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Who am I ?
Senior partner general practice
Trainer in general practice
Petersfield Screening
Occupational health
Life and Death
Decline and death NOW
IDEAL
Infection
Genetics
Trauma
Cancer
Autoimmune
Endocrine
Vascular
Drugs
Henri Frederic Amiel
To know how to grow old is the
masterwork of wisdom, and one of
the most difficult chapters in the
great art of livingJournal 21Sept 1874
What is Health?WHO definition
a state of complete physical, mental
and social well-being and not merely
the absence of disease or infirmity
Psychological HealthMood and Mind
Use it or lose it• Studies show that active minds less likely
to have dementia – Bridge helps the brain.
High IQ protects against Alzheimer's
What you think is what you feel• Value of positive thinking
10
Optimum performance
Burnout /Breakdown
Rustout
HIGH
LOW STRAIN / PRESSURE
pERFORMANCE
Pressure or stress
12
Different Perspectives of stress
Stimulus based
Noxious environment - heat, cold, lack of sleep
Social ridicule / failure / bad relationships
13
Different Perspectives of stress
Response based
General adaptation syndrome1}Alarm reaction - defence mobilisation - lowering of resistance
2}Stage of resistance - coping mechanisms resistance restored
3}Stage of exhaustion - Adaptation declines
14
Different Perspectives of stress
Interactional models.
Outcome dependent on interaction between person and environment
Cooper - Stress due to misfit between perceived demand and perceived abilities
Cox - Stressor - perception of stress -> appraisal of ability to cope -> stress reaction
Stress and careers
Early career - understanding the system,
establish oneself - REALITY SHOCK
Mid career - reflecting on achievements,
achieving a balance, ‘locked in’ - THE MID-
LIFE CRISIS
Late career - reduced capability, anticipating
the future - END GAMES
16
Effects of Stress in retirement
Self Definition from role
Lack of ‘Power’
Depression
Beravement
• Status
• Money
• Social contacts
17
Effects of Stress in retirementShort Term
Fight or flight
Long Term
Physical - Many different body systems affected
Social - Work and home - Stress Spiral
Psyche - Anxiety / Depression
18
Long Term PhysicalCardiovascular
Gastrointestinal
Respiratory
Skin
Reproductive
Neurological
Immune
Social HealthEverard 1999
Activities which help to connect socially more benefit than isolated hobbies to ‘pass the time’• Enhanced well being
• Improved mental and physical health
• Keeping busy is not the key– Do the things you enjoy – in company!!
Social Health
Study at Centre for aged Mass
Extreme elderly who were socially
engaged
• More likely to survive for 2 years
irrespective of other illnesses.
Spiritual Health
No values conflict
Behaving as you believe is right
Values conflict stress
Belonging
Faith
Life Expectancy UK Men
BestChiltern 78.4East Dorset 77.9Ryedale77.9Wokingham77.8Fareham 77.6South Norfolk77.6South Oxford77.5
WorstGlasgow 68.4Inverclyde 69.2W Dunbarton69.1Manchester70.1Eilean Siar 70.9Merthyr Tydfil71.1Liverpool 71.2
Deaths per 100,000 UK and Developing countries
UKHeart attacks 234Stroke 124Cancer lung 46Pneumonia 34Chronic Bronc 28Cancer colon 25Cancer stom 21
Abroad8771---9546------
Deaths per 100,000 UK and Developing countries
UKRTA 19Suicide 17Diabetes 15Diarrhoea --Perinatal --TB --Measles --Malaria --
Abroad19------7157472621
Hypertension
Reduce alcohol if excessive
Medication – if >=160, and/or>=100 or
30% risk of heart attack at 10 yrs
• Diurectics
• B Blockers
• Calcium antagonist
• ACE / Angiotensin II inhibitors
Raised Cholesterol
May be hereditary
Related to Genes / Weight / Diet
Predisposes to
Heart disease
Strokes
Furring up of arteries
Raised Cholesterol
Average British Cholesterol = 6.2 mM/L
Desirable Cholesterol = < 5.2 mM/L
Good and bad types
Good should be > 0.9 HDL
Bad should be < 3 LDL
Ratio of total to good should be less than 4
Diabetes Mellitus
Insulin dependentIn young people Presents with • Thirst• Weight Loss• Tiredness
