatment, independent psychiatrist agrees then not breaking article 3. Restraint is not torture unless done other than for protection
Article 5 - right to liberty and security. Limited liberty if section
Right to education - if a child is detained, they must get education
Common Law regarding detainment
it is used until the mental health can be put into place
- Right to detain a person if the person is at right to self or others
- Right to restrain with reasonable force (no more than necessary)
- If patient cannot consent: done in best interests
- Treatment must be body recommeded
Leventhal’s self-regulatory model of illness behaviour
Representation of a health threat depends on
- Patient interpretation: symptom perception, social messages
- Coping - mechanisms
- Appraisal: is coping effective
These all determine the emotional response to a health threat
5 areas of illness representations
- Identity - symptoms, signs, labels and diagnosis
- Cause: perceived causes
- Consequences: perceived physical, social, economical etc
- Timeline: perceived timescale
- Control or cure
Patient may not match the clinician
Method of quantifying patient belief on disease
Illness perception questionnaire
Coping strategies and groupings
Problem focused - seeking new information, practical support, learning new skills, new interests, actively participating in treatment
Emotion focused: sharing feelings, expressing anger in appropriate ways, acknowledging loss, emotional support
Unhelpful: denial, reoccupation with minor issues, blaming
Ways in which patients with learning disabilities are vulnerable
BIOLOGICAL
- Genetic vulnerability
- Brain damage
- Physical disability
- Sensory impairment
SOCIAL
- small circle of friends
- limited opportunities for social interaction
- decreased finance, employment
- decrease support
- at risk of exploitation
- poor housing
- limited choices
PSYCHOLOGICAL
- coping strategies
- low self-esteem
- lack of assertiveness
- feeling helpless
Family support available for those with learning difficulties
Access to family advocacy Family support and info groups Disability support groups Skills training and emotional support Respite care Formal carers assessment
Role of FHx in breast cancer
BRCA gene
Calculate carrier probability using BOADICEA or Manchester scoring system
Refer for screening if
- 1 first degree under 40
- 1 male relative
- 1 first degree with bilateral
- 2 first degree or 3 second degree at any age
- 1 first or second degree with both breast and ovarian
Only do genetic screening if mutation risk 10-20%
Preventing cancer in BRCA gene positive women
Risk reducing mastectomy
Risk reducing oophorectomy
Chemoprevention - tamoxifen or raloxifene
Impact of caring for a mental health patient
Stress and worry
Social isolation
Guilty for taking time for self
Financial stresses
Physical health problems - demanding role
Depression - feeling hopeless
Frustration and anger - may not have had a choice about being a carer
Low self-esteem
Emotion strain - especially if patient attempts suicide
Patients with mental health are unpredictable and therefore challenging to care for
Stigma from others on behalf of patient - many try to cope alone
Reduced specialist mental health respite
Epidemiology of suicide
Increase in men
men choose more lethal methods - hanging, guns
Women tend to choose poisoning and self-cutting
Males have higher success rate
4500 per year
Incidence 19 per 100,000 men and 5 per 100,00 women
Increased in whites and Asians
highest in 15-44 years, although elderly also at risk
RFs Previous self harm Single/widow/divorced/separated Prisoners Vets/doctors/pharmacists/farmers Immigrants/refugees Recent life crisis Victim of abuse Mental illness Chronic physical illness
Epidemiology of self harm
Increased in females 1-4% of adults 10% of 15-16 year old girls Highest in adolescents and college students Increased in South Asians
RFs Borderline personality disorder (70% self harm) MH - depression, bipolar, schizophrenia, drug and alcohol misuse Domestic violence Eating disorder Armed force veterans Prisoners Asylum seekers Victim of abuse Gay/lesbian/bisexual
Members of community mental health team and their roles
Community psychiatric nurse (CPN) - facilitates treatment plan and monitors progress
Social worker - housing and benefits, make the most of available services
Clinical psychologist - delivers CBT
Psychiatrist - diagnoses and develops care plan
OT - maintain own skills and develop new ones. Back to work. Keep up motivation
Pharmacist - advice on meds
Admin staff - first point of call, arrange appointments
Counsellor - taking treatment and developing coping strategies.
Barriers to rapid diagnosis and treatment of MI
Symptoms - large variation between patient’s
Patient decision time
- Shorter in men than women (women tend to be atypical)
- STEMI has shorter time as more severe presentation
- ** increase education to decrease time
Symptom recognition - men more likely to realise MI
More likely to use ambulance if
- educated about MI
- Increase symptoms severity
- STEMI
- Increased age
- Increased distance to hospital
- Prehospital ECG, and meds decreases time to treat
- Incorrect level of triage
- Busy EF
- Further from hospital / increases time to treatment
- No access to phone
- Minimal education
Outcome indicator
Describes the effects of healthcare on the status of the population e.g. proportion with surgical site infection
Process indicator
Measures what is actually done in the giving and receiving of care.
e.g. number of patients receiving the correct antibiotics
Advantages of publically available performance indicators
Patient choice
Patient’s want the information
Increased transparency and openness
Managers more likely to focus on quality than cost
Ensures accountability of staff/ providers of care
Identify areas for concern and improvements
Disadvantages of publically available performance indicators
Only focussing on measured activity
Lose sight of long term outcomes
Avoiding new approaches in fear of worse outcome
Altering behaviour tot gain advantage
- Decreased access to care in high risk patients
- e.g. number treatment with antibiotics in first hour will cause overtreatment of non-cases
Cost of producing information - resource demanding
Patients may not use info
Epidemiology of CHD
1/5 men and 1/7 women will die from CHD More common in males Increase South Asians. Increased in northern England Increased with age
RFs Smoking Lower socioeconomic group Poor diet - high LDL Alcohol Physical wellbeing: work stress, decreased social support, depression and anxiety Hypertension Diabetes Hypercholesterolaemia FHx - 1st degree relative in men under 55 in women under 65 Obesity
RFs for CVD from highest to lowest importance
Apo-B/Apo-A1 protein (genetic) Current smoker Psychosocial e/g stresses Abdominal obesity Hypertension Daily fruit and veg intake Exercise Diabetes Alcohol
High risk hypertension patients
Patients at a high risk of complications from hypertension
- older age, men over 55, women over 65
- Diabetes
- Renal disease/proteinuria
- LV hypertrophy
- Established vascular disease
- CHD
- Stroke
- Peripheral vascular disease
For high risk patients aim for 130/80
Others aim for 140/90
Lifestyle changes to reduce CV risk
Cardioprotective diet - 5 a day - reduced refined sugars - 2 portions of fish a week - wholegrain carbs Physical activity - 150 minutes of moderate or 75 minutes of high intensity Lose weight Reduce alcohol consumption Smoking cessation Decreased salt consumption
Health benefits of smoking cessation
Decreased lung and other cancers Decreased CVD risk Decreased risk of COPD and respiratory symptoms Decreased risk of infertility Increased life span
20 minutes: decreased HR and BP 12 hours: CO levels drop to normal 2-12 weeks: increase circulation and lung function 1-9 months: decreased cough and SOB 1 year: half risk of CHD 5 years: risk of stroke that of non-smoker 10 years: half risk of lung cancer 15 years: risk of CHD that of non-smoker
Epidemiology of breast cancer
15% of total cancer paitents 31% of female cancer patients Most common cancer in the UK Increased in women Increases with age Highest in Caucasians - western Europe FHx - BRCA gene defect Most common cause of cancer in 15-49 years Most are detected in stage I or II Incidence has been increasing
RFs (separate flashcard)
RFs for breast cancer
COCP Alcohol Increased adult height Ionising radiation HRT Raised BMI post-menopause (protective pre-menopause) Decreased breast density History of Hodgkin's lymphoma, melanoma, lung, bowel, uterus Ca Increased breast density Benign breast disease Digoxin Diabetes Smoking increased birth weight Increased dietary fat Increased bone mineral density Decreased age at menarche Decreased parity Increased age at menopause Increased age at first giving birth
Protective factors for breast cancer
Breastfeeding Hysterectomy / oophorectomy pre-menopause Physical activity Regular aspirin / NSAIDs Osteoporosis Coeliac disease
Principles of screening
- Condition should be an important health problem
- Recognisable latent or early symptomatic stage
- Natural history of condition should be understood
- Accepted treatment for patients with recognised disease
- Suitable test or examination with high level of accuracy
- Test should be acceptable to population
- Agreed policy on who to treat
- Facilities for diagnosis and treatment should be available
- Cost of screening should be balanced
- Screening should be a continuing process
Define sensitivity
Effectiveness of a test to detect disease in all of those with disease
True positives / true positives + false negatives
Define specificity
The extent to which a test gives negative results in those without disease
True negative / true negatives + false positives
Define positive predictive value
Extent in which a person with disease in those that test positive
True positive / true positive and false positive
Define negative predictive value
Extent to which a person without disease in those with a negative test result
True negative / true negative + false negative
What needs to be agreed in order for screening program to happen?
