health and disease in society

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health and disease in society
2011-03-29 13:11:10
health disease society

semester 3
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  1. why are quality and safety important in healthcare?
    • ensure best possible care
    • variations in health care
    • evidence of medical errors
    • growing legal bills
    • cost of extra bed days
  2. define clinical governance
    a framework through which NHS organisations are accountable for continuously improving the quality of their services and safe guarding high standards of care by creating an environment in which excellence in clinical care will flourish
  3. what are the 6 dimensions of quality
    • safety
    • accessibility
    • equity
    • patient centred
    • effectiveness
    • efficiency
  4. what is an adverse event
    what does it mean if it is preventable
    adverse event: an injury caused by medical management rather than underlying disease that prolongues hospitalisation, produces a disability or both

    preventable: an adverse event that could be prevented given the current state of medical knowledge
  5. james reason's framework of error
    what are active failures?
    what are latent conditions?
    • active failures = acts that lead directly to a patient being harmed
    • latent conditions = the predisposing conditions that increase the likelihood of an active failure latent conditions can be error provoking or create long lasting problems/holes
  6. list three types of active failures
    • slips and lapses - error of action eg accidently give 0.5 g rather than 0.05 even though they know 0.05 is the correct dosage
    • mistake - error of knowledge/planning eg give perfect treatment for migrane but the problem is a rain tumour
    • violation - intentional deviation from protocol, standards, safe procedures etc.
  7. describe the swiss cheese model
    • organisations are full of holes but errors occur when these all come into line some holes are due to active failures others are due to latent conditions
    • the different layers are put into place by defences, barriers and safe guards
  8. how can health care safety be improved?
    standardise, create independent checks, learn when things go wrong
  9. how do we assure quality?

    what is the quality assurance mechanism in the NHS?
    set standards, monitor performance, have change mechanisms in place

    • guidance and standards - NICE
    • financial incentives - QUOF (the quality and outcome framework - sets national quality standards with indicators GPs score points and payments are calculated based on points achieved.) CQUIN (commissioning for quality and innovation - 1.5% of trusts income depends on achieving measurable goals in three areas: safety, effectiveness and patient experience)
    • disclosure - increase emphasis on disclosing information about performance, publish quality accounts annually
    • audit - national and local- 'a quality improvement process that seeks to improve patient care and outcomes through the systematic review of care against criteria and the implementation of care'
  10. describe a clinical audit

    what are standards
    chose topic > criteria and standards set from research evidence > first evaluation > implement change > second evaluation > set new standards

    standards are set nationally by NICE and by National Service Frameworks - set explicit EB national standards and attempt to address variations the CQC ensures the NSF standards are met locally
  11. why do we need social sciences research and why do doctors need to know about it
    • we need this research so that we can be more confident in providing patients with information and evidence about social life choices
    • policies and practices are based on social science research this needs to be evaluated and intergrated.
  12. describe the 2 main methods of doing social research
    QUANTITATIVE - collection of numerical data eg. RCT, cohort, case control, cross sectional surveys,

    QUALITATIVE - aims to make sense of phenomena in terms of meanings people bring to them eg. interviews, focus groups
  13. summarise quantative methods of social sciences research
    • begin with idea/hypothesis
    • questionnaire is a common method (must be valid and reliable)
    • good for: describing, measuring, finding relationships, allowing comparisons
    • but: force people into categories, don't allow expression, may not establish causality
    • point of view of researcher
    • static
    • structured
    • generalisation
  14. summarise qualitative methods of social sciences research
    • 4 methods:
    • ethnography and observation - study of behaviour in its natural context can be overt or covert
    • interviews - semi structured
    • focus groups - flexible, increase participation
    • documentary and media analysis - eg. medical records, tv, newspapers
    • good for: understanding perpectives of those involved, accessing unrevealed info, explaining relationships between variables
    • but: not good for finding consistent relationships or generalisability
    • casp offers a tool for appraisal - rigour, credibility, relevance
    • point of view of participants
    • establishes meaning
  15. whaat factors should be considered when choosing a study design?
    • topic under investigation
    • research teams preferance/expertise
    • time and money available
    • funders/audience

