Hadsoc Flashcards
(171 cards)
1
Q
What is clinical governance?
A
Framework through which NHS organisations are accountable for continuously improving the quality and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.
2
Q
What is the meaning of equity?
A
Everyone with the same need gets the same care
3
Q
What is the meaning of inequitable care?
A
Patients across England vary in the extent to which they receive high quality care and in access to care.
4
Q
What is an adverse event?
A
Injury caused by medical management (rather than the underlying disease) and that prolongs the hospitalisation, produces a disability, or both
5
Q
What is a preventable adverse event?
A
An adverse event that could be prevented given the current state of medical knowledge
6
Q
Why do medical errors happen?
A
Everyone is fallible
Most medicine is complex and uncertain
Most errors result from “the system” – e.g. inadequate training, long hours, ampoules that look the same, lack of checks etc.
Personal effort is necessary but not sufficient to deliver safe care
7
Q
What types of error lead to problems with quality and safety in healthcare?
A
Slips and lapses
Mistake
Violation
8
Q
Describe ways of conceptualising quality in healthcare
A
Using the Swiss cheese model
Successive layers of defences, barriers and safeguards
Hazards are able to penetrate the barriers leading to losses.
Active Failures - Happen at the sharp end of practice, closest to the patient e.g. administration of the wrong dose
Latent Conditions (or failures) - Predisposing conditions that make active failures more likely to occur e.g. poor training, poor design of syringes, too few staff
9
Q
Explain how a systems-based approach can promote quality in health care
A
Remove human factors to give a safer design
o Avoid reliance on memory
o Make things visible
o Review and simplify processes
o Standardise common processes and procedures
o Routinely use checklists
o Decrease the reliance on vigilance
10
Q
What is a clinical audit?
A
Quality improvement process that seeks to improve patient care and outcomes through systematic review of care against criteria and the implementation of change.
11
Q
What are the components of an audit?
A
Choose topic Research evidence Criteria and standards First evaluation Implement changes Second evaluation
12
Q
Describe policies and organisations for encouraging quality in the NHS
A
NHS outcomes framework NICE quality standards Clinical commissioning groups (CCG) Commissioning outcomes frameworks (COF) Quality and outcomes frameworks (QOF) Quality accounts Care quality commissions (CQC) Clinical audit
13
Q
What does the NHS outcomes framework do?
A
Provides a national overview of how the NHS is performing
Holds the Health Secretary and NHS CB accountable for £95bn of public money
Acts as a catalyst to change NHS culture and behaviour to drive up quality.
14
Q
What are the NICE quality standards?
A
Set of statements that are markers of high quality, clinical and cost effective patient care across a pathway or clinical area
e.g. Stokes have 11 statements including Brain imaging within 1 hour of arrival if indicated
15
Q
What are Clinical commissioning groups?
A
200 groups that commission services for their local populations and drive quality through contracts
16
Q
What are commissioning outcome frameworks?
A
Hold CCGs accountable for their progress in delivering outcomes
Drive local improvement in quality and outcomes for patients
17
Q
What do COF indicators do?
A
Measure quality
18
Q
What are quality and outcome frameworks?
A
Sets national quality standards with indicators in Primary Care.
Clinical, organisational and patient experience
General practices score points according to how well they perform against indicators - Practice payments are calculated based on points achieved
19
Q
What are quality accounts?
A
All trusts are now required to publish quality accounts, increasing the disclosure of information about performance, both at organisational level and individual level.
o Published annually
o Publically available
o Focus on safety, effectiveness and patient experience
20
Q
What are care quality commissions?
A
The CQC considers NICE quality standards, checks quality accounts and can:
o Impose registration ‘conditions’ if not satisfied
o Make unannounced visits
o Issue warning notices, fines, prosecution, restrictions on activities, closure
21
Q
What are the main two types of social science methods for investigating health and illness?
A
Qualitative
Quantitative
22
Q
What is quantitative research?
A
Collection of numerical data, which begins as a hypothesis
23
Q
What are the advantages of quantitative research?