Relatively rare about 2-3 per 1000 people
Diabetes Mellitus
Non insulin dependant diabetes
Familial
Related to weight
Incidence 2% of total population 10%
over 70 yrs
Reduces life expectancy by 10 years
Diabetes Mellitus
AffectsIncrease heart attacksIncrease strokesKidney damageEye damageNerve damage – neuropathy
• Numbness, weakness, impotence
Blood vessels damage• Poor peripheral circulation – intermittent
claudication and gangrene
Osteoarthritis Disease of articular cartilage Possible link to heart disease OA hands
Wear and tear diseaseSome inflammation alsoMay be hereditary
• Hands affected ends of fingersMainly weight bearing joints
• Spine• Hip• Knees• Ankles
Osteoarthritis
Prevent by
Avoiding excessive weight
Not overstraining joints
Symptoms
Pain
Reduced movement
Osteoporosis
low bone mass – Bones thin and spongy
1/3 of all women>601/12 of all men > 60
Serious as fracture neck of femur common terminal event cf in elderly women
24% of women die in the year following a hip fracture
Osteoporosis
Osteoporosis symptoms
Height loss
Protruding abdomen
Dowagers hump
Reduced Lung capacity
Oesophageal reflux
Osteoporosis
Causes• Premature menopause• Alcohol• Steroids – ( prednisolone > 7.5 mg per
day)• Thin – BMI < 19• Family history• Low calcium intake• Smoking
Osteoporosis
Diagnosis• Dual energy X-ray absorptiometry – DEXA
– Gold standard
• Ultrasound – also tests structure– T score - = SD compared with young adult– Z score - = SD compared with age matched
control– -2.5 SD= osteoporosis
Osteoporosis Prevention
Exercise in youth – builds bone massCalcium Supplements – if :-
• Deficient in diet
• On steroids
• Postmenopausal > 5 yrs and thin
Vitamin D – Aids calcium absorption assimilation
• 800iu per day – or from fish oil/milk/egg etc
HRT
HRT
Recently linked to increase ofPE x2.17DVT x2.07MI x1.29Cancer Breast x1.26
But reduces Hip fractureCancer Bowel
XS deaths about 1:500
Disease Prevention
Skin Cancers
• Commonest cancers known in Caucasians
– Related to sun exposure
– Burning
– Family History
Disease PreventionSkin Cancers
Solar Keratoses• Premalignant
• Sun exposed areas
• Non pigmented
• Roughening
Seek Help
Treatment – liquid nitrogen
Disease PreventionSkin Cancers
Basal Cell carcinoma (rodent ulcer) • Common• Sun exposed areas• Whipcord edge• Central ulceration• Locally invasive only• Slow growing• Danger near eye
Treatment - excision
Disease PreventionSkin cancers
Squamous Cell carcinoma• Less common
• Poorly defined edge
• Persistent scaly patch
• Not usually pigmented
• Sun exposed areas
• May be a nodular
• May metastasise
Treatment-excision
Disease PreventionMelanoma – incidence increasing
Family History
Fair skin
Legs in women
Back in men
History of burning ( cf blistering )
Disease PreventionMelanoma
Asymmetry
Varied Pigment
Change in shape or colour or size
Bleeding, Itching
Satellite lesions
Disease PreventionWeight – Apples & pears
Optimal• Body Mass Index
– 19-24 woman– 20-25 man > 25 overweight > 30 obese
• Incidence – Overweight 34% women– Overweight 45% men– Obese 18% women– Obese 16% men
• NB fat children fat adults – look after your grandchildren
Disease PreventionWeight
Overweight causes
• Diabetes
• Raised cholesterol
• Raised blood pressure
• Joint disease cf hips knees
Disease PreventionDiet
No salt at the table reduces BP
Fresh food – fruit antioxidants
Walnuts 50 g per day can reduce cholesterol
Red wine 2-3 units per day but :-
• Empty calories
• Hypertension if binge
Disease PreventionDiet
Fish 3x per week reduces heart
disease
Fibre reduces transit time – and
bowel cancer
To loose weight keep to low fat diet
Disease PreventionDiet
Low cholesterol
• Animal fats
• Beware Hidden fats – biscuits, crisps, cakes
• Beware Tropical fats – palm oil, coconut
and advocado
Disease PreventionDiet
Tea – some evidence protects DNA and therefore cancer
Chocolate
Vitamins – evidence for protection vs cancer and ihd disappointing.