    different methods can be used in the same study
  16. define evidence based practice
    intergration of individual clinical expertise with the best available external clinical evidence from systematic research
  17. why do we need systematic reviews and why are they useful to clinicians
    • minimise bias
    • address clinical uncertainty
    • highlight gaps in research and poor research
    • offer quality control and increased certainty
    • offer authorative, up to date, generalisable conclusions
    • reduce delay between research discoveries and implementation
    • relatively easy to convert into guidelines/recomendations
  18. critiques of evidence based practice/medicine/healthcare
    • impossible to create and maintain systematic reviews across all specialities
    • challanging and expensive to disseminate and implement findings
    • complimentary therapy ignored as biomedical options better funded
    • certain groups not well served in the evidence base
    • doesn't align with most doctors reasoning - works for 80% why not other 20%
    • doesn't mean it will work for the individual patient
    • may lead to unreflective rule following doctors
  19. what are the problems with getting evidence into practice
    • doctors dont know about the evidence
    • doctors ignore the evidence
    • systems can not support the innovation
    • decisions reflect different priorities
    • resources not available to implement change
  20. what is social class?
    segement of the population distinguished from others by its similarities in labour market position and property relations
  21. how is social class measured?
    • individual: registrar generals scheme (mans occupation), NS-SEC (whole adult population - 8 categories)
    • area: townsend deprivation score (unemployment, car ownership, ovarcrowded housing, housing tenure) gives post code area score
    • education: years of education, highest achievement
    • income: household incoeme, poverty line
  22. what is the association between socio-economic factors and health
    • more likely to die at a younger age and experience more years of ill health if you live in adverse socio-economic conditions
    • UTILISATION - more deprived groups under use preventative services, they are willing to consult but manage health as a series of crisis
  23. what inequalities exist within countries?
    • social status
    • wealth
    • environment
    • education
  24. what is ethnicity?
    how is it linked to health and socio-economic status
    • identification with a social group on the basis of shared values, beliefs, customs, traditions, language and lifestyle
    • infant mortality and mental health higher in black caribbean and pakistani populations in the UK
    • CVD more prevelant in pakistani men
    • pakistani and bangleshi have smallest % in managerial and proffesional occupations
    • lack of translation services available
    • social networks may deter seeking help
    • stigmatisation and stereotyping
  25. what is gender:
    how is gender linked to health and socio-economic status
    • gender is not the same as sex
    • gender relates to culturally appropriate behaviour of men and women not biological differences
    • mortality is greater in males
    • men are more likely to commit suicide or die violently
    • higher rates of disability in women
    • women more likely to access primary care
    • cultural expectations of what is gender appropriate
  26. what theories does the black report use to explain why inequalities occur?
    • artefact
    • social-selection
    • behavioural-cultural
    • materialist
  27. what is the artefact explanation in the black report
    • the existance of health inequalities is due to the way statistics are collected and in particular to problems with the measurement of class
    • eg. occupation recorded differently on census and death certificate
    • this is the most discredited explanation as if anything data problems underestimate inequality
  28. what is the social selection explanation in the black report
    • direction of causation is from health to social position
    • social mobility
    • sick individuals move down the social hierarchy and healthy individuals move up
    • this doesn't work alone as it is found in children where mobility is not possible
  29. what is the behavioural cultural explanation in the black report
    • ill health is due to peoples choices and descisions
    • people from disadvantaged backgrounds tend to engage in more health damaging behaviours
    • contributory but not sole explanation
  30. what is the materialist explanation in the black report
    • inequalities in health arise from differential access to material resources
    • low income, unemployment, work environments, low control over job, poor housing
    • most powerful explanation
  31. what was the marmot enquiry?
    • 2010
    • aim: to provide evidence based strategy for reducing health inequalities
    • 6 objectives: every child best start, maximise capability and control, fair employment and good work, healthy standard of living, healthy and sustainable communities, health prevention
  32. what is the difference between inequality and inequity?
    • inequality - when things are different
    • inequity - inequalities that are unfair and avoidable
  33. what are lay beliefs?
    • how people make sense and understand health and illness
    • constructed by people about areas in their lives about which they have no specialist knowledge
    • not simply a watered down version of medical knowledge
    • socially embeded
    • complex
  34. why is understanding lay beliefs important?
    • impact on health behaviour
    • impact on illness behaviour - what people do when they have symptoms
    • impact on compliance/adherance with treatment
  35. sociological work has shown that your perceptions of health are strongly influenced by how much you think you can assert control in your health these perceptions are culturally and socially conditioned
    what are the three perceptions of health?
    • negative definition: health equates to the absence of ilness - especially common in socio-economically disadvantaged people, the elederly and those with chronic conditions
    • functional definition: health is the ability to do certain thingseg. no time off work, get through the day, stay independant
    • positive definition: health is a state of wellbeing and fitness, an aspirational state, this is more common among affluent people
