Week 6

Question 1

Justifying a mental health act

Answer 1

Common law and mental capacity act 2005- competency: cognitive ability to understand and weigh up the key issues relevant to the decision
But mental illness may affect the process of decision- other than cognitively e.g. moderate depression may alter values but the person may still have good cognitive abilities

Question 2

Justifying overruling refusal of treatment

Answer 2

-argue that the illness interferes with their normal values- so respecting the patients autonomy is to respect what that person wants when free from depressive illness
-argue that it is right because it is in their best interests (and others) todo so and they’re suffering from a mental illness
-English law takes this second (paternalistic approach), at least about the treatment of the mental (not physical) illness

Question 3

Overruling refusal of treatment

Answer 3

A person can be treated for a mental disorder under the MHA without reference to their capacity
Ethical problems with this approach
Override a competent patients refusal:
-either it assumes that the presence of a mental illness automatically renders someone incompetent (false) or it simply discriminates between the physically and mentally ill
Protection of others as well as the patient- not usual in physical disorders to be treated for someone else’s sake

Question 4

Protection of the patients or the protection of others

Answer 4

The question of capacity is central to overriding refusal for the sake of the person himself
The main method by which society protects itself from those dangerous to others is through the criminal law- it may be inappropriate to use the criminal law in the case of some mentally ill-they are not responsible for their dangerous acts. The central issue in the case of dangerousness to others is not capacity but responsibility

Question 5

MHA: discrimination

Answer 5

-allows a competent patient’s refusal to be overruled
-gives society much wider powers forcibly to restrain for the protection of others, mentally disordered people compared with those without mental disorder
-eg dangerous mentally ill can be detained almost indefinitely
But those without mental disorder cannot be kept in a secure place, however dangerous they are thought to be, if they have either not yet committed a crime or have served their prison sentence

Question 6

Mental health act 1983

Answer 6

Mental disorder
‘Dangerous’ to either themselves or others
Informal and compulsory admissions

Question 7

Compulsory admission 3 routes:

Answer 7

1. Admission for assessment S.2
2. Emergency assessment S.4
3. Admission for treatment S.3

Question 8

Admission for assessment S.2

Answer 8

GROUNDS:
-A:mental disorder= ‘nature and/or degree’ which warrants detention- assessment
And
B: dangerous (to self or others),
application by NR/AMHP,
supported by 2 Drs (1 psychiatrist),
lasts for up to 28 days

Question 9

Emergency assessment S.4

Answer 9

GROUNDS the same as S.2 i.e
A- mental disorder= ‘nature and degree’ which warrants detention assessment
And
B-dangerous (self/others
Application 1Dr
-up to 72 hours

Question 10

Admission for treatment S.3

Answer 10

GROUNDS:
A-mental disorder= ‘nature’ which warrants treatment in hospital
And
B- dangerous (self/others)
And
Mental illness is ‘treatable’= alleviate or prevent deterioration in mental illness
Treatment includes symptoms
Application similar to S.2- although where SW makes the application NR must be consulted
-up to 6 months
-period is renewable
-cannot be used to enforce treatment on an out-patient basis

Question 11

Section 1: removal of categories of mental disorder

Answer 11

Section 1 amended the wording of the definition of mental disorder in the 1983 act from ‘mental illness, arrested or incomplete development of mind, psychopathic disorder and any other disorder or disability of mind’ to
“Any disorder or disability of the mind”

Question 12

Section 4: replacement of “treatability” and “care” tests with appropriate treatment

Answer 12

Section 4 introduced a new “appropriate medical treatment test” into the criteria for detention under section 3 of the 1983 act, related sections of part 3 and the corresponding criteria for renewal and discharge. The effect was that these criteria could not be met unless medical treatment is available to the patient in question which is appropriate taking account of the nature and degree of the patients mental disorder and all other circumstances of the case

Question 13

Professional roles

Answer 13

Chapter 2 provided for roles which are central to the operation of the 1983 act potentially to be performed by a wider range of professionals than previously. In particular it replaces the role of the ‘responsible medical officer” (RMO) with that of the “responsible clinician” RC and the role of the ‘approved social worker’ ASW with that of the “approved mental health professional “ AMHP

