Post on 28-Apr-2015
Health Services, Chronic Illness, and Disability [Medicine in Society]
Kishu Pharasi
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Lecture 02: Overview of Disease Control Clinical medicine for: Individual Vs. Population à the needs of the population may differ from the needs of an individual There are two types of Knowledge: Tacit (unspoken) vs. Explicit (obvious) Explicit knowledge is gained though: Evidence, Statistics and Experience – known as Generalizable knowledge and is gathered by various means (research, experience, data) Data-‐‑Information-‐‑Knowledge Continuum (D-‐‑I-‐‑K) Data: set of discrete objective facts about events Information: data transformed by the value of contextualization, categorization, calculation, and condensation Knowledge: derived from information through human interactions: comparisons, assessments of consequences. What is Evidence based Health Care/Clinical Practice/ Medicine: continuous use of current best evidence in making decisions about the care of individual patients of the deliver of health service. Basically using best evidence in making choices in treatment. Evidence Based Medicine Triad:
T Individual clinical expertise T Best external evidence T Patient values & expectations
Comprehensive Disease Control: process through which people pool resources to reduce the burden of disease in order to:
T Prevent disease by reducing risk and promoting health T Find disease early T Improve treatment T Increase number of people who survive and live with chronic disease
This is done by promoting good health/choices/ facilities etc.
Interventions Primary prevention: Proactive intervention to avoid risk, health promotion Secondary Prevention: timely detection to detect and treat condition Tertiary Prevention: late interventions to minimize consequences
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End of life Care: improve QOL What is healthcare commissioning: process by which commissioning bodies
1. Asses need of local population 2. Identify priorities for investment / Plan 3. Acquire these services through contracts 4. Ensure services are provided effectively and monitor outcomes
What is a System: System is a set of services with a common aim/ common set of objective for that particular health problem à e.g. diabetes system What is a (disease control) Programme?
T Systems can be grouped into programme egg cancer program/ CVD programme. Public health programme designed to reduce the number of cases and death and improve QOL of patients though implementation of evidence based strategies for prevention early detection, diagnosis, treatment and palliation making the best use of available resources. Each gets its own budget/ resources allocation.
What is Managed Care? Ø Systemic approach to care management: predetermined care package given to group
of patients who have certain common conditions (can set CORE INTERVENTIONS)
What is a Care Pathway? § Route most patients follow through the journey of care. Sets out
anticipated best practice and outcomes What is a Clinical Network? Programmes, systems and networks are the best way to manage complex human endeavors like healthcare. A Clinical Network is a set of individuals and organizations that deliver the system (e.g. cancer network)
Lecture 03: Health Promotion
Health promotion: process of enabling people to increase control over and to improve their health. The combination of education and environmental supports for action and conditions of living conductive to health Three approaches to health promotion:
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1. Medical (traditional) – absence of disease/disability 2. Behavioral (lifestyle) – health as energy, functional ability, disease preventing lifestyle 3. Socio-‐‑environmental (structural) – being in control
Can use these different approaches to try and change people’s perception to health Target for health Promotion:
1. High-‐‑risk approach: identify few high risk and target them = greatest benefit to individuals at greatest risk.
2. Population approach: target the entire population = modify risk for the whole community substantial population benefit.
To change people’s perception of health we must be able to understand different ways of influences:
Individual level Health Belief Model: individual’s perception off the threat posed by health problem and the benefits of avoid the threat and factors influencing the decision to act Stage of chance model: individual’s motivation and readiness to change a problem behavior Theory of planned behavior: individual’s attitudes towards a behavior, perception of norms and belief about the ease or difficulty of changing Precaution adoption Process model: individuals journey from lack of awareness to action
Intrapersonal Level Social Cognitive Theory: personal factors, environmental factors, and human behavior exert influence on each other
Community Level Community organization: Community driven approach to assessing/solve health & social problems Diffusion of Innovations: hot new ideas, products and practices spread within a society Communication Theory: how different types of communication affect health behavior. Using Legislation to promote healthy behavior e.g.
T Seatbelt wearing mandatory 1989 T Smoke free public places T NY Trans-‐‑Fat Ban
Using Economic incentive to promote healthy behavior egg.
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T Tax on cigarettes T Tax unhealthy foods?
Try to use Healthy Counter Marketing vs. unhealthy marketing Some other interventions
T Increase social capital (rich = increased health) T Educate women
Lecture 04: The Case for Action on Tobacco Use & Smoking
More poor/disadvantaged smoke more Over 10 million UK adults smoke (20 % of all adults) 81400 deaths, ½ regular smokers die 50% smokers routine & manual occupation Both parents smoke = 4x more likely child will Best control Policies: UK at top followed by Ireland, Norway, turkey, France What is Tobacco Control:
T Reducing smoking prevalence is limited in effect if not linked to wider TC activities T Effective TC is based on WORLD BANK – 6 Strand APPROACH
1. Stop the promotion of tobacco a. Need National Action Legislation (Tobacco advertising & promotion act
2002). Local councils must enforce tobacco laws as well. Need to work together
2. Making tobacco less affordable a. Increased prices do have an effect. (Tax rev in 2010 9 billion) BUT illicit
tobacco sells for ½ normal price therefore used much more in poor places
3. Effective regulation of tobacco products a. National Action Legislature – age of sale, stopping counterfeit tobacco.
Council laws
4. Helping tobacco users to quit a. NHS Stop Smoking Services: most successful route to quite and most cost
effective NHS treatment there is
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5. Reduced exposure to 2nd hand smoke a. Legislation: 2007 smokefree places element of Health Bill. Education,
campaigns
6. Effective communication for tobacco control a. Get them to most effective routes of quitting. National communication
essential ! ¼th of all cancers = tobacco 1/5th of all CVD ½ of all Respiratory disease
Death from smoking > total of next 6 greatest causes of preventable deaths UK TOBACCO CONTROL PLAN – list of goals that they want to achieve by 2015
T reduce smoking prevalence among adults 18.5% or less T Reduce it in younger people 15 y.o 12% or less T Reduce smoking during pregnancy 11 % or less etc
NICE : Lots of published guidelines
T All healthcare profess, should be trained to give brief advice on stopping smoking T HCP should identify and record smoking and bring it up ever suitable time.
NHS Stop Smoking Services
-‐‑ seen as global leader in helping smokers to quit -‐‑ evidence shows local stop smoking services provide most effective type of support -‐‑ Multiple providers
o Primary care o Pharmacies o Hospitals o Private and voluntary sector
30 Sec – 3 As Ask: smoking status at every opportunity Advice: to stop and inform of best quitting options Assist: refer to stop smoking services
Lecture 05 Early Detection & Treatment
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Part 1: Primary Prevention Screening: improve overall outcome by detecting disease early. Members of a defined population do not necessarily perceive they are at risk of a disease or its complication, are asked questions or offered a test to identify those individuals who are more likely to be helped than harmed by further tests or treatments to reduce the risk of the disease or its complications. Program not a test. National Screening Committee: evaluate all research to ascertain benefits and harm and value for money à advice the government. Eg
T Breast cancer T Cervical Cancer T Antenatal Sickle cell
There are others that are NOT APPROVED by the NSC: prostate cancer, chlamydia, Vascular risk Problems With Screening
T Interventions of poor benefit to harm are practiced T People use unevaluated/ unproven T Don’t need it – low prevalence T Better way to stop problem ( better to treat smoking vs lung cancer) T How many they are, who they are will they participate – religion ethnicity, socio
economic T IS IT WORTHWHILE? If you find it early, will it actually help? T What are the policies for further post screening diagnostic testing? Is it worth it?
Criteria For introducing Screening:
1. Should be a serious health problem 2. High quality RCT as evidence that it reduces
death 3. Benefits outweigh harm 4. Value for money 5. Any better way to fix it 6. Is it scientifically justified ? 7. Do we have the Resources 8. Effectiveness
o Sensitivity : how good at correctly identifying case = A/ A+C o Specificity: how good at correctly identifying non case D/ D+B
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o PPV (positive predicative value): Probability of having disease if +ve test -‐‑-‐‑-‐‑-‐‑ A o NPV (negative predictive value) : Probability of not having a disease if –ve test D
T Prevalence = A+ C/ A+B+C+D T Accuracy: Sensitivity + Specificity
QUESTION -‐‑-‐‑-‐‑-‐‑ Both screenshots from Lecture 5 Part 1: HES Screening by Dr. E. A. 1st October
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Use NATURAL FREQUENCY – given out of 1000 Biases in Screening
T Lead time Bias: all you actually do is find it early but no outcome T Length time Bias: find less aggressive disease, no point to fix it. Not actually doing
harm, over diagnosis. Other Things to consider
T Giver patients informed consent T Quality Management T Compliance T Peer review of evidence (does it actually help)
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Part 2: Secondary Prevention
Good practice in Early Detection and treatment T about 25% of cancers are first picked up in A & E ( not good)
Dementia:
T ½ the people never have a formal diagnosis made at any stage of their life T early diagnosis would allow for planning and prep, but usually made in crisis
Why this Delay?
