Health Servises HES

1. Primary prevention

   • Prevention before it occurs by promoting and maintaining good health.

   • E.g. interventions to address wider health determinants (poverty, housing, eduction, employment). Reduce risk factors (exercise, quit smoking). Immunisation

2. Secondary prevention

   • Early Dx & Rx of disease before onset of Sx - to reduce the impact of a disease

   • E.g. Screening (breast Ca), care pathways, Rx like diet or exercise to reduce risk

3. Tertiary prevention

   • Optimal Rx of established condition to soften the impact and improve QOL.

   • E.g. limit disease progression, rehabilitation, support groups

4. Quaternary prevention

   • Avoid over medicalisation - protect from unnecessary intervention / medical harm

1. Absence of disease - medical model of health

2. Well being - health seen as complete physical, mental and social wellbeing

3. A resource - Health is resource of everyday life, benefits social and personal factors not just physical and mental health

• Income

• Education

• Employment

• Housing

• Social connection

• Environment

• Commercial influences

• Healthcare

Doctors treat disease while health promotions addresses the conditions that create diseases

• The process of enabling people to increase control over, and improve their health (Ottawa charter)

• The combination of educational and environmental supports for actions and conditions of living conducive to health (Green L, Kreuter M 1990)

Healthcare

• Vaccination programmes

• Diabetes Prevention Programme

• Smoking cessation

Community

• Active travel schemes

• Green social prescribing

Policy

• Soft drinks levy

• Tobacco legislation

Digital

• Online safety regulations

• Digital literacy programmes

• Bio Medical (clinicians)- Absence of disease, promoting models

  • Rx BP, assess risk factors, GP review

• Behavioural (individual)- Health as energy, functional ability of an individual, disease-preventing lifestyles.

  • salt reduction, smoking cessation, weight management

• Socio-environmental (local athority / Gov)- Connected to one’s family/friends/community, being in control, ability to carry out tasks that are important or have meaning.

  • living condition, active travel, work/school health policies

1. High-risk approach

   • identify few who are at high risk & target intervention on them > large benefit to those at high risk. E.g. CVD screening in primary care

   • Cons: leaves the root cause untouched > small impact on total disese burden

2. Population approach

   • target whole population for intervention - modify their risk > great population benefit. E.g get everyone to reduce salt to better their BP

   • Cons: although huge benefit to community, it offers little benefit to each individual

BCT help to understand why people behave the way they do.

• Individual level theories

• Interpersonal level theory

• Community level theories

Note: learn about behaviour change wheel (COM-B model)

• Capability - do they know how?

• Opportunity - can they?

• Motivation - Do they want to?

It demonstrate the strategies that are available.

• Eliminate choice - isolation of patients with infectious diseases.

• Restrict choice - remove unhealthy ingredients from food.

• Guide choice through disincentives - taxes on cigarettes

• Guide choices through incentives - tax breaks for buying bikes used to travel to work.

• Guide choices through changing the default policy: instead of chips provide another healthy option

• Enable choice: enable individuals to change their behaviours > participation in stop smoking programmes.

• Provide information to public - encourage to walk more.

• Do nothing or simply monitor the current situation.

1. Health communication - to positively influence e.g ads, billboards, leaflets, food labelling

2. Health education - aim to improve knowledge / skills beneficial to health to patient / community. E.g how to manage asthma / DM, 1:1 sessions

3. Self-help / mutual aid - people with common experiences support eatch other e.g. alcoholic anonymous, CVD rehabs

4. Organisational change - create supporting evironment to make healthy choices e.g no smoking /healthy eating policy

5. Community development / mobilisation - petitions by locals

6. Policy / legislation - enforced by law e.g smoke free zones, seat belt, sugar tax

Tuberculosis

• Social interventions (improved housing, hygiene, wealth) allowed for a drastic reduction in the prevalence of TB

•  Medical interventions (antibiotics and immunization) allowed for further reductions in prevalence.

• Should consider health promotion in all consultations. 

• Ask about lifestyle (smoking / exercise)

• Offer advice and appropriate referral, e.g., dietician and smoking cessation service

• Empower patients to manage chronic disease and offer appropriate support.

• Goal setting, review, monitor

• Undertake public health research.

• Contribute to national reports.

• Advocacy by professional bodies/coalitions (have huge influence in governments - help change policies)

• define screening, interpret the sensitivity / specificy & predictive values of a screening test

• Differentiate between screening programmes & diagnostic test

• Potential harms of screening

• Describe the criteria for assessing the appropriateness of implementing a population screening programme

• Explain “ volunteer bias”, “lead time bias” and length time bias

• It is a process of identifying apparently healthy people who may be at increased risk of disease / condition

• They can be offered information, further tests, Rx to reduce their risk +/- any complications arising from the disease

• Leads to early detection of - disease (Cancer), pre-cursor to disease or susceptibility to disease (CVD) in people with no signs or Sx of the disease

• Can be done by - questionnaire (score), exam (BP check), lab (smear test) or imaging (mammography)

• Sensitivity = rate of true +ves (TP) - proportion of diseased people correctly identified as diseased (i.e how good is the test at picking up the disease) > few false -ve

  • Sensitivity = a/(a+c)

  • More useful when the test result is -ve > ideal for screening where missing a disease > serious consequences e.g transfusing HIV +ve blood

• Specificity = rate of true -ves (TN) - proportion of healthy people identified as healthy. (i.e how good the test is at R/O people without the condition) > few false +ve

  • Specificity = d/(b+d)

  • Most useful when test result is +ve > less likely to label healthy person as diseased = ideal for screening where false Dx can be serious e.g. TOP as Dx Down’s

In summary: 

• Higher sensitivity is good at ruling people out through an increasing rate of true positives

• Higher specificity is good at ruling people in through an increasing rate of true negatives

Predictive values can be calculate to figure out how positive or negative a result actually is. i.e:

• If you test positive, how likely is it that you really have the disease? -> PPV = a/(a+b)

• If you test negative, how likely is it that you really don't have the disease? -> NPV = d/(c+d)

• Prevalence = how common or rare the disease is in the group being tested?