Question 14

Safeguards for patients

Answer 14

Patients nearest relative
Section 23 introduced a new right for a patient to apply for an order displacing the NR on the same grounds available to other applicants under the 1983 act as it stands and on the additional ground that the NR is unsuitable to act as such

Question 15

Electro-convulsive therapy

Answer 15

Section 27 inserted a new section 58A into the 1983 act. That new section provided that ECT and any other treatment provided for by regulations made under subsection (1)(b), can only be given when the patient either gives consent or is incapable of giving consent

Question 16

Supervised community treatment

Answer 16

The supervised community treatment SCT provisions allow some patients with a mental disorder to live in the community whilst still being subject to powers under the 1983 act. Only those patients who are detained in hospital for treatment

Question 17

Essential issues

Answer 17

Every competent adult has a legal right to refuse treatment even if life saving
They need not give any explanation, rational or otherwise
This respects the individuals right to autonomy
Capacity should be assumed until proven otherwise by a functional assessment
Suicide is no longer a criminal act

Question 18

“Common law principles”

Answer 18

Is there capacity to refuse treatment?
-common law principles allowed treatment in an emergency, to prevent loss of life or deterioration of health in someone without capacity
Incorporated as statue in mental capacity act with guidance on “substitute decision making”
Is there a mental disorder here?
-there may be a need for a mental health act assessment in arranging treatment for ongoing mental disorder

Question 19

Competence (mental capacity act 2005)

Answer 19

Take in and retain information
Understand that information (in appropriate terms)
Weight up the information to arrive at a decision
Communicate that decision
The mental health act acknowledges that mental disorders can impair capacity
However compulsory hospital admission and treatment are only for that mental disorder or a physical illness contributing to that disorder or now physical consequences of the disorder
“Appropriate treatment” must be available

Question 20

Mental capacity act v mental health act

Answer 20

Initial guidance was to use MCA in the first instance as the “least restrictive” option compared with MHA
Subsequent case law reversed the guidance
Where a patient met the criteria for detention under the MHA had to be used
However this has been complicated by other judgements and every case should be considered individually

Question 21

Mental health act 1983 amended 2007

Answer 21

8 years in the making
Heated debate
2 abandoned bills
Finally amendments of the 1983 act
-broadened definition of mental disorder
-removal of exclusions
-appropriate treatment test
Supervised community treatment
Conditions set by RC on a community treatment order- treatment, attendance at appointments etc
Must be considered for any patient on section 3 who is going on 7 days s17 leave or more
Initial estimates of ~600 orders nationally
Probably 10x that number of people and therefore greater numbers of patients still subject to compulsion
“The psychiatric ASBO and just like a lobster pot”
The OCTET study found absolutely no difference in outcome between CTO and control

Question 22

some historical perspective

Answer 22

WW II: 3-7 million people forced to move during, 11 to 12 million forced to move afterwards
Partition of India (1947): displaced >14 million people along religious lines, large scale violence- estimates of several hundred thousand to 2 million dead

Question 23

Why do people migrate

Answer 23

Work, educational, or family reasons
-able to financially support themselves and have access to healthcare
-migration even in favourable circumstances does create some vulnerabilities eg: distancing from habitual support mechanisms and lack of familiarity with culture with social structures

Question 24

Who migrates and why? National picture UK

Answer 24

Data is gathered from a variety of sources in an attempt to capture the complexity
-national insurance numbers, GP registrations, population surveys, national census
It’s almost impossible to gain an accurate picture of undocumented migration and how many people are here illegally
-as the “windrush crisis” has shown some people are unaware of their own immigration status/official bodies may not be aware of their status
Estimated 674000 people have irregular or undocumented immigration status: around 400000 live in London, the number of undocumented children increased 56% between 2011 and 2017, this is likely to rise dramatically as a result of the illegal migration act 2023
Reasons for immigration to the UK (excluding asylum)
-49% work
-12% joining or accompanying family
-27% for study
-13% other/no reason stated

