health and disease in society

• ensure best possible care
• variations in health care
• evidence of medical errors
• growing legal bills
• cost of extra bed days

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

• safety
• accessibility
• equity
• patient centred
• effectiveness
• efficiency

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

• 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

• 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.

• 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

standardise, create independent checks, learn when things go wrong

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'

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

• 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.

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

• 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

• 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

• topic under investigation
• research teams preferance/expertise
• time and money available
• funders/audience

different methods can be used in the same study

intergration of individual clinical expertise with the best available external clinical evidence from systematic research

• 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

• 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

• 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

segement of the population distinguished from others by its similarities in labour market position and property relations

• 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

• 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

• social status
• wealth
• environment
• education

• 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

• 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

• artefact
• social-selection
• behavioural-cultural
• materialist

• 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

• 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

• 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

• inequalities in health arise from differential access to material resources
• low income, unemployment, work environments, low control over job, poor housing
• most powerful explanation

• 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

• inequality - when things are different
• inequity - inequalities that are unfair and avoidable

• 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

• impact on health behaviour
• impact on illness behaviour - what people do when they have symptoms
• impact on compliance/adherance with treatment

• 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

• 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

• 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

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

• 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

• 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

the process of enabling people to increase control over and improve their health

• 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

• 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

• 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

• DILEMMAS
• 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
• PREVENTION PARADOX
• interventions that make a difference at the population level may not have much of an effect on the individual
• EVALUTATION
• 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

• 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

• focuses on how the chronic illness impacts on social interaction and role performance
• negotiated reality

• the storytelling and accounting practices that occur in the face of illness
• often includes the onset, getting a diagnosis, reaction to the diagnosis

• 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

• 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

• 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

process by which the shattered self is reconstructed in ways which explain the appearance of illness

• 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

• use of word handicap
• impleies problems are intrinsic

• MEDICAL
• 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

• MEDICAL
• 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

• 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

• 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

• mortality
• morbidity
• patient based outcomes

• not always recorded acurately
• doesn't assess outcomes or quality of care

• collection not always acurate/reliable
• doesn't tell anything about patient experience
• not always easy to use in evaluation

• 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

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

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

• physical function
• symptoms
• global judgement of health
• psychological wellbeing
• social wellbeing
• cognitive functioning
• personal constructs
• satisfaction with care

• qualitative
• quantitative - specific or generic

• appropriate in some cases
• gives access to areas other don't reach
• good for an intial look
• very resource hungry
• not easy to evaluate

• 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)

• try to capture broad range of aspects of health status
• relevant to wide range of patients
• ADVANTAGES
• 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

• DISADVANTAGES
• loss of detail
• loss of relevance
• may be less sensitive to change as a result of an intervention
• may be less acceptable

• 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

• 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

• 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

• ADVANTAGES
• very relevant content
• sensitive to change
• acceptable to patients

• DISADVANTAGES
• can't be used in people who don't have the disease
• comparison is limited
• may not detect unexpected effects

• specific instrument
• specific site
• 12 items
• have you in the last 4 weeks been able to ...?

• 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

• person presents with sypmtoms
• self defined as patient
• presents to GP, A&E, etc
• a diagnosis is made

• person presents with symptoms related to a disease/problem
• GP then takes this opportunity to check for other diseases eg. BP measurement, urine dipstick

• 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

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

• 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

• 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

• 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

• 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

• 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

• 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

• 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)

• proportion of the people who are test negative who do not have the disease
• = d / c+d
• = true negatives / false negatives + true negatives

• 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

• universal
• comprehensive
• free at point of delivery

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

• setting national standards
• shaping direction of the NHS
• set national tariff

• overall responsibility
• health services, social care and public health

• strategic health authorities
• link between DH, PCTs and hospital trusts

• oversee planning and development
• build capacity of local services
• performance management

• 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

runs the trust (often several hospitals)

• strategy setting
• operational management
• respond to local need and national requirement

• 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

• approve job descriptions
• discipline
• interview panels and equal ops
• clinical excellence points - salary top ups
• conduct strategic overview

• 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

• 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

• strategic: analyse plan make decisions
• financial: set priorities manage a budget
• operational: run things execute plans
• human resources: manage people and teams

• 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

• 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

• 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

• 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

• can lead to inequalities and discrimination
• open to abuse
• based on social deservingness not clinical need
• doctors are unwilling to do it

• technical
• political

• 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

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

• set nationally
• improve quality
• only get paid fixed amount

• 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

• 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

• 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

• technical: most efficient way of meeting a need
• allocative: choosing between the needs that need to be met

identify, quantify, value resources needed

costs include: direct, indirect, intangible, recurring/non-recurring, start up/maintenance

• 1. cost minimisation analysis
• 2. cost effectiveness ananlysis
• 3. cost benefit analysis
• 4. cost utility analysis

• outcomes assumed to be equivalent
• focus is on cost
• eg. what protheses should be used for a hip replacement

• used to compare interventions with a common health outcome
• is extra benefit worth extra cost?

• all inputs and outputs valued in monetary terms
• can be used to compare interventions outside of healthcare
• methodologically difficult
• HARD

• 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

• 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

• 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

• 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

describes the social and historical process that results in an occupation becoming a profession

asserting a claim over a body of knowledge/expertise

establishing control over market and exclusion of competitors

establishing control over professional work practice

• 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

• learning values and attitudes
• by interacting with others
• absorbing norms and values

• formal: knowledge tested in exams formally taught
• informal: attitudes and beliefs not formally examined but observed in work place self learnt

• 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

• 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

• 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