Non-Medical Sciences

Stages of an Audit

- Preparation

- Select a criteria for standards

- Measure level of performance

- Make improvements

- Sustain improvemenys

- (Reaudit)

Values of the NHS

- Collaboration

- Compassion

- Commitment to care

- Respect and dignity

- Improving lives

- Everyone counts

NHS Constiutions

Department of Health (2011)

- what dr + pt can expect from NHS

- protected from sudden political change

Health and Social Act (2012)

- Clinically led commissioning

- Increased pt involvement in NHS

- Renewed focus on public health (Public Health England)

- Concerned bodies to set standards for care + data collection

- Allow healthcare market competition in best interest of pt

Clinical Commissioning Groups (CCGs)

- Run by GPs, nurses + consultants

- Healthcare for local area

- In charge of 60% of NHS budget

NHS Foundation Trusts

- Care provided by CCG's commission

Eg. ambulance, primary care services

Types of Private Healthcare

Type 1 + Type 2

Type 1 Private Healthcare

Pt pays for healthcare directly / private health insurance

Type 2 Private Healthcare

Healthcare remains public but services are outsourced to private firms

Stigma

Negative stereotyping associated with a particular characteristic leading to discrimination

Types of Stigma

- Discreditable stigma

- Discrediting stigma

- Enacted stigma

- Felt stigma

- Projected stigma

Discreditable Stigma

Can be hidden from others

Discrediting Stigma

Can not be hidden from others

Enacted Stigma

Discrimination due to being different

Mechanic and Volkart's Triggers to Consultation

- Frequency of illness in population

- Familiarity of symptoms

- Predictability of outcome of illness

- Amount of threat + loss resulting from illness

Health Belief Model

(3PsBCS) (SSBBCS)

- Perceived susceptibility

- Perceived severity

- Perceived benefit

- Barriers

- Cue to action

- Self efficacy

4 Quadrants Approach (for decision making)

- Medical indications

- Patient preferences

- Quality of life

- Contextual features

Tanahill's Model of Health Promotion

(PPE)

- Prevention

- Protection

- Education

Dalgren + Whitehead's Rainbow Model (1991)

[innermost to outermost]

- Age, sex and constitutional factors

- Individual lifestyle factors

- Social + community networks

- Living + network conditions

OCEAN Personality Structure

- Openness

- Conscientiousness

- Extroverted

- Agreeability

- Neuroticism

Screening for Women: Breast Screening

- 50-70 yrs

- 70+ can self refer

Screening for Elderly: Bowel Cancer Screening

- 60-74 yrs

- home test kit every 2 yrs

Screening for Elderly: Abdominal Aortic Aneurisms (AAA) Testing

- 65+ yrs

- detects dangerous swelling in aorta

Prenatal Testing

- Amniocentesis

- Chronic villus sampling (CVS)

Prenatal Testing: Carrier Testing

Identification of genetic mutations inherited in an autosomal recessive fashion

Dignity Conservation

(ABCD)

- Attitude

- Behaviour

- Compassion

- Dialogue

Preservation of Dignity

- Control + autonomy

- Privacy

- Emotional processing

- Confidentiality + discretion

- Communication

Theory of Epidemiological Change

- Complex change in patterns of health + disease

- Includes interactions between these patterns + their demographic, economic + sociological determinants + consequences

- Made up of 5 propositions

Theory of Epidemiological Change: Proposition 2

- Long-term shifts in mortality + disease patterns

- Pandemics of infection replaced by degenerative / man-made disease as the main cause of death

3 Stages:

- Age of pestilence + famine

- Age of receding pandemics

- Age of degenerative + man-made diseases

Theory of Epidemiological Change: Proposition 3

Most profound changes in health + disease pattern are amongst children + young women

Theory of Epidemiological Change: Proposition 4

Shift in health + disease patterns closely associated to transitions in demographic + socioeconomic transitions

Theory of Epidemiological Change: Proposition 5

- Peculiar variation in pattern, pace, determinants + consequences of population change

3 Basic Models:

- Classical

- Accelerated

- Contemporary

Theory of Epidemiological Change: Proposition 5 (Classical)

Progressive transition from high mortality + fertility to low mortality + fertility