Question 25

Birmingham is diverse

Answer 25

Both net migration and the diversity of new arrivals is increasing
Home to people of more than 187 different nationalities
A “majority minority” city
In the 2021 census 26.7% population had been born overseas, 39.5% of those born overseas have been in UK for less than 10 years
In some wards almost 30% of residents have a main language other than English and around 10-12% cannot speak English well or at all
- in some wards 15-20% of households do not have a single household member over 16 who speaks English as a main language

Question 26

Forced migration

Answer 26

Refers to the movements of refugees and internally displaced people (those displaced by conflicts) as well as people displaced by natural or environmental disasters, chemical or nuclear disasters, famine, or development projects
Reasons for forced migration also include:
-climate change impact of this is especially severe where other pressures on food security eg conflict
-persecution on basis of religious or political beliefs/activity or sexual orientation

Question 27

Mixed migration

Answer 27

Mixed movements (or mixed migration) refers to flows of people travelling together
Moving in an irregular manner over the same routes and using the same means of transport
The men, women and children travelling in this manner often have either been forced from their homes by armed conflict or persecution or are on the move in search of a better life
People travelling as part of mixed movements have varying needs
May be asylum seekers, refugees, stateless people, victims of trafficking, unaccompanied or separated children and migrants in an irregular situation
Mixed movements are often complex, and can present challenges for all those involved

Question 28

Mixed migration 2

Answer 28

Mixed migrations occur in a range of political and social contexts that impose their own challenges:
-the “opening of the borders” and germanys welcome in 2015
-progressive closure of the Macedonian border in 2016-INDOMENI
-the Greek economic crisis was background to this
—economy shrank 26% since 2008, public services devastated
-60000+ stranded in a society without means to support them
-the most expensive (per head) humanitarian crisis in history
-70 dollars in every 100 spent wasted

Question 29

The migration cycle. Migration is not a single journey

Answer 29

Origin (predeparture and re migration),
Health and wellbeing of people and populations
Destination (temporary or circular or permanent (resettlement)
Short term transit
Interception
Longer term transit
Return

Question 30

Trafficking

Answer 30

“The recruitment, transportation, transfer, harbouring or receipt of persons by means of threat or use of force or other forms of coercion, of abductions of fraud, of deception, of the abuse of power, or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person, resulting in control over another person, for the purpose of exploitation”
Migrants are vulnerable to trafficking before, during or after their journey
‘National referral mechanism” - an official 45 day recovery programme for victims of trafficking after which they may or may not claim asylum or accept repatriation

Question 31

Smuggling

Answer 31

A person or persons pay another party to transport them illegally from one country to another
The person is free once they reach their destination
Its always illegal

Question 32

Some terms- how people move

Answer 32

Modern slavery:
-define by the modern slavery act 2015
-“knowlingly holding a person in slavery or servitude or knowingly requiring a person to perform forced or compulsory labour”
Includes trafficking and exploitation
Over laps with smuggling
-the person paying the smuggler may be offered terms- eg “pay later” and given a deadline -this person is then vulnerable to bonded labour and other abuses
Resettlement:
-official programmes to move recognised refugees from LMIC to high income countries eg Syrian vulnerable persons resettlement scheme

Question 33

The 4 phases of the refugee experience

Answer 33

Anticipation:
-adverse treatment due to race, ethnicity, sexuality, religion or politics
-risk of ethnic violence increases if one group constitutes 40-95% of the population
Adversity:
-conflict, ethnic cleansing, sexual violence, torture
Survival:
-risks and challenges of the journey
Integration:
-challenges and barriers in the host country

