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Why is quality and safety important?

- evidence patient are being harmed and receiving sub standard care
- variations in healthcare e.g. Postcode lottery
- direct costs and legal bills


Sections in defining healthcare quality

Patient centred


Three principles NHS was built on

- free to point of access
- meets needs of everyone
- based on clinical need, not ability to pay


- adverse effect
- preventable adverse effect
- never event

Adverse effect
- injury caused by medical management that prolongs hospitalisation, produces disability or both
- common and many unavoidable e.g. Chemo hair loss, streptokinase may cause haemorrhage but not in everyone

Preventable adverse effect
- adverse effect that should have been prevented given current state of medical knowledge e.g. Op on wrong body part

Never events - many occur in surgery - they are preventable adverse effects which have evidence so clear that they should not happen


James Reason's framework of error

Active failures
- acts that directly harm the patient
Latent conditions
- predisposing conditions that make active failures more likely to occur
E.g. Poor training, few staff, poor design of syringes, over reliance on individual responsibility


Reason's model of Swiss Cheese

Holes in the Swiss cheese - some due to active failures and others due to latent conditions
Errors occur when the holes line up so barriers to those failures not working


Define clinical governance

Framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical care can flourish


Name the 6 NHS quality improvement mechanisms


Standard setting
- NICE sets standards based on best quality evidence to define what high quality of care should look like
- CCGs using budgets to meet needs of local population
Clinical audit and quality improvement
- clinical audit: quality improvement process that aims to improve patient care and outcomes through systematic review of are against criteria and implementation of change
- quality improvement is more continual so you are constantly improving care
- disclosing information about performance to patients and public
Registration and inspection
- organisations must be registered with quality care commission
Financial incentives
- QOF (quality and outcomes framework) - primary care GPs score points relative to indicators
- CQUIN (commissioning for quality and innovation) - trusts achieving measurable goals
- National tariff (healthcare resource groups)


Define evidence based practice

Integration of individual clinical exposure with best available external clinical evidence from systematic research


Why are systematic reviews needed?

- traditional literature may be biased and subjective
- quality of studies sometimes poor
- can highlight gaps in research
- can help address clinical uncertainty

They are useful as saves clinicians time, reduces delay between findings and implementation, help prevent bias decisions


Practical and philosophical criticisms around evidence based practice

Practical criticisms
- impossible to create and maintain systematic reviews across all specialities
- RCTs not always feasible/necessary/desirable

Philosophical criticisms
- If works at population level does not mean it will work at individual level
- potential of EBM to create unreflective rule followers
- when does professional autonomy and responsibility overtake EBM?
- does not align with doctors mode of reasoning


Why is there a gap between evidence and implementation?

- Evidence exists but Drs do not know about it
- Doctors know about it but do not use it e.g. Do not agree
- Resources not available to implement change
- Commissioning decisions reflect different priorities


Quantitative research methods

Reliable and repeatable

Use questionnaires
- should be valid (measure what they are supposed to measure) and reliable (measure things consistently)
- published questionnaires already tested for validity and reliability


Qualitative research methods

Makes sense of phenomena in terms of meanings people bring to them
- Observation and ethnography
- Interviews
- Focus groups
- Document and media analysis


Pros and cons of qualitative research

Good as
- understand perspectives
- access info not in quantitative research
- explain relationships between variables

Not good at
- finding consistent relationships between variables
- generalisability


What classification is used do to measure health of people in different socioeconomic positions?