T Therapeutic Nihilism: there isn’t a cure so why even bother T Potential negative reaction to diagnosis T Worried about competence
Benefits Of early diagnosis and intervention
T institutional care can be delayed up to 18 months T crisis intervention/ emergencies reduced
Hereditary Hemochromatosis à try to pick it up ! autosomal recessive disorder of iron absorption ( 1/200 north European). Eventual iron overload causes widespread organ damage esp liver heart Hepatitis C no distinguishing feature eventually need liver! 216 k people in the uk. Chronic needle users greatest risk. 4 step approach
T prevent new infections T increase awareness of new infections T increase number of cases identified -‐‑-‐‑ not actually working! T get diagnosed and into treatment
Type 1 Error : Making a diagnosis when there isn’t a problem ( or at least not yet) Type 2 Error: Missing or failing to make a diagnosis early enough to make a difference Over diagnosis : Asthma, ADHD, high blood pressure, Cholesterol, prostate, thyroid, lung cancer -‐‑-‐‑ > medicine has gone from helping the sick to interfering with the well Part 3: Tertiary prevention ( chronic disease management)
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Tertiary: later stage, act to prevent and limit impact of established disease à complex intervention given to a limited number of sick individuals Good analogy: MATCHES Prevention : reduce eliminate, limit onset of cause, complications death 1 ary: Don’t play with matches à no disease and no risk factors 2 ary: sprinklers & warnings (detect fire before it spreads) à disease present but patient doesn’t know/ minor 3ary: Damage control ( fire control) à end stage disease, major impact, can’t stop it) 3 ary: using measure available to reduce or limit impairment & disturbance & promote the patient’s adjustment to the condition. No endpoint, ongoing, lack of clear margins. Established disease. ( leading onto end of life care) Chronic Diseases : now dominant cause of mortality : 6/10 adults have a chronic illness Accounts for 80% gp visits, 60% hospital bed stays, 80% healthcare spending
1. Stroke
110k strokes a year costing over 8 billion pounds can result in many impairments: cognitive, gait, visual dysphagia May need help with many things: bathing, walking toilet National Stoke Strategy: specialist coordinated rehabilitation started soon after discharge greatly reduces mortality and long term disability -‐‑-‐‑ work much better then simply discharge ex: tasktraining, arm re-‐‑education, aerobic training
2. CVD
Remains largest morality cause . 1 million men, 0.5 million women post MI Rehabilitation involves lifestyle changes and cardiac reconditioning & psychological techniques. Long term management : psychological health , lifestyle, cardio-‐‑protective therapies, medical risk factors UK CARDIAC REHABILITATION : about 300 programs 100k participants 50% post mi Phase 1: Counseling and assessment Phase 2: post discharge support Phase 3: structured exercise program Phase 4: long term Maintenance
3. Renal Disease
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Dietary advice, self management plans etc…
From Lecture 5 Part 1: HES Screening by Dr. E. A. 1st October
Lecture 06: End of life Care End of life care: Series of clinical and care related processes that take place before, during and after death Gold standard is HOSPICE! The ideal:
T Planned care T Managed exacerbation of conditions T Excellent symptom control T Everyone aware T Good death/bereavement
Good Death:
T to know when death is coming and to understand what can be expected. T To be able to retain control of what happens. T To be afforded dignity and privacy. T To have control over pain relief and other symptom control. T To have choice and control over where death occurs
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T To have access to information and expertise of whatever kind is necessary T To have access to any spiritual or emotional support req T To have access to hospice care in any location not only in hospital T To have control over who Is present and who shares the end. T To be able to issue advanced directive which ensure whishes are respected T To have time to say goodbye and control over other aspects of timing T To be able to leave when its time to go and not have life prolonged pointlessly
Palliative Care: area of healthcare that focuses on relieving and preventing suffering in patients (appropriate for all patients not only hospice) Epidemiology of Death: Over the years we have been seeing a gradual decline in the amount of people dying in hospitals and an increase in home & hospice death 30% home 10% hospice 40% Acute (hospital) 5% nursing home Poorer people use Acute settings while the richer people use Hospice! Can also see a few variations in ethnics groups As you get older your death become more musicalized à less in home, more in hospitals, nursing homes, hospice. Weekend deaths in hospital Increase! Since doctors/other staff aren’t present
Lecture 07 : Health Economics: Introduction and overview Economic Analyses =
T How much resources should be allocated if we want to achieve a target (Normative Stance)
T tries to predict the costs and benefits associated with alternative courses of action ( positive stance)
Opportunity Cost: the value of the consequences forgone by choosing to deploy resources in one way rather in their best alternative use. à what you’re loosing by choosing this path of action; the implications
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Eg. 1 IV Fertilization = 2700$ = 1 heart bypass = 11 cataract removal = 150 mmr vaccine Efficiency:
Technical: produce output in the best possible way possible without wasting scares resources. Meeting an given objective at least cost. Allocative: producing the pattern of output that best satisfies the pattern of consumer’s wants/ needs (each individual person satisfied)
Economic Evaluation : a comparative analysis of alternative courses of action in terms of both the COST and the CONSEQUESNCES Cost Effective Analysis : must choose one single outcome : eg lives saved or increased survival Cost Utility Analysis : must consider QOL à Quality adjusted Life years QALY Many different types of Economic evaluation
T cost consequence analysis T cost effectiveness analysis T cost minimalisation analysis T cost utility analysis T cost benefit analysis
Incremental economic Approach: answers the question “ what is the difference in costs and the difference in consequences of option A compared to option B Marginal Benefit: increase in benefit as a result of increasing production by one additional unit eg. 1 cookie = 3 happiness 2 cookie = 9 happiness, 3 cookie = 10 happiness 1st cookie = 3, 2nd cookie = 6, 3rd cookie = 1 Marginal Cost: The increase in total cost you increase production by one additional unit Incremental Cost Vs Marginal Cost ( From Lecture 7: Health economic: introduction and overview. By Dr. T. R. October 8th )
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Cost effectiveness Analysis : (CAE)
T one of the main techniques used. Consequences given in nat or physical units T results in terms of cost per unit effect eg life saved/ complications avoided
Incremental Cost effective Ratio: ( ICER) : Wikipedia: The incremental cost-‐‑effectiveness ratio (ICER) is an equation used commonly in health economics to provide a practical approach to decision making regarding health interventions. It is typically used in cost-‐‑effectiveness analysis. ICER is the ratio of the change in costs to incremental benefits of a therapeutic intervention or treatment. The equation for ICER is: ICER = (C1 – C2) / (E1 – E2) where C1 and E1 are the cost and effect in the intervention or treatment group and where C2 and E2 are the cost and effect in the control care group. Costs are usually described in monetary units while benefits/effect in health status is measured in terms of quality-‐‑adjusted life years (QALYs) gained or lost.[3]
From Lecture 7: Health economic: introduction and overview. By Dr. T. R. October 8th Cost Utility Analysis: CUA Wikipedia: In health economics the purpose of CUA is to estimate the ratio between the cost of a health-‐‑related intervention and the benefit it produces in terms of the number of years lived in full health by the beneficiaries. Hence it can be considered a special case of cost-‐‑effectiveness analysis, and the two terms are often used interchangeably. Outcomes are measured in: Quality Adjusted Life Years ( QALY)
o combines qol and life years gained through an intervention
T Can be used to compare across treatment areas T Increasingly common T Required by decision makers.
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To calculate use same formula as ICER but results are $$$/ QALY gained Cost effectiveness plane From Lecture 7: Health economic: introduction and overview. By Dr. T. R. October 8th
Decision: NICE – Consider new therapy to be Cost effective if cost/ QALY < 20, 000 pounds 20 – 30 k pounds is an area which will be considered taking other factors into account This threshold has facilitated clear and consistent decision making Defining Equity: requires a depart from the pursuit of maximum ( max QALY etc) to ensure more equal distribution in relevant outcomes. In healthcare the issue of equity focuses on the pursuit of a fair distribution and the burden of finance What do we want to distribute equally?
T health T use of health care T access of health care
Horizontal Equity: people with equal health needs receive equal treatment irregardless of demographic. “Equal access to treatment for equal need is the appropriate expression, rather than expenditure or utilization” Range of factors/barriers
T geography, waiting times, patient info. T Differences in the units of measurement
Vertical Equity: Individuals with unequal needs should be treated according to their differential need
T obvious but operationally difficult T how unequal do conditions need to be in order to pursue equity objectives (chronic
versus trivial complaints)? T financing: unequal treatment funded through ability-‐‑to-‐‑pay mechanisms (progressive
taxation-‐‑based system)
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Lecture 08: Measurement of outcomes and costs in economic analysis
We are interested in the Maximum total benefit for the budget. Case study: Hypertension à hypothetical new treatment, should the NHS use it? Economic Evaluation: Perspective à Relevant costs and outcomes, but what are they? Depends on: Perspective of analysis (health service, public sector, patient) , and type of economic evaluation (cost effectiveness, cost utility analysis) Outcomes: Clinical Outcomes
T Measured in natural units T Proxy outcomes -‐‑-‐‑ by product
o Cancers detected o Changes in cholesterol
T Condition specific measurements -‐‑-‐‑ looking for specific scores o Roland Morris questionnaire for back pain o CAT COPD assessment test
T Generic Measures -‐‑-‐‑ general health o Life years gained
Using Clinical Outcomes. Advantages: T often measured as a part of a clinical study T easily understood/ transparent to clinitions Limitations T lack of comparability across different disease areas T what does $ per unit reduction in mmhg really mean T only an intermediate outcome T what if more than one outcome?
o Eg: cost, impact on Life expectance, impact on QOL? Valuing Health: Quality adjusted Life years (QALY)
T Combines LENGTH and QOL into a single unit T QOL: max =1 (perfect health) 0 = death
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T Used to weight life years QALY = E (length of life) (QOL) -‐‑-‐‑-‐‑ as QOL decreases separate equations into segments of length QOL and add the sums. Total gain in QALYs with treatment = QALY with treatment – QALY without treatment Where do we get this information?
T Life years: life tables/ literature, death records T QOL: judgment, questionnaires
o Euro QOL EQ-‐‑5D o Five dement ions: Mobility, self care, usual activities, pain/discomfort,
anxiety/depression -‐‑-‐‑-‐‑ each with three levels ( new version = 5)
Advantages of QALYS à main outcome of interest to decision makers but not perfect.
T take account of impact on Quality and quality of life T common unit of measure that can be used across disease area T convenient tool for measurement
Disadvantages T family care/benefits , qol T discrimination T whose values T end of life treatment T Patient benefits not captured by it : control/empowerment, knowledge, satisfaction etc
Types of Cost Direct cost
a) Health and social services resources use eg inpatient outpatient, tests drugs a. Intervention and usual care cost related medication b. Primary care cost ( gp, nurse) c. Secondary care cost ( a&e, outpatient, surgery, investigation ) d. Social Services ( nursing home, home adaptation
b) Non-‐‑ Health services resources use. Eg patient transportation, informal care a. Cost of time & transportation b. OTC medication c. Private helth care d. Paid Carer’s
Indirect Cost
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a) Wider cost implication to society eg lost production a. Unable to work/ time off work/ reduced productivity
Lecture 09: Nice and National Level Decision Making
Function of nice :
T Technology appraisal : o Independent assessment of evidence including Cost effectiveness analysis.