  36. what is lay epidemiology
    • different to lay beliefs
    • 2 distinct issues:
    • understand how and why illness happens
    • understand why it happened to a particular person at a particular time
  37. what influence do lay beliefs have on behaviour?
    • preventative/health behaviour: activity undertaken to prevent illness, eg. giving up smoking for long term benefit
    • illness behaviour: symptom iceburg many people with symptoms don't consult the doctor due to a range of factors eg. culture, how the symptom disrupts life, tolerance threshold, resource availabilty, lay referal
  38. what is lay referal and why is it important?
    the chain of advice contacts which the sick make with other lay people prior to or instead of seeking help from health care proffessionals it has a massive impact on how and when people access care
  39. many asthma suffers don't take their medication as prescribed what are the 3 main groups researchers identified?
    • deniers and distancers: deny having asthma/proper asthma, didn't take madication
    • accepters: accepted doctors advice took medication as prescribed happy to take it in public
    • pragmatists: only took medication when asthma was bad
  40. define the term determinants of health
    • a range of factors that have a powerful and cumulative effect on the health of the population because they shape behaviours and environmental risk factors
    • eg the health career representation
  41. what is health promotion?
    the process of enabling people to increase control over and improve their health
  42. what are the principles of health promotion
    • empowering: enabling individuals and communities to assume more power over the determinants of health
    • participatory: involving all concerned at all stages of the process
    • Holistic: fostering spiritual, physical, mental, and social health
    • intersectoral: collaboration of agencies from different sectors
    • equitable: guided by a concern for social justice
    • sustainable: changes that can be maintained when funding ends
    • multi-strategy: variety of approaches, eg. policy, organisational, community, legislation
  43. what are the approaches of health promotion
    • medical or preventative: encouraging early detection
    • behavioural change: encouraging change eg.MIs
    • educational: explaining issues
    • empowerment: patient centred
    • social change: smoking ban in public places
  44. what are the three levels of prevention
    • primary: prevent onset of disease or injury by reducing exposure to risk factors
    • secondary: detect and treat a disease at an early stage
    • tertiary: minimise effects of an established disease
  45. what are the problems with health promotion
    • ethics of interferring in peoples lives
    • victim blaming - focusing on individual behavioural change plays down socio-economic factors
    • fallacy of empowerment - giving people the information gives them the power - NO
    • reinforcing negative sterotypes
    • unequal distribution of responsibility - implementing health education advice is often left to women
    • interventions that make a difference at the population level may not have much of an effect on the individual
    • does it work?
    • types of evaluation =
    • 1. process: focus on assessing the process of the programme implementation employs many qualitative methods
    • 2. impact: assesses the immediate effects of the intervention - easiest to do
    • 3. outcome: most important, timing is very important (delay/decay), measures what is actually achieved
    • difficulties with evaluation = possible lag time to effct, many potential confounding factors, high cost
  46. sociological critiques of health promotion
    • structural: material conditions that give rise to ill health are marginalised
    • surveillance: role in monitoring and regulating the poulation
    • consumption: lifestyle choices not just seen as health risks but also tied up with identity construction
  47. what is the sociological approach to chronic illness
    • focuses on how the chronic illness impacts on social interaction and role performance
    • negotiated reality
  48. what is an illness narrative
    • the storytelling and accounting practices that occur in the face of illness
    • often includes the onset, getting a diagnosis, reaction to the diagnosis
  49. what are the works of chronic illness
    • illness work: managing the symptoms, this has to be done before coping with the social relationships
    • everyday life work: coping and strategy to get normalisation - can try to maintain pre-illness life or redesignate new life as normal life
    • emotional work: the work that is done to protect the emotional wellbeing of others - this has an impact on social relationships and role
    • biographical work: loss of self, who you are and why you matter
    • identity work: how other people see you, management of actual and imagined reaction of others, illness may become status and stigma may be attached to the individual
  50. what is biographical disruption
    • chronic illness is a major disruptive experience
    • grief for former life
    • biographical shift from a perceived normal
    • older people however may see chronic illness and biologically normal
  51. what are the 4 types of stigma
    • discreditable: nothing seen but if found out... eg. HIV
    • discredited: physically visible characteristic or well known stigma that sets them apart
    • enacted: the real experience of prejudice, discrimination and disadvantage as a consequence of their condition
    • felt: fear of nacted stigma/ feeling of shame
  52. what is narrative reconstruction
    process by which the shattered self is reconstructed in ways which explain the appearance of illness
  53. what are the three concepts that the ICIDH use to attempt to classify the consequences of disease
    • impairment: abnormalities in the structure or functioning of body
    • disability: performance of activities
    • handicap: broader social and psychological consequences or living with impairment and disability
  54. problems with the ICIDH
    • use of word handicap
    • impleies problems are intrinsic
  55. what are the medical and social models of disability
    • disability is deviation from the medical norms
    • disadvantages are a direct consequence of the impairment and disability
    • needs medical intervention to cure or help