National Statistics Socio-Economic Classification

Calculated via Census data


6 explanations for inequalities in Health

BAMS (Black Report) PI

Behavioural cultural
- ill health is due to people's choices and decisions (does not consider adverse conditions and social processes)
- health inequalities are evident due to the way statistics are collected
- inequalities in health arise from differential access to material resources e.g. Housing conditions, income, employment
Social selection
- Health determines class/ position through social mobility
- psychosocial pathways act in addition to direct effects of absolute material living standards e.g. Stressors
Income distribution
- countries with greater income inequalities have greater health inequalities
- increased income inequality, increased social-evaluative threat, increased stress, decreased health


- inequality
- inequity

Inequality - when things are different

Inequity - inequalities that are unfair and avoidable

Can have inequality without inequity
E.g. Different gps offering different services to meet needs of region. But if region had as,e needs then it would be an inequity


Why do people in deprived areas have higher rates of GP/ emergency services and use less preventative services?

- Manage health as series of crises
- Normalisation of ill health
- Use more accessible services
- Reflects lack of cultural alignment between health services and lower socio-economic groups


Define health promotion

Enabling people to increase control over and improve their health

Public Health England has duty to protect and improve nation's health and wellbeing and reduce health inequalities


Sociological perspectives on health promotion

- focuses on individual responsibility - victim blaming
- way of monitoring and regulating population - encourages self surveillance
- health promotion privileges certain lifestyles and those wealthier - widens inequalities


5 approaches to health promotion

- medical/ prevention e.g. Smoking
- behaviour change
- educational
- empowerment - client centred approach
- social change e.g. Smoking ban


Levels of prevention

Primary prevention
- prevent onset of the disease by reducing exposure to risk factors e.g. Immunisations

Secondary prevention
- detect and treat disease at early stage to prevent progression/ further complications e.g. Screening

Tertiary prevention
- minimise the effects of an established disease


Health promotion dilemmas

- Ethics of interfering with peoples lives
- Victim blaming
- Fallacy of empowerment (information does not give people power)
- Reinforcement of negative stereotypes
- Unequal distribution of responsibility
- Prevention paradox (interventions that make a difference at population level may not make much of a difference at individual level)


Types of health promotion evaluation

Process evaluation
- assesses process of programme implementation so how the programme was put into place and how it is being delivered/received
Impact evaluation
- assesses immediate effects of the programme
- baseline data needed before and after intervention
Outcome evaluation
- measures long term consequences
(delay: some interventions take a long time to have an effect)
(Decay: some interventions wear off rapidly)


What are lay beliefs?

How people understand and make sense of health
Constructed by people with no specialised knowledge


Perceptions of health
- negative definition
- functional definition
- positive definition

Negative definition - health is absence of illness (common in lower socioeconomic group)
Functional definition- health is the ability to do certain things so do what is important to you (lower socioeconomic group and elderly)
Positive definition - health is a state of wellbeing and fitness


What is the interplay between lay and medical beliefs?

As lay people engage with professional concepts and are exposed to new concepts, the way they understand them and embed them in everything they know is a process of understanding and refinement


- illness behaviour
- sick role behaviour

Illness behaviour is the activity of an ill person to define illness and seek solution so what people do when they have symptoms e.g. Advice from lay people. Internet

Sick role behaviour is the formal response to symptoms so the step after illness behaviour where someone seeks formal help.


Symptom / iceberg illness

The iceberg are all the symptoms people experience but those above the he water fare thoe hsymptoms atare of opeople who seek mdical help.
Under water do nothing or self treat.


Name some factors that influence illness behaviour?

Illness behaviour - behaviour of person with symptoms e.g. Lay people opinions
- culture
- visibility of symptoms
- extent to which symptoms disrupt life
- tolerance threshold


Lay referral system

Chain of advice seeking contacts the sick makes with other lay people prior to/ or instead of seeking help from HCPs


What is symptom evaluation?

Relates to the fact that when patients often have explanations for their symptoms but wen they are not able to it usually prompts consultation


Three groups relating to adherence
- deniers and distancers
- acceptors
- pragmatists

Deniers and distancers
- deny they have the condition and so do not take the medication etc

- accept the diagnosis and doctor's advice
- normal life having controlled symptoms through medication

- do not use preventative medication for condition unless it was aggravated
- accept condition but see as mild illness


What is a chronic illness?