Submissions also received from the tech sponsor and other experts. Should be a mix of new and old technologies but in practice dominated by expensive new drugs. Dis investment from technologies which are not cost effect is an important part of the process ( in theory)
T Clinical guidelines T Public health programmes and interventions
Multiple Technology Appraisals: 14 months à Referral à assessment à consultation à 1st committee meeting à consultation à2nd committee meeting à appeal à publication Single Technology Appraisals: May be quicker and part of a MTA later? NICE rationing principle : CEA ( cost effective analysis)
T clinical and cost effectiveness, economic evaluation… NICE reference case for CEA:
T the different elements that NICE look for when considering a new drug : o what are the comparator therapies o perspective on costs/ outcomes o measurement of health effects : QALYS o Equity Weighting
Nice Appraisal Committees
T Origionally on committee meeting monthly but too much work so split into 2 groups w overlap of members
T Now 4 Separate committees each with its own chair T Made of a varaiety of different members
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o Medical 35% o Other clinical 24% o Methodologists ( health economics statistician) 17 % o Managers 8% o Lay members 9% o Manufacturers 6%
Impact of NICE decision Making
T approved tech must be funded within 3 MONTHS OF POSITIVE GUIDANCE being issued
T approval means “right to prescribe” T Studies of impact show very little evidence of change in prescribing patters from NICE
guidelines Clinical Guidelines: aim is to produce guidelines for whole clinical pathway. Example : Alzheimer’s Basically a drug was introduced in 2006 which was to be prescribed to those with moderate but not mild Alzheimer’s. Lots of appeals followed etc. NICE changed their calculation but didn’t change their ruling. At one point decided they should not be given to ANYONE since the benefits are not worth the cost. This resulted in outcry putting pressure on the “value for money “ formula that NICE uses. Now the drug is ok for moderate patients but not mild. Part of NICE à Center for Public Health Excellence: CPHE : reports consist of evidence review and series of recommendations. Recommendations can be to various external bodies
T Deals with public health issues T Standing committee: PHIAC – Public health interventions advisory committee ( like
technology appraisal committee) T Programme development groups ( same ase Guideline development groups)
Other national level bodies
T National screening committee: o Decisions on whether to implement screening programs o Criteria for appropriateness 8 ( see previous lectures)
T Cancer Drug Fund o Cancer drugs are often very expensive, perception that cancer is somehow more
important than other conditions
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o Special fund for cancer drugs as means of bypassing NICE technology appraisal criteria
Lecture 10: Doctor’s decision-‐‑making health economics and health policy
T watch a news story : hospitals allowing top up care : patients pay extra money to get the best medication/ care that NICE has not found to be cost effective and is thus unavailable. Though banned in the UK this is happening in over 30 hospitals. After a review it is now LEGAL in the UK.
QALY : Quality adjusted life years LYG : life years gained The rest of the lecture looks at the case of using a new cancer drug SUNITINIB vs the normal drug. The lecture discusses the path that NICE took to determine whether it was worth the money, and if it was effective.
T is effective at increasing progressive free survival, before death T is almost double expensive as the drug normally used
But overall it showed that it was worth it! And cost effective! Doctors “ need to reconcile the health need of individual patients and the health needs of the community in which they live, balancing these with available resources.
Lecture 11: Justice and the NHS Ethics of allocation of resources:
T Classical definition: how should we live? T Medicine: how should we treat patients T Allocation of resources – “how should we allocate our resources” OR “Who gets what? T Who should we treat/ What level?
Economics
T Limited resources but unlimited demand T How does one go about distributing/rationing resources?
o Feudal System: hierarchical – lord of the manor
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o Adam Smith: father of modern economics à Capitalism – market economics laissez fare
o Price determines how goods are distributed o Thatcher’s Free market, no intervention
T More money, more goods, more health 1890s Keynes – Welfare State à new way of thinking
T Keynesian economics – antithesis of the free market – role of the state to invest, especially in times of financial depression and eg high unemployment 1930s
T Financial benefits T State Education T Public housing initiatives T Employment creation and development T Health service aimed to help individuals to be healthy
Beveridge Plan William Beveridge added to the Keynes economics with his own ideals = Keynes-‐‑ beveridge plan 1942 He identified 5 Giant Evils (giants of want) is society and his plan was to reform social welfare to address these:
T Ignorance T Disease T Idleness T Squalor
After WWII many questions were raised about all previous govt policy and provided the catalyst of “Welfare State” by new labor gov. in 1948ish. Based of beveridge’s plan this lead to the creation of NHS and National insurance. Creation of Welfare State:
T 1948 enactment T NHS : healthcare for all – free at the point of deliver
Creation of the NHS -‐‑-‐‑ minister for health aneurin bevan ( labor party) Created in 1948 to
T provide equitable distribution of health services T provide services which were accountable to the nation T give a sense of collective purpose or mission T promote the health of the nation
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Opposition to the NHS T Carlton club – tory party T NHS had strong opposition 1. Conservative party & 2. Medical professionals T Aneurin bevan was forced to make concessions T “ silenced them by stuffing their mouths with gold”
Inevitability of Rationing T Initial expectations that cost of NHS would be self limiting (as needs was met) T December 1948 – 4 months into NHS: revised budgets from 176 million into 225 million! T Bevan
o The rush for spectacles, as for dental treatment, has exceeded all expectation.. part of what has happened has been a natural first flush of the new scheme, with the feeling that everything is free now it does not matter what is charged up to the exchequer. But there is also without doubt a sheer increase due to people getting things they need but could not afford before and this the scheme intended
T Bevan talked about the need to stem the cascades of medicines pouring down British throats
T Introduction of 1 shilling prescription charge in 1949 T 1951 charges introduced for dentistry and optical service
Different Concepts of Justice Justice as desert à you have to earn it basically
T treat people equally according to how deserving they are T Deserve poor or good health –self-‐‑inflicted diseases/ injuries T Smoking, drinking, working down a coal mine eg lung transplant for cystic fibrosis v
smoker T Noble failures: tried really hard to give up smoking v someone who gave up but found
it easy – moral credit for trying? Or didn’t know smoking was bad when started. T Poverty: deserving/ undeserving T Can be used to justify a two tier health system or a private system
Justice as maximizing utility
T Jeremy bentham utilitarianism T Maximum benefit for the most number of people T Whichever treatment produces the most good for the most people T Not the same as justice as effectiveness T But Majority trivial poor health needs would outweigh sever health needs by the
minority
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T Desert wouldn’t com in it at all – if the majority smoked then resources would be directed in order to combat these diseases
Justices as satisfying need
T Karl Marx “ from each according to his ability, to each according to his need T Money would be spent on people who have lots of health care needs and no money
who have no health care needs T Need not just naturally generated by by social environment T NHS is based on this ? T Problem in defining need vs want – IVF T Subjective v objective
Value of life:
T while it is always a misfortune to die when one wants to go on living, it is not a tragedy to die in old age; but it is, both a tragedy and misfortune to be cut off prematurely
T life threatening disease? T lifeboats at the titanic – rule of rescue?
Fair Innings Approach:
T someone who has already had a fair innings ( for ex a fit elderly person) will get lower priority in the distribution of health gains then a young person who without treatment will certainly not reach the societal norm ( through premature death and or lifelong disability – alan Williams
Departure from efficiency Criterion ??
T Success of fundraising for great Ormond street T PBS allows rule of rescue T Cancer Research UK biggest medical charity
NICE
T The Chairman of NICE claims that there was “ no role for NICE in the rationing of treatments to NHS patients”
T Ignores inevitability of rationing and need for NICE to inform rationing in the NHS T NICE criteria appears to be $25000 per QALY
Justice: judicial review Judicial review-‐‑ constitution: balance of power between government, parliament and the judiciary “rule of law”
T Parliament is sovereign but has to satisfy legal process T Judiciary-‐‑ acts as a check on the Gov
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T The NHS act imposes on the Sectretary of the Stat a duty to continue the promotion … of comprehensive health services
SOS/NHS/DoH – government, so actions are reviewable by the judiciary
1. was the procedure for making the decision reasonable 2. were the grounds for making the decision reasonable
Case Study: Who should be saved? Lecture 12: Safeguarding Patients rights: Incompetent adults and Mental Capacity Act 2005 The issue is: who gets to decide what’s best for a patient who can’t decide for themselves-‐‑ because they lack capacity Prior to Mental Capacity Act 2005
T Common law –courts – doctors Parliament changed this position and have given lawyers/courts/patients a greater role. Docs argue that they are in the best position to judge Other issues: Common law previously set the test for capacity in the case of Re C – but doctors may argue the test should have been a medical one Ethical principles behind the MCA 2005
T Liberal western democracy 18th cent. Enlightenment – freedom of the individual is the single most important right we have as citizens
T Human rights – part of our constitutional rights T Autonomy/ individualism à even if make wrong decision they have right to.
Mental Capacity Act 2005
T Clarifies law dealing with incapacitated T Codifies Capacity ( previously RE C test) and best interests Patients Rights T Give Autonomy via
o Advanced Directives
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o Introduce concept of substituted decision making o Court of protection
Key Principals Liberalism
T purpose to support/enable, not restrict/ control T all practical steps must be taken to help T unwise decision don’t evidence incapacity T acts done to incapacitated must be done in their best interest T least restrictive option should be chosen
(2) Lack of Capacity: T Patient deemed to lack capacity if unable to make decision for self because of impairment/disturbance in the function of mind or brain
T May be Permanent or temporary T Decision specific: capacity relates to this decision at this time ( now like gillick/fraser
test) T Equal consideration – can’t make assumption based on age, appearance or other
unjustified assumption. (3) Test of Capacity unable to make decision if, on balance or probabilities patient unable to
1. Understand 2. Retain 3. Use or weight the information communicated to them with appropriate assistance 4. Communicate decision / Believe
The test for capacity is now the same for all areas of the law
T need to review capacity as new skills may be learnt T repeated inappropriate decisions may evidence incapacity T seriousness of consequences requires greater understanding
Assessment of Capacity
T who should asses? Person who wishes to take some actions – the determinator – no longer just the doctor.
T May be carers, dr, lawyer T More serious decisions call for greater professional involvement as advisor
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Temporary incapacity: T fears/pain. medication/ alcohol/illegal drugs/ diabetic hypo T reversible unconsciousness T When do you treat?