A
Reliable Repeatable Good at describing Good at measuring Can find relationships between things Allow comparisons
24
Q
What are problems with quantitative research?
A
May force people into inappropriate categories
Don’t allow people to express things
May not access all important information
May not be effective in establishing causality
25
Examples of quantitative research designs
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RCT
Cohort Studies
Case Control Studies
Cross-sectional surveys
Questionnaires
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26
What are advantages of questionnaires?
VALID - measure what they’re supposed to measure
RELIABLE - Measure things consistently . Differences in results come from differences between participants, not from differences in understanding questions
Published Questionnaires may have been tested for validity and reliability
27
What type of questions an be asked in a questionnaire?
Mainly closed questions
| Some open questions - longer to analyse
28
What are advantages of qualitative research?
Understanding the perspective of those in a situation
Accessing information not revealed by quantitative approaches
Explaining relationships between variables
29
What are the problems with qualitative research?
Not good at finding consistent relationships between variables
Generalisability
30
Examples of qualitative research design
Ethnography and observation
Interviews
Focus groups
Documentary or media analysis
31
What is evidence based practice?
Involves integration of individual clinical expertise with the best available external clinical evidence from systematic research.
32
What are the advantages of systematic research?
Address clinical uncertainty and highlight gaps or poor quality in research
Offers authoritative, generalisable and up to date conclusions
Save clinicians from having to locate and appraise the studies for themselves
Reduce delay between research discoveries and implementation
33
What are practical Criticisms of Evidence-Based Practice Movement
Impossible to create and maintain systematic reviews across all specialities
Challenging and expensive to distribute and implement findings
RCTs seen as the gold standard, but not always feasible or desirable (ethics)
Choice of outcomes very biomedical, limiting which interventions are trialled and therefore funded (e.g. NICE Guidance)
Requires ‘good faith’ from pharmaceutical companies
34
What are philosophical Criticisms of Evidence-Based Practice Movement
Population-level outcomes may not apply to an individual
Evidence-Based Medicine may make professionals ‘unreflective rule followers’
Professional responsibility/autonomy
Might be seen as a means of legitimising rationing, with potential to undermine trust in the doctor-patient relationship and ultimately the NHS.
35
What are the difficulties of getting evidence into practice?
Resources not available to implement change
Evidence exists, but doctors don’t know about it
Doctors know about evidence but don’t use it
Organisational systems cannot support innovation
Commissioning decisions reflect different priorities - What if patients say they want something else?
36
What is a social class?
Segment of the population, distinguished from others by similarities in labour market position and property relations.
37
How are socioeconomic statuses classified?
Individual
Area-based - townsend deprivation score
Education
Income
38
What is the Townsend Deprivation Score?
```
It is a measure of deprivation by looking at the following variables:
• Unemployment
• Car ownership
• Overcrowded housing
• Housing tenure
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39
What does the health and socioeconomic status show?
The less deprived a population, the higher their life expectancy and disability-free life expectancy.
40
What is ethnicity?
Identification with a social group – on the basis of shared values, beliefs, customs, traditions, language and lifestyles.
41
What is the link between health and gender?
Social and biological variances between genders both influence health
42
What is the Black report?
Report published by the department of health, which gave four theories to explain why inequalities occur
1. Artefact Explanation - Health inequalities are evident due to the way statistics are collected (measurement of class)
2. Social Selection Explanation - Sick individuals move down social hierarchy, health individuals move up. Chronically ill and disabled people are more likely to be disadvantaged
3. Behavioural-Cultural Explanation - Ill health is due to people’s choices/decisions, knowledge and goals. Disadvantaged background tend to engage in health-damaging behaviours.
4. Materialist Explanation - Inequalities in health arise from differential access to material resources. Most Plausible
43
What is inequality?
When things are different (not equal)
44
What is inequity?
Inequalities that are unfair and avoidable
45
What factors have a link to access to healthcare?
Gender - females use primary care more
Ethnicity - some groups have higher use of primary care. South African Female Elders have higher use of mental health consultations.
