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.