Question 34

The journey

Answer 34

> 52760 dead inside Europe or Mediterranean since 1993
18000 children missing
Drowning- rivers and oceans: Mediterranean, evros river on land border of Greece and turkey
Violence from border officials and police: illegal border push backs and denial of right to claim asylum, refoulment- forcible return to countries they are fleeing, deportation and detention
Unsafe modes of transport: refrigerated lorries (suffocation), under trains, road traffic accidents
Hypothermia/hostile environments (eg desert)
Carbon monoxide poisoning
Unsafe and unsanitary conditions inside camps: fire, disease, malnutrition
Poor access to healthcare
Suicide and addiction

Question 35

After arrival in UK

Answer 35

Immigration process
-‘culture of disbelief’. Disbelief of accounts of abuse, torture or reason for forced migration. Inexperienced and inadequately trained home office case workers (freedom from torture 2017)
-age disputes- incorrect assessments expose minors to risk and increase vulnerability
-limited access to legal advice and legal aid to appeal/poor quality advice
-immigration detention- can be indefinite with poor access to healthcare
-continued uncertainty
The “hostile environment” in the UK
-proof of ‘right to reside’ needed to access rental accommodation, drivers licenses, employment, some healthcare
-family reunification challenging
-dispersal (no control over destination and moves disrupt supportive relationships with individuals and organisations) and NRPF status

Question 36

After arrival in the UK- seeking asylum

Answer 36

The 2022 immigration bill
Applied to arrivals from June 2022
-those who arrive by any route and apply for asylum without delay and arrive without passing through a “safe” country
-same asylum process as previously
-5 year permission to stay with the right to indefinite leave after this if protection still needed
-governments intention was to remove some people to Rwanda if arrived after 1st jan 2022 this has been challenged

Question 37

The illegal migration bill 2023

Answer 37

Places a legal duty on the Home Secretary to remove anyone arriving irregularly to the uk, which includes those arriving by small boat and other means of transport either:
-to their home country (32 safe countries)
-or to a safe third country such as Rwanda. The duty to remove does not apply to unaccompanied children who the Home Secretary will only be required to remove when they turn 18
Anyone arriving after 20 July 2023 will have their asylum claims declared “inadmissible”
-the government then intends to “detain and swiftly remove” these people
There is no legal duty on the Home Secretary to detain people, it is only a power to do so and people can only be removed to their home country if they are from one of 32 counties, which are the EU 27 member states, Iceland, Liechtenstein, Norway, Switzerland, Albania, anyone else would have to be removed to a safe country

Question 38

Arrival in Uk- seeking asylum

Answer 38

2 circumstances for people claiming asylum in Uk:
-pre July 2023 arrival- route to full refugee status:
—living conditions often very basic dirty and/or dangerous
—basic accommodation and limited financial support (£35 a week)
—no automatic right to work (limited rights for some)
-post July 2023 arrival the illegal migration bill:
—no right to claim asylum (inadmissibility)
—threat of removal to Rwanda or other “third country”
—for many: basic isolated accommodation in refugee camp like conditions with limited freedom of movement
-a small number of people in very limited circumstances will have admissible claims

Question 39

After arrival- the path to indefinite leave to remain (regular migration)

Answer 39

Initial status- by whatever route is usually “limited leave to remain” 2-5 years of leave to remain
Need to accumulate 10 years in UK before “indefinite leave to remain ILR” can be granted and then UK citizenship
LLR granted in 30 month chunks, necessitates recurrent applications
Total cost of achieving individual ILR and citizenship -well in excess of £20000
-considerable financial burden on low income individuals, driven into debt
-cost to families enormous and recurrent
-cost have risen 1440%since 2003

Question 40

After arrival- destitution

Answer 40

Destitution:
“Destitution means going without the bare essentials we all need. That’s a home, food, heating, lighting, clothing, shoes and basic toiletries. We define destitution as when people have lacked two or more of these essentials over the past month because they couldn’t afford them; or if their income is extremely low- less than £70 a week for a single adult”
Joseph Rowntree foundation

Question 41

Destitution

Answer 41

90% of refused asylum seekers remain in UK and brave destitution rather than electing to leave
-this leads to destitution
-the illegal migration act may lead to a huge increase in destitution- no right to remain, not possible to be removed from UK
—hostile environment means access to accommodation, education, healthcare, law enforcement severely restricted
—high risk for exploitation and trafficking