“Best interest” treatment – the doctrine of necessity T life saving treatment T diagnostic treatment T has to be justified by determinator as the immediate patient’s best interest
Person making determination must consider all relevant circumstances and take the following steps ( the statutory checklist)
T Will patient regain capacity, can decision wait T Involve patient to max extent using practical steps to support T Consider past and present wishes, relevant beliefs and values, other factors pt would be
likely to consider if able T Must take into account view of anyone named by pt regarding best interest T If life sustaining treatment, determination of best interest must not be motivated by
desire to bring about death
Who decides what is best for those that lack capacity? 1. Patient by advanced directive made when had capacity 2. Proxy decision maker 3. Court of protection 4. Doctor/determinator as per best interest
Advanced Refusal
T To apply to life sustaining treatment, must be in writing, signed by patient or at patients direction and witnessed in writing
T If doctor suspects AR exist, must make reasonable effort to find out what it says, time permitting, but can act in emergency
T Reference cases of doubt to CoP and act to save life in meantime.
Lasting Powers of attorney ( LPA) T By proxy substituted healthcare decision making introduced T Extends to welfare and healthcare not just property and welfare T LPA must be registered and certificated from an independent person T Donor and done must be over 18 T Donor may place restriction on power
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T Donor can provide for replacement but done cannot appoint successor nor delegate authority
Court of protection
T New court to deal with all areas of decision making for incapacitated has all the power of the high court
T Do judges make better decision for patients then docs? : Objective impartial, trained in logical reasoning, listens to both sides of the argument. Not personally involved, trained to make decision in others best interest
Power to make T One off declaration T Substituted decision T Appoint deputies T Call for reports
Summary of key points
1. Formally assess capacity 2. Make formal assessment of best interest via checklist req including whether
temp/permanent 3. Check whether there is an advanced directive 4. Check whether there is a proxy-‐‑ LPA 5. Finally check whether the Court of Protection has appointed a deputy made an order
Lecture 13: Disability Studies and Health
Terms we use to describe ppl change over time and differ in different societies. Feeble-‐‑minded, idiot, moron and imbecile were common place early last century. Language influences attitudes therefore good reason for rejecting offensive terminology. Many different Laws : Old poor law, gilberts act, new poor law act, idiots act, lunacy act Eugenics T “the application of biological principles to upgrade the physical and mental strength of
the nation” proposed by Charles Darwin saying that week member of society propagate leading to the descent of man = should better the nation through selective breeding ( of sorts)
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Idiot: someone who is unable to guard himself against common physical dangers Imbecilic: someone who is incapable of managing or being taught to manage his own affairs Feeble minded: someone requiring care and supervision for his own protection or the protect of others Moral Imbecile: who was not mentally defective Eugenics education Society advocates 4 strategies to prevent such degeneration 1. Sterilization 2. Marital regulation 3. Birth control 4. Segregation of the unfit
T Feeble minded at the center of this debate, T National Association for promoting the welfare of the feeble minded emerged in 1896
Formation of NHS in 1948 The Tragic/Charity Model
T depicts people as victims of circumstance, deserving of pity T Traditionally used by charities to fun raise T This model condemned by its critics as disenabling à seen as icons of pity
T from tragedy and pity stem a culture of care T critics suggest that charity funds should be channeled to promote
o empowerment of disabled people o full integration into society as equal citizens
The Medical Model
T disability results from an individual persons limitations (mental or physical) T not associated with social or geographical environments
WHO definition of 1980:
Impairment: any loss or abnormality of psychological, physiological or anatomical structure
Disability: restriction or lack of ability ( resulting from an impairment ) to perform an activity in the manner or within the range considered normal for a human being
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Handicap: any disadvantage for a given individual, resulting from an impairment or disability that limits or prevents the fulfillment of a role that is normal for that individual
T Also known as the functional-‐‑limitation model T Dominated formulation of disability policy for years T Does not have therapeutic aspects, does not offer a realistic viewpoint of disabled
people themselves. The Discrediting of Institutional Care
T Discrediting the Eugenics Movement: occurred due to its association with the NAZI regime in Germany.
T Hospital scandals: series of scandals from the 1960’s onwards revealed the sever neglect of people in institution
T The growth of therapeutic optimism. Belief that positive change is possible due to the application of new treatment tech
The Chronically Sick and Disabled Persons Act 1970 First law in the world to deal with the rights of disabled people, sorta like magna carta for disabled. The Social Model
T Disability is a consq of environmental, social and attitudinal Disability: “loss or limitations of opportunities to take part in the normal life of the community on an equal level with others, due to physical or social barriers” disabled peoples international
T it argues that disability stems from a failure of society to adjust to meet the needs and aspirations of a disabled minority
T parallels the doctrine of racial equality If the problem lies with the society and the environment, then the society and environment must change. This model implies that the removal of attitudinal, physical and institutional barriers will improve the lives of disabled people, give them the same opportunities as others on an equal basis. Strength of this model: focuses on society not the individual Challenge of this model: as more in the population get older more impairment rise, making it harder for society to adjust
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Main criticism
T Taken to an extreme, it suggest that disability would be eradicated if society was changed in the appropriate ways. It does not acknowledge the limitations which may result from impairment ( eg pain) that change to the social context could nor remove
The Social Adapted Model ( Bio psycho social approach)
This is the model advocated by the WHO. Based on social model but incorporates elements of the medical model by identifying the significance of impairments
Recognizes that not all problems of impairments can be currently addressed, but if we recognize our environments as discriminatory, then we can do much to change it
Recognizes the inability of some disabled people to adapt to the demand of society may be a contributory factor to their condition
Maintains that disability stems primarily from social and environmental failure to take in to account the needs of disabled citizens
The advantage is that it does not focus on individual limitation but takes into account of people capabilities and potential ( bio psycho social) **ICF : International Classification of Functioning Disability and Health**
T Embodies what is now termed the biopsychosocial model T a synthesis of the medical model and social approaches to disablement
Disability Discrimination Law The DDAct (1995, 200) makes it unlawful for you to be discriminated against in
T employment T trade union and qualification bodies T access to goods, facilities and services T the management, buying or renting or land or property T education T regulations dealing with buses coaches and trains
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DDA 2005 brought in new measure creating a legal duty for public authorities to actively promote disability equality A persons right not to be discriminated on the grounds of disability is protected by DDA and the HR Act. Equality Act 2010 – Protects many characteristic of life : age, gender, disability, race etc Lecture 14 = People talking about their disabilities
Lecture 15: Deaf Awareness and Health
National Deaf Mental Health Service : 1 of 3 specialized services in UK, working primarily with profoundly deaf, BSL users ( British Sign Language) Deafness 1 of 7 of the UK population have some degree of hearing impairment = 8.7 million people 673 k of theses are severely or profoundly deaf. Men > women 50k to 120k use BSL as preferred/first language 23k deafblind people 32k deaf children
Hard of hearing: often used to describe people who have lost their hearing gradually but can be mild hearing loss earlier. Up to 40 db hearing loss – can’t hear whisper in a quiet library 6.5 million hard of hearing , 6 million of theses over 60 Moderately Deaf 40-‐‑70 db loss – have difficulty following speech without a hearing aid but can use an amplified telephone. Severely Deaf 71-‐‑95 db loss can’t hear normal conversation and rely on lip reading and/or sign language and text/ email may hear city traffic = 85 db Profoundly Deaf Usually born deaf or become profoundly deaf in childhood. >95 db hearing loss Very limited environmental noise, can’t hear heavy traffic, pneumatic drill, maybe nothing Deafened
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120 K – profoundly deaf after acquiring language either though childhood or as an adult, can be gradual or sudden Deaf Blind Born deaf and blind, born blind and become deaf or vice versa therefore have different froms of communication and language Cause Of Deafness 50% genetic infection/ injury e.g. rubella Conductive malformations of the auditory tract Ototoxic drugs e.g. gentamycin Acquired Deafness
T infections : otitis media (acute or chronic) meningitis, encephalitis, measles T Loud noise above 90 db T Obstruction T Trauma T Drugs – aspirin gentamycin T Meniere’s T Tumor
Different models of deafness
Medical Models of deafness Deafness is a developmental deficiency or disease – defect to be corrected or cured by equipment, surgery. Eg cochlear implant Individuals adjustment and behavioral change would lead to an effective cure Main aim of professionals is to teach the deaf child to speak. Deaf people/children reminded that the are different: their speech is not right. That its their responsibility to make themselves understood and fit in. Social model of deafness Disability is a socially created problem. Communication between deaf and hearing people is the barrier with the hearing people unable to use sign language ( it’s the hearers fault)
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Society creates barriers through lack of awareness, attitudes and lack of accessible information for deaf people. Therefore need to manipulate the social environment to improve access and participation. Regoc and accept individuals differences Cultural Model of Deafness BLS speakers see selves as part of social, cultural and linguistic minority. Deaf people do not see selves as disabled. Not experienced loss and have a positive attitude towards their deafness. Shared social beliefs, behavior, art, history, values Communication: Use English by residual hearing, lip-‐‑reading and speech with or without equipment. 10k profoundly dear use BSL as their 1st or chosen language, others use a variety of signed languages. Eg SSE makaton, cued speech Sign Language
T over 200 sl in world T Similarities in some groups ( often related to colonial/missionary education) T Movement and orientation of hands, arms, facial expressions ( 3d communication) T Not just gesture/ mime
Not translation of individual words but thoughts ideas concepts can be expressed in one signed movement Deaf Education
T Mainstream v Deaf school T Oral T BSL T Total communication: blends wide variety of modalities including sign, speech, body
lang, writing images NB cultural differences in schools Literacy 20% of deaf school leavers unable to complete an interview in either sign or speech despite all normal IQ Average reading age for general UK population = 13 Average for profoundly deaf population = 7 The sun = 11
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Breaking the Sound barrier RNID survey T 1:6 deaf people avoid going to their gp because of communication problems T 1:6 deaf and hard of hearing also said they had trouble in arranging a doctor’s
appointment T 23% said they left a doctor’s appointment, unsure what was wrong with them
Some problems deaf people encounter T doctors not looking at the patient when talking to them T Doctors refusing to write things down T Some cases doctors flatly refused to accept that the patients could not hear T 24% of deaf/hard of hearing had missed at least one appointment due to poor
communication T for 19% more than 5 occasions T RNID estimates that the cost to the NHS in terms of missed appointments alone is 20
million a year Communication Tactics Don’t shout Don’t cover mouth Don’t speak to fast Don’t assume nod means I understand Don’t ask do you understand Contacting a Deaf Person Text, Textphone (minicom), Fax, Email, Videophone, Typetalk Text Relay Deaf person uses minicom (textphone) and types message to operator who reads text to hearing person Deaf to hearing person: Dial 18001 then full phone no. Hearing to deaf person dial 18002 then full no Using a BSL Interpreter
T public bodies/private sector/business/ industry responsibility to book and pay – it is not the responsibility of the deaf person themselves
Equality Act/Access to work
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Interpreters :
T shortage of fully qualified interpreters in uk only 737 in 2011 T take 7 years to become fully qualified
How to book an interpreter
T agencies/freelance T ad hoc/ contracts T check the needs of the deaf person as far as possible T not all interpreters are appropriate for every deaf person
How to use a sign language interpreter
T check they’re qualified, registered and experience in health interpreting. Send info to interpreter before meeting if possible
T Look at the deaf person like you would hearing T Make sure the deaf person can see the interpreter clearly T The interpreter is NEUTRAL and does not take sides T The interpreter will not offer opinion other than to ensure effective communications. T The interpreter will interpret everything that is said or signed
Prevalence of Mental Health problems
T greater overall prevalence in the hearing 40-‐‑50 % ( 25% lifetime prevalence) due to
T social exclusion T life stresses T lack of access to treatment
Language and communication Non specialist MH workers may not be able to elicit facts or observe comm Interview conducted through a sign language interpreter may inhibit the interaction and therefore diagnosis. Effects of diagnosis 18% referrals to deaf MH service had no psychiatric disorder But Length of stay in hospital higher, up to 20 X that of hearing.
