Transcript Health after work - Welcome to the BHBT Directory

Health after work
Dr M Feldman
Petersfield Screening
Who am I ?
Senior partner general practice
Trainer in general practice
Petersfield Screening
Occupational health
Life and Death
Genetics
Decline and death NOW
Infection
Trauma
IDEAL
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 living
Journal 21Sept 1874
What is Health?
A healthy person is one who has been
inadequately investigated
What is Health?
WHO definition
a state of complete physical, mental and
social well-being and not merely the
absence of disease or infirmity
The Four Cornerstones
Psychological
Social
Spiritual
Physical
Psychological Health
Mood 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
Stress
Negative aspects of too much or too
little pressure
Pressure or stress
Optimum performance
HIGH
p
E
R
F
O
R
M
A
N
C
E
Rustout
Burnout /
Breakdown
LOW
STRAIN / PRESSURE
10
Pressure or stress
two types of people
11
Different Perspectives
of stress
Stimulus based
Noxious environment - heat, cold, lack of sleep
Social ridicule / failure / bad relationships
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Different Perspectives
of stress
Response based
General adaptation syndrome
1}Alarm reaction - defence mobilisation lowering of resistance
2}Stage of resistance - coping mechanisms
resistance restored
3}Stage of exhaustion - Adaptation declines
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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
14
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
Effects of Stress in retirement
Self Definition from role
Lack of ‘Power’
Depression
Beravement
• Status
• Money
• Social contacts
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Effects of Stress in retirement
Short Term
Fight or flight
Long Term
Physical
- Many different body systems affected
Social
- Work and home - Stress Spiral
Psyche
- Anxiety / Depression
17
Long Term Physical
Cardiovascular
Reproductive
Gastrointestinal
Neurological
Respiratory
Immune
Skin
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Long Term Psychological
Addiction
Insomnia
Depression / anxiety
19
Social
Marital Problems
Relationship Problems
Stress Spirals
20
Social Health
Everard 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
Physical Health
Life Expectancy UK Men
Best
Chiltern
East Dorset
Ryedale
Wokingham
Fareham
South Norfolk
South Oxford
Worst
78.4
77.9
77.9
77.8
77.6
77.6
77.5
Glasgow
Inverclyde
W Dunbarton
Manchester
Eilean Siar
Merthyr Tydfil
Liverpool
68.4
69.2
69.1
70.1
70.9
71.1
71.2
Deaths per 100,000 UK and
Developing countries
UK
Heart attacks
Stroke
Cancer lung
Pneumonia
Chronic Bronc
Cancer colon
Cancer stom
234
124
46
34
28
25
21
Abroad
87
71
--95
46
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Deaths per 100,000 UK and
Developing countries
UK
RTA
Suicide
Diabetes
Diarrhoea
Perinatal
TB
Measles
Malaria
19
17
15
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Abroad
19
----71
57
47
26
21
Leading causes death UK
Circulatory disease
IHD
CVA
Cancer
Colon / Stomach
Lung
Breast
Prostate
Causes of Disease
Circulatory
Family History
Hypertension
High Cholesterol
Diabetes
Smoking
Hypertension
Incidence about 25%
Predisposes to
Stroke
Heart attack
Heart failure
Hypertension
Management
Weight Loss
Low salt diet
Exercise
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 dependent
In 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
Affects
Increase heart attacks
Increase strokes
Kidney damage
Eye damage
Nerve damage – neuropathy
• Numbness, weakness, impotence
Blood vessels damage
• Poor peripheral circulation – intermittent claudication and
gangrene
Diabetes Mellitus
Treatment
Weight loss
Low fat diet
Oral medication
Insulin
Osteoarthritis
Disease of articular cartilage
Possible link to heart disease OA hands
Wear and tear disease
Some inflammation also
May be hereditary
• Hands affected ends of fingers
Mainly weight bearing joints
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Spine
Hip
Knees
Ankles
Osteoarthritis
Prevent by
Avoiding excessive weight
Not overstraining joints
Symptoms
Pain
Reduced movement
Osteoarthritis
Osteoporosis
low bone mass – Bones thin and
spongy
1/3 of all women>60
1/12 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 – spongy bones
Can effect – back, hip and wrist
Back
• Wedging is seen
Osteoporosis
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 mass
Calcium 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
Osteoporosis Treatment
Calcium – Vitamin D – ok
HRT – stops the rot
Biphosphonates – a cure
HRT
Recently linked to increase of
PE
x2.17
DVT
x2.07
MI
x1.29
Cancer Breast x1.26
But reduces
Hip fracture
Cancer Bowel
XS deaths about 1:500
Disease Prevention
Skin Cancers
• Commonest cancers known in Caucasians
– Related to sun exposure
– Burning
– Family History
Disease Prevention
Skin Cancers
Solar Keratoses
• Premalignant
• Sun exposed areas
• Non pigmented
• Roughening
Seek Help
Treatment – liquid
nitrogen
Disease Prevention
Skin Cancers
Basal Cell carcinoma (rodent ulcer)
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Common
Sun exposed areas
Whipcord edge
Central ulceration
Locally invasive only
Slow growing
Danger near eye
Treatment - excision
Disease Prevention
Basal cell carcinoma
Disease Prevention
Basal cell carcinoma
Disease Prevention
Skin 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 Prevention
Squamous Cell carcinoma
Disease Prevention
Melanoma – incidence increasing
Family History
Fair skin
Legs in women
Back in men
History of burning ( cf blistering )