Socioeconomic class - normalisation of ill health
46
What are chronic illnesses?
Range of conditions, which are long term and tend to have profound influence on the lives of sufferers.
47
What is a biographical disruption?
A key sociological concept, identifying chronic illness as a major disruptive experience.
48
What are illness narratives?
People’s narratives of their illness, which offer a way of making sense of the illness, and they perform certain functions.
49
What is narrative reconstruction?
Process by which the shattered self is reconstructed in ways that explain the appearance of illness.
Comes from a desire to create sense of coherence, stability and order in the aftermath of biographical disruption.
50
What are the 5 different work types of chronic illness?
Illness work - symptom management i.e. physical signs
Everyday life work - manage daily living i.e. new life as normal
Emotional work - manage own emotion and that of others
Biographical work - loss and subsequent reconstruction of self
Identity work - maintain acceptable identity
51
What is stigma?
Negatively defined condition, attribute, trait or behaviour conferring “deviant” status; a “spoiled” identity.
52
Describe the types of stigma
Discreditable stigma - stigma yet to be revealed
Discredited stigma - visible or well-known stigma
Enacted stigma - discrimination has occurred
Felt stigma - fear of enacted stigma. Scared of discrimination
53
Assess the suitability and value of HRQoL instruments in a range of areas
o Is there published work showing established validity and reliability?
o Is there other published work showing successful use of the instrument
o Is it suitable for your area of interest
o Does it adequately reflect patients’ concerns in this area?
o Is the instrument acceptable to patients?
o Is it sensitive to change?
o Is it easy to administer and analyse?
54
What are the ways of conceptualising disability/
Medical model of disability
Social model of disability
International Classification of Impairments, Disabilities or Handicaps (ICIDH)
International Classification of Functions, Disability and Health (ICF)
55
What is a disability seen as in the medical model?
Change from medical norms
56
What is a disability seen as in the social model?
A form of social oppression
57
What are the problems of the medical model of disability?
Lacks recognition of psychological and social factors, focussing purely on the biological. It also uses stereotyping and stigmatising language.
58
What are the problems of the social model of disability?
Leaves out biological factors, with an overly drawn view of society. It also fails to recognise bodily realities and the extent to which these are solvable socially.
59
What does the ICIDH do?
Attempts to classify the consequences of disease as:
o Impairment - Concerned with abnormalities in the structure of the functioning body
o Disability - Concerned with the performance of activities
o Handicap - Concerned with broader social and psychological consequences of living with impairment and disability
60
What is the ICF?
WHO’s framework for measuring health and disability at both individual and population levels.
61
What are reasons for the rise of patient-based measures as outcomes of healthcare
o Indication of the need for healthcare
o Target resources where they are most needed
o Assess the effectiveness of health interventions
o Evaluate the quality of health services
o To use evaluations of effectiveness to get better value for money
o To monitor patients’ progress
62
What are measures of health?
Mortality, morbidity and patient-based outcomes
63
How can patient based outcomes be used?
o Be used clinically
o Be used to assess benefits in relation to cost
o Be used in a clinical audit
o Be used to measure health status of populations
o Be used to compare interventions in a clinical trial
o Be used as a measure of service quality
64
What are Health-Related Quality of Life (HRQoL)?
Quality of life in clinical medicine represents the functional effect of an illness and its consequent therapy upon a patient, as perceived by the patient.
65
What are key points of HRQoL?
o Emphasis on patient’s own views
o Emphasis on functional effects
o Emphasis on therapy as well as illness
66
How can HRQoL be measured?
Via Qualitative or Quantitative methods
67
What are advantages of using Qualitative Methods to Measure HRQoL?
o Good for initial looks at HRQoL
| o Very resource hungry (Training, time)
68
What are disadvantages of using Qualitative Methods to Measure HRQoL?
Not easy to use in evaluation, especially RCTs
69
What are the disadvantages of using Quantitative methods to measure HRQoL?
Relies on the use of questionnaires known as ‘instruments’ or ‘scales’
70
Difference between reliability and validity?
