This report synthesises evidence from seven integrated care case studies, and identifies lessons for policy-makers and service providers to help with the challenges ahead. Around the world, rapidly ageing populations are resulting in increased demand for health and social care services, which presents significant challenges for national health and care systems. Many have adopted an integrated care approach to meet the needs of older people with chronic or multiple conditions. This approach often involves a single point of entry – designating a care manager to help with assessing needs, sharing information, and co-ordinating care delivery by multiple caregivers (formal and informal).
almost 6 years ago
Our report argues for a new approach that brings together funding for general practice with funding for many other services. This would entail new forms of commissioning, with GPs innovating in how care is delivered. As England’s population both expands and ages, so the demands on primary care will grow. Within the current commissioning and funding system innovative models of primary care provision are already being used. This report describes examples of these through four case studies in different areas of England. It also highlights how the existing system is imperfectly understood, particularly regarding contracts.
almost 6 years ago
Our qualitative assessment of the impact to date of medical revalidation on the behaviour of doctors and the culture of organisations within seven case study sites across England. Medical revalidation of doctors became a statutory obligation for all employing organisations in 2012, but its origins stretch back to 2000. In that period, the NHS has undergone many changes and been scrutinised by several reviews. It was against this shifting context that The King's Fund carried out a qualitative assessment of the impact to date of medical revalidation on the behaviour of doctors and the culture of organisations within seven case study sites across England.
almost 6 years ago
In the initial interviews with patients who suffer psychotic symptoms, it might be striking that the usage of terminology of descriptive psychopathology lingers on an arbitration of knowledge of 'truth' by using terms like delusions or hallucinations with their definition as false beliefs or false perceptions (Casey & Kelly 2007). These terms can cause annihilation of value to patient's experience, which may pose an initial strain on the egalitarian patient-doctor relationship. In an era, where deference to experts is dead, it might be worthy on agreeing on the effect of these experiences prior to lablelling them. Delusions can not be objectively detected and described, because it evolves and exists within subjective and interpersonal dimensions. Severe psycopathological symptoms share the fact that they are statistically deviant, and thus can be labeled as 'unshared'. Symptoms may be perceived as 'distressing' and they might be 'disabling' to them. The outcome behaviour which may raise concern can be a 'dysfunctional' behaviour (Adams & Sutker 2004). Jaspers considered the lack of understandability of how the patient reached conclusion to be the defining factor of a delusional idea. The notion of defining 'delusion' as false belief was challenged by Jaspers. Sims gives the example of a man who believed his wife was unfaithful to him because the fifth lamp-post alone on the left was unlit. What makes it a delusion is the methodology not the conclusion which may be right (Sims 1991). Some delusions might be mundane in their content, others may not be falsifiable. Dereistic thinking is not based on logic but rather on feelings. It is possible to find ways to evade falsification; an ad hoc hypotheses may also be part of the presentation. Fish stated that delusional elaboration may follow delusion and/or hallucination which may have convergence with the concept of the ad hoc hypothesis. Absence of verification from the patient's side does not lead to deductive falsification (Casey & Kelly 2007). Otherwise, the doctor-patient relationship carry the risk to transform to detective-suspect relationship, where the latter may perceive the need to present evidence of innocence. Mental health professionals are usually encountered by people who suffer to various degrees or make others suffer, and not because of various degrees of conviction. The primary role of the therapist is to be defined as some one who tries to alleviate the sufferings of others rather than correcting their beliefs. Communicating with patients in terms of how functional is their belief rather than it's truth may prove to be more egalitarian and clinically tuned. This may provide some middle ground in communication, without having to put an effort on defining the differences between