Encompasses a wide range of conditions which are
- long term
- have profound influence on live of sufferer
- often co-morbid conditions


What is an illness narrative?

Refers to story telling and accounting of the practices that occurred in the face of the illness


Types of work related to chronic illness


Illness work
- getting diagnosis
- managing symptoms
- self management
Biographical work
- loss of self (plans in future etc)
Emotional work
- protect emotional being of others and self
- impact on role and dependency
Everyday life work
- coping and strategy
- normalisation
Identity work
- stigma
- not treated the same


Types of stigma:
- Discreditable
- Discredited

- Enacted
- Felt

- nothing can be visibly seen but if found people would have different view
- physically visible characteristic or well know stigma sets person apart

- real experience of prejudice, discrimination and disadvantage due to condition
- fear of enacted stigma so fear that if someone knew they would be treated differently


Medical v social disability

Medical disability
- disability is deviation from medical Norms
- need medical intervention to help
(Lacks recognition of social and psychological factors)

Social disability
- Problems due to product of the environment and failure of the environment to adjust not due to abnormalities of the pele


Three commonly used measures of health

Patient based outcomes


What are patient based outcomes?

Used to assed the well being of patients from their point of view
Focuses on patient concerns

Patient recorded outcome measures are good as
- improves clinical management of patients
- comparison of providers e.g. Hospitals


What is health related quality of life?

Functional effect of an illness and its consequent therapy upon a patient, as perceived by the patient

- psychological well being
- social wellbeing


Quantitative v qualitative methods of measuring HRQoL

Quantitative methods use instruments or scales
- reliable and valid (measures what it intends to measures)
- published instruments tested for reliability and validity, can be used to compare across different groups

Qualitative methods good to initially look at dimensions of HRQoL


Generic quality of life measures advantages and disadvantages

Generic instruments
- can be used with any population and covers general health

+ used for broad range of health problems
enables comparisons across treatment groups
can detect unexpected positive and negative effects of interventions

- generic so less detailed
Les sensitive to changes that occur due to an intervention
Loss of relevance as too general


Specific quantitative instruments to measure HRQoL

Specific instruments evaluates health dimensions specific to a disease, site or dimension

SF-36 (Short form 36)
- 4 week recall period
- 36 items into 8 dimensions
- responses scored so scores for each dimension added (0-100) but cannot add up all dimension scores to give overall score

EuroQol EQ-5D
- generates single index value for health status
- full health 1, death 0
- 5 dimensions and 3 levels for each
- also draw s line for where you feel your health is


What type of specific instruments are there for measuring HRQoL?

Disease specific
Dimension specific
Site specific

+ relevant, sensitive to change, acceptance to patients
- cannot use with people who do not have the disease, may not detect unexpected effects as focused on one condition


What should you consider when picking an instrument for measuring HRQoL?

- are there studies showing established reliability and validity
- have there been published studies showing the instrument was used successfully
- is it suitable for your area of interest
- is it sensitive to change
- is it acceptable to patients


Spontaneous presentation v Opportunistic case finding

Spontaneous presentation is when a patient presents themselves with symptoms e.g. GP

Opportunistic case finding is when person presents with symptoms related to a disease or problem and then by chance something else is found


Define screening

Systematic attempt to detect an unrecognised condition by the application of rapid tests to distinguish apparently well people into those who probably do and do not have the disease

Purpose of screening
- give a better outcome compared with finding something in the usual way so if the treatment can wait there is no point screening


Five criteria from U.K. National screening committee for assessing screening

Condition - needs to be important
Test - simple, save, acceptable to population, sensitivity, specificity, PPV, NPV
Intervention - what to do to people when diagnosed with condition, need evidence that intervention at pre symptomatic phase is better than usual care
Screening programme - proven effectiveness in reducing mortality and morbidity
Implementing - management and monitoring