Lecture 16: Visual Disability
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What is visual disability?
T being unable to see or unable to see very clearly T How much one sees depends on a number of factors, nut just the level of sight
Visual Acuity
T the ability of the eye to see in detail Distance Acuity
T Each eye is tested separately using a SNELLEN CHART T Tested at a distance of 6 m normal 6/6 ( USA! 20/20 as feet used) T If can’t see the top letter @ 6 meters then test nearer the chart (5,4,3,2,1)
Snellen Chart comprises rows of letters of decreasing size labeled 60 (top), 34,24,18,12,9,6,5 Normally distance acuity i.e. 6/6 means that the row of letters with the number 6 underneath can be read at a distance of 6 m. Other lower levels of visual acuity :
T Counting fingers T Hand movements T Perceptions of light T No perception of light ( stone blind)
Who definition : 6/6 – 6 /18 normal Distance you see it clearly/ distance a normal person sees it clearly Blind and partial sight registration
T Registration takes place on the recommendation of an ophthalmologist T Blind: see only the top letter of the eye chart or less @ 3 meter = 3/60 T i.e. a blind persons sees at 3 meters what a person with normal eyesight would see at 60
meters T Sight impaired: sees 6/60 or better
Sight Loss
T Almost 2 million people in the uk are living with sight loss 37 england. 1/30 people T Older = have an increasing likelihood to experience sight loss
1/5 people 75 or older have sight loss
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½ people aged 90 and older have sight loss 2/3rd of people with sight loss are women People from black and minority ethnic communities are at > risk of the leading causes of sight loss ¾ of people with learning disabilities are estimated to have either refractive error or to be blind/partially sighted Main Causes of Blindness in adults in the UK
T Age related macular degeneration leading cause ( >65 y.o.) T Other significant causes of sight loss : glaucoma, cataract, and diabetic retinopathy
Future Projections : the UK population is getting older = more sight loss. Predicted that by 2020 number of sight loss will increase to 2.25 million. By 2050 will be almost 4 million. Prevention UK: nearly 2/3rd of sight loss in older people caused by refractive error and cataracts à can be cured quite easily. Over 50% or sight loss can be avoided. What is refractive error? Very common eye disorder. Occurs when the eye can’t clearly focus the images from the outside world. The result of refractive errors is blurred vision, which is sometimes so severe that it causes visual impairment. Three most common refractive errors are
1. Myopia (shortsightedness): difficulty seeing distant objects clearly 2. Hypermetropia (longsightedness) : difficulty seeing close objects clearly 3. Astigmatism : distorted vision resulting from an irregularly curved cornea
Cost of sight loss
T 2008 = 6.5 billion pounds and likely to increase ( doesn’t include children) o 2.2 billion in direct health care costs: eye clinics o 4.3 in indirect costs : unpaid career
Number of Blind and Partially sighted people in England 147 800 people are registered as BLIND ( march 2011) 151,000 people were registered as PARTIALLY SIGHTED ( march 2011)
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Registration voluntary but recondition for receipt of certain financial benefits. Reliability difficult to determine. 1.86 million : number of people in the UK living with sight loss that has a significant impact on their daily lives. 33% of registered blind or partially sighted people who are also reported as having an additional disability. Realities of sight loss
T only 8% of registered blind and partially sighted people were offered formal counseling by the eye clinic
T In the years after registration < 25% who lost their sight say they were offered mobility training to help them get around independently
Worldwide
T 285 million people visually impaired worldwide (39 million Blind/ 246 million have low vision) but going down!
T 90% of visually impaired live in developing countries T globally uncorrected refractive errors main cause. Cataracts remain leading cause of
blindness in middle and low income countries
80% of all visual impairments can be avoided or cured !! Females > risk then males 65% of visually impaired = 50 and older 19 million children visually impaired due to refractive errors. Major Causes of Worldwide Blindness
T cataracts ( 50%) T uncorrected refractive errors T glaucoma T age related macular degeneration T corneal opacities T diabetic retinopathy T childhood blindness Trachoma: eye disease caused by infection with the bacterium chlamydia trachomatis. It is the leading cause of infectious blindness globally responsible for 1.3 million cases of blindness. Estimated it is a pandemic in 55 countries mainly in Africa and Asia
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Typical Blind Person Woman Has Age related macular degeneration Also hearing problems, arthritis, cvd and diabetes Can’t read write, recognize faces Time trade off Analysis TTO Patient asked how long they theoretically expect to live Then they are asked what is the max amount of time (if any) they would be willing to trade for a return to normal health during the years that remain. This utility value associated with the disease is then calculated by subtracting the proportion of time treated from 1.0 eg TTO of 0.6 = a 40% decrease in the average patient’s QOL . Blind TTO 0.47, sever stroke 0.34 What can blind and partially blind people see T ver few blind people see nothing at all T a minority can only distinguish light T some have no central vision, others have no side vision T some see everything as a vague blur, other a patchwork of blanks and defined
Lecture 17 experience of blind
Lecture 18: Learning Disability
Mental retardation : official WHO term. Used in USA Intellectual disability: current international term Learning disability: official UK Learning difficulty: used by uk educational services ( preferred by ppl with ld) Mental impairment: legal term used differently in DDA and mental health acts Who definition : Mental retardation is a condition of arrested or incomplete development of the mind, which is especially characterized by impairment of skills manifested during the development period, which contribute to the overall level of intelligence, ie cognitive, language, motor and social abilities.
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1. general impairment of intellectual function 2. consequences in terms of severe impairment of social function 3. onset before physical maturity 4. therefore excludes people who develop cognitive impairments in adult life.
Measurement: IQ tests
T developed to identify children who needs special educational help. ( standardized with 100 mean)
T Soon people started using them instead to measure innate and fixed ability – used to compare people
Problems with IQ tests
T Measure narrow range of skills -‐‑not life skills T Under performance T Invalid application – not standardized on people with LD = different strengths and
weaknesses. Adaptive Behavior Scales: measure skills in daily living by checklists, interview with carers and observations in activities such as self help, communication etc Generates a series or rating scales Problems with AB Scales
T ignore extent or support from a career or whether communication is available T may be variable in performance in settings T poor performance may indicate lack of opportunity rather than lack of skills.
Use these measurements to :
T Identify areas in which people most need help to learn and to achieve. T Measure changes in performance over time and a result of therapeutic action T Identify eligibility for specific series for disabled people
GRADES
MILD IQ 50-‐‑70. Hold conversations, full independence in self-‐‑care. Basic literacy MODERATE IQ 35-‐‑50. Limited language. Needs supervision in self care. Usually fully mobile
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SEVERE IQ 20-‐‑35. Uses worlds/ gestures for basic needs. Activities need to be supervised. Marked motor impairment likely PROFOUND IQ < 20. Very limited words, gestures or none. Severely limited mobility. Incontinent Epidemiology
T Problems in estimating numbers because no UK national register of learning disability T Gp Records more effective, but low or mild LD often overlooked
MILD LD 14/1000 people across all age-‐‑ranges. Most don’t have identified organic cause, strongly associated with poverty and disadvantage Most not in contact with specialist services, and rates on registers therefore increase though school years ( more children identified) and then decrease after leaving school MORE SEVER LD -‐‑ moderate, severe, profound 3-‐‑4/1000 much more likely to have identified organic cause Less association with poverty Contact with specialist series continues after school. High morality rates result in declining proportion among the elderly. Communication
T Distinguish receptive from expressive communication more can understand language than speak it.
T Understanding may be limited to key words Assisting
T environmental adaptation ( signs color coding ) T interpreters T Assisted communication, but also use simpler English
Total Communication approach – uses all of the above methods
History Early 19th cent : commitment to humane care and education à creation of special schools Early 20th cent: eugenics application of social Darwinism à total institutions
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Late 20th cent : Century normalization à community integration Eugenics: Concept that fitness of the race imperiled by higher reproduction of least intelligent + social welfare preserving the weak. Aimed to prevent reproduction by the weak and encourage the strongest to reproduce – thoroughbreds
T Prevention of reproduction : sterilization, separation of sexes T Failure to educate : formally classed uneducable T Failure to treat : health needs not investigated T Discrediting : seen as threat to race
End of Eugenics -‐‑-‐‑ > was adopted by Nazis Post 1945 triumph of universalism – idea that all human life is of worth, expressed in declaration of rights – Universal declaration of human rights and the European convention of human rights. Rights of Disabled People.
T Neither UDHR or ECHR specified disabled people T Subsequent un declaration have asserted application to disabled people.
Normalisation 1: compensatory services are needed to enable the disabled person overcome ordinary challenges of life and also to live a life comparable to that of other people in society Normalisation 2: ( Social Role Valorization) : US approach, Propose importance of disabled people associated with valued social roles as noted that disabled people are assigned derogatory labels because of the separateness of their appearance, environment or way of life. Impact of Universalism
T Closure of large institutions, preference for ordinary domestic settings T Greater access for disabled people to universal public services, employment and
community facilities. Enforced by law Challenges
T rise of consumerism: people defining self as what they purchase from competing corporation
T may lead to loss of sense of people sharing universal rights – disabled seen as negative consumers.