Question 42

After arrival in the UK- NRPF (regular migration)

Answer 42

Some people are granted a right to stay in the UK but have “no recourse to public funds (NRPF)
-eg adult dependent or spouse of someone with settled immigration status
-parent of a child who is a UK national
-visa overstay
-can be nationality specific
NRPF status causes a lot of confusion about what people are ands are not entitled to claim/access
-its complex but does not reference to healthcare or social services
In general NRPF means cannot claim welfare benefits and housing or homelessness support

Question 43

After arrival

Answer 43

Public discourse in high income countries presents migrants as burden and exaggerates numbers: stigma, hostility, hate crime. However migration benefits eg NHS by far more than it costs -taxes paid and staffing
Rise of the far right in Europe: wave of (largely Islamic) refugees triggered a political back lackeys since 2015, increasing criminalisation of humanitarian and integration efforts, election of politicians/governments on anti-immigration platforms
37% of Drs in UK gained their qualifications abroad
1% increase in migration increases GDP by 2% per person

Question 44

After arrival- internationally

Answer 44

Integration is challenging:
-cultural and language barriers- education and employment
-loss of status, profession and standing in society
-family separation
-difficulties gaining employment and low wage occupations with high risk of hazards (with limited protection)
—construction (in US Latino construction workers 1.84x more likely to die than non Latinos)
—agriculture
—fishing (54% of trafficked workers in Thailand experienced violence vs 10% non-trafficked workers)
—domestic work (in UK employers often have influence due to immigration status DW visa)
—sex work (higher risk of contracting HIV than non-migrant workers)

Question 45

Mortality and migration

Answer 45

The “healthy migrant”
Myth or reality- data can be conflicting and context dependent
-migrants to high income countries have a mortality advantage compared to their non-migrant counterparts . SMR for migrants lower across all ICD-10 counterparts
Migrants are healthier than the UK born population
-in 2019 27% said they had a long term condition compared to 42% uk born
-those who have lived longer in the uk are more likely to have health problems than those recently arrived (age matched)
The opposite is true for those that migrate in circumstances that cause marginalisation eg seeking asylum (Guintella et al 2018)

Question 46

Migration and mental health

Answer 46

Migrants who arrive under favourable circumstances report better mental health than UK born (5% vs 10%)
Torture and exposure to violence/trauma: PTSD
Detention and deportation: UK is one of the few countries who allow indefinite immigration detention, new bill all will be detained
Ongoing uncertainty: backlog of asylum cases- huge and growing. Average 75% of initial decisions were negative between 2004-19 (35% of refusals are overturned at appeal)
Challenges with integration: once asylum granted 28 days to sort out NI number, job, housing, bank account, benefits. Many refugees are at high risk of homelessness at this point

Question 47

Migration and mental health: forced migration

Answer 47

Torture and exposure to violence/trauma: PTSD, other mental health effects (anxiety, depression)
Detention and deportation
Ongoing uncertainty: backlog asylum cases, the illegal migration act- perpetual limbo
Challenges with integration: once asylum granted 28 days to sort NI number, job, housing, bank account, benefits. High risk homelessness

Question 48

Torture and survival

Answer 48

21% of refugees have been tortured. 30% torture survivors meet diagnostic criteria for PSTD. However torture survivors may have very complex and quite severe symptoms without meeting any threshold for diagnosis of a single disorder
A substantial proportion of torture survivors report direct or indirect involvement of clinicians in their abuse
Patients experience of torture is often under recognised boy clinicians (this is the norms)
Unprompted disclosure is rare and experiences within the immigration process may reduce expectations of being believed
Torture is assault on the wellbeing of an individual which impacts on multiple levels: physical, psyche, integrity, spirituality, social stigma and marginalisation. It degrades, dehumanises and debilitates
Goal is to break down personality leading to breakdown of cognitive and behavioural function.
It’s effects are pervasive can be longstanding (10+ years), relapse and remit and extend to families and communities where torture has occurred