Frequency of screening Ages at which it should be performed Defined mechanisms for referral and treatment Information systems that can: - Send out invitations - Recall for repeat screening - Follow patients with abnormality - Monitor and evaluate the program
Breast cancer screening
50-70 (trial extension from 47 to 73)
Every 3 years
Mammography
Benefits of breast cancer screening
Allows for less aggressive treatment
Increases prognosis
Decreased mortality
Pain Radiation Anxiety (false positives) Does not detect 20% of cancers Over diagnosis and over treatment
Over diagnosis
A cancer or disease that is picked up by screening that would not otherwise have come to attention in that person’s lifetime
Over treatment
Unnecessary medical interventions
- Either due to over diagnosis
- OR extensive treatment for a disease which only requires limited treatment.
Psychological impact of a cancer diagnosis
Employment and income
- financial hardship
- may have to give up work due to illness/ appointments
Social engagement
- harder to participate in social events and maintain friendships
- decreased energy and mobility
Change in family dynamics
Emotional distress
Uncertain about unwanted changes to self and life
Feelings - shock, disbelief, fear, anxiety, guilt, sadness
Depression and anxiety
Fertility - can cause infertility
Change in relationships with family and friends
Inability to perform social roles
Changes to sex drive
Changes to body image
Feelings of guilt and self-blame
Factors associated with delayed presentation of breast cancer
Older age Lower educational level Non-white ethnicity Non-recognition of symptom seriousness Decreased social support Presentation type - no breast lump No pain Presence of co-existing morbidity Fear of cancer diagnosis Competing life priorities Embarrassment around breast exam
Effect of culture on psychological response to diagnosis and treatment (breast cancer)
Members of ethnic minorities can often delay in help seeking
Blacks and Hispanics have more advanced breast cancer when detected and have poorer survival rates
Less likely to have mammogram if single, decreased education and unemployed
Increased set backs - unemployment, trouble returning to work, struggle with interpersonal relationships
Differences in knowledge and beliefs regarding cause, symptoms, curability and consequences
Differences in trust in physicians
Some cultures RE male examination worries.
Some cultures stress importance towards families and putting others first
FHx in breast cancer
BRCA1 and 2 gene
Can calculate carrier probability using:
BOADICEA or Manchester Scoring system
Refer if:
- 1 1st degree under 40
- 1 1st degree male
- 1 1st degree with bilateral cancer
- 3 2nd degree or 2 1st degree with breast cancer at any age
- 1 1st or 2nd degree with breast and ovarian cancer
Prevention of breast cancer in BRCA +
Risk reducing mastectomy
Risk reducing oophorectomy
Chemoprevention- tamoxifen or raloxifene
Role of a post mortem
Examination of a patient after death
Carried out by a pathologist to establish the cause of death or determine effects of treatment
Who is the coroner
Independent official with legal responsibility for the medical-legal investigation of certain deaths including: sudden, unexplained, unnatural or violent in nature
What deaths are reportable to the coroner?
Sudden deaths from unknown causes
Any case where cause of death unknown
Any vehicle, boat, train or plane accident
Any suspicious circumstances
Suicide
If not been seen or treated in last 14 days
Any death within 24 hours of admission
Due to possible negligence, misconduct or malpractice
Any death caused by a treatment or anaesthesia
Any infant death or still birth
Death due a crime
Detained under Mental Health Act 1983 or under police custody
Death linked with occupational hazard e.g. mesothelioma, bladder cancer
Due to fall or fracture
Reasons for retaining tissue after post-mortem
Controlled by Human Tissue Authority
- Examined with microscope
- Complex abnormality requiring detailed examination
- Sample may need preparation prior to examination
- Preparation can take weeks
Benefits of post mortem
Provides valuable information on cause of death
Provides vital info for future treatment/research
Gives relatives information which may impact on their health
Data can improve and assess medical care and research - cause and prevention of disease
Assists in education of doctors and students
Provides accurate mortality and morbidity stats to improve public health
Confirmation of death
- Full extensive attempts at reversible causes of cardiorespiratory arrest
Body temp, endocrine, metabolic and biochemical abnormalities
One of the following criteria is met:
- Meets criteria for not attempting CPR
- Attempts of CPR failed
- Life sustaining treatment has been withdrawn
Observe individual for minimum 5 minutes
Primary care
- No mechanical cardiac function: absent central pulse on palpation, absent heart sounds on auscultation
Hospital: one of
- Asystole on ECG
- Absence of pulsatile flow on arterial monitoring
- Absence of contractile activity using echo
Check reflexes to light, corneal reflexes, and motor response to supra orbital pressure
Who can confirm death?
Doctors
Nurses
Suitably trained ambulance clinicians
A doctor’s legal duty is to notify the cause of death, not the fact the death has taken place
Defining death in primary care
Unresponsive patient with temperature over 35 degrees with no drug or alcohol use
- No spontaneous movement
- No respiratory effort
- No heart sounds or palpable pulse
- Absence of corneal reflexes
- Pupils fixed and dilated
Role of death certificate
Allows relatives to register the death
Provides a permanent legal record of death
Allows relatives to arrange a funeral and settle estate
Provides national statistics regarding cause of death and trends in disease
Given to the next of kin to deliver to the Registrar of Births, deaths and marriages within 5 days who decides if it needs reporting to the coroner
Reasons that cannot be used as cause of death on death certificate
Old age Organ failure e.g. renal/heart/liver Mode of dying e.g. cardiac arrest or shock Diabetes Any abbreviations
Epidemiology of lung cancer (not RFs)
3rd most common cancer in the UK
2nd most common cancer in males and females in the UK
13% of total cancer cases
Increases with age
Increased in males
Higher in Caucasians
FHx - yes
87% non small cell lung cancer
13% small cell lung cancer
Most diagnosed in stage 4
RFs for lung cancer
Smoking Low BMI Past cancer (breast, Hodgkin's lymphoma) Asbestos Radon Silica dust HIV Air pollution Ionising radiation Hx of pneumonia, TB, silicosis, COPD Production of coal/coke Organ transplant recipients Diet high in red meet or total fats
Medical conditions that decrease the risk of lung cancer
MS
Coeliac
Parkinson’s
Role of MDT
Bring together staff with necessary knowledge and skills to ensure high quality diagnosis, treatment and care
- Considers patients as whole, not just disease
- Takes into account patients views, preferences and circumstances
- Makes recommendations not decisions
- Final decision is patient and clinician
Effective MDT should result in:
- Treatment and care considered by field experts
- Offered opportunity to enter clinical trials
- Continuity of care
- Good communication between 1y, 2y and 3y care
- Good data collection
- Improved equality
- Better adherence to local and national guidelines
- Promotion of good working relationships between staff
- Optimisation of resources
Psychological effects of stoma
Shock Depression or anxiety esp if due to prolonged recovery, long lasting disability Alteration in body image - scar Alterations in body function - stoma Change in daily routine Problems with self care and ADLs Impact on relationships Feelings of embarrassment - sex life Rejection from partner Altered sleep habits due to fear or leakage, pain or discomfort Self- conscious Modification of diet Employability and insurance issues
Physical side effects of chemotherapy
Fatigue 2y cancer Weight gain Diabetes Ulcers in mouth Anaemia Memory loss Decreased libido Decreased hair Infertility Neuropathy Osteoporosis Renal, liver, lung, cardiac damage Pain Premature aging Early menopause
Psychological effects of chemotherapy
Fear of recurrence Grief Loss of libido Loss of physical dependence Loss of fertility Depression Body image and self-esteem (hair loss) Relationship strain Worry of outside world (increased infection risk) Decreased energy Anxiety Fear of losing job - missing for illness and medical appointments Requiring assistance with ADLs Emotional stresses Financial stresses - decreased work, cost of travelling Feelings of isolation
Reducing cardiovascular disease in community
- Policy approaches: global, national and local
- Healthcare delivery: access to care, quality of care, drugs and technologies
- Heath communication: media
- Determinants: cultural and social norms, health inequalities,
- Identify groups that are high risk
- Assess levels of major preventable causes of CVD
Focus on
- Education
- Schools
- Work
- Environmental change
- Policy change
In what ways can education lower CVD?