Features of the test in screening
- sensitivity
- specificity
- positive predictive value
- negative predictive value

- first column
- out of all the people with the disease, how many were detected positive in the test

- second column
- out of all the people without the disease, how many were detected negative in the test

Specificity and sensitivity are characteristics of the test so they do not change even if the population characteristics change

- first row
- out of all the people who test positive, how many actually have the disease

- second row
- out of all the people who test negative, how many people do or actually have the disease

These change with population characteristics


It can be difficult to evaluate screening programmes due to
- lead time bias
- length time bias
- selection bias

- lead time bias
Early diagnosis falsely appears to prolong survival
Patient lives the same amount of time but longer knowing they had the disease so looks like they lived longer as they found out about the disease earlier

- length time bias
Screening better at picking up slow growing unthreatening cases than aggressive fast ones so diseases that are detectable through screening are more likely to be favourable prognosis anyway

- selection bias
Studies of screening often skewed due to healthy volunteer effect


Sociological critiques of screening

Victim blaming
Feminist critiques
Moral obligation to screening


Compared to previously what has changed in the structure in the NHS

- increasing role of managers
- increasing marketisation of provision
- change in NHS structure


Role of Secretary of State

Accountable for NHS
Responsible for promoting healthcare
Leads department of health


Role of department of health

Sets national standards that commissioners and providers have to follow
Sets national tariff


Role of NHS England

Authorises CCGs
Commissions primary care services and specialist services


What are CCGs

Clinical commissioning groups
Brings together GPS, nurses, public health, patients etc and responsible for flow of money in NHS budget


All clinicians should have the opportunity to become
- partner
- leader

- takes responsibility for management of finite resources

- works with other clinicians and managers to change systems where it will benefit patients


What is a
- clinical director
- medical director

Clinical director
- each directorate (speciality) is led by a clinical director
- has to implement audits, continue medical education and training for staff, design and implement policies on junior doctor work etc

Medical director
- above clinical directors
- most senior doctor in organisation that sits on board of NHS trust
- responsible for quality of medical care
- communicates between board and medical staff
- approves job descriptions, involved in disciplinary hearings


Define profession

Type of occupation able to make distinctive claims about its work practices and status


Define professionalisation

Process of an occupation becoming a profession

Involves three elements
- asserting an exclusive claim over a body of knowledge
- establishing control over market and exclusion of competitors
- establishing control over professional work practice

(Remember GMC now has lay members so medicine no longer as much of a profession compared to previously)


Define socialisation

Process by which professionals learn during their education and training the attitudes and behaviour necessary for their professional role

This occurs through the interaction with others. The formal curriculum refers to knowledge/ tested in exams while the informal curriculum are the attitudes and beliefs acquired but not formally examined


What are some critiques of professions?

- protected monopolies
- seek to optimise own interested and not their clients


What services are fitness to practice concerns reported to?

Medical Practitioners Tribunal Services (MPTS)

- this group's sits above the GMC and decides if someone is struck off or not
- so GMC still says what doctors can/can't do but if someone falls short, they investigate the person and if there is a question of their FTP they hand the decision to MPTS.


What does revalidation involve?

Local evaluation of doctor's practice through annual appraisals


Implicit v explicit rationing

Implicit rationing
- care is limited but neither the decisions or the basis of the decisions are clearly expressed
- so allocation of resources through individual clinical decisions without criteria for those decisions being explicit
- can lead to inequalities and discrimination, decisions based on social deservingness, patients not aware of all options

Explicit rationing
- clearly set out procedures are followed to make decisions of who gets treatment etc
- care is limited but decisions are explicit
- transparent and accountable decisions, more equity in decision making, more clearly evidenced based however heterogeneity of patients and illnesses, impact on clinical freedom, complex


Define opportunity cost

When spending resources on one thing/treatment, these resources now cannot be used in other treatments
Measured in benefits foregone


Technical v allocative efficiency

Technical efficiency
- you have decided the bets outcome but are finding the best way to do it

Allocative efficiency
- you are choosing between the many needs to be met


What is an economic analysis?