Question 49

Migration and mental health the result

Answer 49

It’s fearful and sad looking back
It’s frightening looking forward to the risk of destitution, detention and deportation
In the UK post illegal migration act- perpetual limbo and jeopardy
It’s not over once your asylum claim is accepted
Many people (especially the undocumented and those with refused or inadmissible claims) can be caught in limbo, destitute for many years
“The trans national state” deportation to unsafe environments prompts repeated journeys, recurrent deportations
Individuals bouncing around between European countries looking for one which will finally accept their claim

Question 50

Migration, gender and health

Answer 50

Both male and female patients are at risk of sexual violence, exploitation and transactional sex
-before during or after migration
-not only those trafficked for purposes of sexual exploitation
-girls and women at increased risk of early and forced marriage
Access to reproductive health and contraception
-can be poor- most settings
-host nations culture and legal/social structures apply
-menstrual hygiene
Maternity care and obstetrics
-maternal and infant mortality and morbidity very compared to resident population
Individuals (esp women) with unstable or irregular immigration status at risk of intimate partner/domestic violence
Persecution in home and transit countries on basis of sexuality

Question 51

Migration and infectious disease

Answer 51

Suspicion of migrants as the cause of disease outbreaks is a persistent and damaging myth
Migrants come from countries where infectious disease profiles differ from host nations
Always ask about immunisation status and offer catch up immunisations
-can be disrupted by migration or circumstances that lead to forced migration
Screening can benefit individuals and decrease healthcare costs associated with treatment and complications
-but in some settings this come at the cost of stigmatisation and negative media and political messages
Migrants are highly unlikely to transmit disease to host populations
-transmission more likely within households and migrant communities rather than to host communities and individuals
-pandemic situations may differ

Question 52

Migration and infectious disease TB

Answer 52

TB and latent TB infection
Collaborative TB strategy for England 2015-2020
Screen all 16-35year olds arriving from countries with TB incidence >150/100000 and all sub Saharan Africa
TB in high risk populations- advise about signs and symptoms
Be alert to non pulmonary TB- More common then in non migrant population
HIV: screen all new registrations in communities where HIV prevalence is more than 2 per 1000 (this includes large part of W midlands). Screen those from countries of origin where prevalence >1%
Hep B: screen according to country of origin risk
Hep C: screen if from a country of origin higher risk than host nation

Question 53

Access to health care and universal healthcare

Answer 53

What is universal access to healthcare?
-all people can use preventative, curative, rehabilitative and palliative health services they need, at sufficient quality to be effective while also ensuring the use of health services does not expose the user to financial hardship. The UCL

Question 54

A word about working with superdiverse populations

Answer 54

There is not such thing as cultural competence when working within Super-diverse populations – one can nev er aspire to grasp all the nuances. The best we can aim for is to approach our patient’s cultural background with a sense of humble curiosity – treat people as competent interpreters of their own lives, admit your ignorance and let them guide you”
A word about working with Superdiverse Populations
Paraphrased from - Sarah Temple- Smith
Project Manager & Children’s Psychotherapist
The Refugee Council

Question 55

What advantages does equitable access to health care bring to society

Answer 55

Inequitable access to healthcare drives health inequality and thus social inequality
Unequal societies- are less economically stable, have higher crime rates, are more violent and are less happy
It’s estimated that the annual cost of health inequalities is between £36 billion to £40 billion though lost taxes, welfare payments and costs to NHS
Health inequality costs around 1.4% of GDP in European countries (EU parliament)
All of the above need to be place into the context of the pandemic
We are not safe until we are all safe

Question 56

Why is access to healthcare important

Answer 56

Matter of public health: communicable disease, drug and alcohol treatment
Financial sense: delayed access to treatment, inappropriate use of services, resource burden of checking and changing patients, health inequalities cost
Enshrined in medical ethics and NHS principles: responsibility to protect and promote the health of all patients, NHS founding principle “based on clinical need not the ability to pay”