• Single best factor which impacts the PPV / NPV

• Prevalence of a disease = (a+c) / (a+b+c+d)

• To calculate ‘a’ - work out no of true +ve

• Prevalence is 1 in 1000 > in a population of 100k, 100 pts with HIV. Out of these, the test wil identify 99% (sensitivity) as having the disease -> so ‘a’ = 99

• Using this, can calculate ‘c’ - false -ve = 100-99 = 1

• This leaves population of 99,900 without disease (100k-100

• To calculate ‘d’ -work out true negative

• There are 99,900 people without HIV - of these the test will correctly identify 99% (specificity) —> 99,900 x 0.99 = 98,901 TNs = ‘d’

• Using this, calculate ‘b’ - false +ve

  • Test would have flagged 1% as +ve falsly > 99,900 (without the disease) - 98,901 (correctly identified as without disease) = 999 = FPs = ‘b’

Using these, +ve predictive value (PPV) and -ve predictive value (NPV) can be calculated

In this E.g. the +ve PV of 9.02% = of those tested +ve, only 9.02% actually had the disease, the rest are false +ve

The -ve PV of 99.99% means if you tested -ve, its 99% reassuring that you dont have the disese.

Screening programmes:

• Comprehensive disease control activity based on the identification & Rx of persons with either unrecognised disease or unrecognised risk factor for disease

• The benefit must outweights the risk caused by screening

Screening test:

• Specific technology (survey questionnaire, physical observation or measurement, laboratory test, radiological procedure, etc.) used to help identify persons with unrecognized disease or unrecognized risk factors for disease.

Despite potential benefits such as early Dx, less invasive Rx, better outcomes & reduced mortality, there are potential harms:

• True +ve > being labelled

• False -ve > false reassurance, disregard Sx, delayed intervention

• False +ve > cost of futher test, anxiety, fear of future screening

• True -ve > cost & risks of screening programme

Screening in UK employes national screening committee that

• Addvises ministers using latest research evidence, MDT expert groups & patient/service users.

• Assess proposed new screening against the crieteria to ensure it will do more good than harm at resonable cost

Examples of screening programmes:

• AAA, bowel cancer, cervical screening, newborn / preg screening, breast and diabetic eye

-> Natural Hx of disease - conditions worth screening only if the natural Hx of disease is understood. To do this, need:

• Pre-clinical detectable period, tests that can be applied and treatment that will alter outcome

-> Criteria used by NSC (pic)

Biases can occur when comparing outcomes (e.g survival time) of patients identified by screening to those identified clinically, bias can occur:

-> Volunteer bias

• Decision to attend screening is often influenced by individual’s health awreness.

• ?more healthy people attend screening - important to consider how participants recruited for screening

-> Lead time bias

• Amount of time gained by earlier detection of a cancer by screening than by later detection with Sx -> apparent increase survival.

• To minimise this bias, mortality rate should be Ax rather than survival

• Early Dx doesnt necessarily mean longer life

-> Length time bias

• Those with long pre-clinical phase more likely to be detected by screening + have better progosis (less aggressive disease)

• 
  

• Define tertiary prevention

• Describe some examples

• Integrate prevention concepts

Reducing impact of disease (once established) in symptomatic patients. Main goals are:

1. Provision of Rx and rehab to minimise progression & complication e.g # prevention in osteoporosis

• Targets patients with establised (chronic) disease

  • Intervention starts after acute pahse is over

  • Focused on specific, often small group of people living with the illness

• Focus is to improve function & prevent further disabiity / complications & disease progression

• There is lack of clear boundaries:

  • Ongoing process > long term interventions > No clear end point

  • In most areas, there is limited evidences & poor consensus = need to be adaptive, MDT

Can be carried out either via rehab programme or chronic disease management.

• Typically complex interventions - multifaceted at multiple levels that work together

Possible strategies:

• Medical Rx + routine reviews

  • E.g. DM (monitor BMs / U+E / eye), cancer survivor (monitor for recurrence / Rx SE), chronic pain, osteoporosis (bisphophonates)

• Rehabilitation (PT/OT)

  • E.g post CVD, CVA (speech / mobility / motor skills), pulmonary (breathing / QOL) and amputation (for functional independence)

• Patient education & self-management - mobile apps / support groups

Input comes from MDT

• Doctor, specialist nurse, OT, PT, dietician, pharmacist, social worker, SALT, psychologist

Primary:

• Health promotion around smoking, alcohol, exercise, healthy weight, diet.

• Rx CVD risks - HTN, high cholesterol, obesity, DM

Secondary:

• Early recognition using FAST (Face, Arms, Speech, Time).

• Management of TIA via medications and surgeries. E.g. anti-platelents, statin, anti-HTN, carotid endarterectomy

Tertiary

• Stroke rehab to regain lost functions and improve QOL.

• MDT for holistic approach, Long term process with specialist stroke units, tailored to patient’s need

• Evidence based - stroke rehab reduces disability & mortality

• E.g SALT (speech,swallowing), PT (mobility, balance, coordination), OT (care needs, ADL), cognitive therapy (momory, attention), psychological counselling (depression, anxiety)

Tobacco is the leading cause of illness, disability & death

• Has significant cost impact, accounts for 25% of cancers

• High prevalence in - men, unemployed, in deprived areas, gay / lesbian / bisexual, lack of qualifications

Control measures

• Public awareness campaigns, health warning on packaging, tobacco duty & tax

• Age restrictions, ban open display, ban public smokin

• Offer pharmacotherapy & behaviour support

• It is about caring for people in incurable illness to relieve their suffering & supporting them through difficult time.

• WHO - An approach that improves QOL of patients & families facing life threatening illness through prevention & relief by early identification, assessment & Rx of pain, physical, psychosocial & spiritual needs.