what is 'true' and what is 'real'. The criterion for demarcation between what is real and what is pathologic may be different in the patient-doctor relationship. The assertion on the clinician's part on the falsity of a belief or experience can have the risk of dogmatism. The statistical deviance of symptoms, their distressing nature, disabling consequences, the resultant dysfunctional behaviour and apparent leap from evidence to conclusion may be a more agreeable surrogate starting points. This might be more in line with essence of medicine or 'ars medicina' (art of healing). Concordance with patients on their suffering may serve as an egalitarian platform prior to naming the symptoms. The term delusion commonly identified as false fixed belief, when used by a psychiatrist, it does not address only a symptom. It rather puts the interviewer in the position of an all knowing judge. After all, a service-user may argue that how come a doctor who never encountered or experienced any of the service-user's aspects of the problem as being persecuted at work and home, as plainly false. Then, does the psychiatrist know the truth. From a service-user point of view what he/she experience is real; which might not necessarily be true. The same applies for people who lead an average life, people who go to work bearing with them their superstitions, beliefs about ghosts, luck, horoscopes, zodiacs, or various revered beliefs. This term has the risk of creating a temporary crack in the mutual sense of equality between the therapist and the service-user. This may be due to the labelling of certain dysfunctional belief as unreal by one side. It has the potential for a subtle change in the relationship to the mental health professional placing himself/herself in the omniscient position and it contrasts with the essence of medical practice where practitioners assume the truth in what the patients say as in the rest of subjective symptoms as headache for example. The subsequent sequel of this is other labels such as 'bizarre delusions' or 'systematised delusions', further add to the deviation of the role of the professional therapist to an investigator in the domain of 'Truth' and architecture of 'Truth'. Furthermore, it might be strenuous to the relationship when the therapist - based on skeptic enquiry - starts explaining such symptoms. For example, if the service-user believes that Martians have abducted him, implanted a device in his brain and sent him/her back to earth, and the response communicated back is the 'delusional'. It could be argued by the service-user that the therapist who had not seen a Martian or a brain device before, labelled the whole story as 'delusion' in a rather perceived dismissive labelling with no intention to check on the existence of Martians or the device. In other words, the healer became the arbiter of truth, where both lack evidence for or against the whole thing; one member in the relationship stepped into power on basis of subjective view of plausibility or lack of thereof. In the case of hallucinations, the clinician labelling the patient's experience as hallucinations can be imposing fundamental dilemma for the patient. For example, if a patient hears a voice that says that everything is unreal apart from the voice, and the clinician says that the voice is the thing that is unreal. Both do not give evidence to their 'truth' apart from their statement. The clinician's existence to the patient's subjective reality is distorted by the multiple realities of the patient, and arguing on basis of mere existence that the 'voice' is the one that is 'false', does not give the patient a clue of the future methodology to discern from both, since percetption is deceived and/or distorted. In this case, another tool of the mind can be employed to address the patient. The same can be applied to a concept like 'over valued ideas', where the clinician decides that this particular idea is 'over valued', or that this 'idea' is 'over valued' in a pathological way. The value put on these ideas or not the patient values but the clinician's evaulation of 'value' and 'pathology'. The cut of point of 'value' and 'over value' seems to be subjective from the clinician's perspective. Also, 'derailment' pauses the notion of expecting a certain direction of talk. The concepts of 'grooming' and 'eye contact' implicitly entail the reference to a socio-cultural normative values. Thus, deviation from the normative value is reflected to the patient as pathology, which is an ambiguous definition, in comparison to the clarity of pathology. The usage of terms like 'dysfunctional unshared belief' or 'distressing auditory perception' or other related terms that address the secondary effect of a pathologic experience may be helpful to engage with the patient, and may be more logically plausible and philosophically coherent yet require empirical validation of beneficence. Taylor and Vaidya mention that it is often helpful to normalise, but this is not to minimise or be dismissive of patient's delusional beliefs.