- Media emphasising importance of lifestyle behaviours and risk factors
- Public education campaigns to make aware of guidelines for primary and secondary prevention
- Ongoing education of public in CPR
- Guide for prevention, diagnosis and treatment made available
- Limit food advertising to youth
- TV shows for children should promote physical activity
- Teaching in schools
- Compulsory physical education in schools
- healthy school meals
- CPR teaching
What ways can change in environmental factors lower CVD?
- Supermarkets selling fruit and veg at reasonable price
- restaurants offering dishes which meet nutritional guidelines
- Low fat/calorie snacks
- healthy food at check outs
- Support of physical education programmes
- Smoke free areas
In what ways can a change in policy lower CVD?
- Increase unit price for tobacco
- Removal of tobacco advertising
- NHS treatment for smoking cessation
- 5 a day
- 30 mins exercise per day
- Change for life
- No smoking indoors
- Alcohol recommended limits
Levels of evidence
1a - meta-analysis of RCTs
1b - evidence from at least one RCT
2a - evidence from at least one well designed controlled study
2b - evidence from at least 1 other type of well designed studies
3 - well designed non-experimental descriptive studies
4 - evidence from expert committee reports or opinions
Evidence behind dermatological treatments
High levels of evidence for
- PUVA + UVB in psoriasis but is associated with increased cancer risk
- Systemic steroids in eczema (no evidence as to which is the best steroid)
- Little evidence for methotrexate used in psoriasis
- Ciclosporin is the best systemic drug for psoriasis
Dangers of excessive sun exposure
Increased risk of skin cancer
Skin burn - cells and blood vessels are damaged
Heat exhaustion - core temp > 40, sickness, headaches, excessive sweating, feeling faint
Heat stroke - core temp > 40, body cells begin to break down and body functions stop working, organ failure
Vomiting, confusion, hyperventilation, decreased consciousness
Repeated damage leads to premature skin ageing
- Decreased elasticity, dry wrinkled and discoloured
Damage to eyes
UK Mental health services
GP Community mental health team (CMHT) Early intervention service (EIS) Crisis resolution team Home based treatment (HBT) Assertive outreach team (AOT) Day hospitals In patient units Improving Access to Psychological therapies (IAPT) Support groups and charities - Mind, Rethink, SANE, AA, The Samaritans
Role of GP in mental health services
Bulk of treatment done by GP
If referral required usually to community mental health team
Can refer to early intervention service for psychosis
Some patients can present to A&E instead
They will be assessed by a psychiatrist and then referred
Screen and diagnose MH problems
Role of Community Mental Health Team in mental health services
MDT: psychiatrist, mental health social workers, CPNs, psychologists
Co-ordinates patient care
Monitors patients in the community
Initial assessment by psychiatrist then holistic care plan
Role of Early Intervention Service in mental health services
Used to improve short and long term outcomes of schizophrenia and other psychotic disorders
Exclusively PSYCHOSIS at first presentation
- Preventative measures
- Earlier detection of untreated cases
- Intensive treatment and support in early stages of disease
Role of crisis resolution team in mental health services
24/7
Acts as gateway to various psychiatric services e.g. admission
Most common referrals comes form GP, A&E and CMHT
Rapid assessment to determine if admission of home based therapy (HBT)
Role of Home Based Treatment team in mental health services
Short term intensive home based care
MDT as per CMHT
Visits up to 3x per day with gradual decreased
Role of Assertive outreach team in mental health services
For revolving door patients
Reluctant to seek help therefore present at times of crisis
Often have most complex mental health and social problems
Specialist MDT dedicated to engaging them in treatment and providing support.
Role of day hospitals or in patient units in mental health services
If they cannot be safely managed in community
- Patient is danger to self or others
- Requires specialist care or supervised treatment
- Patient lacking social structure
- Carer can no longer cope / needs respite
Most are involuntary / informal
Role of key worker in mental health services
Usually a CPN or social worker
Co-ordinates and administers treatments
Has knowledge of local services and encourages and allows access
Liase with GP and other agencies
Assists with planning and monitoring of care
Specialist mental health services
General adult Old age Child and adolescent Liaison Substance abuse Forensic Learning disability
Psychiatry
Social and cultural factors contributing to depression
Social support - those with more are less likely to get depression
- Helps to know they are not alone
- Someone pushing them towards getting better
Strong family network
Decreased socioeconomic group have decreased stability and increased risk of depression
High stress job or environment can worsen depression
Ethnic minorities are at higher risk of depression - immigration status, decreased income and education level
Different populations talk about depression differently and have different help seeking behaviour
Services may not be available in native language
Less likely to seek help for depression if: elderly, young adult, ethnic minority or decreased social support
Financial implications may be barrier to treatment- child care, transport
Stigma is different in different populations
Different groups have different beliefs and preferences RE treatment e.g. CBT/medication
Primary health promotion strategies to increased mental health
- Health visitors for all at risk of post natal depression
- School based prevention of violence, bullying, offending or re-offending
- Screening and brief interventions for alcohol abuse
- Promotion of well being at work
- Supported employment for those recovering from mental health problems
- CBT for those with medically unexplained symptoms
- Suicide prevention
- Early intervention service
- Debt advice
- Anti-stigma campaigns
- Increased focus or social support
- Tackle social and economic inequalities
Political action regarding mental health problems
Public Health White Paper
- Tackle substance addiction through minimum alcohol pricing policy
- Promote public health interventions to prevent future inequalities
- Ensure suicide prevention strategy
- Prioritise mental health within smoking cessation
- attended to discrimination and stigma around MH (time to change)
- Target public mental health interventions for high risk people: cared for children, unemployed and homeless
- Promote importance of MH and well being
RFs for chronic liver disease
Hepatitis
- Travel to high risk areas
- IVDU
- Male homosexuality
- Healthcare worker
- Tattoos and piercings
- Blood transfusions
Alcohol Medications FHx Obesity Metabolic syndromes Heart failure
Methods for prevention of chronic liver disease
In high risk areas - wash hands, no salad or ice
IVDU - needle exchange programmes
Condoms
PPE at work.