  • Can be in conjunction with other therapies to prolong life e.g chemo or RT

Supportive palliative care

• Is about living as well as dying - aim is not to prolong life or shorten it, but to improve QOL for the time left. Can complement the Rx already being given.

• As the population is increasing & more people are living longer > more people surviving iwth chronic conditions = more people will need palliative as time progresses.

• Enables the supportive and palliative care needs of both patient and family to be identified and met throughout the last phase of life and into bereavement.

• Aim to help somone nearing EOL to be comfortable.

• Supportive care = management & prevention of adverse effects caused by cancer & its Rx. - including physical & psychosocial support. e.g Macmillian

• It is not same as palliative care - it is a form of palliative care to help those in their final months / yr of their life.

There should be a holistic approach to palliative care where we look at the patient’s:

• Physical symptoms and needs.

• Psychological well being.

• Social factors and situations.

• Spiritual beliefs and needs.  

Total pain - one issue affecting / causing issues in other areas.

• Frailty / co-morbidities / dementia

• Organ failure

• Cancer

• sudden unexpected death

-> Most people now a days die in the hospital, next is their own home, then NH & few in hospice.

NHS EOL policy 2008

• Covers all conditions & all settings.

• Aim to bring QOL to those approaching EOL, enchance choice in life and invest in palliative.

Liverpool care pathway 2013

• Removed due to lack of communications with family.

• Later replaced with individual EOL care plan - patient should be placed on EOL by senior cons with patient & health care team.

New national framework 2021-2026

• Each patients should be seen as individual & should have tailored EOL care specific to them. Should be well informed by HCPs on what their next Rx is.

• To maximise comfort & welbeing.

How people prepare for EOL care, and includes 3 elements.

• What do you want to happen (Advance statement): Statements of wishes and preferences, not legally binding.

• What do you NOT want to happen (Advance decision): Decision to refuse treatment (legally binding)

• Who will speak for you if you lack capacity: Assigning a proxy or lasting power of attorney.

1. Define the concepts of scarcity and opportunity cost

2. To recognise health care as an economic good

3. Define and distinguish between the concepts of technical

efficiency and allocative efficiency

4. Define economic evaluation

Key take home from this lecture:

• We can think of health care as being an economic good.

• No health care system in the World has ever achieved levels of spending sufficient to meet all the wants of all its clients.

• Health economics seeks to inform the allocation of scarce resources. It is NOT about choosing the cheapest option. It is about directing resources to treatments which bring about the greatest health improvement across the population.

Scaricity is the heart of all economics - how to use limited resources:

• Resources are limited or constrained. (finite resources)

• The potential uses of these resources are unbounded. (infinite wants)

-> As a society, we have finite resources but infinite wants - so need to be careful with how we use the limited resources.

-> Economics is therefore study of how decisions are made in the context of sarcity

• Quantify the costs & benefits of healthcare interventions

-> Economic goods = any good or service that is scarce relative to out wants for it

• Value of the consequences forgone by choosing to depoly resources in one way rather than in their best alternative use

  • Given in a fixed budget in NHS, increasing production in one speciality > diverting resources away from other

• E.g If hospital have 1m for budget and it choose to spend it on new lab, the opportunity cost would have been extra nurse hire / other outreach programme that it can no longer fund

Positive economics

• An objective, fact-based stream of economics, focusing on data analysis and the use of facts and figures

• Makes objective statements that can be proven / disproven by researching the data

• “how does life expectancy in UK compared to Europe?”

Normatice economics

• Value based, sujective stream of economics which considers personal opinons & values to make decision on what is the right thing to do.

• “UK gov should increase spending on healthcare”

• Most rationing is by price in daily life

• When healthcare is free, there need to be other form of rationing or priority setting

  • Prioritise treatment which are most cost-effective > gives greatest amount of benefit / outcome for investment

  
  

Efficiency:

• The allocation of scarce resources in a way that best helps us achieve our goals. Important in both +ve & normative economics

• Technical efficiency = Producing output in best way possible, without wasting the limited resources i.e Optimise process for a given output

• Allocation efficiency =Producing output that best satisfy the consumer’s wants/needs

• In other words, TE looks at doing things right, while AE looks at doing the right thing overall

Equity

• Relate more on normatic economics & is synonymous with fairness & social justice.

• Most equitable outcome may not be most efficient

• Decision in NHS is made ideally based on evidence - which need to be generated -> economic evaluation

• Its the comparative analysis of alternative courses of action in terms of both cost & consequences - comparing standard Rx to new intervention

• Cost benefit analysis = monetary value of health improvement must be assessed

• Cost effective analysis = beneficial in techinical efficiency - cost expressed in units and outcome in numbers. E.g no of asthma attacks prevented

• Cost utility analysis = beneficial in allocative efficiency - cost expressed in units and outcome expressed as QOL yrs

Methods of economic evaluation:

• Above methods usually focuses on efficiency - but don’t address equity

ICER = difference in cost / difference in outcome

• E.g Zopiclone costs £1.75 > 6hrs sleep. Newer drug cost £2 > 7 hrs sleep

  • Cost difference = £2 -£1.75 = 0.25p

  • Outcome difference = 7-6 = 1hr

  • Henve ICER = 0.25/hr = costs 25p to get extra hr of sleep

• If the ratio is low, the decision is made to choose new, better Rx as cost is not high.

• Understand what outcomes and costs can be collected and measured within a health economic analysis 

• Understand the rationale for their inclusion

• Recognise the limitations of different measures of costs and outcomes

• Promoting the efficient use of heath care resources

• Ensuring that maximum total benefit is derived fom the limited resources available

Economic evaluation - need to identify relevant cost & outcome

Clinical outomes - measured in natural units

• Proxy outcome - e.g cancer detected / change in Ch level

  Condition specific measures - e.g Questionnaire for pain

  Generic measures - Yrs of life gained

• Advantages = measured as part of clinical study, easy to understand, transparent to clinicians

  Limitations = lack of comparability across different disease, what if more than one outcome?