Reliability - consistancy of results on repeat
| Validity - accuracy of results
71
What are advantages of Specific Instruments?
very relevant content
sensitive to change
acceptable to patients
72
What are disadvantages of Specific Instruments?
cannot be used with people who don’t have the disease comparison is limited
cannot detect unexpected effects
73
What are the types of specific instruments?
Disease specific - Asthma Quality of Life Questionnaire
Site specific - Oxford hip score
Dimension specific - Beck depression inventory
74
What are advantages of generic instruments?
Can be used with any population (including healthy people)
Generally cover perceptions of overall health
Also questions on social, emotional and physical functioning, pain and self-care
75
Outline Short-Form 36-item Questionnaire (SF-36)
Contains 36 items that assess HRQoL - Grouped into 8 dimensions
Responses to questions are scored
Scores within each dimension are added together to give a score (0-100)
Dimension scores are not added together to give an overall score
76
Advantages of Short-Form 36-item Questionnaire (SF-36)
acceptable to people
only takes 5-10 minutes to complete
good reliability
responsive to change
77
Outline EuroQol EQ-5D
Five dimensions
• Mobility, self-care, usual activities, pain/discomfort, anxiety/depression
Three levels for each dimension
• No problems
• Some/moderate problems
• Extreme problems
78
Advantages of EuroQol EQ-5D
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widely used
good population data is available
been well validated
tested for reliability
particularly suitable for use in economic evaluations
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79
What are lay beliefs important in medical practice?
o Impact on health behaviour
o Impact on illness behaviour
o Impact on compliance/non-compliance (adherence) with treatment:
Deniers – “I don’t have asthma”
Distancers – “I don’t have proper asthma”
Pragmatists – Only use preventative medication when asthma was bad
80
What are lay beliefs?
Constructed by people to understand and make sense of areas in their lives about which they have no specialised knowledge
Socially embedded
Medical information may be rejected if it is incompatible with competing ideas
81
What is the epidemiology behind lay beliefs?
Understand why and how illness happens - Combination of person, familial and social sources of knowledge
Why it happened to a particular person at a particular time
Not infallible (always exceptions)
When Lay Epidemiology does not fit “randomness and fate”, “The last person you would expect”.
82
What is the negative definition of health?
Absence of illness
| more often seen in lower socioeconomic groups
83
What is the functional definition of health?
Ability to do certain things
84
What is the positive definition of health?
state of wellbeing and fitness
| more often seen in higher socioeconomic groups
85
What are health behaviours?
Activity undertaken for the purpose of maintaining health and preventing illness
86
What are illness behaviours?
Activity of ill person to define illness and seek solution
87
What are sick role behaviours?
Formal response to symptoms, including seeking professional help
88
What is the lay referral system?
Chain of advice-seeking contacts which the sick make with other lay people prior to seeking help from health care professional
89
What are some determinants of health and disease?
Poverty
Social exclusion
poor housing
poor health systems
90
What is primary prevention?
Aims to prevent onset of disease/ injury
| Reduce exposure to risk factors e.g. quit smoking
91
What is secondary prevention?
Aims to detect and treat disease at early stage
| Prevents progression e.g. monitor BP
92
What is tertiary prevention?
Aims to minimise effect of established disease
| Steroids for asthma
93
What are some health promotion strategies?
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Medical/ Preventative
Behaviour change
Educational
Empowerment
Social change
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94
What are some dilemmas raised by health promotion?
Ethics of interfering in peoples lives
Victim blaming - e.g. more expensive to eat healthy diet
Mistaken belief that giving people information gives power
Reinforce negative stereotypes
Unequal distribution of responsibility - often left to women when about health e.g cooking
Prevention paradox - population level intervention might not be effective at individual level.
95
What is the relevances of lay beliefs on health promotion intervention?
Candidacy - if people don't see themselves as candidates, they won't take on board information
Lay epidemiology
96
What are the difficulties of evaluating outcomes of health promotion?