Tattoos and piercings only though registered practices
National screening of blood transfusions
Recommended alcohol limits: 14/ weeks, 2 free days
Promote MH to decrease Paracetamol OD
Drs aware of drug interactions
Obesity: national health eating, change for life. increase exercise programmes
In metabolic syndromes: control diabetes and weight
Physical problems associated with dialysis
Not treated daily so can feel tired and nauseous between treatments
Gain fluid weight between sessions
Must limit fluid intake and diet strictly
Pain and discomfort
Additional for PD:
- Increased risk of peritonitis
- Problems with sleep and rest
Psychosocial issues associated with dialysis
Difficulty arranging transport
Difficulty managing a fixed schedule around other plans
Difficulties with going on holiday - need treatment while there
Alteration in marital, social and family relationships - may develop carer role
Feelings of loss of personal control
Increased anxiety and depression
Uncertain future, large demands of illness
Dependence on machinery, medication and healthcare
Loss of freedom (less with PD)
Feelings of frustration
Decreased quality of life
Impaired self and body image
Impact on sexual activity
Feeling like a burden
Impact of mental health on primary care
COMMON
Large range of conditions seen by GP: adjustment reactions, anxiety, depression, schizophrenia, bipolar disorder, addiction
90% of MH problems are managed by GPs
GPs only receive 10% of MH funding
30% of GP visits have a mental health component
30% will have sick leave due to MH problems
Patients with MH problems have more consultations regarding physical problems Increased use of services Increased cost Decreased appointments available In 10 minute appointments: - Difficult to spot a problem - Run late if more than 1 problem or brought up last - patient dissatisfied if rushed
National Framework for Mental Health 1999
Primary care to care for common mental health problems
Primary care to contribute to health promotion
Lack of clarity regarding management of complex, chronic and disabling non-psychotic problems
- GPs require good understanding of healthcare needs in these patients
Types of living organ donation
Directed donation
Direct altruistic donation
Non directed altruistic donation
Donor chain
Describe a directed organ donation
Living organ donation
Health person donates organ to a specific person where there is a relationship between them
Describe a directed altruistic organ donation
Living organ donation
Donation to specific individual but no evidence of genetic or emotional relationship between donor and recipient
Describe a non directed altruistic organ donation
Living organ donation
Health person donates organ to unknown recipient matched by NHSBT
Describe donor chains in organ donation
Living organ donation
Non directed altruistic donors can donate into paired or pooled scheme
Match 2+ donors to recipients and the organ at the end of the chain goes to best matched NHSBT patient on list
- Occurs when donor can’t donate to friend/relative as they are not a match
- Enter a pool, when friend gets a kidney, they donate theirs
Legislation covering organ donation and tissue removal
Human Tissue Act 2004
Human Tissue Act 2004
Covers England, Wales and Northern Ireland
Established the Human Tissue Authority to regulate activities concerning removal, storage, use and disposal of human tissue
It governs consent for storage and use of organs taken from living person for transplantation
Consent for removal is under Mental Capacity Act 2005
All living donors must be approved by HTA before hand
Criteria from HTA for living organ donation
- no reward has or is to be given
- Consent for organ removal for transplant has been given
- Independent assessor has conducted separate interviews with donor and recipient and submitted a report to HTA
- Report is sent to HTA approvals team
Independent assessor for HTA
- Has completed HTA training
- Does not have any connection to those being interviewed
- Cannot be the same person who provides info on risk or the procedure
- They must assess whether the requirements have been met
- will interview donor and recipient separately as well as together and produce a report.
When in transplantation does the report not go to the HTA approvals team?
If the donor is a child
If the donor is an adult who lacks capacity
In all cases of pooled or paired
In all altruistic non directed
In cases where HTA have not delegated decision making
In these cases decision is made by HTA panel
What information should living organ donors receive?
- Surgical procedures and medical treatments, long and short term risks
- Changes of transplant being successful, side effects and complications
- Right to withdraw consent at any time
- until anaesthetic in live
- Until time for first incision in deceased - Right to be free of coercion or threat - consent under these circumstances will not be accepted by the independent assessor
- The fact it is an offence to receive reward or payment and penalties involved
- fine and up to 3 years imprisonment - Donors can seek expenses
- Travel costs and loss of earnings
In altruistic non-directed or pooled donors
- ANONYMITY of donor and recipient and CONFIDENTIALITY must be respected
Rules regarding decreased organ donation
- Removal, storage and use of organs from the deceased is governed by the Human Tissue Act 2004
- Consent must first be obtained
- Trained staff should determine if deceased has given consent by checking Organ Donor Register
- If consent established, inform those close to decreased
- If no records, speakto spouse/partner - done by transplant coordinator
- If deceased wishes unknown, but they have nominated representative, they can consent
- Ask for consent from relatives
- A family member CANNOT OVERRULE deceased wishes - no legal right
- Consent is only required from one person in the hierarchy and should be obtained from the highest ranking
- If number 1 does not consent, lower down cannot overrule
- Spouse/partner
- Parent/child
- Brother/sister
- Grandparent/grandchild
- Niece/nephew
- step mother/father
- Half brother/sister
- Friend
If a decision is not made quick enough for organs to not deteriorate, can take minimum steps necessary to preserve organs under HT Act
May need coroners consent
Use least invasive procedure e.g. cold perfusion
Psychosocial impact of diabetes
Travelling: extra stresses
- Hot weather can affect insulin
- Have to take all insulin supplies with you
- Cost of insurance
- Risk of hypo in unusual settings
Carrying diabetes ID - stigma and labelling
Eating out difficult: choosing food with unknown content
issues with driving - need to inform DVLA if multiple hypoes
- Car insurance CANNOT be increased due to diabetes
Restricted career choice
- Blanket ban on armed forces
- Difficult to manage with shift work
- Subject to individual medical assessment in police, ambulance or fire service
- Embarrassment of hypo in community or work
- Increased sexual dysfunction
- Can alter relationship dynamic
- Difficulty making new relationships esp if sexual dysfunction
- Increased risk in pregnancy
- Increased risks to baby
Often diagnosed in school
- Stigma/bullying
- Disruption to schooling with meds
- Having to inject at school
- Worry of hypos at school
- Reliance on teachers for medication
- issues with compliance
Anxiety/Grief/Depression/Shame/Guilt
TB control of spread in the healthcare setting
- Admit to single room until at last 2 weeks of treatment
- Minimise the number and duration of outpatient clinics
- See patients in less busy areas at less busy times
- Risk assess for multi-drug resistance - if it is then negative pressure room only
- Don’t admit to wards with immunocompromised patietns
- Ideally keep at home
- Patients wear surgical mask when leaving the room
Contact tracing in TB
Only screen close contacts Do not routinely trace social contacts Risk assess - Social contacts in high risk groups - School pupils - Hospital in patient in the same bay for > 8 hours - Flights > 8 hours < 3m ago
Inform HPA
Oppotunistic case finding in TB
Assess new entrants from high burden countries.
In places of high TB - mobile Xray e.g. homeless and drug users - can use simple incentives like food and drink
Screen prisoners within 48 hours of arrival
Methods of ensuring adherence to TB meds
Allocate named TB case manager
Health and social care plan and support
Offer directly observed therapy if
- not adhering
- homeless
- drug abuse
- Multidrug resistant
- prison
- at patient request
- to ill to administer
Address fears of stigmatisation Emphasise importance of completing - educate! - Home visits - Education booklet - Random urine tests - Reminder letters - pill counts - Calls/texts as reminders - incentives - Support
Current stance of the UK on organ donation
Opt - in system
A person has to register their consent to donate organs in the event of their death
out-out organ donation system
Presumes consent for organ donation unless a person has registered an objectification in advance.
If an objection has not been registered, family can still be given the opportunity to confirm any unregistered objection as an extra safeguard
Hard opt put organ donation system
- and countries that use that system
Doctors can remove organs from every adult that dies unless a person has registered to opt out
- Austria
- Singapore: however, they automatically opt out Muslims
Soft opt put organ donation system
- and countries that use that system
Doctors can remove organs from every adult who dies unless they have opted out or relatives tell the doctors not to take organs
- Belgium it is the relatives responsibility to tell the doctors
- Spain: relatives should be consulted
Reasons for the opt out system of organ donation
- More organs become available.
- better supply of organs - get organs from those who would donate but didn’t volunteer
- Reduces current pressure on relatives consent when they are grieving.
- Up to 90% support organ donation but number signed up is much lower.
- Still allows those with strong objections to do so
- Reduced wastage of organs
- Every organ has the chance to save a life
Reasons against the opt out system of organ donation
May not have heard about opt out - may object and still have organs removed (not respecting patients wishes)
- Creates a pressure to donate - people may feel ashamed of opting out
- Can’t dictate what happens to peoples bodies when they die (autonomy)
- Very sensitive issue and as such should be entirely voluntary
- Costly and complicated to implicate - would need to reach every person
- Would be better to design a program to increase number of donors
- Suggests that bodies belong to state once dead - seen as offensive
- Don’t get consent, just a lack of consent.