Question 57

Charging in secondary care

Answer 57

Chargeability in secondary care depends on immigration status. Undocumented migrants (including. Refused asylum seekers) are charged
Charges must be paid before treatment which can be withheld if a patient cant pay
“Urgent or immediately necessary” treatment to be provided regardless of ability to pay
Some services are exempt: A&E some communicable diseases and family planning
Some groups are exempt incl. refugees, asylum seekers, survivors of some types of violence, recognised survivors of trafficking

Question 58

The NHS surcharge

Answer 58

Payable by anyone applying for a visa over 6 months for study, work or family visit
-allows access to the NHS on the same basis as a resident
The NHS surcharge doubled from £200 to £400 per person in Jan 2019
It’s estimated this will raise £220 million per year for the NHS and that each person entering on such a visa uses on average £480 of NHS services
A “double tax” on migrants- many will be paying income tax ( or will have a relatives who pay) and other forms of taxation eg VAT and/or will be contributing to the economy in other ways eg university fees

Question 59

Restricting access and charging for NHS services

Answer 59

Can be argued that it is counterproductive and could be considered to be politically motivated
Erodes the primary principle of the NHS that care is free at the point of delivery and available for all
Is complex and can be inconsistently applied and can lead to:
-erroneous charging
-racial profiling
-denial of urgent and immediately necessary care
-a deterrent effect on individuals seeking care
Likely does not save the NHS money- evidence base is evolving - the context of covid pandemic makes this more likely

Question 60

Ethical approaches

Answer 60

Consequentialist- the end result is the only thing that matters
Deontologists- you have done the right thing by following the rules and guidelines
Virtue ethicist- individual and later the practice peer group agrees the hows of practice that serve the patient and societal well being
Values vs virtues
Phronesis virtue is the how to navigate the other hows to come to a decisions

Question 61

Phronesis or practical wisdom

Answer 61

Concept which advocates a way to make ethical decisions that are grounded in an accumulated wisdom gained through previous practice dilemmas and decisions

Question 62

Virtue ethics and Phronesis concepts

Answer 62

Virtue is a ‘mean’ between two extremes (‘vices’ or poles)
Poles : ‘too much’ excess and ‘too little’ deficiency
Where on the continuum is right for any given situation
Practical wisdom or Phronesis is the virtue of discerning the appropriate course of action in any given situation
Phronesis: executive virtue or the chair of moral debate to navigate a way through all virtues of relevance

Question 63

Ethical approaches

Answer 63

Consequentialist- the end result is only thing that matters
Deontologists- you have done the right thing by following rules and guidelines
Virtue ethicist- individual and later the practice peer group agrees the hows of practice that’s serve the patient and societal well being

Question 64

Phronesis or practical wisdom

Answer 64

A concept which advocates a way to make ethical decisions that are grounded in an accumulated wisdom gained through previous practice dilemmas and decisions

Question 65

Townsend score

Answer 65

Measures: unemployment, non-car ownership, non-home ownership, household overcrowding
Based on census data can be out of date
Measures deprivation not affluence a low Townsend score doesnt mean area is affluent but that there’s few deprived people living there

Question 66

Carstairs score

Answer 66

Low social class, lack car ownership, overcrowding, male unemployment

Question 67

Jarman score

Answer 67

Initially for determining relative primary care needs populations
%elderly living alone, % children under five, %unskilled workers, %overcrowded houses, %changed address in last year, %residents living in household where head born in new commonwealth or Pakistan, %unemployed, % households containing lone parents

Question 68

What 7 domains comprise the English indices of deprivation

Answer 68

Income
Employment
Education
Health
Crime
Barriers to housing and services
Living environments

Question 69

International classification of diseases 10 or 11

Answer 69

Death
Diseases signs and symptoms
Abnormal findings
Complaints
Cancer
AMR
Covid 10

Question 70

Basic unit of hospital episode statistic database

Answer 70

Episode of care: period of time that patient spends under care of consultant

Question 71

Evidence based medicine

Answer 71

Integration of best research evidence with clinical expertise and patient values SACKETT et al 1996
Assessing a situation and asking good questions
Accessing/acquiring relevant research evidence
Appraising the evidence
Act applying the findings to clincial practice or health policy decisions
Assessing the consequences of actions undertaken