    • SOCIAL
    • problems are product of environment and failure of environment to adjust
    • disability is a form of social oppression
    • political action and social change are required
  56. critiques of the medical and social models of disability
    • lack of recognition of social and psychological factors
    • stereotyping and stigmatising language

    • SOCIAL
    • body is left out
    • overly drawn view of society
    • failure to recognise bodily realities
  57. what is the ICF
    • revised model of the ICIDH
    • focuses in the components of health rather than the consequences of disease
    • key compnents = bodily structures/functions, activities, participation
    • all the components and relatationships between them are affected by personal and enviromental contextual factors
  58. why do we need to measure health
    • so we have an indication of need for health care
    • we can target resources where they are most needed
    • we can assess the effectiveness of interventions
    • evaluate the quality of health services
    • evaluate effectiveness and therefore get better value for money
    • monitor patients progress
  59. what methods are used to measure health
    • mortality
    • morbidity
    • patient based outcomes
  60. why is mortality not very useful in measuring health
    • not always recorded acurately
    • doesn't assess outcomes or quality of care
  61. why is morbidity not very helpful in measuring health
    • collection not always acurate/reliable
    • doesn't tell anything about patient experience
    • not always easy to use in evaluation
  62. what are patient based outcomes and why do we use them
    • attempt to assess well-being from the patients point of view
    • better for conditions where we are managing not curing
    • can measure health status of population not just the sick
    • focused on patient centred care
    • can be used to compare interventions in a clinical trial
    • can be used clinically
    • can be used in clinical audit
    • can show up iatrogenic effects of care
    • patient involvement in decision making
  63. what are PROMs
    patient reported outcome measures

    • data used to:
    • assess the relative clinical quality of providers of elective procedures
    • to research what works
    • to assess referal thresholds
  64. what is health related quality of life
    functional effect of an illness and its consequent therapy upon a patient as perceived by the patient