Define audit
Clinical audit is a quality improvement cycle that involves measurement of the effectiveness of healthcare against the agreed and proven standard for high quality and taking action to bring practice in line with these standards to as to improve the quality of care and health outcomes
Main challenges posed to an effective audit
- Purpose: many are done as a tick box exercise with little understanding as to why
- Burden of evidence: perceived needs to collect sufficient data from poor sources to justify conclusions
- Time: takes a long time to extract meaningful data from notes and written records
- Organisational inertia: external pressure on clinicians to measure, report and improve often results in resistance to change
- Lack of support: not enough support from superiors and audit departments
- Cultural factors: traditional hierarchies can disempower junior doctors
Define quality improvement
Wider goal than Audit
QI is an umbrella under which audit sits
It is used in examining a clinical process and seeking to improve it. There are circumstances where clinical audit may be appropriate
- Encourages data collection from a resource that can determine if change is needed
- Has a more collaborative working style to investigate problems
Problems with audits
Not useful if there are no national agreed criteria and standards e.g. patient safety, patient experience and performance of a service
Rarely take into account local differences
When should an audit be used?
Used to check clinical care meets defined quality standards and monitor improvements to address shortfalls identified
Most effective for ensuring compliance with specific clinical standards and driving clinical care improvement
Pre-requisites for an audit
Evidence based clinical standards drawn from best practice
Audit proforma comprised of measures derived from the standards
PDSA cycle
Plan
Do
Study
Act
Used to introduce and test potential quality improvements and refine them on a small scale prior to wholesale implementation
Most effective when a procedure, process or system needs changing or a new procedure, process of system needs introducing
Tests changes to assess their impact, ensuring new ideas improve quality before implementation on a wider scale
Making changes can give unexpected results so it is safer to test on a small scale first and allows stakeholders to be involved in proposed changes.
Risk factors for drug addiction
Early aggressive behaviour Lack of parental supervision Substance abuse Drug availability Poverty Care giver who uses drugs Fhx of drug addiction Male Mental health disorder Peer pressure Loneliness, anxiety or depression Child abuse Neglect Poor academic performance ADHD Bullying Deviant peer group Conduct disorder Poor family relationships
Protective factors against drug addiction
Self-control Parental monitoring Academic competence Anti-drug use policies Strong neighbourhood attachment Consistent discipline in childhood
Aetiology of drug addiction
Environmental - risk factors
Genetics: development of addiction can be influenced by genetics
Stages of drug addiction
Initial use
- Motivated by: curiosity, peer pressure, psychodynamic processes
- If drug taken repeatedly - casual drug use
- More frequently using high doses - intensive drug use
- Compulsive drug use = substance has strong motivational properties and appears to govern an individuals behaviour
- Experimental or circumstantial
- Casual drug use
- Intensive drug use
- Compulsive drug use
- Addiction
Theories of drug addiction
Physical dependency model - after repeated exposure, get withdrawal symptoms. They act as negative reinforcement and cause continued drug use
Positive reinforcement model - drug acts a positive reinforce causing a change in behaviour
Reinforcement system in the brain
- Reinforcers are thought to increase the effect of dopamine
- Increased dopamine release
Potential future health promotion strategies for alcohol reduction
Minimum unit pricing
Label alcohol with health warnings
Sale of alcohol in shops restricted to certain times
Higher tax on alcohol
Prohibit alcohol advertising and sponsorship - or limit to purely factual information
Regulartion of alcohol packaging and design
Train all health and social workers on giving alcohol advice
Recommended alcohol units
No more than 14 units per week in men and women
Ideally 2 alcohol free days
Stages of change
Precontemplation Contemplation Preparation Action Maintenance Relapse
Stages of change
Precontemplation stage
User is not considering change
Is aware of negative consequences
Is unlikely to take action soon
- Need information linking substance with problems
- Brief intervention: education about negative consequences
Interview approach
- express concern
- agree to disagree about severity of problem
- suggest bringing family member
- explore perception of drug abuse problem
Stages of change
Contemplation stage
User is aware of some pros and cons but feels ambivalent to change - not yet committed to a change
- Explore feelings of ambivalence
- Seek to increase awareness of continued abuse and benefits of stopping
Interview approach
- Elicit positives and negatives, help tip the decisional balance
- Ask about past abstinence
- Consider trial
- Self-Motivational statements of intent and commitment
Stages of change
Preparation
User has decided to change and begins to plan steps towards recovery
- Needs to work on strengthening commitment
- List options for treatment to choose from
Interview approach
- Clarify goals and strategies
- Acknowledge significance, offer options and advice
- help patient decide on achievable action
- Consider and lower barriers for change - finances, transport
- Have them publically announce plans for change
Stages of change
Action
User tries new behaviours, not yet stable
First active step towards change
- help executing the plan
- brief interventions can help prevent relapse
Interview approach
- Source of encouragement and support
- Acknowledge negatives and reinforce importance in continuing
- Support realistic view of change using small steps
- Identify high risk situations and develop coping strategies
Stages of change
Maintenance
Established new behaviours on a long term basis
- help with relapse prevention
- Support lifestyle changes
- Help to practice and use coping strategies
- Maintain supportive contact
- Anticipate difficulties and recognise the struggle
Stages of change
Relapse
recurrence of symptoms and must now cope with consequence and decide what to do next
- Help them re-enter the change cycle
- Commend any willingness to reconsider positive change
- Explore what can be learned from relapse
- Express concern about relapse
- Support patient so recovery seems achievable
Limitations and harms of PSA as screening tool
- may not reduce the change of dying from prostate cancer. Some tumours grow very slowly and are unlikely to threaten life.