Theory of Epidemiological Change: Proposition 5 (Accelerated)

- Accelerated mortality transition

- Fluctuates from age of pestilence + famine and early phase of age of receding pandemics followed by classical model

Theory of Epidemiological Change: Proposition 5 (Contemporary)

Recent decrease in mortality whilst fertility is high

Avoiding Attachment

Mother - distant, disengaged

Child - not very explorative, emotionally distant

Reasonable Patient Test

What would a reasonable pt want to know

Specific Patient Test

What would a specific pt want to know

Mental Capacity Act (2005)

- Applies to 18+ with mental illness

1. Assume they are competent

2. Make an effort to help them make an informed decision

3. They have the right to make the 'wrong' choice

If non-capacitous

- Make a decision in their best interest

5. Make it as least restrictive as possible

Gillick Competence

- Children <16 yrs may consent if they show sufficient understanding

- Both pt + dr must be understand the dynamic of medical issue, dynamic of family and moral issues

Fraser Guidelines on Contraception

Girls <16 yrs must be given contraception if they ask for it

Legally Breaching Confidentiality

- By statue in litigation + fitness to practice cases

- Prevention + prosecution of serious crime

- Notifiable diseases - this does not include HIV/AIDS

- Audits + public health surveillance

- Coroner's inquest

- Reporting gunshot + knife wounds

Social drift and Social Causation

Social Drift - illness leads to low socioeconomic status

Social Causation - low socioeconomic status leads to illness

Disadvantages of Medical Dominance

Exclusion - takes away legitimacy of other professionals

Limitations - restricts other health territories

Subordination - makes sure that other health professionals work under and answer to doctors

Felt Stigma

Feelings of shame + guilt due to experiencing stigma

Projected Stigma

Tactics to avoid enacted stigma

Transtheoretical Model of Change

PCPAM

- Precontemplation

- Contemplation

- Preparation

- Action

- Maintenance

Note: Can enter / exit / re-enter at any stage of the cycle

Prima Fascie

- Principle is binding unless it conflicts with another moral principle

- If it does you must choose between them

- Principle is correct unless proven otherwise

- Use of discretion + judgement to decide which principle outweighs the other

Ross' Prima Facie Duties

- Fidelity

- Reparations

- Gratitude

- Justice

- Beneficence

- Self-improvement

- Non-maleficence

Human Rights Act (1998)

Respect pt rights even if their personal preferences do not align with your own

Salutogenesis

Medical approach focusing on factors that support health + well-being rather than factors that cause disease

Public Health England

- Protects + improves nation's health

- Decreases health inequalities

- Sponsored by Department of Health and Social Care

- Conducts research to improve public health challenges

Food Standards Agency (FSA) (2000)

- Protects public health + consumer's wider interests in relation to food

- Created after several high profile food-bourne illnesses

Factors FSA Monitor

- Food supply

- Food price

- Food availability

- Animal welfare

Marmot's Health Inequality Factors

(HIDES)

- Housing

- Income

- Disability

- Education

- Social isolation

6 Policy Objectives

- Give children the best start in life

- Enable all children to maximise capabilities

- Create fair employment

- Ensure healthy standard of living

- Strengthen role + impact of ill-health prevention

Parsons (1951)

- Implements social order (paternalism)

- Pt who fails to comply viewed as deviant

Stimson (1974)

Patients should have a say in their regimen

Compliance

Extent to which a a pt behaviour matches presciber's recommendations

Concordance

- Open negotiation + agreement

- Both dr + pt have equally valid health beliefs

Internal Locus

Individuals believe they are in control of what happens to them

External Locus

Individuals believe that external factors are in control of what happens to them

What makes up Public Law?