    • emphasis on patients own views
    • emphasis on functional affects
    • emphasis on therapy as well as illness
  65. what are the dimensions of the HRQoL
    • physical function
    • symptoms
    • global judgement of health
    • psychological wellbeing
    • social wellbeing
    • cognitive functioning
    • personal constructs
    • satisfaction with care
  66. what are the ways that we can measure HRQoL
    • qualitative
    • quantitative - specific or generic
  67. describe the qualitative methods of measuring HRQoL
    • appropriate in some cases
    • gives access to areas other don't reach
    • good for an intial look
    • very resource hungry
    • not easy to evaluate
  68. describe the quantative methods of measuring HRQoL
    • relies on questionnaires known as instruments os scales
    • should be reliable (accurate over time) and valid (does it measure what it is intended to measure)
  69. what are the generic quality of life measures
    eg. SF36 and EQ-5D
    • try to capture broad range of aspects of health status
    • relevant to wide range of patients
    • broad range of health problems
    • can be used if no-disease specific instrument
    • enables treatment comparisons
    • can assess population health
    • can detect unexpected
    • detect unexpected effect of an intervention

    • loss of detail
    • loss of relevance
    • may be less sensitive to change as a result of an intervention
    • may be less acceptable
  70. describe the SF36
    • developed in the USA
    • started as 108 questions
    • standard version uses a 4 week recall period
    • widely used in research
    • reliable and valid - used in over 4000 populations
    • contains 36 items that can be grouped into 8 dimensions: physical functioning, social functioning, role functioning physical and emotional, bodily pain, vitality, general health, mental health
    • scored from 0 to 100 in each dimension - a utility score can be derived
    • acceptable to people
    • easy to complete
    • responsive to change
    • population data available
    • not very uiseful in the very sick and elderly
  71. describe the EQ-5D
    • generic measure
    • generates a single index value 1(full health) 0(death)
    • 5 dimensions: mobility, self care, usual activities, pain/discomfort, anxiety/depression
    • 3 levels for each dimension: no problems, some/moderate problems, extreme problems
    • originally desgined to complement other measures but increasingly used as a stand alone measure
    • particularly suitable for use in economic evaluations
    • ends with the thermometer
  72. what types of specific instruments are there to measure quality of life
    • disease specific: Asthma QoL questionnaire, arthritis impact measurement scale
    • site specific: Oxford hip score, shoulder disabilty questionnaire
    • dimension specific: Beck depression inventory, McGill pain questionnaire
    • utility: seek to attach values to different health states
  73. what are the advantages and disadvantages of the specific instruments to measure quality of life
    • very relevant content
    • sensitive to change
    • acceptable to patients

    • can't be used in people who don't have the disease
    • comparison is limited
    • may not detect unexpected effects
  74. describe the oxford hip score
    • specific instrument
    • specific site
    • 12 items
    • have you in the last 4 weeks been able to ...?
  75. what should you think about when selecting an instrument to measure quality of life
    • is there published work showing the reliabilty and validity of the instrument
    • have there been other published studies that have successfully used the instrument
    • is there anything about the way the instrument has been developed that may make it inappropriate for use by you
  76. what is meant by the spontaneous presentation of disease?
    • person presents with sypmtoms
    • self defined as patient
    • presents to GP, A&E, etc
    • a diagnosis is made
  77. what is meant by opportunistic case finding?
    • person presents with symptoms related to a disease/problem
    • GP then takes this opportunity to check for other diseases eg. BP measurement, urine dipstick
  78. what is the definition of diagnosis?
    • the definitive identification of a suspected disease or defect by application of tests, examinations or other procedures (these may be extensive) to definitely label people as either having a disease or not having a disease
    • the diagnosis is made following tests
    • treatment will follow
  79. what is screening?
    a systematic attempt to detect an unrecognised condition by the application of tests, examinations or other procedures that can be applied rapidly and cheaply to distinguish between apparently well persons who probably have a disease or its precursors and those who probably do not