OVERDIAGNOSIS AND OVERTREATMENT - Side effects of overtreatment: surgery, radiotherapy (urinary incontinence, bowel control issues, ED, infection)
- May not be useful for those with fast growing as may have mets before detection
- False positives and false negatives
(anxiety) - Most men with raised PSA do not have prostate cancer
- Non specific test as will detect aggressive and slow growing tumours
When is PSA useful
For monitoring for recurrence
When should a PSA be done
If prostate cancer is suspected
A man over 50 can ask for PSA - GP must explain risks and benefits - Give any written info - Answer any questions -
When should a PSA not be done
Recent urine infection
Ejaculated in last 48 hours
Exercised heavily in last 48 hours
Had a prostate biopsy in the last 6 weeks
Lung disease associated with asbestosis exposure & associated professions
Mesothelioma
Asbestosis
Construction workers
Home remodellers
Shipyard workers
Workers who mine, mill or manufacture it
Lung disease associated with silica exposure & associated professions
Silicosis
Coal miners Foundry works Potters Sand blasters Tunnel workers
Jobs associated with asthma
Woodworkers - wood dust
Pain sprayer - isocyanates
Solderer - colophony
Epidemiology of depression
25% at some point 5% annual 1/4 women, 1/10 men More common in women Increased in Blacks, Asians, refugees Increased in 25-44 and elderly
RFs
- Unemployment
- Lower income
- Debt
- Violence
- Stressful life events
- Inadequate housing
- Poverty
- Smoking
- Lower education
- Genetic FHx
- Pregnancy (post natal)
- Physical illness causing pain
- Dementia
- Other mental health problems
Associations and issues between mental health problems and sensory impairments
- May have unassessed or undiagnosed LD as verbal IQ tests are inaccurate
- Few residential or nursing homes can sign to dead people
- Limited access to specialist mental health services - postcode lottery
- Difficulties communicating with GPs
- Equal prevalence of mental health problems
In children higher prevalence due to:
- Excess organic problems
- Excess emotional, physiological and behavioural disorders
- Delays to access which increases duration
- Care often poor
- Increased stresses
- Socially isolated
Lack or understanding
Little support available
Methods of preventing AKI
NEWS score to assess those at risk
iodinated contrast agents - IV volume expansion if high risk or acute illness with sodium chloride
Stop ACEi and ARBs if GFR < 40
Advice from pharmacy if high risk
Detection of AKI
RIFLE, AKIN, KDIGO
Rise of creatinine of greater than 26 in 48 hours
50% rise in creatinine within 7 days
Fall in urine output to less than 0.5ml/kg/hr
Risk factors for AKI
Over 65 Heart failure Liver disease CKD Past AKI Diabetes Fluid intake dependent on carer Hypovolaemia Oliguria Haematological malignancy Sepsis Urological obstruction Iodinated contrast agents Nephrotoxic meds: ACEi, ARBs, NSAIDs, aminoglycosides, diuretics Deteriorating NEWS score
Define addiction
Compulsive need to use a habit forming substance
This compulsion is accompanied by an increased tolerance and experience of withdrawal symptoms
Impact of addiction on health
Organ damage Hormone imbalance Cancer Prenatal and fertility issues GI disease HIV/AIDS/hepatitis Depression Anxiety Memory loss Mood swings Paranoia
Impacts of addiction on society
More work days lost
Increased number of people claiming benefits and not paying taxes
Increased criminal activity
Illegal drugs - funding other types of criminality
Drain on healthcare resources
Drain on economy
High risk of accidents or becoming a victim of crime
Can destroy communities
Impacts of addiction on the family
Addict is hard to live with Increased physical and verbal abuse Behaviour is erratic Some can be high functioning but most are poor providers Financial difficulties Unable to care for children - neglect Set bad examples to child May steal or manipulate family members Increased divorce rate Change of relationship with friends and family
Impacts of addiction on the individual
Person is obsessed with substance and neglects other areas of their lives Life is unfulfilling - filled with despair Increased morbidity Increased mortality Worse mental health Increased suicide risk Poor attendance at work Mood swings Hard to find employment Increased probation, arrests, prison time Increased homelessness Secretive behaviour
Information that should be given to an obese person
Being overweight and general health risks
Realistic targets for weight loss
Distinguishing between weight loss and maintaining weight loss
Realistic exercise and healthier eating targets
Treatment options
Healthy eating in general
Medical and surgical options
Diet changes advised for obese person
DO NOT
- use restrictive and nutritionally unbalanced diets as they are ineffective in the long term and can be harmful
- FOLLOW FADS
BE
- Flexible
- Encourage diet improvement even if no weight loss
Diet with 600kcal deficit per day
Can consider 800-1600 kcal per day but less balanced
Swap unhealthy and high energy foods for healthier choices
5 fruit and veg a day
Wholegrain varieties of starches
Lower sugar milk and dairy - yoghurt, soy
Eat beans, pulses, fish, eggs, meat and other protein
2 portions of fish per week
Plenty of fluid
Define overweight, obese and morbidly obese
Over weight BMI >25
Obese BMI > 30
Morbidly obese BMI > 40
Social implications of obesity
Discrimination Lower wages Lower quality of life Transport difficulties - planes, trains, buses Difficulty buying clothes More likely to commit suicide More likely to divorce Fewer friends Depression and anxiety Body dissatisfaction
Physical implications of obesity
Increased risk of: heart disease stroke diabetes hypertension high cholesterol asthma sleep apnoea gallstones kidney stones infertility OA fatty liver disease cancer: leukaemia, breast, colon Increased morbidity and mortality life expectancy reduced by more than 9 years
Economic implications of obesity
Lost days of work High employer insurance premiums Lower wages and income Large costs on the health care systems Increased social services having to provide care
Members of the cancer MDT
Surgeon Radiologist Histopathologist Oncologist - clinical and medical Haematologist Palliative care specialist GP Physicians of appropriate speciality Clinical nurse specialist Ward nurses MDT coordinator Admin/managerial
Domains important for MDT functioning
Structure
- Membership and attendance
- Technology (Availability and use)
- Physical environment of the meeting room
- Preparation for MDTs
- Organisation and admin during the meeting
Clinical decision making
- Team working
- patient centred care
Team governance
- Leadership
- Data collection, analysis and audit
Professional development and education of team members
Benefits of an MDT
Improved clinical decision making
More coordinated patient care
Improvement to overall quality of care
Evidence based treatment decisions
Increased number of patients being considered for trials
Improved timeliness of tests and treatments
Improved survival rates
Increase proportion of patients staged (cancer)
Epidemiology of obesity
62% of UK adults are overweight or obese
65% men, 58% women
25% of them are obese
prevalence is similar among men and women
More men are overweight
More women are obese
Women are more likely to have extremely high BMI values
Causes of obesity - contributing factors
May behavioural, societal and physiological factors
Outlined in Foresight Report 2007
BIOLOGY
- influence of genetics and ill health: Prader-Willi, hypothyroidism, Cushing’s
ACTIVITY ENVIRONMENT
- influence of environment on the individuals activity behaviour
- e.g. decision to cycle to work influenced by road safety, cycle shelters, showers
PHYSICAL ACTIVITY
- Type, frequency, intensity
SOCIETAL INFLUENCES
- Impact of media, education, peer pressure, culture
INDIVIDUAL PSYCHOLOGY
- Drive for particular foods
- Consumption patterns
- Physical activity patterns or preferences
FOOD ENVIRONMENT
- Availability and quality of fruit and veg near home
- Demand for convenience
- Lack of perceived time
FOOD CONSUMPTION
- tendency to graze
- Parental control
Reasons for increasing obesity prevalence
Frequent large meals Good high in refined grains, red meat, unhealthy fats, sugary drinks Increased television Increased use of cars Busier lifestyles Longer commutes - snacking Increased advertising Sleep issues Increased stresses and boredom Decreased cost of fats and sugars
What is the HPA
Health Protection Agency
Key organisation in the control of communicable diseases
What law covers control of infectious diseases?
Public Health Act 1984 (control of diseases) & 1988 (infectious diseases)
Aims to reduce the spread of communicable disease
- Act on clinical suspicions, do not wait for definitive diagnosis
- Legal requirement to notify HPA
- Notify Consultant in Communicable Disease Control
Ways to minimise infection spread?
Treat patient
Minimise chances of other getting same infection
- Chemoprophylaxis after meningitis to contacts
Reduce infectiousness of the bug = antibiotics
Contain infectivity
- Isolate in side room
- Exclusion from certain activities e.g. work or school
- Hand washing
- PPE
- Managing blood and body fluids adequately
- Education of patients
- Cough etiquette
IMMUNISATION
Powers of the consultant in communicable disease control
Notification of infectious disease Prevents sale of infected articles Prevents infected people from using public transport cleaning and disinfection of premises Excluding people from work and school Offering immunisation Compulsory exclusion Remove to hospital and detain there Obtaining information from households and schools to prevent spread of disease
Notifiable disease list
Polio Acute encephalitis Anthrax Cholera Diphtheria Dysentery FOOD POISONING Malaria MEASLES MENINGIGT MUMPS Plague Rabies RUBELLA SCARLET FEVER SMALL POX TETANUS TB typhoid fever VIRAL HEPATITS viral haemorrhagic fever WHOOPING COUGH YELLOW FEVER
**HIV is not a notifiable disease but practioners should make sure that any sexual partners have been notified
Define primary prevention
Activities aimed at stopping a disease from developing in the first place
Define secondary prevention
Activities aimed at stopping adverse events once a disease has happened
Define tertiary prevention
Limiting the impact that adverse effects have on health
Primary, secondary and tertiary prevention examples in CHD
Primary
- Smoking cessation in someone without heart disease
- Weight loss in someone without heart disease or diabetes
Secondary
- Antiplatelet therapy post MI
- Statins for those post MI or stroke
Tertiary
- Beta blockers in heart failure
- Cardiac rehabilitation program post MI
What is the prevention paradox?
A preventative measure that brings a large benefit to the community offers little to each participating individual
Most heart disease occurs in people who are not high risk.
It is easy to identify those at high risk
If you improve chances for people at low risk then stands to gain more as a population.