Prevention The causes of LD are very divers and therefore multiple prevention strategies required. Foetal Alcohol Syndrome, Obstetrical Trauma, Meningitis, cerebral anoxia Prevention Strategies :
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T Prenatal screening T Folate therapy in pregnancy, health educate to reduce alcohol consumption T Neonatal care T Health education to reduce accidents, vaccinations
Morbidity and Morality
Morbidity T high rate of chronic disorders, 60% have chronic disorders/ disabilities in addition to LD
(specific set of disorders ass. With each syndrome) T High Rate of Injuries, less capacity to asses risk
Psychiatric Disorders
T 4 x more likely to suffer common mental disorders. May result from stress involved in coping with dependence.
T High prevalence (10x) of autistic disorders T Challenging behavior
Morality
T life expectancy risen vs before T trend still continuing & mean age @ death for people with more sever LD now in late
50s early 60s @ a Higher risk
T epilepsy , bronchopneumonia, CVD T Disorders associated with the syndromes causing the LD T Higher prevalence of other neurological disorders T Unhealthy lifestyle T Poor access to healthcare
Access to Healthcare -‐‑Poor access: higher rates of untreated and undiagnosed disorders and low uptake of routine screening and tests Hospitals
T hospital staff often unfamiliar and embarrassed in communications with PLD. Do not speak to patient, ask for consent or use expertise of career. Little staff training
T poor information to patient before admission about hospital procedures T = fear and distress
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Lecture 19: An introduction to Occupational Health
The promotion and maintenance of the highest degree of physical, mental and social well being of workers in all occupations by preventing departures from health, especially those due to work Occupational Medicine: clinical component of occupational health Disadvantages of Unemployment
T families without a working member are much more likely to suffer persistent low income and poverty
T Psychiatric disorders among children aged 5-‐‑15 in families whose parents have never worked is
o Almost double that of children with patents in low skilled jobs o Almost 5 times greater than children with parents in professional occupations
Work related ill Health in UK Traditional Work Related ill Health:
T musculoskeletal T trauma T poisoning/ infection T respiratory
Modern Work Related ill Health: T Stress T STSD T Chronic fatigue Syndrome
Hazard: Something that might cause harm eg. Loud noise at concert Risk: The likelihood of that hard actually occurring ( in a given circumstance) eg going to 3 concerts a week RISK from noise High Another example Hazard : lead pipe (potential) Risk : cut/grind/heat the pipe and inhale the dust/fumes Types of Hazards
T chemical T physical
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T Mechanical T Biological T Psychio-‐‑social à working hours/ shifts, organizational hierarchy, bullying, stress Role of Government T Legislation :
o Health and safety at Work Act 1974 o EU Directives o Various other regulations
Professional bodies
o Faculty of occupational Medicine o Society of occupational medicine
Occupational Health Services Who provides specialist occupational health ? Is it the responsibility of the NHS>
T NO : NHS charter – free healthcare from the point of illness to discharge from hospital treatment ( not back to work)
T YES: NHS plus, Service to NHS No legal obligation for ALL employers to provide an Occupational health service ( obligation to provide first aid) Provision of OH services across the UK is sporadic
T size of company and nature of industry T 72% public sector workers have access to an OH doc at workplace T <20% private sector workers have access
Special Occupations
T Statutory obligation to provide regular health screening in environments in which employees might be at significantly high risk to specific health hazards associated with their work.
o Ionizing radiation o Lead o Asbestos
T Have an appointed doctor In house services : getting rarer -‐‑-‐‑ rolls Royce, armed services, royal mail
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Independent provider : Heath management, BUPA, ATOS OH team Role ( sample of roles)
T identifying hazards and factors adverse to health T matching people with jobs appropriate to their health T assisting the return of the sick and injured to work at the earliest opportunity T Health promotion in workplace
Lecture 20: Identifying Occupational Disease
Why the interest?
T work related ill health costs money! T Workplace Health & welfare systems exist to improve health, wellbeing and
productivity of the workforce The occupational History
T what do you do for a living: what do you actually do at work? T What do you use at work? i.e. tools substances etc T How long have you been doing this type of work? T D you have more than one job T Have you don any different kinds of work in the past T Have you been told that anything you use at work may make you ill T Has anyone at work had the same symptoms T Do you have hobbies that may bring you into contact with chemical T Is there a occupational health doctor or nurse at your workplace ?
Reporting Systems
1. Voluntary reporting systems : eg THOR, OPRA, SWARD ( see later) etc THOR
T anonymous, confidential T provides information resource for OH specialist T Provides resource for occupational epidemiology T Main Disease: Diffuse pleural thickening, mesothelioma etc
OPRA – Occupational Physician Reporting Activity
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T occupationally-‐‑ related ill health T Highlights diseases missed by other reporting systems
Main diseases : Musculoskeletal, mental health, contact dermatitis SWROD – Surveillance of Work-‐‑Related & Occupational Respiratory Disease Mainly reported : occ asthma, mesothelioma, pneumoconiosis, pleural disease, lung cance
2. Periodic reporting systems : SWI (survey of work-‐‑ related illness), death certificates SWI ( survey of work related illness) Data 2007-‐‑08 2.1 million reported suffering from illness caused or made worse by work 1.3 million sufferers had worked within the last year 29.3 million days lost through work related illness Sufferes had average absence 16.9 days due to work related illness Mental Health & MSD ( musculoskeletal disorders ) 442 k reported stress related illness 13.5 million days lost due to stress – 30 days per affected case 539 k reported MSD million days lost due to MSDS – 16 days per affected case Top 5 Categories in SWI
1. Musculo-‐‑skeletal 2. Mental health (stress, depression or anxiety) 3. Respiratory 4. Skin 5. Hearing Loss
Statutory Reporting Systems
T Social security (industrial injuries) (prescribed diseases) Regulations 1985 o Recording new cases of specified prescribed disease claims assessed for
disablement benefit The Industrial Injuries Scheme provides non-‐‑contributory no fault benefits for disablement because of an accident at work or because of one of over 70 prescribed disease ( match occupation and exposure)
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RIDDOR: Reporting of Injuries, Diseases and Dangerous occurrence Regulations 1995 Statutory reports by employers to enforcing body (HSE or local authority)
T fatal injuries T injuries involving 3+ dys absence T dangerous occurrences T reportable diseases
Some RIDDOR data T Men have sig. higher rate of injury and fatal accidents T Men aged 16-‐‑24 have higher rate of injury then older men T No variation in injury rate with age for women
T Risk of injury in first 6th months with employer twice that for employees 12 months +
T Part time workers @ higher risk of injury ( <16 double risk for 30-‐‑50 hrs )
Comparison of deaths from work related illnesses and injury 57% cancer 38% Chronic Obstructive Pulmonary Disease 2% other malignant respiratory disease 2% fatal 1% asbestosis
Lecture 21: Fitness for Work and Return to Work
Assessing fitness for work T Pre-‐‑ employment T After sickness absence T Interval assessment as per Job Req. T After an incident at work
A GP is rarely involved with determining fitness to start work. This is normally the Employer’s responsibility (with advice from their Occupational Health adviser)
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Return for Work A GP is often involved in assessing return to work. Fundamental question
T Does a patient want to return to work T Does a patient need to be symptom free ( of 100% fit) before returning to work T Is (some) work feasible
The Medical Condition To make a proper assessment it is necessary that you know
T the nature of the medical condition T any appropriate clinical guidelines T work factors that might aggravate health problems T health factors that will effect work T the patient’s expectation and needs in relation to work
Also need to know if the medical condition is
T Temporary or permanent T Stable/progressive/relapsing T Controlled on treatment or no available treatment T Complications
The Job
T Does it require special mobility, strength, or endurance? T Are there any specific fitness standards? T Safety responsibilities? T Functional limitations, and what they can do T Reasonable adjustments
o Can slight alterations to the work or exemptions from some duties enable the patient to continue to work?
SMARTIES Stamina Mobility: walking, bending, stooping Agility: dexterity, posture, coordination Rational: mental state, mood Treatment: Side effects, duration of
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Intellectual: cognitive abilities Essential for job: food handlers, diving Sensory aspects: safety – self and others Special forms GPs need to fill out for Fitness to drive. At a glance guide to the current Medical Standards of fitness to drive Return to work: Considerations
T Return to work should be one of the key clinical outcomes by which the success of treatment is measured
o It needs to be an integral part of the case management plan T Can medical certification be used to support the patient’s return to work, by specifying
adjustments to facilitate recovery and rehabilitation? T Whatever you recommend, the employer takes the “risk” of returning the patient to
work i.e. not a litigation issue for doctors Medical Certificates
T What forms do you use? : Form SC2 T After how long an absence must complete SC2: 4 days T After how long an absence may an employer ask for a Medical Certificate?: 7 days
The sick note is now a fit note, called Med 3. What’s it used for?
T Just to provide certification for statutory sick pay ( and other benefits) T Advisory (to the patient). Not an instruction
This can only be issued by a registered medical practitioner. What is sickness absence? Absence from work attributed by the employee to illness or injury and accepted by the employer as such Work Absence Types
T Short term o unCertificated o self-‐‑certificated o doctor’s certificate
T Long Term T Unauthorised absence or persistent lateness T Other authorized absences:
o Maternity/paternity
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o Public or trade union duties o Compassionate leave
Long Term Absence:
T usually need for clinical intervention in those who have been off work for a month or longer
T long-‐‑term absence can become permanent and the risk of this outcome grows from this point on
Managing sickness absence is clearly an employer’s responsibility but when it’s really due to ill health then doctors will get asked for further information
T is it a medical cause? T can he/she return to work? T is there anything the company can do to help?
Rehabilitation-‐‑ why bother Employer
T financial: absence cost up to 15 % of pay costs T Retaining experience
o Safer environment o Increase productivity o Job satisfaction o Reduced employee turnover
T Public image Legislation – equality act Employee – work is good for you! Waddell and Burton 2006 Going back to work
T improved general and mental health T reduced psychological distress and minor psychiatric morbidity T Minimizes the Harmful physical, mental and social effects of long-‐‑term sickness
absence T Reduces the risk of long-‐‑term incapacity T Improves QOL and well being
Return to Work Components
T management commitment
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T employee involvement T education T team approach : hr, management, oh, clinicians T Monitor/identify on going risks T Effective use of rehabilitation and health facilities
Lecture 22: Occupational Health: Linking theory to practice
Disease diagnosis: role of work
T Caused by work? T Aggravated by work? T Not related to work?