Statue law + Common law

Civil Law / Private Law

- Person vs Person

Tort's Law

- Branch of civil law

- Deals with acts leading to harm of an individual's rights, property or reputation

- Fair compensation

Contract Law

Ensures parties abide by mutual obligations

Important Human Rights Articles

(2,3,5,8)

- Right to Life (article 2)

- Prohibition of Torture (article 3)

- Right to Liberty (article 5)

- Right to respect for private life (article 8)

Priority Setting

(AIM DEN)

- Age

- Type of illness

- Merit

- Demand

- Effectiveness

- Need

Replacement Rate

- Number of children a couple would have to have to replace themselves

- Less developed countries require more children per couple due to death (additional 0.1-0.3)

Replacement Rate + Fertility Rate

- More developed countries have a tendency towards replacement

- Higher fertility rate than replacement rate leads to population growth

- Lower fertility rate than replacement rate leads to population decline but it takes a few decades

Why more developed countries have a tendency towards replacement

- Decreased child mortality rates

- Better access to food + medicine

- Less civil war

Population Screening

- Identifying healthy people who may have increased chance of a given disease

- Forms secondary prevention

- A programme of inter-related activities - not just a test

Benefits of Population Screening

- Improves long term health outcomes

- Sorts who may require additional testing

Difficulties of Population Screening

- False positives may lead to over-detection / over-treatment

Screening during Pregnancy

- Infectious diseases

- Down's, patau's and edward's syndrome

- Sickle cell disease and tharassaemia

- Physical abnormalities (mid-pregnancy scan)

Screening for Newborns

- Physical exam of eyes, heart, hips + testes

- Hearing test

- Blood spot test to check for rare conditions

Screening for diabetics

- Annual diabetic eye checks for 12+ yrs

- Detects early signs of diabetic retinopathy

Screening for Women

- Cervical screening

- Breast screening

Screening for Women: Cervical Screening

- 25-64 yrs

- Every 3 years for 26-49 yrs

- Every 5 yrs for 50-64 yrs

Screening for Elderly

- Bowel cancer screening

- Abdominal aortic aneurisms (AAA) testing

Focus Group

- Assembly of people discussing a particular viewpoint

- Researcher must be actively encouraging of + attentive to the group interaction

Advantages of Focus Groups

- Participation's thoughts

- Good at looking at what they think as they do exploratory research

- Quick results

- Saves time + money

- More data

- Minority group data

Disadvantages of Focus Groups

- Unsuitable for reflective practice

- Can cause conflict

- Use of vulnerable people

- Impact of bringing individuals from different levels of an ganisation

- Observer interference

- Sensitive topics are opted out

- Less control - discussion may go off topic

Genetic Testing during Pregnancy

- Carrier testing

- Pre-natal testing

Prenatal Testing: Amniocentesis

- Removal + testing of cells from amniotic fluid

- Check's baby's genetic / chromosomal condition

Prenatal Testing: Chronic Villus Sampling (CVS)

- Small sample of cells from placenta removed for testing

- Can be carried out earlier than amniocentesis

Prenatal Testing: Psychological Impacts

- Concerns on tests

- Stress-provoking

Beeston + Globus (1979)

- Anxiety levels highest prior to amniocentesis

- Peaks again prior to test results notification

Psychological Impacts of Testing during Pregnancy

- Anxiety

- Embarrassment

- Inferior social status (mostly in women)

- Helplessness regarding offspring's health

Predictive Testing

One's own risk for developing a disease later on in life

Predictive Testing: Psychological Impacts

Distress after learning test results

Advantages of Genetic Testing

- Future decision making in a partner (carrier testing)

- Peace of mind

- Early treatment

Disadvantages of Genetic Testing

- Change in social status (may lead to stigma)

- Psychological distress

- Long process (esp in <18 yrs)

- Negative result may lead to survivors guilt

Risks in Genetic Testing

- Miscarriage

- Stigmatising children

- Breaking confidentiality to prevent harm to other family members

- Risk of selection / slow elimination og variety on population

- Is it beneficial for the child or the parent?

Dignity

Inherent worth of every human being

Effects of Breaching Dignity

- Embarrassment

- Withdrawal

- Anger

- Apologetic

Virtue Ethics

- Focuses on character of moral agent rather than righteousness of an action

- Fuller ethical analysis than just principilism / consequentialism

Principilism

Based on core moral principles than abstract philosophical theories

Consequentialism

Moral righteousness of an action is based solely on the outcomes

Utilitarianism

Bring about the greatest happiness for the greatest number of people

Stigma with the MMR Vaccine

- Less people getting MMR vaccine due to unsubstantiated claims released in the Lancet by Andrew Wakefield

- Loss in herd immunity