Question 72

Why are reviews/systematic reviews undertaken

Answer 72

Doctors need a way of locating the best most reliable evidence on which to base clinical decisions
-assimilate large volumes info/evidence on a topic
-investigate why some pieces of primary research come to different conclusions to others about a similar clinical question
-increase precisions of an estimate of effect size. Metaanalysis- summary estimate of effect increases sample size and statistical power

Question 73

Narrative review

Answer 73

Not conducted according to explicit methodology
The literature chosen to be included narrative review may reflect views of the review author rather than unbiased representation of all literature available

Question 74

Systematic review

Answer 74

Attempts to collate all evidence that fits pre specified eligibility criteria in order to answer a specific research question. Uses explicit systematic methods that are selected with a view to minimising bias thus providing more reliable findings from which conclusions can be drawn and decisions made. The aim when conducting a systematic review is that another independent researcher replicating the review methods would come up with the same conclusions from literature

Question 75

Key characteristics of systematic review

Answer 75

Clearly stated set of objectives with pre defined eligibility criteria
Explicit reproducible methodology
Systematic search that attempts to identify all studies that would meet the eligibility criteria
Assessment of the validity of findings of included studies
Systematic presentation and synthesis of the characteristics and findings of the included studies
Start with a Clear question: Population, Intervention, Comparator, outcome

Question 76

Advantages of systematic reviews

Answer 76

Can be the best source of evidence
Assimilation large amounts of research evidence
Provide reliable unbiased estimates of effect
Increase precision of estimates of effects
Provide information about the generalisability and consistency of effect
Identify what information is missing
Useful for making decisions
Should critically appraise it using CASP

Question 77

Metanalysis

Answer 77

Is the use of statistical methods to summarise the results of more than one independent primary study
Individual results need to be expressed in the same way
Typically weighted average of results across studies
Not appropriate when primary studies in review are considered different to eachother methodologically and clinically -heterogeneity

Question 78

Statistical heterogeneity

Answer 78

Exists when the true effects being evaluated differ between studies ands may be detectable if the variation between the results of the studies is above that expected by chance
May be caused by:
-clinical differences between studies
-methodological differences between studies
-bias
I2 describes the percentage of variability in effect estimates due to heterogeneity rather than chance. The closer to 100% the higher the inconsistency that cannot be explained by chance alone. Heterogeneity

Question 79

Difference types of bias

Answer 79

Bias is a systematic error or deviation in results or inferences from the truth
Selection bias: systematic differences between the characteristics of the intervention group subjects and the control group subjects
Performance bias: systematic differences in care being provided between the intervention and control group apart from the intervention being evaluated
Attrition bias: systematic differences between the intervention and control groups in drop outs or exclusions
Detection bias: systematic differences between the intervention and control groups in how outcomes are ascertained, diagnosed or verified
Publication bias: bias caused by only a subset of all the relevant data being available eg due to nonpublication of studies which show no effect or selective reporting of outcomes in studies
Lead time bias: effect overestimation of survival time with screening detected diseases because of detection at earlier point in the natural history of disease but with no real increase in survival time
Over-diagnosis bias: length time bias overestimation of screening benefit due to screening preferentially identifying good prognosis diseases

Question 80

Virtue continua

Answer 80

Virtue(mean): negotiates excess:doctor deficiency: patient
Virtue: justice/fair
Virtue: trust/integrity/confidentiality
Virtue: lawful
Virtue: collaborative
Virtue: culturally competent
Virtue: interpersonal/emotional intelligence
Virtue: recognising limits to treatment
Virtue: approachable/available mentor
Virtue: balanced approach
Virtue: reflective
Virtue: courage to have difficult conversations
Virtue: resilience
Virtue: phronesis excess:seen all know all can deal with all. Deficiency: applies theory or follow guidelines
Virtue: resources awareness