Designing the intervention is difficult
Timing - results may defer on when you evaluate
delay - longer time to have effect
decay - wear off rapidly
Potential concurrent confounding factors
High costs of evaluating research
97
Define screening
Systematic attempt to detect unrecognised condition by application of tests, examinations, or other procedures, which can be applied rapidly to distinguish between apparently well persons who probably have disease and those who probably don't
98
What are different ways of detection of a disease?
Spontaneous presentation
Opportunistic case finding - find pathology whilst looking for something else
Screening
99
What are the criteria for implementing screening programme relating to the condition?
Must be important health problem
Epidemiology and natural history well understood
Must have early detectable stage
Cost-effective primary prevention interventions considered and implemented (if possible)
100
What are the criteria for implementing screening programme relating to the test?
```
Simple and safe
Precise and valid
Acceptable to population
Test value distribution must be known
Agreed cut off level must be defined
Agree policy on whom to investigate further
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101
What are the criteria for implementing screening programme relating to the treatment?
Effective evidence based treatment available
Early treatment must be advantageous
Agreed policy on whom to treat
102
What are the criteria for implementing screening programme relating to the programme?
Other options considered
Benefit should outweight physical and psychological harm
Facilities for diagnosis and treatment
103
What are false positives?
People who come out with a positive screening test who do not have the disease
104
What are false negatives?
People who test negative for the screening test but actually do have the disease
105
What is sensitivity?
Proportion of people with disease who are test positive
True positives / (true positives + true negatives)
106
What is specificity?
Proportion of people without disease who are test negative
Probability a non-case will test negative.
True negatives/ (false positives + true negatives)
107
What are positive predictive values (PPV)?
Probability someone who has tested positive actually has disease - strongly influenced by disease prevalence.
True positives / (true positives + false positives)
108
What are negative predictive values (NPV)?
Proportion of people who are test negative who actually do not have disease
True negatives/ (false negatives/ true negatives)
109
What are the advantages of screening?
Early detection of disease may improve outcome
| True negatives reassure patient
110
What are the disadvantages of screening?
False positive expose patients to invasive diagnostic tests
False negatives falsely reassure patients
False negatives not offered diagnostic testing they may benefit from
Expensive interventions divert money from treatments
111
What are the types of bias when evaluating effectiveness of screening programmes?
Lead time bias
Length time bias
Selection bias
112
What is lead time bias in screening?
Patients who are screened survive longer, but only because they were diagnosed earlier.
Patients live same amount of time, but knowing for longer that they have the disease
May impact quality of life
113
What are length time bias in screening?
Screening are better at picking up slow-growing, unthreatening cases
114
What is selection bias in screening?
Those who screened more regular are likely to engage in other health behaviours that protect them from disease.
115
What are examples of screening programmes in UK?
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Abdominal aortic aneurysm
Bowel Cancer
Breast cancer
Cervical cancer
Diabetic retinopathy
Down's syndrome
PKU
Sickle cell and Thalassaemia
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116
What are the sociological critiques of health promotion and screening
Structural critiques - Victim blaming
Individualising pathology
Surveillance critiques - Individuals and population subject to this
Social constructionists - health and illness practices seen as moral
Feminist critiques - screening targeted more towards a gender
117
What are the potential queries raised about screening programmes?
Alteration of usual doctor-patient contract - normally sick person goes to doctor
Complexity of screening programmes - who to screen?
Limitations of screening - screening carries potential harm
118
What is a brief history of the NHS?
Created in 1948
Universal - covered everyone
Comprehensive - covered all health needs
Free
Initially run by department of health
Health and Social care act 2012
119
What are the roles of a medical director?
Doctor who has overall responsibility for medical quality
Communicates between board and medical staff
Leadership of medical staff
Approves job description, interview panels, equal opportunities
120
What are the roles of a clinical director?
Overall responsibility for directorate
Provide medical education and training
Implement clinical audit
Induction of new doctors
121
What is the current structure of the NHS
* Secretary of state for health - overall accountability for NHS
* Department of health - sets national standards, shapes direction of NHS, Sets national tariff
* National Commissioning Board - Authorise CCGs
* Clinical Commissioning groups - Bring together GPs, nurses, specialists, public health, patients,
* Primary, secondary and community services
* Patients
122
How do scare resources impact work of doctors?