In the HTN case study above:

• Shorterm outcome = BP reduction

  Longterm outcome = No of stroke/MIs, No of CVD & death

Which durg to fund A or A?

• Drug A - low cost, moderate impact on life expectancy/QOL

  Drug B - high cost, large impact on LE & QOL

QALYS = quality adjusted life yrs

• Combines length & QOL into one unit -> cost-utility analysis

• QOL measured - 1 (perfect health) to 0 (equivalent to death)

• QALY = Σ (length of life) x (QoL)

• X axis = yrs of life. Y axis = value of QOL

• Solid line = prognosis without treatmnet

• Dashed line = prognosis with treatment

• A = area where prognosis with Rx has additional QALYs

• B = area where no Rx gives more QALYs

• White area + B = QALYs without treatment

Calculating QALYs from graph above:

• Prognosis without treatment: (0.7x1) + (0.6x2) + (0.4x1) + (0.3x1) + (0.2x1) + (0.1x2) = 3.0

• Prognosis with treatment: (0.5x1) + (0.6x1) + (0.7x1) + (0.8x1) + (0.9x4) = 6.2

• Total gain in QALYs: 6.2 – 3.0 = 3.2

A questionnaire with predetermined weights, with each dimension having 5 levels:

The 5 dimentions:

• Mobility, self-care, usual activities, pain/discomfort and anxiety/depression

Outcomes of Euro-QoL 5L Health States

• Health state is how patient complete these questionnaire & each answers is assigned a number (tariff)

• Tariff = QOL value (lower QOL = lower tariff) 1= no problem

• E.g QOL with Rx > 11111 (value 1.0) for 10 yrs. vs QOL without Rx >21212 (value 0.743) for 10 yrs

  • QALYS = QALYs with Rx - without Rx for 10 yrs

    • (1.0x10) - (0.743x10) = 2.57 QALYs gained

1.      EQ-5D questionnaire.

2.      Value judgement (e.g., by asking clinical experts)

3.      Direct measurement of QOL from patients using health state description.

4.     Life tables & literature (long term), death recoded in study (short term)

5.      Published values in literature.

Advantages:

• Takes into account impact on quality & QOL

• Common unit of measure that can be used across disease areas

• Convenient tool for measurement e.g EQ-5D

Disadvantages:

• Places no emphasis on who gains the QALY - child vs old patient > not addressing equity

• Whose value we take ?patient / carer / clinican

• Insensitivity of questionnaire, EOL Rx

• Discrimination, may not take broader patient benefit into consideration, or family/carer benefit into consideration.

Patient benefits not captured by QALYs:

• Control / empowerment - pt feel in control of their condition due to intervention

• Reassurance - given by screening test

• Knowledge

• Satisfaction with care

• Capability - e.g independence

• Family / carer QOL

Health and social care costs:

• Intervention / related medications

• Primary care cost - GP / nurse visit

• Secondary care cost - A&E, OP, IP, surgery, test, Ix

• Social services - NH, POC, home adaptations

Patient / carer incurred cost:

• Cost of time & transport for health visits

• OTC meds / appliances

• Paid carers, informal carer time

Indirect costs:

• cost due to lost production = unable to work due to diability, time off work due to illness - these dont apply to UK analysis but are collected for reference

• Measurement of quantities of resources from case notes / data system / patient questionnaire

• Assigment of unit cost or price to those resources

• Define quity, types & distinguish from equality

• Explain importance of equity in economic evaluation

• Describe trade-offs between efficiency & equity in healthcare

• Identify methods used to integrate equity in economic evaluation

• Apply concepts to motivating economic exaples

-> Existing Economic evaluation methods such as cost benefit / cost effective & cost utility analysis focus on efficiency but don’t adress equity.

-> The standard cost effecitve analysis (CEA) methods don’t capture the health impacts of Equity.

-> Equity = fairness in the distribution and allocation of health across society.

• Equality on the other hand is giving equal access.

• Efficiency = greatest good for greatest number

-> Health Equity: addresses differences in population health that can be traced to unequal economic & social conditions

-> Health inequalities / disparities = Preventable health differences between groups of people - this can affect how frequently a disease affects a group & how many get sick

Horizontal equity

• Equal treatment / use of NHS resources of people who are in equal need > individuals with same need for care have same use of healthcare.

  • If 2 people need urgent lapchole, horizontal equity states both should get equal access to this service

Varitical Equity

• Unequal treatment / use of NHS resources of people who are unequal in needs > individuals with different levels if illness have different level of use

  • pt with complex illness would get more resources allocated compared to one with minor illness

Comparing extra cost or new Rx against the extra health outcomes, CEA might not be enough because:

• Considering equity in economic evaluation in itself impose a cost

• Impact of policy decisions in distribution of costs & benefits on variables like gender, age, location, severeity, status

• Population wide public health interventions not adequately accounted for

Subgroup analysis of groups / patients:

• Do a CEA for particular Rx and consider the population, then repeat the analysis using subgroups experiencing inequality to assess the impact this has

Equity weighting

• Attaching different weights to health outcomes > value same health gain differently depends on who receives it (greater value for disadvantaged)

• Wight can be based on views of pupulation / decision makers / clinicians

• Reflects to what extend society sacrifices health gains for equity

Other tools for promoting equity

• Ensure universal health coverage

• Target subsidies - e.g free for low income groups

• Prioritisation framework - e.g NICE social judgement in UK

• Offers a framework for incorporating social & ethical values for funding interventions above the threshold

• Recognises that society & patients have valid claims to resources over and above the cost-effectiveness evidence

• Health technology assessment (HTAs) - Cost effectiveness threshold by NICE is £20-30K

  • If cost per QALY of new Rx is within this range, it is considered acceptable use of taxpayers money for the benefit it gives

  • Some exceptions to this are - EOL care, ultra-orphan drugs to Rx rare conditions and cancer drung funds

-> NICE primarily centered on maximising health gains but it allows for exceptions based on fairness, justice & compassion.