Compares inputs (resources) and outputs (benefits and value attached to them) of alternative interventions
Allows for better decisions to be made about which interventions represent best value for investment


Four types of economic evaluation

- cost minimisation analysis
Outcomes assumed to be equivalent so focus is on cost
- cost effectiveness analysis
Comparing drugs or interventions that have a common health outcome by comparing cost per unit outcome
- cost benefit analysis
All inputs and outputs have monetary terms so think about how much money is given to healthcare and other services e.g. Education
- cost utility analysis
Type of cost effectiveness analysis that measures quality of adjusted life years (QALY)


What is a QALY?

They adjust life expectancy for quality of life
1 QALY is one perfect year of health or = 10 years with 0.1 quality of life


Criticisms of QALYS

- controversy about the values that they embody (quantity v quality of life)
- may disadvantage common conditions
- technical problems with their calculations
- do not assess impact on carers and family


Define complementary therapies

The practice of complementary and alternative medicine involves any medical system based on a theory of disease or
method of treatment other than the orthodox science taught in medical school


Why might people turn to complementary therapies?

- preference for a holistic approach
- feel they receive more time and attention from practitioner
- persistent symptoms not relieved by conventional treatment
- concern about real or perceived adverse effects of conventional treatment


Concerns over complementary therapies

- safety and competence of practitioners
- social factors
- costs
- guilt for spending money
- denial


For and against NICE evaluating complementary therapies

- high public interest
- half GPS provide access
- should apply same standards to everything
- address inequalities in access

- money limited in NHS
- poor quality evidence
- NICE has higher priorities


Challenges in conducting trials to look at complementary therapies

- who will fund it
- trial of single intervention may not reflect reality
- finding placebos is challenging
- difficult to double blind


EBM and complementary therapy issues

- to what extent is EBM relevant and applicable to complementary medicine
- whose evidence counts
- validity to EBM principles


Why are we interested in patient's views related to healthcare?

Evidence that patient satisfaction is important outcome
Ethical views
Increased external regulation of health services
Means of securing funding


What is healthwatch England?

Healthwatch England is the national consumer champion in health and care
Ensure voice of consumer strengthened and heard by commissioners


What are PALs

Trust based patient advice and liaison services

They offer confidential advice, support and information on health related matters


What is the parliamentary and health service Ombudsman?

Ombudsman sits above all different healthcare organisations and undertakes independent investigation into complains that NHS in England has not acted upon properly or fairly

You can either complain initially to local CCG or hospital and then if not sorted properly then goes to Ombudsman


Disadvantages of using locally developed DIY instruments to get patients views on healthcare

May not comply to basic standards for questionnaire design
May not have proven reliability and validity
Lack comparability
Tend to find higher levels of satisfaction rather than published instruments


Challenges in responding to dissatisfaction to healthcare experience

Views may not be reasonable or rational
How much resource should be diverted to satisfy issues from complaints
How should patients concerns about someone's clinical competence and/or fitness to practice be viewed?


Sociological approaches to patient professional relationship


- argues doctor patient relationship based on a set of socially prescribed roles for Dr and patients
- sick role associated with rights to be excused from obligations and seek medical attention, want to get well, not to abuse role
- Dr role includes work in interest of patients, be objective, non discriminatory, autonomy and status
- roles important as imbalance of power in relationship so for relationship to work doctors and patients must trust each other and work together

Conflict theory
- Dr holds power and patient has little choice but to accept dominance of Dr
- lay ideas are being marginalised
- medicalisation of everything

Interactionist approach
- Interested in patterns of interaction between doctor and patient

Patient centred model
- aspiration that relationship less hierarchal and more cooperative
- patient views taken into account, holistic care
- shared decision making