Folic acid 800 mcg per day reduces homocysteine and heart disease
Adequate calcium – for bones
Disease Prevention
Exercise
Helps control diabetes
As good as antidepressants
Protects bones – if weight bearing
Disease PreventionExercise
Flexibility• Move all joints daily
Cardiovascular• Duration
– 30 mins per day
• Intensity– 60-80% of capacity ( 220-age)
• Frequency– 5 times per week
Disease PreventionImmunizations
Flu and pneumococcal vaccine if > 65 or• Asthma
• Diabetes
• Renal disease
• Cardiac disease
Travel jabs
Disease PreventionDental checks
Optician
Free glaucoma screen if family history
Cataracts
Driving – night vision
VDU, reading glasses
Disease PreventionHealth Screening
Full History and examination
Blood pressure
Exercise stress ECG +cardiac risk assessment
Liver function tests
Renal function tests
Thyroid
Diabetes
Disease PreventionHealth Screening
Visual acuity
Glaucoma check – commonest cause of
blindness
Grip strength
Hearing
Prostate Specific Antigen for carcinoma
prostate
Disease PreventionHealth Screening
Lung function testsCervical SmearMammographyAortic aneurysm > 55 yrsTropical screening• Schistosomiasis• Ova and parasites
The State of the NHS
HospitalsDirty
• Hospital acquired infection – kills 5000 per
year
– Could be reduced by 15% saving £150 billion
• Dirty linen, litter, food left in wards for days
overflowing toilets, pigeons in canteen
• 80% of filthiest – cleaned by contracters
The State of the NHS
The DoctorsStressed out – BMJ survey 2001 of 1400 GP• Workload
– Average GP sees 150 patients per week 7200/ yr
• Underpaid• Health service falling apart• Poor support• Declining control over work• Politicians stoking patient expectation
The State of the NHS
The Doctors• Survey of 11000 NHS staff vs British
Household panel
– General population –18% minor psychiatric
problem
– Doctors – 28% minor psychiatric problem
– Other professionals ( non NHS) 18%
• Other studies range hospital consultants
– 23- 33% Burnout – and exhaustion
The State of the NHS
The DoctorsStudy of doctors vs management consultants
• Job always stressful?
– 20% GP
– 11% Consultants
– 5% Junior Doctors
– 5% Management consultants
1:3 Doctors are planning to retire early
The State of the NHS
Recent BMA survey of all GP’s
22 380 responded
66% of entire workforce
86% Voted to hand in resignation
next April unless working conditions
improve
The State of the NHS
The WaitingBHB Out patients
• Medicine 08 weeks• Eyes 11 weeks• Rheumatology 11 weeks• Gynae 15 weeks• Surgery 15 weeks • Urology 22 weeks• Orthopaedics 24 weeks• Skin 25 weeks
The State of the NHS
The WaitingNB effect of 18/12 month deadline and day cases
Operations and investigation
• MRI 8 weeks urgent 20
routine
• Breast cancer 6 weeks
• Hip replacement 16 months
• Hernia 14 months
• CABG 12 months
The State of the NHS
The Stories• 17 months to see a therapist for
depression– Barnett
• 2.5 years for cardiology treatment– Liskeard
• 18 months in pain awaiting disc surgery– Salford
• 2 years to see a psychologist– Cumbria
State of NHS – advice to GP’s
United StatesTreat patients with cholesterol lowering drugs if 10% risk at 10 yrsTarget LDL ( bad cholesterol )= 2.6
United KingdomTreat only if 30% risk at 10 yrsTarget LDL = 3
The State of the NHS
The solutionGo private
• Pay yourself– Cataract £2400– Hip replacement £7800– Knee replacement £8400– Hysterectomy £4300– CABG £12500
• May be able to arrange fixed price service with a private hospital
– NB find out what's included and what's not
Private medical insurance
Number of people insured up 5.5% on last year6.9 million people coveredMainly company schemes – 4.8 millionCosts are increasing – average plan
1990£4112001£1000
Private medical insurance
What’s coveredInpatient costs• BUT – check if ceiling or specific hospitals
only
Outpatient costs• Vary with policy may even include
– Home nursing– Psychiatry– Ambulance
Private medical insurance
What’s notLong term problems• Eg Chronic fatigue, renal failure, dialysis
Common exclusions• Cosmetic surgery, sleep disorders, nursing
home, HRT, vaccination, out patient drugs and dressings.