(Taylor & Vaidya 2009). The concept can be extended to cover other terms such as 'autistic thinking, 'apathy', 'blunting of affect', 'poor grooming', 'over-valued ideas', other terms can be applied to communicate these terms with service-users with minimal deviation from the therapeutic relationship. The limitation of these terms in communication of psychopathology are special circumstances as folie a deux, where a dysfunctional belief seems to be shared with others Also, symptoms such as Charles-Bonnet syndrome; usually does not have negative consequences. The proposed terms are not intended for use as a replacement to well carved descriptive psychopathological terms. Terms like 'delusion' or 'hallucination' are of value in teaching psychopathology. However in practice, meaningful egalitarian communication may require some skill in selecting suitable terms that is more than simplifying jargon. They also may carry the burden of having to add to the psychiatric terminology with subsequent effort in learning them. They can also be viewed as 'euphemism' or 'tautology'. However, this has been the case from 'hysteria' to 'medically unexplained symptoms' which seems to match with the zeitgeist of an era where 'Evidence Based Medicine' is its mantra; regardless advances in treatment. Accuracy of terminology might be necessary to match with essence of scientific enquiry; systematic observation and accurate taxonomy. The author does not expect that such proposal would be an easy answer to difficulties in communication during practice. This article may open a discussion on the most effective and appropriate terms that can be used while communicating with patients. Also, it might be more in-line with an egalitarian approach to seek to the opinion of service-users and professional bodies that represent the opinions of service-users. Empirical validation and subjection of the concept to testing is necessary. Patient's care should not be based on logic alone but rather on evidence. Despite the limitations of such proposal with regards to completeness, it's hoped that the introduction of any term may help to add to the main purpose of any classification or labelling that is accurate egalitarian communication. DISCLAIMER This blog is adapted from BMJ doc2doc clinical blogs Philosophical Streamlining of Psychopathology and its Clinical Implications http://doc2doc.bmj.com/blogs/clinicalblog/_philosophical-streamlining-of-psychopathology-its-clinical-implications The blog is based on an article named 'Towards a More Egalitarian Approach to Communicating Psychopathology' which is published in the Journal of Ethics in Mental Health, 2013 http://www.jemh.ca/issues/v8/documents/JEMHVol8Insight_TowardsaMoreEgalitarianApproachtoCommunicatingPsychopathology.pdf Bibliography Adams, H. E., Sutker P.B. (2004). Comprehensive Handbook of Psychopathology. New York: Springer Science Casey, P., Kelly B., (2007). Fish's Clinical Psychopathology: Signs and Symptoms in Psychiatry, Glasgow: Bell & Bain Limited Kingdon and Turkington (2002), The case study guide to congitive behavior therapy for psychosis, Wiley Kiran C. and Chaudhury S. (2009). Understanding delusion, Indian Journal of Psychiatry Maddux and Winstead (2005). Psychopathology foundations for a contemporary understanding, Lawrence Erlbaum Associates Inc. Popper (2005) The logic of scientific discovery, Routledge, United Kingdom Sidhom, E. (2013) Towards a More Egalitarian Approach to Communicating Psychopathology, JEMH · 2013· 8 | 1 © 2013 Journal of Ethics in Mental Health (ISSN: 1916-2405) Sims A., Symptoms in the mind, (1991) an introduction to psychopathology, Baillere Tindall Taylor and Vaidya (2009), Descriptive psychopathology, the signs and symptoms of behavioral disorders, Cambridge university press
Dr Emad Sidhom
about 6 years ago
When is it medically advisable to eat some one else's poo? When you need a poo transplant. Poo transplants could be the solution to one of the biggest problems facing the NHS today- the bacterial infection Clostridium difficile. C.diff, as it's known to its friends, infects about 18,000 people in England and Wales every year and is involved in the deaths of about 2000 people. C.diff typically arises due to imbalances in the normal gut bacteria. The gut is like a city, a city with about 100 trillion bacterial residents happily munching away on a banquet of bowel contents. The average person has about 1000 different types of bacteria in their gut, and about 3% of healthy adults have C.diff in that mix. The C.diff doesn't cause