Healthcare expenditures is rising.
| Healthcare system goes about this problem by allocating resources in relation to competing demands.
123
What are the different ways of rationing in the NHS?
Deterrent - demands obstructed e.g. prescriptions
Delay - waiting list
Deflection - GP deflect demand from secondary care
Dilution - fever tests, cheaper drugs
Denial - patient denied service
124
What are the range of approaches to resource allocations in healthcare?
Explicit rationing
| Implicit rationing
125
What is explicit health care rationing?
Use of institutional procedures for systematic allocation of resources within health care systems
126
What are the advantages of explicit rationing?
Transparent, accountable
Opportunity for debase
Use of evidence based practice
More opportunities for equity in decision-making
127
What are the disadvantages of explicit rationing?
```
Very complex
Heterogeneity of patients and illness
Patient and professional hostility
Threat to clinical freedom
Evidence of patient distress
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128
What is implicit health care rationing?
Allocation of resources through individual clinical decisions without criteria for those decisions being explicit
129
What are the disadvantages of implicit rationing?
Inequities
Discrimination
Open to abuse
Decisions made on social deservingness
130
What are the levels of rationing?
1) How much to NHS compared to other government priorities
2) How much to allocate across sectors
3) How much to allocate to specific interventions within sectors
4) How to allocate interventions between different patients in same group
5) How much to invest in each patient once intervention initiated.
131
What does the National Institute for Health and Care Excellence do?
Provide guidance on whether treatments can be recommended for use in NHS
Appraises new drugs and devices
132
What are tariffs?
Payment by Results
When a hospital treats a patients, diagnosis and treatment are recorded
• Information decides which HRG the patient is assigned to and therefore which tariff is paid
133
Define scarcity in terms of resources
Resources limited
| Need outstrips resources. Prioritisation is inevitable.
134
Define efficiency in terms of resources
Getting the most out of limited resources.
135
Define equity in terms of resources
The extent to which distribution of resources is fair.
136
Define effectiveness in terms of resources
The extent to which an intervention produces desired outcomes.
137
Define utility in terms of resources
The value an individual places on a health state.
138
Define opportunity cost in terms of resources
Once you have used a resource in one way, you no longer have it to use in another way.
139
Explain cost minimisation analysis
Outcomes assumed to be equivalent, e.g. all hip prostheses improve mobility equally, so choose the cheapest one.
Not often relevant as outcomes are rarely equivalent
140
Explain cost effectiveness analysis
Used to compare drugs or interventions which have a common health outcome
• E.g. blood pressure in terms of cost per reduction of 5mm/Hg
141
Explain cost benefit analysis
All inputs and outputs valued in monetary terms
| • “How much would you pay to have your hip replaced?
142
Explain cost utility analysis
Quality of health comes produced or foregone
| • QUALY
143
What is The Quality Adjusted Life Year (QALY)?
Allows for broad comparisons across differing programmes
Uses a single index incorporating quality and quantity of life
1 perfect year of health = 1 QUALY
o Assumes that 1 year in perfect health is equal to 10 years with a quality of life of 10% of perfect health.
o Measured using EQ-5D
144
What is incremental cost-effectiveness ratio (ICER)?
Ratio to assess cost-effectiveness by integrating the QUALY score with the price of treatment
145
What cost per QUALY is usually approved?
??????
146
What are the disadvantages of QUALY?
Do not distribute resources according to need, but according to the benefits gained per unit of cost
Technical problems with their calculations
QUALYs may not embrace all dimensions of benefit; values expressed by experimental subjects may not be representative of the population
```
RCT evidence
• Comparison therapies may differ
• Length of follow-up
• Atypical patients
• Atypical care
• Limited generalizability
• Sample sizes
• Statistical models can address some of these problems, but still not great.