• Ways in which healthcare interventions are restricted in order to control spending or increase efficiency

• Rationing is a response to situation where demand exceeds supply for healthcare

• Demography - change in population demographics

  • People have high life expectancy / larger proportion of elderly population

• Pattern of disease - rates of different disease rise or fall in the population > resources managed to match this e.g Covid

• Medical technology - As tech improves, less priority may be needed on certain condition / disease to invest in newest intervention which may be more expensive

• Staffing & service organisation - each speciality has sub-specialities > raise cost > minimum staff > create pressure

• Expectation & culture - as population ageing, expectations are changing

Rationing can be done either Explicitly or implicitly - most healthcare systems use mix of both to manage resources

-> Implicit rationing

• Not acknowledged, less visible & based on hidden allocations.

• Involves decisions made by managers / professionals / front line staff as they allocate resources within fixed budget

• E.g Delays, weighting list, dilution (less time/pt) and denial of Rx based on eligibility

• E.g Nuse or doctor prioritse task / time spend with patient depending on staffing / pressure

-> Explicit rationning

• uses public, formal & clear set of rules to determine who receives resources and who don’t.

• Political methods = discussion & consensus via surveys, voting & conferences

• Technical methods = cost effectiveness evaluation

• E.g Triage system in A&E uses formal crieteria to priotise patients based on severity of conditions

NICE is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

-> Hopes to tackle

• underachievement of health services

• Unacceptable variation in care

• Poor uptake of effective practice

• Excessive use of inappropriate treatments

• Continued use of ineffective treatments.

ICER = incremental cost-effectiveness ration

• ICER <£25K/QALY = usually accepted unless poor evidence

• ICER £25-35/QALY = judgement considered:

  • ?health-related QOL was properly measured, innovating nature of technology & non health objectives

• ICER >£35K/QALY = usually rejected unless there is strong arguments with respect to above criteria.

  • EOL has additional guidance

- Outline some common models of distributive justice and provide some critiques of these

- Identify and discuss the models mentioned in the NHS constitution

- Discuss the necessity for rationing and outline some potential approaches

- Define an ‘orphan drug’ and present ethical arguments for and against investment in unprofitable pharmaceuticals

• The NHS was founded in 1948 to address social injustice by providing healthcare for everyone.

• Its principles include universal access, care free at the point of delivery, central funding, comprehensive services, high quality and equity.

Healthcare resources are limited, while demand is high - hence models of distributive justice employed:.

• Egalitarianism - favours equal shares (everyone get same)

• Meritocracy - rewards contribution (everyone gets according their contribution)

• Socialism - allocates according to need / ability

• Libertarianism - prioritises individual choice

• Rawlsian fairness asks what rules people would choose without knowing their social position.

• Egalitarianism supports equal rights and access to care.

• Resources should be allocated equally amongst all members of the society

• A lottery allocation may be used when a resource is scarce.

• However, equal allocation may overlook differences in clinical need & do not take account of different needs. e.g organ need or congenital issues

• Meritocracy allocates rewards according to merit or contribution. = Those who contribute more, receives more

• In healthcare, this could favour people considered more deserving. > prosocial behaviours.

  • Advocates for people e.g parents, veterans, tax payers, business owners & volunteers

• But merit can reflect unearned advantages, and responsibility for health-related behaviour is often difficult to judge. e.g private education can be purchased, business owners contribute my exploiting their workers?

• Socialism asks people to contribute according to their ability and receive according to their need.

• The NHS reflects this by pooling public funds to provide care based on clinical need (where most needed). - those who benefited most should contribute most.

• Critics point to bureaucracy and possible effects on incentives. - promotes helplessness & dependence on state

• Libertarianism prioritises individual choice (autonomy) and responsibility, with a limited role for the state (gov).

• People would decide how much to spend on healthcare. e.g health insurance / pay for procedure you want

• Critics argue this overlooks how poverty, luck and unequal resources restrict people’s choices.

• The veil of ignorance asks people to make social rules without knowing their own health, wealth or status.

• This encourages rules that people could accept from any position, including when they are vulnerable or unwell.

• The role of society is to ensure that privileges, burdens, and resources are distributed fairly.

• Critics - encourages culture of victimhood - e.g if people are allocated based on their disadvantages, they will exagerate their degree of disadvantage.

  • Also there is no reward for contributing > discourages pro-social behaviour

• Equality gives everyone the same access or treatment.

• Equity adapts support to different needs so people have a fairer opportunity to benefit.

• NHS services aim to be comprehensive, patient-centred, high quality and available to all according to clinical need.

• Decisions must also use public funds responsibly and remain accountable. - best value for taxpayer’s money

• Accountable to the public, communities, and patients that it serves.

• Demand rises due to factors such as an ageing population, multimorbidity, increased consumption of resources and costly treatments.

• Because funding and resources are limited, choices must be made about which services and treatments to provide.

• Role of NICE - decides which novel Rx offers value for money for NHS, calculates cost effectiveness using QALY (how much life is gained)

• First-come-first-served gives patients an equal chance of an ICU bed (egalitarian distribution).

  • But this can block another person who is in greater need from accessing the bed

  • So when bed is scarce (e.g pandemic), priority is given based on clinical need / better survival rate regardless of who came 1st (utelitarian approach)

• Clinicians may also consider likelihood of recovery, duration of admission, utility of resouce, how quickly a bed may become available and whether transfer is possible.

• Prioritising a patient with a better chance of survival may increase the chance of saving a life.

• However, changing priority after treatment begins can cause severe distress, and criteria such as age raise concerns about fairness and discrimination.

• Prioritarianism gives extra weight to helping those who are worse off.

• It may favour younger patients because they have had less opportunity to benefit from life.

• However, age-based priority can disadvantage older people and needs careful justification.

• “Double jeopardy” describes how people with rare diseases may have serious health needs and fewer treatment options.