Disease Prevention
Melanoma
Asymmetry
Varied Pigment
Change in shape or colour or size
Bleeding, Itching
Satellite lesions
Disease Prevention
Melanoma
Can spread easily
Early excision can cure
Prognosis related to depth
Disease Prevention
Melanoma
Disease Prevention
Melanoma
Disease Prevention
Melanoma
Disease Prevention
Melanoma
Disease Prevention
Melanoma
Disease Prevention
Weight – Apples & pears
Optimal
• Body Mass Index
– 19-24 woman
– 20-25 man > 25 overweight > 30 obese
• Incidence
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Overweight
Overweight
Obese
Obese
34%
45%
18%
16%
women
men
women
men
• NB fat children  fat adults – look after your
grandchildren
Disease Prevention
Weight
Overweight causes
• Diabetes
• Raised cholesterol
• Raised blood pressure
• Joint disease cf hips knees
Disease Prevention
Diet
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 Prevention
Diet
Fish 3x per week  reduces heart disease
Fibre  reduces transit time – and bowel
cancer
To loose weight keep to low fat diet
Disease Prevention
Diet
Low cholesterol
• Animal fats
• Beware Hidden fats – biscuits, crisps, cakes
• Beware Tropical fats – palm oil, coconut and
advocado
Disease Prevention
Diet
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
Reduces cholesterol
Helps weight loss
Lowers blood pressure
Disease Prevention
Exercise
Helps control diabetes
As good as antidepressants
Protects bones – if weight bearing
Disease Prevention
Exercise
Flexibility
• Move all joints daily
Cardiovascular
• Duration
– 30 mins per day
• Intensity
– 60-80% of capacity ( 220-age)
• Frequency
– 5 times per week
Disease Prevention
Immunizations
Flu and pneumococcal vaccine if > 65 or
• Asthma
• Diabetes
• Renal disease
• Cardiac disease
Travel jabs
Disease Prevention
Dental checks
Optician
Free glaucoma screen if family history
Cataracts
Driving – night vision
VDU, reading glasses
Disease Prevention
Health Screening
Full History and examination
Blood pressure
Exercise stress ECG +cardiac risk assessment
Liver function tests
Renal function tests
Thyroid
Diabetes
Disease Prevention
Health Screening
Visual acuity
Glaucoma check – commonest cause of blindness
Grip strength
Hearing
Prostate Specific Antigen for carcinoma prostate
Disease Prevention
Health Screening
Lung function tests
Cervical Smear
Mammography
Aortic aneurysm > 55 yrs
Tropical screening
• Schistosomiasis
• Ova and parasites
Disease Prevention
Health Screening
Faecal Occult blood if family history bowel
cancer
Skin cancers
The State of the NHS
Hospitals
Dirty
• 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 Doctors
Stressed 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 Doctors
Study 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 Waiting
BHB Out patients
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Medicine
Eyes
Rheumatology
Gynae
Surgery
Urology
Orthopaedics
Skin
08
11
11
15
15
22
24
25
weeks
weeks
weeks
weeks
weeks
weeks
weeks
weeks
The State of the NHS
The Waiting
NB 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 States
Treat patients with
cholesterol lowering
drugs if 10% risk at
10 yrs
Target LDL ( bad
cholesterol )= 2.6
United Kingdom
Treat only if 30%
risk at 10 yrs
Target LDL = 3
The State of the NHS
The solution
Go private
• Pay yourself
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Cataract
Hip replacement
Knee replacement
Hysterectomy
CABG
£2400
£7800
£8400
£4300
£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 year
6.9 million people covered
Mainly company schemes – 4.8 million
Costs are increasing – average plan
1990 £411
2001 £1000
Private medical insurance
What’s covered
Inpatient 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 not
Long 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 policies
More cover
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•
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 insurance
Comprehensive 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 policies
Clinicare 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
Couple 57/59
Couple 68/70
Securehealth Hospital
Plan
727
1493
WPA Poplar
680
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1369
-
2000/2001
Basic
Standard
OHRA Medios Healthcare
Comprehensive
Abbey Option2
Clinicare classic
2666
1617
NU fair and square
Royal Sun alliance
3102
1703
-
1182
2471
Values1
Secure health Executive
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 options
Link 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
Benedon
Cheap and cheerful –
• 85p per person per week
• No pre existing exclusions
• No increase with age
Private medical insurance
Benedon
BUT
• Have to be < 60 at application
• Has to be a Benedon hospital for in patient[ 8
in country]
• NOT covered
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Adult ENT
Breast Surgery
Endoscopic surgery
Orthopaedics
-Lithotripsy
-Transplants
-Plastic surgery
-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
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Hospital charges
Consultant fees
Tests CT , MRI etc for in patients
DXT as outpatient
NOT
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Pre existing problems
Psychiatry / alcohol / cosmetic / ambulances
Outpatient treatment before surgery/inpatient
Physio
Private medical insurance
CS Healthcare Core+
• As Core but with
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Routine Outpatient
Physiotherapy to £500
Chiropractic to £500
Private ambulance
• BUT
– No psychiatric treatment
– Drugs or alcohol
– Cosmetic surgery
Health After Work
The End