them any problems because its numbers are kept in check by the other gut bacteria. However treatment with broad spectrum antibiotics such as clindamycin, cephalosporins, ciprofloxacin and co-amoxiclav, can disrupt this happy community- killing off vast swathes of bacteria but crucially not the C.diff. Given free rein the C.diff multiplies rapidly and produces toxins which damage the gut. In some people this causes mild diarrhoea and abdominal pain, in others it can lead to torrential diarrhoea, perforation of the colon and death. Traditional treatment includes stopping any broad spectrum antibiotics and possibly prescribing antibiotics which target the C.diff such as metronidazole or vancomycin. However with antibiotic use comes the risk of resistance. Moreover our current approach isn't entirely effective and about 22% of patients treated suffer a recurrence. This can result in a cycle of illness and hospital admission which is costly to the patient and the hospital. So it's time to start thinking outside of the box. Cue the poo transplant. The thinking goes like this- if the cause of the problem is disruption to the normal community of gut bacteria, why not just pop those bacteria back in to crowd out the C.diff? Simples. Practically, the first step is to identify a donor, usually a close relative of the patient, and screen them for a range of infectious diseases and parasites. It's also advisable to make sure they haven't recently consumed anything the intended recipient is allergic to, before asking them to make their "donation". You then pop it in a household blender and blitz it down, adding saline or milk to achieve a slurry consistency. Next you need to strain your concoction to remove large materials- one medic in the UK uses coffee filters. Top tip. Then you're ready to administer it- about 25ml from above (e.g. via nasogastric tube), or 250ml from below. Now, its important to note that poo transplants are still an experimental treatment. To date only small case studies have been carried out, but with 200 total reported cases, an average cure rate of 96% and no serious adverse events reported to date, it's worth carrying out a large trial to assess it thoroughly. Poo transplants- arguably the ideal treatment for a cash strapped NHS. It's cheap, plentiful and it seems to work. Now to convince people to consume someone else's poo... Bottoms up! FYI: This was first posted on my own blog. Image Courtesy of Marcus007 at de.wikipedia [Public domain], from Wikimedia Commons
Dr Catherine Carver
almost 7 years ago
Itraconazole is an antifungal drug used widely to treat fungal infections and is active against Aspergillus, Candida and Cryptococcus. It is effective and now much cheaper as it has passed out of the period of time granted to its inventor to exclusively sell it - there are now several competing manufacturers. It seems to be an increasingly useful and used drug now it has become more accessible which is a good thing in the main but this makes it increasingly important that this drug is properly understood and its very severe potential side effects appreciated and guarded against. These are the warnings published by the World Health Organisation Risk of congestive heart failure The agency says that while the available evidence suggests that the risk of heart failure with short courses of itraconazole is low in healthy, young patients, prescribers should exercise caution when prescribing the drug to at-risk patients. Amendments to the product information of all itraconazole formulations have been made to reflect this information. Risk to pregnant women By April 2000 the UMC had received 43 case reports from 5 countries regarding the use of itraconazole by pregnant women. 25 of these pregnancies ended in embryonic or foetal death. The remaining 19 reports described a variety of congenital malformation or neonatal disorders. In the 38 reports in which the route of administration was specified the drug was taken orally. The data suggested that: inspite of the approved recommendations and warnings itraconazole is being taken by pregnant women for minor indications, reported human experience seems to lend support to the experimental evidence that itraconazole is teratogenic, there is a predominance of abortion, and more firm warnings may be needed in the product information.Although not apparent from the UMC reports, a further question of interest was if itraconazole might decrease the reliability of oral contraceptives and so lead to unintended exposure in pregnancy. Care thus needs to be taken about which patients are prescribed itraconazole, adequate monitoring needs to be put in place if needed and sufficient advice given with the drug to ensure the patient is aware of the risks involved and the signs & symptoms to look out for.