• Cost-effectiveness measures may disadvantage them because treatments benefit smaller numbers of people.

• Disadvantaged people find themselves disadvantaged x2

• Orphan drugs - drugs to treat rare diseases and may need government support because they are not commercially viable to develop.

• They can still be very expensive, making fair access difficult.

• Pure utilitarian approach would not justify the invest,ent to save such small no of peple - because they focus on greatest good to larger no of people.

UK strategey for Rare diseases:

• Improve recognition - training clinicians

• Internationally co-ordinated research

• Review of how cost-effectiveness is considered in rare diseases

• Improve access to international experts & strategic funding of research in rare diseases.

• Assumption of capacity unless otherwise established.

• All practical steps taken to assist in decision making.

• Patients are allowed to make unwise decisions.

• If the patient lacks capacity, decisions taken must be in the patients’ best interests.

• If the patient lacks capacity, decisions taken must be the least restrictive options

• Stage 1: Does the person lacks the capacity to make a particular decision?

  • Functional test: understand / retain / weight up / communicate

• Stage 2: Is the lack of capacity because of an impairment or disturbance in the functioning of their mind/brain?

  • Diagnostic test: This could refer to mental health conditions, brain damage, stroke, pain, overwhelming emotional state, confusion, shock, fear, panic.

Note: patient may have capacity to make some decisions but not others. It is therefore reviewed for each cases.

• An official statement by an individual which grants a selected person the right to make certain decisions on their behalf if they end up losing capacity (e.g unconsious)

• The role is registered with the Office of the Public Guardian and must be presentable to HCPs.

• Officual statement made or form filled by someone when they have capacity where they can choose to refuse treatment in future when they lack capacity.

• They must state and show in the declaration that they understand the risks associated with refusing said treatment, be it death or serious injury.

• This is a legally binding document - can be written (for lfe sustaining Rx) or verbal (in non-life sustaining treatment).

Independent Mental Capacity Advisors

• This is an advisor who finds out everything they possibly can about the person and comes to an objective decision. This advisor cannot be someone paid to look after the patient. 

The Doctor

• The MCA obliges doctors to seek the family's views, but the family ultimately has no decision-making ability. 

• The judge may be the principal decision maker if a case is taken to court of protection. 

• This may be in the case when there is nobody to speak for the patient or if there is a big disagreement between family and doctor. 

• Hospital ethics committees can be a helpful body to help guide in decisions but never make decisions.

The Court of protection can decide whether someone has the mental capacity to make a particular decision for themselves.

• Can also appoint a deputy to make ongoing decisions for people who lack capacity.

• Can action urgent or emergency application where a decision must be made on behalf of someone, without delay.

• Can make decisions about LPA and consider any objections to their registration.

• Can make decisions about when someone can be deprived of their liberty under the MCA.

• Care often came from churches, monasteries and later almshouses or hospitals.

• After the monasteries were dissolved, many people lost support and became homeless.

• Poor Laws generally provided aid to disabled people, who often lived in their communities and could marry and work

Ideas about natural selection influenced the eugenics movement, which sought to improve society’s physical and mental characteristics.

Some people labelled “feeble-minded” were blamed for social problems. This contributed to support for legal confinement and legislation including the Mental Deficiency Act 1913

The social model.

Models of disability and their historic context:

• Tragedy / charity model - Viewed disabled people as tragic figure who require charity & assistance

• Medical model - Considered diasbility as medical issue > focused on cure / fixing rather than addressing external factors

• Social model - views disability as being result of environmental, social & attitudinal barriers rather than individual dificit - advocates for societal adjustment to support disabled individuals

• Biopsychosocial model - emphasises the role of biological, psychological & social factors in health - suggest that health & disability are influenced by combination of these elements

• International classification of functioning, disability & health (ICF) - introdued by WHO hat measures disability and health across biological, psychological, and social dimensions. ICF is inteded for use within MDT to support individual recovery by considering bio-psycho-social factors.

The social model sees disability as arising from environmental, social and attitudinal barriers, rather than simply from an individual’s impairment.

It calls for society to remove or adjust these barriers so disabled people can participate fully.

It consists of different professionals who develop a common set of aspirations and goals involving a disabled person or patient, to create improved outcomes for them.

Examples - doctors, nurses, physiotherapists, occupational therapists, speech and language therapists, psychologists and social workers.

The Equality Act 2010.

It followed the Disability Discrimination Act 1995 and later additions in 2005

1. Disability

2. Race

3. Sex

4. Gender reassignment

5. Religion or belief

6. Age

7. Marriage and civil partnership

8. Pregnancy and maternity

9. Sexual orientation

Deafness = a severe level of hearing loss where an individual cannot hear sounds below a certain threshold, even with amplification devices like hearing aids. 

• WHO defines disabling hearing loss as > 40 dB in adults or > 30 dB in children. - limits the ability to hear & communicate without assistive device

• Hearing loss ranges from mild to profound; severe loss is 71–95 dB and profound loss is over 95 dB.

-> Men are affected more than women

• Congenital deafness may be genetic (50%) or associated with conditions affecting the auditory system (Cochlear dysplasia); some people also have visual impairment.

• Acquired causes include ototoxic medicines (Gentamycin), infection, prolonged loud-noise exposure, obstruction, trauma, Ménière’s disease and tumours.

• Arrange for a qualified interpreter if possible.

• Avoid relying on family members for translation.

  (miscommunication and misrepresentation of symptoms.)

• Using written notes may supplement communication until an interpreter arrives.

  (These notes must be concise and clear.)

• Approach with respect and empathy for Mary’s Autonomy.

• Use simple, clear language and avoid medical jargon.

• Ask the patient to repeat back the procedure and what they understand.

• Involve a family member or advocate if appropriate and consented to.

• Use visual aids and written information.

• Assess for a hearing impairment, to allow Mr Birdwhistle to receive the required support/ interpreter.

• Using the NHS 111 BSL service to book an urgent appointment, also gives her an opportunity to communicate to an interpreter via video.