Define risk
Probability that an even occurs in a given time
Determining risk of CHD
Joint British Societies Risk Prediction chart
Uses UK GP data rather than Framingham data
QRISK 2
- Overestimates low risk
- Underestimates high risk
- Does not take into account socioeconomic position and ethnicity
QRISK2 criteria
Age Sex Postcode Smoking Diabetes Angina or MI in first degree relative < 60 CKD stage 4 or 5 AF On BP treatment RA Cholesterol BMI
Diabetes Prevention Program Trial
DPPT
In overweight people with raised fasting glucose
- Allocated to either: intensive lifestyle changes OR standard lifestyle recommendations + metformin OR placebo
- Incidence of diabetes was lower in the intensive lifestyle changes group
- Lifestyle is better than metformin for preventing T2DM
Intensive lifestyle was minimum 150 minutes of exercise + 16 lesson curriculum + 7% weight loss
Risk factors for T2DM with relation to weight
Degree in which patient is overweight
Change in weight
Duration patient is overweight
Increasing BMI
Basic CAMHS structure
Informal Tier Tier 1 Tier 2 Tier 3 Tier 4
CAMHS Tier 1
Professionals
Any tier 1 person can refer to a PRIMARY MENTAL HEALTH WORKER
They are not mental health specialists but have regular contact with children and young people
Offer advice and treatment for less severe problems, promote good mental health, facilitate early identification of problems and refer
- Teaching assistants
- Teachers
- Paediatricians
- GP
- Social worker
- Health visitor
- School worker
- Public health nurses
- Voluntary workers
Role of primary mental health worker
In CAMHS
Bridge between tier 1 and 2
- provides consultation and advice to the professional in tier 1
- Assess the child
- Carry out short term work with the family - up to 4 session
- Co work with referring professions
- Refer onto other agencies .e.g. social service and education and support services
- Refer up tiers 2, 3, 4
CAMHS Tier 2
Everyone that specialises in child mental health
Specialist CAMHS clinicians working in community setting
Offer consultations to support severe or complex needs
- Psychologist
- Nurse
- OT
- Social worker
- Psychiatrist
- Psychologist
- CPNs
- Creative therapists
CAMHS Tier 3
Teams depend on locality and requirements
Very specialist teams
Family therapy LD Attention problems Looked after children Eating disorder Autism Adoption support Paediatric liaison Self-harm Psychosis Bereavement Palliative care
CAMHS Tier 4
Inpatient units For young people with - psychosis - severe eating disorders - severe OCD - severe depression
What are health visitors
Qualified nurses with specialist training who work in the community
Steps of an audit
- Select topic
- Review literature
- Set standards
- Design audit
- Collect data
- Analyse data
- Feedback findings
- Change practice
- Set/review standards
- Reaudit
Steps of an audit
Select a topic
Can be a
- Process e.g. timing and content of letters,
- Structure e.g. quality of facilities
- Outcome e.g. number of people referred
Topic should encompass as many as possible of:
- Concern to service users
- Important and of interest to members of the team
- Of clinical concern
- Financially important
- local or national importance
- Practically viable
- New research evidence available on the topic
- Ideally supported by good research
Steps of an audit
Review literature
Find out if there are any national standards to base your standards on
Find out if any previous audits have been carried out to help with the designing methods and setting standards
Look for guidelines or research on the topic
Steps of an audit
Set standards
Requires discussion between staff and the reading of relevant literature
Comparing current practice against standards can highlight problems which may have otherwise been unrecognised
Choose a criterion and a target (% to be achieved)
A criterion should be clear and precise, should be measureable and indicates the boundaries of measurement
Steps of an audit
Design an audit
Who will be inolveed What data needs collecting Sample size Data analysis Start and end date
Steps of an audit
Data collection
Design should have already been determined
Maintain confidentiality using patient idetifiers with separate lists
Develop a way of storing data - coding system
make sure it is secure and conforms to legal requirements
Steps of an audit
Feedback findings
Communicate findings to relevant stakeholders if the audit is to have any impact on quality of service being provided
- Audit reports (passive)
- Discussion of results (active)
Steps of an audit
Change practice
If care needs improving - create action plan
- What needs to change
- How can that be achieved
- Who needs to take these actions
- When will they happen
- How will they be monitored
- How and when to assess
Define relative risk
Also referred to as risk ratio
It is the probability of an event occurring
e.g. developing a disease in an exposed group vs non exposed group
RR = probability when exposed / probability when not exposed
Used in RCTs and cohorts
Define absolute risk
Risk of developing the disease over a period of time
Number of events in a group/ number of people within the group
Define relative risk reduction
Absolute risk in control - (absolute risk in treatment / absolute risk in control)
RRR = 1 - relative risk
Define absolute risk reduction
Absolute risk in the control group - absolute risk in the treatment group
Number needed to treat
1 / absolute risk reduction
Needs to be expressed as a whole number
NNT BENEFIT = round up
NNT HARM = round down
Extending the time period in which the risk is expressed will decrease the number needed to treat
What information is needed in order to assess a number needed to treat?
Needs to have a time period e.g. within 10 years
Look at the nature of the outcome
Decide if looking at something that is getting better or work (NNT benefit or harm)
Define attributable risk
Differnece in the rate of a condition between an exposed and unexposed population.
Also called risk difference of risk rate difference.
Incidence in exposed - incidence in unexposed
Define population attributable risk
Reduction in incidence that would be observed if the population were entirely unexposed in comparison to its current exposure pattern.
Strategies to tackle obesity in the community
Increase availability of heathier food in public service venues
Improve availability of healthy food - subsidise
Provide incentives for food retailers to locate healthier products in prime areas
Small portion sizes in public service venues
Limit advertisement of unhealthy goods
Discourage consumption of sweet drinks
Increase support for breastfeeding
Increase school PE requirements
Compulsory PE
Enhance infrastructure to encourage walking and cycling
Improve safety in areas where people could be physically active e.g. schools
Healthy school dinners
Clear food labelling
Increased education - change for life
Weight loss advice
Promote physical activity in the work place
Raise awareness of complications
Teaching in schools about healthy diets and exercise
National cancer research institute
Started in 2000 with NHS cancer plan
Brings together all the key players in research to identify where research is most needed
Partnership of UK cancer research funders to promote collaboration
Support advancement of areas lacking in research
NHS supported clinical trials
Comprised of 7 government partners and 14 charities
Activities of the national cancer research institute
Maintains database of cancer research in UK
Organising annual NCRI cancer conference
Developing a plan to network UK cancer registries and encourage epidemiological research
Revitalise UK radiotherapy research
Development of the national Cancer Research Network
Setting up a network of experimental cancer medicine centres
Publish reports on key areas
Establish the National Cancer Intelligence Network
National Cancer Research Institute AIMS
Foster research aimed at:
- better prevention leading to lower cancer risk for the individual
- earlier diagnosis
- better, cost effective treatments with more people cured
- less inequality in outcomes for patients
- improvements in health and quality of life for people who survive cancer
National Cancer Research Network
Aims to improve speed, quality and integration of research to improve patient care
- Increase funding for trials
- Provides researchers with practical support
- Increases participation in clinical research, raising the number of patients entering trials
- Engages with stakeholders
- Ensures research is translated into benefits for patients,
Define screening
Public health service
Members of a defined population, who do not necessarily perceive they are at risk of, or are already affected by a disease or complications, are asked a question or offered a test to see who are more likely to be helped than harmed by further tests of treatment to reduce the risk of disease or its complications
Screening programs offered in the UK
Retinography for diabetic eye disease breast cancer mammography Colorectal cancer FOB Cervical cancer - smear AAA - US Down's syndrome Guthrie Heel Prick test - PKU, hypothyroidism DDH - infant screening Deafness - neonatal screening
Diabetic retinopathy screening
Everyone over 12 with diabetes receives it annually
During pregnancy - at first antenatal clinic and at 28 weeks
Breast cancer screening
Mammography
Women aged 50-70 (47-73)
Every 3 years
Colorectal cancer screening
Faecal occult blood
Every 2 years from 60-74
Cervical screening
Cervical Smear
Every 3 years from 25-50, every 5 years 50-65
Tests for HPV and cell changes
AAA screening
Men aged 65 are offered US scan
If normal, never tested again
If small-medium then regular monitoring
Key concepts of screening
Requires a judgement between balance of helping and harming
Early detection is necessary for screening but in itself does not provide benefit
Population screening is about programmes not tests
Harms of screening
AAA - a person that dies during surgical repair of AAA detected through screening
Down’s - loss of normal foetal following investigation of a high risk screening test
Colorectal cancer - healthy individual who suffers from perforation of bowel during colonoscopy following screening
Patients receiving additional tests due to false positives on screening e.g. biopsy
Lead time bias
If you succeed in early detection of a disease then you increase the time between diagnosis and death - even if treatment is useless
- care not to count this extra time as benefit
- Need to use number of events prevented rather than survival time.