    • a person who is labelled screen positive doesn't definitely have the disease
    • further tests are required to make a diagnosis

    the NSC (national screening committee) definition = screening is a public health service in which members of a defined population who do not necessarily percieve they are at risk of or are already affected by a disease or its complications are asked a question or offered a test to identify those individuals who are more likely to be helped then harmed by further tests or treatment to reduce the risk of a disease or its complications
  80. what is the purpose of screening?
    • to give a better outcome compared with the finding of the disease in the usual way
    • if treatment can wait until there are symptoms there is no point in screening
    • finding something earlier is not the primary objective
  81. what are the criteria for screening programmes
    • disease/condition: needs to be an important health problem, need to know the epidemiology and natural history, must have an early detectable stage, cost effective primary preventions must have been considered and implemented where possible
    • test: simple and safe, precise and valid, acceptable to the population, need an agreed cut off level, the distribution of test values in the population must be known, there must be an agreed policy on whom to investigate further
    • treatment: effective evidence treatment must be available, early treatment must be an advantage, agreed policy on who to treat
    • programme: proven effectiveness, quality assurance, facilities for treatment diagnosis and counselling, benefit should outweigh harm
  82. what errors do screening programmes make
    • false positives: refer well people - stress, anxiety, inconvienence, direct and opportunity costs
    • false negatives: fail to refer people who do actually have an earlier form of the disease - inappropriate reassurance, possible delay of presentation with symptoms
  83. what are the features of test validity?
    • sensitivity: if i have the disease will i test positive
    • specificity: if i dont have the disease will i test negative
    • positive predicted value: if i have tested positive do i have the disease
    • negative predicted value: if i test negative what are the chances i really dont have the disease
  84. talk about specificity of the test
    • proportion of people without the disease who are test negative
    • probability a non-case will test negative
    • = d / b+d
    • = true negatives / false positives + true negatives
    • if specificity is high then the test is good at identifiying people without the disease as not having the disease
  85. talk about the sensitivity of the test
    • proportion of the people with the disease who are test positive
    • also known as the detection rate
    • sensitivity is the probability that a case with test positive
    • = a / a+c
    • = true positives / true positives + false negatives
    • if sensitivity is high then the test is very good at correctly identifying the disease you are screening for
  86. talk about the positive predictive value of the test and prevalance
    • probability someone who has tested positive actually has the disease
    • value is strongly influenced by prevalence of the disease
    • = a / a+b
    • = true positives / true positives + false positives
    • low prevalence = lower ppv
    • prevalence = a+c / a+b+c+d
    • (true positives + false negatives / whole population)
  87. talk about the negative predicted value of the test
    • proportion of the people who are test negative who do not have the disease
    • = d / c+d
    • = true negatives / false negatives + true negatives
  88. what are the issues raised by screening
    • alteration of usual doctor patient contract: doctor approaching healthy person turns people into patients
    • complexity of screening programmes:
    • evaluation of screening programmes: must be based on good quality evidence, lead time bias - false apperance that survival is prolongued, length time bias - slow easy treat diseases are detected so have a favourable prognosis
    • limitations of screening: need informed choice
    • sociological critiques of screening: victim blaming, individualising pathology, surveillance critiques and feminist critiques
  89. three core principles of the nhs
    • universal
    • comprehensive
    • free at point of delivery
  90. what is the 2010 white paper and how may it affect the nhs?
    equity and excellence: liberating th nhs

    • devolution of power to front line
    • role of allocation to GPs
    • increase in use of markets
    • save £20 billion by 2014
  91. nhs structure from 2002-2010?
  92. what are the responsibilities of the department of health/secretary of state for health?
    • setting national standards
    • shaping direction of the NHS
    • set national tariff

    • overall responsibility
    • health services, social care and public health
  93. what are the SHAs
    what are their 3 main responsibilities
    • strategic health authorities
    • link between DH, PCTs and hospital trusts

    • oversee planning and development
    • build capacity of local services
    • performance management
  94. what are primary care trusts
    • improve public health
    • determin local health needs and ensure they are met
    • commission primary secondary and community health care for the local population
    • responsible for the flow of the majority of the budget
    • clinical governance
    • address NSF requirements
    • ensure NICE guidelines are followed
  95. what is the board?
    runs the trust (often several hospitals)