Criteria for Diagnosis
T Description of EFFECT T Assessment of EXPOSURE T Acceptable TIME SEQUENCE T Considering of COMPETING CAUSES
Flowchart:
1. Hazard identification 2. Exposure assessment 3. Risk Characterization 4. Prevention and Control 5. Risk communication 6. Health surveillance
Exposure monitoring: (part of 2) Environmental & biological eg considering the amount of spray a worker would inhale in a day of work Risk Characterization (standard setting, part of 3): effectively studying how different does effect different people. Are some people immune, are some people very sensitive? Occupational Exposure limits (OEL) ( part of 3): Information
1. Toxicological a. Critical health effect type
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b. Does Response c. Acute vs Chronic problems
2. Occupational exposure data 3. Derived level achievable? Aka is it possible that workers will get too much exposure?
e.g. A paint sprayer is exposed to air borne isocyanates when spraying. Isocyanates are assigned an OEL of 2mg.m^-‐‑3. Personal 8 hr TWA (guessing means exposure) measured to be 1mg.m^-‐‑3 Is this person at risk of developing respiratory disorders? Health Surveillance (6) : putting in place systematic, regular an appropriate procedure to detect early signs of work-‐‑related ill health among employees exposed to certain health risks; and acting upon the results. When is it appropriate?
1. Identifiable disease or effect related to exposure 2. Reasonable likelihood that disease will occur under conditions of exposure 3. Valid technique for detecting indication of disease or effect
Did case study of HS on employee who solders. à talked about different step one would take to find out what’s wrong with them and if its because of the soldering.
Lecture 23: Overview of Health Inequalities
Population health: Overall sum of health across the population/ distribution of health across the population What is health inequality: unacceptable and avoidable differences/ variation in health status or outcome between different population groups Differences in the distribution of resources/ services across populations which do not reflect health needs. Principals of
T Horizontal Equity: equal care for equal need T Vertical Equity: unequal acre for unequal need
Multiple dimensions of inequality : eg geography, age, gender, ethnicity etc. Inequalities by level of depravation
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Life expectancy is strongly associated with level of deprivation The difference in male life expectancy @ birth between those living in the most deprived areas and those living in the least deprived areas was 8.8 years in 2005-‐‑ 09. In females the difference was 5.9 years
In London: Travelling east from Westminster, each tube stop represents nearly one year of life expectancy lost Inequalities by socioeconomic group
Infant mortality rates in England and wales show a distinct gradient by socio-‐‑economic class. 2007-‐‑ 09, rate higher for fathers in routine and manual occupations (5/1k) vs 4.5/1k 6.8/ 1k for others: long term unemployed, never worked, students Rates lowest for babies with fathers in managerial and professional occupations 3.2/ 1k Prevalence of smoking also varies this way. 28% adults in routine and manual occupations smoked vs 15% in managerial and professional ( 21% overall)
Inequalities by age : basically older you are the less medical attention you get. Called ageism, age discrimination. Reduction of treatment = higher rates of death especially in cancer Inequalities by Ethnicity:
Infant mortality rate, highest Black, then Asian, which are both almost double rate then white.
Inequalities by Disability:
Learning difficulties & disabilities more likely to be unemployed 13% Not in education, semployment or training (NEET) vs 7% average england
Review of health inequalities in England: Marmot Review à 2008 6 policy objectives
1. give every child the best start in life 2. enable all children, young people and adults to max their capabilities and have control
over their lives 3. create fair employment and good work for all
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4. ensure a health standard of living for all 5. create and develop health and sustainable places and communities 6. strengthen the role and impact of ill health prevention \
Then showed few graphs about different life expectancies in affluent vs non-‐‑affluent communities in england.
Lecture 24: Ethnic Minorities and Health Inequalities in the UK
White british 85 % White other 5 .3 % Indian 1.8 % Pakistani 1.5 % Irish 1.2% Black 1.8% …. Etc. BME = Black and minority ethnic Acculturation: in reality, one culture group will dominate the other
T assimilation T integration T de-‐‑culturation
Ethnicity: results from many aspects of differences: race, culture, religion and ethnicity. Sense of belonging, group identity Race: Physical appearance, genetic, permanent Culture: Behavior attitudes, upbringing Ethnic minority: increased risk of CVD, ischemic heart disease, ++diabetes( 3-‐‑5 times greater vs Whites) , hypertension, hyperlipidemia, obesity, smoking Black Caribbean Men: stroke and schizophrenia Cancer: Lower in BME groups higher in Scottish and Irish.
BASICALLY – it is important to take account of ethnicity
Lecture 25: Caring for Patients from different Cultures Values: things we hold important. Exist at individual & cultural level Understanding values is the key to understanding behavior eg different values: independence, privacy..
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Conflicts and misunderstandings can occur in health care between the values of the health care culture and that of the patient population Second most important concept in understanding people’s behavior is understanding their world view. Worldviews consist of peoples assumptions about the nature of reality. People often interpret events in a matter that is consistent with their beliefs. Ethnocentrism and Cultural Relativism
T Refers to attitudes T Most humans are ethnocentric – western health care systems tend to be ethnocentric
Time orientation: a persons focus regarding time varies in different cultures ( focus on past press or future… Language issues: idioms, difference in language terms even in English speaking countries. The role of Religion, the role of family, sex roles, views on birth and death.. Cultural Competence
T understanding your own culture and biases T becoming sensate to the cultures of others T appreciating differences T acquiring knowledge and understanding of other’s cultures esp values beliefs.
apply your knowledge Asking the right question : principals of culturally competent care should apply to all patients. Learn to ask the right questions 4 cs
1) what do you call your problem 2) what do you think caused your problem 3) how do you cope with your condition 4) what concerns do you have regarding your condition
Lecture 26: Social factors in well Being
Different perspective on ways of thinking about mental abnormality and normality in contemporary society eg sociological, psychiatric, psychoanalytical, legal
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Social class and Mental Well being: T poverty T social isolation theory T social drift theory T opportunity and stress hypothesis T neurotic vs psychotic T life events and psychiatric symptoms
Women, Men And Mental well-‐‑being
T over representation of women in psychiatric diagnosis T no differences in schizophrenia and bi-‐‑polar disorder T anorexia and bulimia T antisocial personality T substance misuse
Gender and Sexuality Gay men and lesbians present more mental health problems than heterosexuals Also more likely to abuse substances Gay and bi-‐‑sexual men are 4 x more likely to commit suicide than their heterosexual equivalents Likely to be a result of the stress created by societies responses. Childhood sexual abuse and mental health problems Strong evidence that victims of abuse more prone to mental distress Girls are at higher risk than boys of sexual victimization. Boys are at greater risk from stranger perpetrators
Lecture 27: Cancer inequalities
Policy drivers: Cancer Reform Strategy 2007 -‐‑-‐‑ annual updates Cancer registries receive lots of different information: eg. Wait times, radiotherapy, national clinical audits, Evidence of cancer inequalities
T by dimension of inequality T By type T By Metric
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Dimension of inequality Age
Increase with age, and evidence that older people treated less intensively. Improvements less sig in 75 + Challenge identifying potential signs and symptoms of childhood cancer
Gender Men diagnosed more and change of death. More women live with it. Men have lower awareness
Ethnicity Awareness lower in BME groups Increased risk for African Caribbean population and Asian cancer vs white population Disability Screening uptake for those with learning disabilities lower
Increased GI cancer (55% of all cancers diagnosed in LD groups) , and 5 X more likely to have testicular cancer
Sexual preference Lesbians may delay seeking help Higher instance of anal cancer in gay men Geography Those without access to public transport face increased travel costs. Inequalities specific to type of cancer Breast Cancer: Age
Risk increases with age. Younger people presenting with symptoms experience delay by hcp. Older patients less likely to have surgery instead given endocrine
Breast Cancer: Disability People with LD have difficulty recog and communicating symptoms. Many barriers for women with ld to attend screening
Breast Cancer: Ethnicity Black and Asian women have poorer survival rates. Blacks Usually have worse prognosis & larger tumor
Breast Cancer: Geography Increasing distance from a cancer center correlated with poorer survival Breast Cancer: Sexual orientation Poor provision of specialist services for lesbian and bisexual women with breast cancer. Breast Cancer: Socio-‐‑economic status
Clear deprivation gap in terms of survival. People from lower groups have more advanced diseases
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Variations in Cancer incidence Inequalities Gender : excess in men Inequalities: ethnicity: BME at lower risk. Religion: little data about impact of religion vs ethnicity
Across the Care pathway: variation by type of cancer statistic/ metric …… Barriers to consulting gp
T emotional barriers T practical barriers T service barriers
Summary of results of CAM omnibus Survey
T awareness of warning signs was low across all ethnic groups, with lowest in African group
T women identified more emotional barriers and men more practical barriers to help seeking, with considerable ethnic variation
T anticipated delay was associated with lower awareness and perceiving more barriers . The rest of the lecture is about differences in breast cancer stats, how often screened, survival…. . .