• Pre existing conditions– Moratorium policy – ok if free from it for 5
years
Private medical insurance
How much typical couple age 68 , 70
• £1200 to £10,000 per year
Increases of premium• With age• With time
Reduce cost by• Shopping around• Paying an XS – can reduce by 50% premium
[ BUPA, WPA]• Only going private if wait > 6 weeks [ 6 week plan
NU]
Private medical insurance
Basic policies• Little outpatient cover• WPA Poplar – good for 50’s
– Includes DXT and chemotherapy and out patients• Secure Health’s Hospital Plan
– Good value for all ages– Full out patients for 3 months after hospital
Budget policies• More expensive
– Little extra – Not usually good value
Private medical insurance
Standard policiesMore cover
• Consultations covered in full• Radiotherapy and Chemotherapy covered• Some Physiotherapy• May cover alternative medicine • Ambulance
BUT • Older groups not well catered for would be better
with comprehensive policy
Private medical insuranceComprehensive policies
Abbey national Option2• No psyche but full cover for alternative medicine• Cap doctors fees
Norwich Union Fair and Square• Limited psyche full cover alternative medicine• Cap doctors fees
Norwich Union Trust Care• Best on extras• Cap doctors fees
SecureHealth Executive• Best for psyche but little alternative medicine
Private medical insurance
Comprehensive policiesClinicare Classic• Full cover alternative medicine• Good psyche
Royal &Sun Alliance Values 1• More psyche than Clinicare • Lots of extras• Full alternative medicine
– But homeopathy limited to £400
2000/2001 Couple 57/59 Couple 68/70
BasicSecurehealth Hospital Plan
727 1493
WPA Poplar 680 -
StandardOHRA Medios Healthcare
1369 -
ComprehensiveAbbey Option2 2666
Clinicare classic 1617 -
NU fair and square 3102
Royal Sun alliance
Values1 1703 -
Secure health Executive
1182 2471
Private medical insurance
Questions to ask• What is the cover?• Is outpatient covered ONLY after in patient?• Is it capped?• Is there an annual limit?• Is there a compulsory excess?• Is there a moratorium?• What are the exclusions?• What is the cooling off period?
Private medical insurance
Other optionsLink a high XS policy like WPA XS or Standard Life Healthcare Choice with self pay• You pay for anything < XS• Eg WPA with XS Cost couple 57, 59 £713
– XS<50 = £1500– Xs>60 =£3000
NB claiming does NOT increase PMI premiums – claim as often as you like
Private medical insurance
BenedonCheap and cheerful –
• 85p per person per week
• No pre existing exclusions
• No increase with age
Private medical insurance
BenedonBUT• Have to be < 60 at application• Has to be a Benedon hospital for in
patient[ 8 in country]• NOT covered
– Adult ENT -Lithotripsy– Breast Surgery -Transplants– Endoscopic surgery -Plastic surgery– Orthopaedics -Cardiac surgery
Private medical insurance
CS Healthcare
Fees - 73£ per month 65 core £125 core+
Fees - £92 per month 70 core £167 core+
• Reduce by up to 60% with £1000 xs
Private medical insurance
CS Healthcare - Core
• Hospital charges• Consultant fees• Tests CT , MRI etc for in patients• DXT as outpatient• NOT
– Pre existing problems– Psychiatry / alcohol / cosmetic / ambulances– Outpatient treatment before surgery/inpatient– Physio
Private medical insurance
CS Healthcare - Core+
• As Core but with– Routine Outpatient– Physiotherapy to £500– Chiropractic to £500– Private ambulance
• BUT– No psychiatric treatment– Drugs or alcohol– Cosmetic surgery