almost 7 years ago
Platelet satellitism can easily catch you unawares, if you are not careful. In this video, the mechanisms and implication of the presence of platelet satellitism is described making use of a case study.
almost 7 years ago
I'd like to tell you a curious story. Jane was a 52 year old woman in need of a kidney transplant. Thankfully she had three loving sons who were all very happy to give her one of theirs. So Jane's doctors performed tests to find out which of the three boys would be the best match, but the results surprised everyone. In the words of Jeremy Kyle, the DNA test showed that Jane was not the mother of two of the boys... Hang on, said Jane, child birth is not something you easily forget. They're definitely mine. And she was right. It turns out Jane was a chimera. Chimerism is the existence of two genetically different cell lines in one organism. This can arise for a number of reasons- it can be iatrogenic, like when someone has an organ transplant, or it can be naturally occurring. In Jane's case, it began in her mum's womb, with two eggs that had been fertilised by different sperm creating two embryos. Ordinarily, they would develop into two non-identical twins. However in Jane's case the two balls of cells fused early in development creating one person with both cell lines. Thus when doctors did the first tissue typing tests on Jane, just by chance they had only sampled the 'yellow' cell line which was responsible for one of her sons. When they went back again they found the 'pink' cell line which had given rise to the other two boys. This particular type of human chimerism is thought to be pretty rare- there are only 30 case reports in the literature. (Though remarkably both House and CSI's Gil Grissom have encountered cases.) What happens far more frequently is fetal microchimerism- which occurs in pregnant women when cells cross the placenta from baby to mum. This is awesome because we used to think the placenta was this barrier which prevented any cells crossing over. Now we've found both cells and free floating DNA cross the placenta, and that the cells can hang around for decades after the baby was born. Why? As is often the case in medicine we're not sure but one theory is that the fetal cells might have healing properties for mum. In pregnant mice who've had a heart attack, fetal cells can travel to the mum's heart where the develop into new heart muscle to repair the damage. Whilst we're still in the early stages of understanding why this happens, we already have a practical application. In the United States today, a pregnant woman can have a blood test which isn't looking for abnormalities in her DNA but in that of her fetus. The DNA test isn't conclusive enough to be used to diagnose genetic conditions, but it is a good screening test for certain trisomies including Down's syndrome. Now, we started with a curious tale, so lets close with a curious fact, and one that's appropriate for Mother's Day: This exchange of cells across the placenta is a two way process. So you may well have some of your mum's cells rushing through your veins right now. In my case they're probably the ones that tell me to put on sensible shoes and put that boy down... (FYI: This is a story I originally posted on my own blog)
Dr Catherine Carver
almost 7 years ago
I recently wrote an obstetric case report which is quite up to date and relevant as NICE have not released their new guidelines on the subject yet. I was wondering if anyone had any experience of getting reports published as a student? I have no idea where to start.
about 7 years ago
All tutorials I've come across teach that to scan lungs and pleura you only need to scan anterior & lateral thorax wall, each made up of 4 segments (sup ant/lat & inf ant/lat). It doesn't quite make sense to me eg when looking for consolidation which might be localized to just one segment. And I've seen case reports of findings on posterior thorax. Can anyone enligthen me about the truth here?
over 7 years ago
I have directed and produced this 20 minute documentary. It is used as a Global Health Education Tool for the Imperial College London Global BSc and Short course. This is a self shot documentary about the ongoing Bhopal Chemical Disaster in India. Looking at the past/present/future of the best industrial disaster in history. Focusing on the Sambhavna Clinic, a primary healthcare that provides free medical care for victims. Filmed in 2010 edited in 2012. This is a case study of a serious global health issue and highlights the ethics of business in the third world and consequences this can have for health. I'm a 23-year-old medical student with a passion for film and photography. I'm interested in the interplay of medicine, sociology, psychology, research and ethics. Film form is a great means to educate, or simply make people think.
over 7 years ago