    • strategy setting
    • operational management
    • respond to local need and national requirement
  96. what are medical directors
    • one person per trust
    • the most senior doctor
    • responsible for quality of care
    • communicate between the board and medical staff
    • must show leadership
    • must demonstrate appropriate values
    • in partnership with human resources
  97. what are some of the tasks of the medical director?
    • approve job descriptions
    • discipline
    • interview panels and equal ops
    • clinical excellence points - salary top ups
    • conduct strategic overview
  98. what are clinical directorates?
    • these are the sections a hospital is organised into
    • can be divided based on speciality or group of specialities
    • each is led by a clinical director
  99. what is the role of the clinical directors?
    • provide continuing education and training
    • policies on junior doctors hours, pay, supervision, tasks and responsibilites
    • implement clinical audit
    • develop management guidelines and protocols for clinical procedures
    • induction of new doctors
  100. what management skills do doctors need?
    • strategic: analyse plan make decisions
    • financial: set priorities manage a budget
    • operational: run things execute plans
    • human resources: manage people and teams
  101. why do we need to set priorities in the NHS?
    • health care expenditure is rising
    • we have an aging population and an increasing burden of disease - demography
    • new stuff is expensive and is offering increased survival not a cure - technology
    • consumerism
  102. what levels of rationing currently exist within the NHS?
    • 1. how much money the government allocate to the NHS vs other priorities eg. education
    • 2. how much is allocated across different sectors eg. mental health, cancer
    • 3. how much does each sector allocate to specific interventions
    • 4. how are interventions allocated between different patients in the same group
    • 5. how much to invest in a patient once an intervention has been initiated
  103. how does rationing occur in the NHS - the 5D's
    • deterent: demands obstructed
    • delay: waiting lists
    • deflection: GPs deflect demand from secondary care
    • dilution: fewer cheaper tests, generic drugs
    • denial: range of services denied to patients
  104. what is the difference between implict and explicit?
    • implict: care is limited but neither the decisions or the bases of the decisions are clearly expressed. this was common pre 1990 clinicians made decisions on whether or not to give treatment
    • explicit: based on defined rules of entitlement
  105. what are the problems with implicit rationing?
    • can lead to inequalities and discrimination
    • open to abuse
    • based on social deservingness not clinical need
    • doctors are unwilling to do it
  106. what are the processes involved in explicit rationing?
    • technical
    • political
  107. what are the advantages and disadvantages of explicit rationing?
    • advantages:
    • transparent
    • accountable
    • oppertunity for debate
    • use of EBP
    • more oppertunities for equity

    • disadvantages:
    • complex
    • heterogenicity of patients and illnesses
    • patient and professional hostility
    • threat to clinical freedom
    • patient distress
  108. what do NICE and PCTs have to do with rationing?
    NICE provide guidance which must be followed on whether new and existing treatments can be recommended for use in the NHS in England and Wales

    PCTs have to determin priorities but if NICE chose to pass something the PCT must make it available
  109. what are tariffs?
    • set nationally
    • improve quality
    • only get paid fixed amount
  110. why don't we just let the public decide about treatments?
    • consultation is problematic
    • resistance to the inevitability of rationing
    • value heroic interventions
    • preference to treat patients with dependants
    • a willingness to discriminate against people who are partially responsible for their illness
    • contrary to spirit of equity
    • not inline with cost effectiveness
  111. what are health economics?
    • provides: a way of thinking and a set of techniques
    • aims to promote: efficiency and equity

    maximising social benefit subject to the resource availability constraints
  112. what are the basic concepts in health economics?
    • scarcity: need outstrips resources
    • efficiency: getting the most out of limited resources
    • equity: same need - same treatment
    • effectiveness: the extent to which an intervention produces the desired outcome
    • utility: the value an individual places on health state
    • oppertunity cost: once you have used a resource in one way it cannot be used in another way this is measured in BENEFITS FOREGONE
  113. what is the difference between technical efficiency and allocative efficiency?
    • technical: most efficient way of meeting a need
    • allocative: choosing between the needs that need to be met
  114. how do you measure costs?
    identify, quantify, value resources needed