• Online bookings via app

• Arrange for BSL interpreters for F2F consultations.

• Video consultations with remote BSL interpreters.

• Electronic communication via text messaging service or email, to reduce the need for in person visits

• The medical model treats deafness as developmental deficiency / disease. - individual deficit to correct or cure via medication & technology.

• The social model locates disability a barriers to communication and participation > isolation & discrimination within society.

• The cultural model recognises Deaf people as a linguistic minority, values Deaf identity and culture. Deaf people dont see themself as disabled & have +ve attitude towards it.

Check that the interpreter is appropriately qualified and give them relevant information in advance.

Ensure good visibility and minimal background noise, allow time for interpretation, and speak directly to the patient rather than to the interpreter

• Speak clearly at a normal pace, face the patient, ensure good lighting and reduce background noise. Gain their attention before speaking.

• Do not shout, cover your mouth, speak too quickly or assume that a nod means they understand

• Deafblind people may communicate using hands-on signing or a deafblind manual alphabet.

• Clinicians should establish the person’s preferred communication method and arrange suitable support.

WHO -> State of physical, mental & social wellbeing, not merely the absence of disease or infirmity.

Medical Model -> health is absence of disease

Ottawa Charter for health promotions

• Peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice & equity, moderate alcohol, cover up in sun, safe sex, cancer screening, drive as per law, learn ABC first aid.

Key determinants of health lie outside healthcare system - they are circumstancs we are born, grow, live & work in

The availability of good medical care tends to vary inversely with the need for it in the population served. To the extent that healthcare becomes a commodity and is distributed as such, with the rich getting more and the poor getting none.

The science of preventing disese, prolonging life, promoting health trough organised effort of society.

• Health protection - adressing wider determinants of health, inequality & lifestyle behaviour

• Health improvement - ensures clinical effectiveness & service planning e.g balanced diet, sugar tax

• Healthcare public health - Protecting against infectious disease, environmental hazards through clinical schemes e.g social distancing, awarness about antibiotics resistance

  
  

Population

• Change in population as more people living longer

Patterns of ill health

• Increased prevalence of chronic illness, changing prevalence of risk factors (inc rate of obesity but decrease in smoking)

• Reduced mortalitiy > more people with chronic illness

Healthcare supply & demand

• There is change in patient expectation, more major drugs / procedure / diagnostic tec advancement > allows Rx of more ill health than before.

Tranditonal models

• Disease-based approach to healthcare > compartmentalisation of many specialities separating physical & mental health services > gaps in healthcare esp to those who are vulnerable (elderly & chronic patients)

Integrated care model

• Delivers health & social care from patient’s perspective - combines processes of care across different disciplines & integrate

• Health + social care, primary + community + 2ndary care

• When you are unable to see, or unable to see very clearly.

• The ability to see depends on several factors, not just your level of sight, external environment may play a role in this.

You can have poor vision but not fulfil the criteria for being registered as severely sight impaired i.e. wearing contacts or glasses 

-> Visual acuity = ability for the eye to see details

• Visual acuity is tested in each eye separately using a Snellen chart, usually at 6 metres (top number).

• In a score such as 6/12, the person can read at 6 metres what someone with average vision can read at 12 metres.

• Normal acuity is 6/6. 6/60 = at 6m, someone can only see the top letter A

• Measurement of lower levels of visual acuity:

  • Counting finger, hand movement, perception of light, no perception of lighgt (stone blind).

  • If vision is below 6/9, a pinhole test can help identify a refractive error.

• An ophthalmologist may recommend registration based on the better-seeing eye’s acuity (how far can you see down the Snellenc hart) and visual field.

• Two categories:

  • sight impaired (SI) - partially sighted

  • severely sight impaired (SSI) - blind

• Registration considers both how clearly someone sees and how much of their visual field is lost; it is not based on acuity alone.

Severely sight impaired

• G1 = People with visual acuity worse than 3/60

• G2 = People who are 3/60 Snellen or better but worse than 6/60 and have a contraction of their visual field

• G3 = People who are 6/60 or better but have a clinically significant contracted field of vision which is functionally impairing them. e.g Bitemporal hemianopia

Sight impaired

• G1 = People with 3/60 to 6/60 Snellen with full visual field.

• G2 = : People between 6/60 and 6/24 Snellen with moderate contraction of the field (e.g., superior, or patchy loss, media opacities or aphakia.)

• G3 = People who are 6/18 Snellen or even better if they have a marked field defect (e.g.homonymous hemianopia

Common causes of sight loss:

• Uncorrected refractive error

• Age-related macular degeneration

• cataract

• Glaucoma

• Diabetic eye disease.

-> Many are avoidable or treatable through eye tests, correctly prescribed glasses and treatments such as cataract surgery

Common causes of Registrable sight loss in adults:

• Age-related macular degeneration – 48%

• Glaucoma – 16%

• Cataract – 12%

• Retinitis Pigmentosa – 10%

• Diabetic eye disease – 8%

Age related macular degenration:

Glaucoma

Cataract

Retinitis pigmentosa

Diabetic eye disease

-> At least 50% of sight loss can be avoided - risk increases with age - 2/3rd of older people with sight loss is caused by refractive error (Short/longsigthed & astigmatism) & cataract

• Uncorrected refractive errors and cataracts are major causes of avoidable visual impairment worldwide.

  • Can be Dx by simple eye test & can be improved by glasses or cataract surgery.

• Other worlwide causes - glaucoma, corneal opacities, diabetic retinopathy, childhood blindness.

• Infectious causes:

  • Trachoma, caused by Chlamydia trachomatis, can lead to blindness (leading infectious cause).

  • Onchocerciasis, or river blindness - caused by Onchocerca volvulus, transmitted by blackflies. Filarial worm is transmitted through bites of infected blackflies > larvae in the body forms nodules > mature into adult worms > move through the body & when they die cause blindness.