Healthy screenee effect
Patients who participate in screening often make other health conscious choices
Different lifestyles between those who take up screening and those who don’t
Length bias
Screening tends to detect disease which progresses more slowly
The screening detected disease will have better outcomes as they have less aggressive disease
It appears as if the cancers detected by screening have better outcome
Mental Capacity Act 2005
Provides statutory framework to empower vulnerable people who are not able to make their own decisions.
It makes it clear who can make decisions, in which situations and how they should go about this.
It applies to those aged 16 and over.
Principles of the Mental Capacity Act 2005
- Presumption of capacity
Every adult has the right to make their own decisions and must be presumed to have capacity unless proved otherwise - The right for individuals to be supported to make their decisions
People must be given all appropriate help before anyone concludes they cannot make decisions - Individuals retain the right to make an unwise decision
- Best interests
anything done for or on behalf of people without capacity must be in their best interests - Least restrictive intervention possible
Assessment of mental capacity is specific for each individual decision at any given time
To have capacity a person must:
Be able to understand information provided
Be able to retain this information
Be able to weigh up pros and cons
Be able to express this decision
When can restraint be used in those that lack capacity
Restraint is only permitted if it is deemed reasonable to prevent harm
Needs to be proportionate to likelihood and seriousness of harm
Advanced Care Planning
Gives the person the right to make decisions about healthcare treatment in the future for times when they no longer have capacity.
- Replaced advanced directives
- Only over 18s
- Must currently have capacity
- Any treatment can be refused except for those to keep a person comfortable - food, water, warmth, shelter
- Can express which treatments you would like but cannot demand
- It carries the same weight as a person with capacity so best interests does not apply
- Can be verbal unless about life-sustaining treatment which must be written and signed by patient and a witness, plus a statement that it is still to apply if life is at risk
- Becomes invalid if the decision is withdrawn while still has capacity
- Must apply to the specific circumstance in question
Lasting powers of attorney
Can appoint an attorney to act on their behalf if they lose capacity in the future
Lets them make financial, property, health and welfare decisions
Attorney must be over 18
Only comes into force once a person loses capacity
Must be registered with the Office of Public Guardian
Independent Mental Capacity Advocate
Appointed if someone without capacity has no one to speak for them
Makes representations about patients wishes
Can challenge the decision maker
MUST be involved if:
- Serious medical treatment
- Stay of more than 28 days in hospital or 8 weeks in care home
- Change to accommodation
Deprivation of liberty safeguards
Provides legal protection for vulnerable adults who are not detained under Mental Health Act 1983 but are restricted in freedom due to an inability ot consent to care or accept treatment
Anyone over 18 with
- mental disorder or disability of the mind e.g. dementia or profound LD
- Lack of capacity to give informed consent
If a person lacks capacity, must apply to a supervisory body for authorisation of deprivation of liberty
NHS Outcomes Framework
Provides a national overview of NHS performance
Supports the secretary of state in holding NHS England to account for improving outcomes and acts to aim to encourage a change in health inequalities.
5 domains
- Preventing people dying prematurely
- Enhancing quality of life for people with long term conditions
- Helping people to recover from periods of ill health or following injury
- Ensuring people have a positive experience of care
- Treating and caring for people in a safe environment and protecting them from avoidable harms
Measuring quality of cancer services
NHS Outcomes framework
- One year survival from all cancers
- 5 year survival from all cancers
- One year survival from breast, lung, colorectal cancers
- 5 year survival from breast, lung, colorectal cancers
- 5 year survival from all cancers in children
Cancer Patient Experience Survey
CCG Outcomes Indicator Set
PROMs
CCG Outcomes Indicator Set for monitor quality of health services - CANCER
Drives local improvement and sets priorities
- Under 75 mortality from cancer
- 1 and 5 year survival from all cancers
- Record of stage of cancer at diagnosis
- Percentage of cancers detected at stage 1 and 2
- Mortality from breast cancer in females
- Patient experience and survivorship
Cancer Patient Experience Survey
CPES
National assessment of patient satisfaction with their cancer treatment.
In 2014 - asked 110,000 patients, 64% response
Positives
- Given enough information
- Offered a range of treatment options
- Treated with respect and dignity
Negatives
- GP and nurses in GP could do more
- Not enough care form health and social services post discharge
Cancer registries
- 4 in the UK
- Responsible for registering all cancer that occur in their population
- Prime aim to establish incidence and survival
- Identify all new cases and follow them through to death
- Allows comparison of incidence in different regions
- Allows researchers to examine long term outcome
provides inform on cancer epidemiology
Bradford Hill Criteria
Criteria for causation - minimal conditions necessary to provide adequate evidence of a causal relationship between incidence and possible consequence
- Strength - larger = more likely to be causal
- Consistency (reproducibility)
- Specificity - causation likely if a very specific population and disease with no other likely explanation
- Temporality - effect after cause
- Biological gradient - greater exposure = greater incidence of effect
- Plausibility
- Coherence - between epidemiological findings and lab findings
- Experiment
- Analogy
Risk factors for chronic liver disease
Alcohol Obesity Viral hepatitis metabolic syndrome healthcare workers IVDU Unprotected sex with multiple partners Working with toxic chemicals Certain medications
Ways to restrict alcohol consumption
Minimum unit price for alcohol Offer interventions for alcohol AUDIT CAGE Raise public awareness Treat alcohol dependence Clear unit information on alcoholic drinks Stop special offers Stop advertising to young people Lower recommended limits Alcohol liaison nurses
Ways to reduce viral hepatitis
Hep B vaccine Antenatal testing for Hep B and C Test in prisons Needle exchange programs Free barrier contraception
Limiting additional damage in chronic liver disease
Alcohol cession Low sodium diet Healthy diet Avoid infections - immunise for hepatitis, influenza, pneumonia Care RE over the counter drugs Weight loss
Cancer care UK
3 levels of care
- Primary care
- Cancer UNITs for populations of 250,000 Treat common cancers Diagnostic procedures Common surgery Non-complex chemotherapy
- Cancer CENTRES for populations of 1,000,000
Treat rare cancers
Radiotherapy
Complex chemotherapy
Palliative care runs alongside all 3 levels
Cancer networks
Established in 2000
28 cancer networks in the UK
Work in local areas with clinicians, patients, managers to deliver the National Cancer Strategy to improve performance of cancer services
Becomes known as Strategic Clinical Networks from 2013
- Now wider than cancers
- One per region
- Seeks to reduce inequalities in care
Cancer plan 2000
4 aims
- Save more lives
- Ensure people with cancer get the right professional support and care as well as the best treatments
- Tack inequalities in health
- Build for the future through investment in the cancer work force - strong research and preparation for a genetic revolution
Calman-Hine Report 1995
Recommendations
All patients need to have access to a high quality of care
Public and professional education into the early signs of cancer
Patients, families and carers to be given clear information about the treatment and outcomes
Cancer care should be patient centred
Primary care is the central focus of cancer care
Psychological aspects need to be recognised
Cancer registration and monitoring
Commitments and recommendations made to improve cancer care and reduce cancer
Lower smoking rates
Reduce waiting times
5 fruit and veg a day
National school fruit scheme - free piece of fruit for children 4-6 at school
Raise public awareness
Cancer screening
Increased funding for palliative care nurses and MacMillan nurses
Investment in staff and equipment
Cancer networks to improve experiences
Extra funding for hospices
End postcode lottery - NICE recommended drugs available to all health authorities