```
147
Describe the policy background to the growth of interest in patients’ views of health services
4 measures to ensure patient satisfaction:
NHS Patient Prospectus (2000) - account of patients’ views and the action taken as a result.
Involving patients and the public in healthcare (2001) - Builds on the patient prospectus as a formal response to the Bristol enquiry.
Health authorities and trusts must “involve and consult” patients and the public (2006) - Decisions about the planning, developing and considering changes in the way services are provided.
NHS Outcomes Framework (2012/13) - Ensuring that people have a positive experience of care.
148
What options are there for accessing patients’ views of healthcare?
• Local Involvement Networks (LINks) (Becoming Local HealthWatch)
o Aim to ensure that each community has services that reflect the needs and wishes of local people.
• Indirectly Investigating Patients’ Views
• Patient Advice and Liaison Services (PALS)
o On the spot help about health services.
o Listen to patients’ concerns, suggestions and experiences
o Provide an early warning system by identifying problems or gaps in services
• Parliamentary and Health Service Ombudsman Reports
o Independent investigations into complaints that NHS has not acted properly or fairly in England
o Ultimate, independent view of what has happened
* Directly Investigating Patients’ Views
* Qualitative Methods
* Quantitative Methods
149
What is the NHS complaint procedure?
* Single complains system (since 2009)
* Focuses on satisfactory outcomes
* Risk assessment to deal quickly with serious complaints
* Independent investigators if needed
* Specialist advocates for those with special needs
150
Explain the concept of patient satisfaction
Sometimes, patient expectations are not reasonable
Things that cause dissatisfaction include:
Poor communication from health professionals
• Patients not allowed to report concerns fully on their own terms
• Full history of presenting complaint not taken
• Reassurance not conveyed
• Appropriate advice not provided
Inconvenience, waiting times
“Hotel” aspects of care
Culturally inappropriate care
Competence
Health outcomes
151
What are the advantages using patient-based outcomes to assess doctors’ performance?
Care is provided to patients, so they should feel it is adequate
152
What are the disadvantages using patient-based outcomes to assess doctors’ performance?
o Patients may not provide an objective view. As they are the patient, their view will naturally be a selfish one as they look to improve their own care.
o Not applicable on the national scale
153
Name the different sociological approaches to understanding the patient-professional relationship
1. Functionalism
2. Conflict theory
3. Interpretivism / Interactionism
4. Patient-Centred / Partnership
154
Explain Functionalism
Whilst the doctor is ‘powerful’, the patient adopts a ‘sick role’. Lay people do not have the technical competence to remedy their situation and thus are placed in a state of helplessness.
Sick Role
o Legitimate reason to be freed of social responsibilities and obligations.
o Placed in a situation of dependence
o Should want to get well and not abuse their legitimised exceptions from normal responsibilities
o Expected to seek out the technical help in the role of the physician and cooperate with them in the healing process.
Doctor’s Role
o Tending to sickness in society
• Use skills for the benefit of patients, not in their own self interests; be objective and non-discriminatory
• Granted intimate access to patients, autonomy, status, financial reward
155
What is the criticism to the functionalism approach?
o Sick role not well thought out – some patients can not get better. Some patients illegitimately occupy the sick role.
o Assumes patients are incompetent and must have a passive role.
o Assumes rationality and beneficence of medicine
156
Explain the conflict theory
Conflict theory states that the doctor’s control is not only the product of professional values or technical expertise, but also due to the fact that the doctor holds all the bureaucratic power. Doctors therefore have a monopoly on defining health and illness and the patient has little choice but to submit to the institutionalised dominance of the doctor.
o Lay ideas are marginalised and discounted
o People become dependent on medicine, lose self-reliance and become sick
o Idea that “medicalization” of childbirth has resulted in loss of control for women
157
What is the criticism to the conflict theory?
o Is this portrayal of the patient-doctor relationship accurate?
o Patients are not always passive, can exert control e.g. via non-adherence or use of complimentary therapies
o Patients may appear submissive in consultation but assert themselves outside of this
158
Explain the Interpretivism / Interactionism theory
These approaches focus on the meanings that both parties give to the encounter. Informal, unwritten rules govern almost every aspect of social life.