    costs include: direct, indirect, intangible, recurring/non-recurring, start up/maintenance
  115. what are the four types of economic evaluation?
    • 1. cost minimisation analysis
    • 2. cost effectiveness ananlysis
    • 3. cost benefit analysis
    • 4. cost utility analysis
  116. what is cost minimisation analysis?
    • outcomes assumed to be equivalent
    • focus is on cost
    • eg. what protheses should be used for a hip replacement
  117. what is the cost effectiveness analysis?
    • used to compare interventions with a common health outcome
    • is extra benefit worth extra cost?
  118. what is the cost benefit analysis?
    • all inputs and outputs valued in monetary terms
    • can be used to compare interventions outside of healthcare
    • methodologically difficult
    • HARD
  119. what is the cost utility analysis?
    • a type of cost effectiveness analysis
    • focuses on quality of health outcomes produced or foregone
    • most frequently used measure is QALY
    • interventions can be compared in cost per QALY terms
  120. what are QALYs and why do we use them?
    • survival and quality of life
    • used since 1970s
    • allow broad comparisons against differing programmes
    • 1 year of perfect health = 1 QALY
    • measure QoL on a HR-QoL instrument eg. EQ-5D
  121. how are costs per QALY used by NICE?
    • QALY score is intergrated with the price of the treatment using the incremental cost-effectiveness ratio (ICER)
    • ICER represents the change in cost in relation to the change in health status
    • this results in cost per QALY figure
  122. what are the criticisms of QALYs
    • do not distribute resources according to need but according to benefits gained per unit of cost
    • technical problems with their calulations
    • QALYs may not embrace all the dimensions of benefit
    • values expressed by experimental subjects may not be representative
    • problems with the evidence of the RCTs used - length of follow up, atypical care, atypical patients, limited generalisability, sample sizes
  123. what is professionalisation
    describes the social and historical process that results in an occupation becoming a profession
  124. what are the three normal elements involved in professionalisation
    asserting a claim over a body of knowledge/expertise

    establishing control over market and exclusion of competitors

    establishing control over professional work practice
  125. key events in the professionalisation of medicine
    • 1518 - henry VIII founds royal college of physicians need an oxford/cambridge degree, anglican. latin exam. based on elite status/social background
    • 1815 - apothecary act
    • 1858 - medical act gives GMC power over registration of doctors, approval and registration of medical schools, doctrine of clinical autonomy (SELF REGULATION)
    • D
  126. what is meant by socialisation into the medical profession?
    • learning values and attitudes
    • by interacting with others
    • absorbing norms and values
  127. what is the difference between the formal and informal curriculum in medical education
    • formal: knowledge tested in exams formally taught
    • informal: attitudes and beliefs not formally examined but observed in work place self learnt
  128. why has the medical profession altered so much since the 1990's?
    • bristol enquiry
    • harold shipman
    • rodney ledward
    • ...
    • the rules were victorian
    • people didn't feel able to report
    • ettiquette rules prevented doctors reporting each other
    • the quality of evidence required was too high
    • credibility gap
  129. how has the GMC changed to fall into line after the disasterous mistakes highlighted in the 1990's?
    • 1993 - tomorrow's doctors
    • 1995 - medical (professional performance) act
    • 1997 - clinical competence
    • 2004 - fitness to practice new proceedures
    • 2007 white paper - trust assurance and safety: the regulation of healthcare professionals in the 21st century - parity of externally appointed layy and professional members, overseen by the council for healthcare regulatory excellence, civil standard of proof required, revalidation introduced
    • rise of managerialism rather than administration
  130. what are the risks of the new structure of the GMC and medical profession after the changes in response to the 1990's?
    • expensive
    • waste time prooving you are good
    • reflection for the sake of it
    • goal displacement - focus on showing you are doing it not actually doing it
    • too harsh on doctors