Lecture 28: Coping with chronic Illness
You need to refer to 1st year lecture: the relationship between physical and mental health…. .. .. . Chronic illness
T a major adverse life event ( a stressor) o unexpected, Unpredictable, Uncontrollable, Life changing
T affects person and their family/friends T require adjustment and adaptation (coping)
Cognitive Transactional Model of Stress
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The important factor is how well a person copes with stress rather then how much they face. (perceived stress) Appraisal is crucial: how am I going to deal with this, what can I use to help me? Impact of chronic illness
T emotional distress T restriction and disruption to normal life T learning how to manage the illness T new ‘tasks’ T changing risk factors to help prevent progression ( behavior changes) T side effects of treatment T Loss of Self (identity, location, role, social standing)
Stress Behavioral: sleep disturb. Use of alcohol/drugs, absenteeism, social withdrawal aggression Physiological: higher bp, rapid shallow breathing, increased HR, dry mouth Affective: depression/anxiety, irritability, loss of humor, Cognitive: lack of concentration, negative thoughts, poor memory Bio chemical: increased metabolic rate, altered endorphin levels Stress can be caused by lack of coping with a chronic illness Stress can lead to bad life choices ( smoking, exercise, sleep) which can cause indirectly lead to chronic illness. Stress can also lead to chronic illness directly Types of Coping Problem Focused : Directly deal with the stressor Emotion Focused : Alter/Reduce negative emotions resulting from the stressor Eg. seeking emotional support, denial, praying, exercise, suicide, self blame Families & chronic illness
T community care increases pressure on families T physical, psychological, social, financial consequences of informal caring ( care burden) T Cargivers needs are often given low priority
How can we help: à Coping interventions
1. information provision 2. social support 3. self management training
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4. stress management training Aims of Coping interventions
-‐‑ reduce distress -‐‑ help to manage illness effectively -‐‑ minimize impact of illness on daily life ( improve QOL) -‐‑ Prevent progression and minimize risk of further heath problem
1. Informal Provision
a. Good communication skills, good intrapersonal skills – leaflets, internet, helplines à Information giving, Advice
2. Social Support a. Can be Emotional, instrumental or informational b. Support groups: social, deal with death, reduce hostility c. Social isolation increases risk of morality in many chronic diseases
3. Self Management training a. helps patient to gain “internal control” over illness. b. Increase self efficacy & optimism
4. Stress management Training a. Problem solving, cognitive restructuring, behavioral change plans +ve thinking
Cardiac Rehabilitation Programmed
-‐‑ Stress management -‐‑ Focus on Type A Behaviors ( Anger & hostility) -‐‑ Type A personality – SNS is hyper responsive to stress, increased risky health
behaviors, don’t benefit from social support -‐‑ Effective – reduce risk of further MI
Examples of type A behavior
-‐‑ thinking of/ doing two things at once -‐‑ hurrying the speech of others -‐‑ annoyed by lines -‐‑ if you want something done do it yourself
Type C Personality C= Cancer Prone
-‐‑ Mainly females -‐‑ Co-‐‑operative & appeasing -‐‑ Compliant & passive -‐‑ Static
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-‐‑ Unassertive and self sacrificing Examples of Type C behavior -‐‑ try to avoid conflicts with others -‐‑ always polite, even to rude people -‐‑ do other people take advantage of you
High N personality N= Neuroticism
-‐‑ Worrying -‐‑ Negative outlook -‐‑ Introspective -‐‑ Low self contempt
Examples of Type N behavior
-‐‑ worry about things that you shouldn’t’ve done/ said -‐‑ feeling easily hurt -‐‑ worry about awful consequences -‐‑ worry to long after an embarrassing experience
Lecture 29: Inequalities in CVD
Multiple causes ( that lead up to the build up of atheroma): risk factors include: High Blood Pressure, smoking, physical inactivity, obesity, genetics, sex and age 1.6 million people have chronic heart condition What is inequality in health?
-‐‑ lack of equality in health outcomes/states -‐‑ close link to health equity ( horizontal/ vertical) -‐‑ Concepts of need and Social justice
Need: Felt need: the subjective experience of a need of help Expressed need: what people demand Normative need : the professional judgment on what is req
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Deprivation Quintiles : dividing the population up into 5 bands of deprivation –each containing 20 % of the geographic subunits sorted by deprivation Whitehall Studies ( 18 k men working across civil service) There is a relationship between the grade of employment, coronary risk factors and coronary heart disease mortality. Lowest grade had 3-‐‑6 times increased risk of CHD. Found that CHD motility increases with age. This was found to be associated with raised BP, smoking, BMI higher, and blood glucose higher. Increased BP = increased CVD mortality Also did a Whitehall study 2 We are sing a gradual decline over time with CHD rates falling but consistently the most deprived quintiles do the worst. Geographic Variation: close association to deprivation/ age distribution Ethnicity:
-‐‑ MI rates higher in S Asians VS non s Asians -‐‑ Stroke rates higher in back vs white -‐‑ Higher rate of diabetes in some groups
Risk Factory Inequalities à increased deprivation = increased behavioral risk
-‐‑ Smoking -‐‑ BP -‐‑ Obesity -‐‑ Physical activity -‐‑ Health service
Smoking & sexual Preference Not well evident by strong methods Summary so far… we have evidence of
-‐‑ inequalities in multiple cvd areas -‐‑ inequalities in multiple CVD risk factors
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-‐‑ Confounding/ pathway variables eg BP INTERHEART
-‐‑ study of potentially modifiable risk factors -‐‑ 52 countries -‐‑ Case control study of AMI
Found 9 factors account for > 90% of risk of 1st MI
1. Smoking 2. Fruit & veg 3. Exercise 4. Alcohol 5. Hypertension 6. Diabetes 7. Abdominal obesity 8. Psychosocial factors 9. Lipids
British Regional Heart Study Focusing on three risk factors
1. Blood cholesterol 2. High BP 3. Cigarette Smoking
Found increased risk associated with increased levels. INTERSTROKE: Similar to INERHEART, were able to found a handful of factors that are account for 90% of all strokes. Hypertension and smoking biggest factors CVD Risk Assessment Risk scoring tool
-‐‑ blood pressure/weight; waits/ cholesterol & HDL/ Glucose -‐‑ Qrisk/ Qrisk 2/ ASSIGN
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2008 NICE goal : reducing the rate of premature deaths from cvd and other smoking related diseases: finding and supporting those most at risk and improving access to services NICE changed their recommendation from interventions focused on high risk individuals to making changes among any given population as a whole 2010: prevention of CVDisease at population level. Fundamentally engages with the challenge of these risk factors.
Lecture 30: Care and Carers Care as a set of tasks : includes help with personal hygiene, continence management, help with eating, advice, shopping Care as an emotional commitment: traditional association of care with love and concern Carer: designates a person who provides long term help to a disabled person, usually a member of their immediate family. Legal recognition in invalid care allowance 1975. Later extended to include social care staff who worked with disabled people in residential and day care services. Care providers
-‐‑ family and friends -‐‑ NHS ( nb, health v social care divide) -‐‑ Charities, local authorities
Staff Carers
-‐‑ Social care providers in England -‐‑ Adult care/nursing home -‐‑ Domiciliary care agencies -‐‑ Paid Personal Care assistant
Problems with Staff Care
-‐‑ concern with instances of abuse and neglect by paid carers -‐‑ system of abuse in contracting system which forces down expenditure, leading to poor
pay, difficulty in recruiting suitable staff.
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-‐‑ Accountability Care Dilemmas
-‐‑ treating a person with sever cognitive impairment as autonomous adult vs need to ensure safety
-‐‑ allowing persons to take risks vs the need to protect from exploitation and danger -‐‑ Allow people to make choices versus the need to protect them from the consequences of
a poor diet, excessive alcohol, smoking Family Care : anyone either living with you or not living with you who is sick , disabled, or elderly whom you look after or give special help to, other than in a professional capacity?
-‐‑ more likely to be women then men ( 60%) -‐‑ most likely to be 45-‐‑65 -‐‑ ½ carers were in paid employment
Impact on family life: Caring for a disabled child
-‐‑ parents of disabled children from all social classes but more likely single parent & poor -‐‑ Caring for disabled child more time consuming & limits parental employment -‐‑ Can have disproportionate effects on parents with low income -‐‑ Stigmatization of parents
-‐‑ Poorer mental health among parents , with sever stress -‐‑ Only Minor effects on siblings of children with learning disabilities founds
1/3rd of adults with learning disability live with elderly parents. Mutual interdependence common
-‐‑ Planning on future: where will they go once parents age or die? Most reluctant to plan, based on lack of confidence in residential care
Young Carers
-‐‑ estimates 150 K young carers, usually supporting disabled parents. Several hours a week
-‐‑ young carers suffer social isolation from other members of their age group -‐‑ worry and stress common,
Official Support for Carers
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-‐‑ Public policy made a sharp divide between Institutional care ( fully funded) & unsupported family care.
-‐‑ Recognition that institutional care usually followed a breakdown of family care
Current Patterns of support
1. Financial support for Family Care Carer’s allowance 53.10 /week for people spending at least 35 hrs a week for someone who receives one of the three main benefits for disabled people. Only one person may clam Carer’s Allowance for each disabled person. The Family Fund: one off payments for families with severely disabled children
2. Respite care for family carers Respite care allows families to continue domestic routines, overcome social isolation and continue employment Divers range : daycare, social clubs, day hospitals, holiday breaks
3. Domiciliary (home) Support for family care Historically targeted according to the extend to disability and the unavailability of alternative sources of help.
4. Social And Psychological Interventions Cognitive behavior therapy and some types of group therapies are in effect in reducing stress. Also useful are contacts between parents who provide info and support. Support groups Warrior carers
-‐‑ Substantial number of family carers do not receive the help they need ( conflict of interest with service – they assign low priority to certain groups)
-‐‑ = Family caregiver needs to act as an advocate (warrior) to get the services they need. Equality Act 2010 : mean carers cannot be directly discriminated against or harassed because they are caring for someone with a disability
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Lecture 31: Patient And Public Involvement in Health Care Making decisions about own health Care Patients can play a distinct role in their health care by:
-‐‑ understanding the cause of disease and the factors that influence health -‐‑ self diagnosing, treat minor condition -‐‑ manage treatment and taking medication appropriately -‐‑ be aware of safety issues etc
Health Literacy : The ability to make sound health decision in the context of everyday life – at home, in the community, at the workplace, the health care system, the market place and the political arena: HL interventions have 3 key objectives
1. to provide information and education 2. to encourage appropriate and effective use of health resources 3. To tackle health inequalities
Shared Decision Making : Process of involving patients in clinical decision. Professionals work to define problems with sufficient clarity and openness so that patients can comprehend the uncertainties surrounding competing decision Self Care: the goal of self management support is to enable the patient to perform 3 sets of tasks
1. managing their illness medically : Taking medication or adhering to a special diet 2. Carrying out normal roles and activities 3. Managing the emotional effect of their illness
Self Efficacy
-‐‑ an individual’s belief in their capacity to learn and perform a specific behavior -‐‑ confidence and ability is key to empowerment and motivation -‐‑ Interventions for self care: building confidence and equipping patients with knowledge
and skills Initiative to educate patients in self management skills.
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-‐‑ people with chronic conditions à depression, eating disorders, asthma, hypertension, diabetes, COPD
-‐‑ Patients gain health benefits -‐‑ Reduction in the rate of hospital admissions
To foster a culture of partnership between health professional and patients, professional need to develop a specific set of skill and attributes eg understanding patient perspective, ability to educate them about protecting their health, the ability to share treatment decision etc Health and Social Care Act 2012 No Decision About me Without Me -‐‑ applies to individual patient care, service development and change, and local/nation levels.