o Every medical encounter is framed by a set of expectations
o Doctor and patients avoid all matters “not fitting” with the ideal of patient and doctor
o Each party orients to an idealised conception of the encounter
159
Explain the Patient-Centred Models / Partnership theory
The aspiration that patient-professional relationships can be less hierarchical and more cooperative if the patients’ view is taken more seriously. It explores the patient’s ICE.
o Shift from traditional ‘professional-centred’ → ‘patient-centred’ model
o Emphasis on equality in the relationship
o Enhances prevention and health promotion
o Enhances the continuing relationship between the patient and doctor
Shared Decision Making
o Doctor and patient both involved in treatment decision making process
• Express treatment preferences
• Treatment decision is made which doctor and patient both agree on
o Doctor and patient both share information with each other
o Patients can contribute their concerns and priorities in relation to presenting problems
160
Distinguish between explanatory approaches and aspirational models of the patient-professional relationship
1. Functionalism – Explanatory
2. Conflict – Explanatory
3. Interpretive/Interactionism – Explanatory
4. Patient-Centred/Partnership – Aspirational
161
What is Professionalisation?
Professionalisation describes the social and historical process that results in an occupation becoming a profession
162
Describe the professionalisation of medicine
Asserting an exclusive claim over a body of knowledge or expertise
• Doctors acted as an elite group, only catering for the wealthy
Establishing control over market and exclusion of competitors
• Women cared for others in childbirth
• Teeth pullers, bone-setters etc.
• Apothecary’s Act began reform process
Establishing control over professional work practice
• GMC formed in 1858 by the Medical Act, giving the GMC power over the registration of doctors
• Traditional model of professional self-regulation
163
What is professional socialisation?
The process through which new entrants acquire their professional identities:
o Formal Curriculum
o Informal Curriculum
164
What are the approaches to regulation of doctors?
Self-Regulation claims that there is such an unusual degree of skill and knowledge involved in professional work that non-professions are not equipped to evaluate or regulate it.
165
What are the criticism to self-regulation?
Claims of virtue seen as self-serving, strategic manoeuvre
Favours the interests of “agents” over “principals”
• Like having to trust a mechanic (agent) with your car (principal)
Bad Apple enquiries – E.g. Bristol enquiry, Harold Shipman - failure to detect signs of unacceptable/unprofessional behaviour
Rules on profession propriety - Doctors discouraged from raising concerns about each other
Control is mostly informal
166
Describe challenges in evaluating doctors’ performance
Fitness to Practice
When there are concerns about a doctor’s fitness to practice they are referred to the GMC. E.g misconduct, criminal caution or conviction, physical or mental illness, or a ruling by a regulatory body. The GMC can be overruled by the Council for Healthcare Regulatory Excellence.
Licensing
Previously you stayed on the register unless actively removed - now revalidated every 5 years
167
Describe the theory and practices underlying at least one complimentary therapy
Acupuncture
Trigger points, and their characteristic patterns of referred pain, can be treated by direct needling at the trigger point. This concept is also used in musculoskeletal medicine, with trigger points being treated by manipulative techniques
168
Why do people turn to complementary therapies?
o Persistent symptoms
o Real or perceived adverse effects of conventional treatments
o Preference for ‘holistic’ approach to their problem
o May feel they receive more time and attention
o High level of satisfaction reported
169
What are Doctor’s perspective of complementary therapies
Common concerns include:
• Patients may see unqualified practitioners
• May risk missed or delayed diagnosis
• May refuse conventional treatment
• May waste money on ineffective treatments
• The mechanisms of some complementary treatments is so implausible it cannot work, e.g. homeopathy
170
What are arguments for NICE evaluating complementary therapies?
High public interest
Half GPs provide access
Could address inequalities in access/opportunity
Should apply same standards
NICE could stimulate more/higher quality research
171
What are arguments against NICE evaluating complementary therapies?
Money in NHS limited
NICE has higher priorities
Poor quality evidence