• Black African & caribbeans are 4-8x more risk of developing certain forms of glucoma and diabetic eye disese compared to white

• Risk of diabetic eye disease is 3x more in south Asians

• Sight loss can affect independence, employment, finances, travel and access to information.

• It may also contribute to low wellbeing, depression and social isolation.

• Everyday tasks such as reading labels or navigating safely can become difficult. - need to rely on some form of support

• Support may include low vision aids such as magnifiers, workplace adaptations, and help from social workers, mobility or rehabilitation officers and technical officers.

• An Eye Clinic Liaison Officer (ECLO) can offer practical and emotional support and help patients maintain independence.

• Organisations such as RNIB and Guide Dogs may also provide assistance.

When registered as blind, people are entiled to:

• Disability living allowance, personal independence payment (PIP) - tax free benefit to help with cost related to disability

• Reduction in TV licence fee

• Tax allowance

• Reduce public transport fee

• Parking concessions.

• A learning disability = significantly reduced intellectual ability to understand new or complex information and difficulty learning or applying skills.

• It begins before adulthood and affects independent social functioning.

• Measurement techniques (IQ test) - include questions that measure range of intellectual skills & knowledge - gives standardised score wiht 100 being population mean.

  • Can lead to discrimination based on scores & stereotyping of groups into different intelligence categories.

  • Measures narrow range of skills - dont always refect how comeone cope with everyday life

  • Patient may have additional disabilites which affect the score > underperformance

  • IQ is not standardised for people with LD

-> Grades are not discrete groups - Ax should take account of sensory impairment

• Mild (IQ 50-70) - holds conversation, Indep/selfcaring

• Moderate (IG 35-50) - limited language, needs supervision in self-care but fully mobile

• Severe (IQ 20-35) - uses words / gesture for basic needs, need supervision, has motor impairment

• Profound (IQ <20) - limited words / gestures, severely impaired mobility & incontinence

• Adaptive behaviour assessments use observations (self-help, communication, academic skills & social competence), interviews with carers and rating scales to understand daily living skills and identify where support may be needed.

• They can track progress after intervention and help determine eligibility for services.

• Limitations = results may be affected by the support available, differences between settings, cultural assumptions and lack of opportunity to develop a skill.

• The UK has no national register of people with LD.

• GP and service registers may miss people with mild learning disabilities, particularly those who are not in contact with specialist services.

• As a result, recorded figures may underestimate the true number.

• Trend is possibly increasing - due to limitted impact of preventative measures, increase in no of premature babies surviving with LD, increase life-expectancy of adults with LD

• Mild LD - 18/1000, most dont have identified organis causes - strongly associated with poverty & disadvantage

• Severe LD - 4/1000, more likely to have organic cause, less associated with poverty, high mortality risk

Distinguish receptive from expressive communication

• A person may understand more than they can say, communicate through gestures or sounds, or understand only key words.

• Clinicians should use clear, simple language, avoid jargon, allow time and follow the person’s lead, go at their pace.

• Environmental adaptations (Pictures, symbols, signs, colour coding) and assisted communication (interpreters, braile, or communication aids may help).

• A “total communication” approach uses the methods that work best for that person.

• Developed by Galton in 1880, concerns that fitness of race was in danger due to higher reproduction of least intelligent.

• Eugenics promoted the idea that society could be improved by controlling who had children. Aimed at preventing reproduction by ‘weak’

• People with LD faced forced sterilisation (prevention of reproduction), separation, exclusion from education (failure to educate), inadequate healthcare (failure to treat) and seen as threat to race (discrediting).

• Nazi Germany adopted eugenic ideas and murdered more than 200,000 disabled people. After 1945, universal human rights principles helped challenge the idea that some lives were worth less than others.

• Normalisation aims to help disabled people live lives comparable to those of others, with appropriate support to take part in ordinary activities and overcome everyday challenges (compensatory services are needed).

• Social role valorisation focuses on supporting people to hold valued social roles and challenging the stigma created by derogatory labels and exclusion.

Impact:

• Greater access for disabled people to universal public services, employment & community fascilities - enforced by law & political action

• Closure of large institutions > prefers ordinary domestic settings, domicillary care.

Challenge:

• Rise of consumerism

• May lead to loss of sense of people sharing universal rights - disabled seen as ‘negative consumers’

• Causes of LD is very diverse - require multiple strategies

• Preconceptional cause (Down’s, PKU) - new born screen

• Prenatal (foetal alcohol syndrome) - folate during pregnancy, educate to reduce alcohol intake

• Perinatal (obstetrical trauma) - optimal obstetric & neonatal care

• Postnatal (meningitis, cerebral anoxia) - health education, vacination

• People with LD often have additional chronic conditions - epilepsy, sensory or mobility impairments, and mental health difficulties. 10x prevalence of austistic disorders

  • Most MH issues (4x) due to coping with dependence & social exclusion.

• They may also face social exclusion, unhealthy living conditions and barriers to healthcare acess.

• These factors contribute to higher rates of illness and mortality e.g bronchopneumonia, cardiovascular disorders and epilepsy-related causes among common causes of death.

• High rate of injury due to lesse capacity to assess risk, high prevalence of sensory impairment & mobility issues

• LD patients also lead sedentary life, unhealthy lifestyle & poor diet

• Barriers can arise at every stage, from arranging an appointment and travelling to the clinic, to explaining symptoms, understanding advice and taking medication.

  • May require help of family / carer

• Communication difficulties can also lead to diagnostic overshadowing, when symptoms are wrongly attributed to the learning disability.

• Hospital may have lack of adapted facilities e.g room for wheelchair, may expect family to provide 24 hr care

• Reasonable adjustments can be remembered with TEACH: allow more Time, adapt the Environment, show a respectful Attitude, use suitable/accessible Communication, and seek Help from carers, advocates or specialists—with the patient’s involvement and consent.

  • GP could offer double appts, training to improve awareness, complex communication

  • Hospitals can use patient passport