Governments Health Policy - Essay Example

1 INTRODUCTION Governments have accepted their responsibility of providing a comprehensive and efficient health service for the short and long term promotion of the public's health and well-being. This responsibility comes with an enormous challenge, because it must be comprehensive, thereby enabling it to encompass the full breadth of primary health care services which the public might require, and it must be cost effective which will further enable it to render the full range of services which the public requires at any time and at any place. If anyone wonders just how important the delivery of primary health care is to the general public and just how much this system is valued by the programs beneficiaries, one can immediately gauge the depth of public interest by the levels of proactive input which was generated by the DOH 2005 Our health, Our care, Our say. In two consultations; independence, well - being and choice was a listening exercise, wherein the ministers and health professionals spoke to the people. And Your health, Your care, Your say; also titled independence, well - being and choice, the citizenry was asked to provide input on, "how improvements could be made to their local services. Clearly this was a monumental change in the overall DOH planning strategy, and it proved to be a very important step in a positive direction. By getting the public directly involved to provide their input and 2 perceptions concerning the quality and content of the primary services delivery system, generated close to 143,000 individual contributors who spoke to the ministers and each other on aspects of the system, as they detailed what they expected from the local social care and NHS services. This was definitely some good old fashioned bottom -up planning. The result of these two consultations produced a white paper; Our health, Our care, Our say, which was unquestionably, a step in the right direction as it will eliminate a considerable amount of central planning and control, and place more of these long range and short term tasks into the day to day operations of the local care delivery units. The primary health care system must be equipped to address all illnesses which affects its public, with a professional networked, holistic approach. Primary Care Health Issues: Smoking Smoking increases the risk of CHD. The long term risk of smoking to individuals has been quantified in a 50-year cohort study of British doctors. The study found that mortality from CHD was around 60 per cent higher in smokers (and 80 percent in heavy smokers) than in non-smokers. Observing deaths in smokers and non-smokers over a 50-year period the study concluded "about half of 3 all regular smokers will eventually be killed by their habit" ( Doll, et al 2004). Second hand smoke (smoke that has been exhaled by a smoker) is also harmful to cardiovascular health. Regular exposure to second hand smoke increases the risk of CVD by around 25 per cent" (Law, et al 1997) It is estimated that smoking caused around 360,000 deaths from CVD in 2000 in the UK. Overall, around one in eight deaths from CVD (14 per cent in men and 12 per cent in women) were attributable to smoking. A higher proportion of premature deaths from CVD, around one in five, were attributed to smoking" ( Petro et al 1950 - 2000). Research from the World Health Organization has estimated the impact of smoking on total disease burden (both mortality and morbidity) in terms of disability-adjusted life years (DALYS) lost. The World Health Report 2002 estimates that "in developed countries around 12 per cent of all disease burden over 20 per cent of CVD is due to smoking: (WHO 2004) In their book UK Smoking Statistics, N Wald et al stated that the first national survey of smoking behaviour in 1948 found that,"the highest recorded level of smoking among men in the UK was 82 per cent: women smoking prevalence remained fairly constant between 1948 and 1970, peaking at 45 per cent in 1966" (Wald et al 1991) 4 By 1990 the difference in smoking prevalence had reduced to just two percentage points (31 per cent in men compared to 29 per cent of women), and since then there has been an excess in male smoking rates between 1 and 4 per cent age points. Within England, smoking prevalence rates are generally higher in the North country, although this pattern is mare marked in women than men" (Office for National Statistics 2003) Over Weight and Obesity Over weight and obesity increase the risk of CVD. As well as being an independent risk factor. Obesity is also a major risk factor for high blood pressure, raised blood cholesterol, diabetes and impaired glucose tolerance" (WDO 2000). According to a Department of Health survey for England which was conducted in 2003, "the adverse effect of excess weight is more pronounced when fat is concentrated mainly in the abdomen. This is known as central or abdominal obesity and can be identified by a high waist - to hip ratio (central obesity is commonly defined as a waist - hip ratio of 0.95 and over in men, and 0, 85 and over in women. In England 43 per cent of men and 38 per cent of women have central obesity" (DOH 2004) In England the per cent age of adults who are obese has increased by over 50 per cent in the last decade. This increase in obesity is particularly marked in men 5 among whom rates have tripled since the mid - 1980s, with men now as likely to be as obese as women" (Health Survey for England 1993). A closer look at these statistics reveal that factors such as ones occupation, and ethnicity also have an effect on one body weight. There has also been a steady increase in the prevalence of obesity in children. Between 1995 and 2002, the prevalence of obesity in England doubled in boys aged 12 - 15 (from 3 per cent to 6 per cent) and increased by over a half in girls (from 5 per cent to 9 per cent)" (Joint Health Survey Unit 2003). The high levels of overweight and obesity among children are likely to exacerbate the trend towards overweight and obesity in the adult population, since compared to thin children. Obese children have a high risk of becoming overweight adults. Data from national surveys of overweight and obesity collected by Professor Boyd Swinburn and his colleagues at Deakin University, Victoria, Australia show that the prevalence rates for overweight and obesity in the UK are some of the highest in the world. For example the prevalence of obesity is the highest for men (out of 40 countries) and the eleventh highest for women (out of 41 countries)" (Swinborn et al) 6 Diabetes Both type 1 and type 2 diabetes result in elevated glucose levels which result in numerous toxic effects. Type 1 diabetes is the most common form of diabetes in children. 90 - 95 percent of under 16s with diabetes have this type. It is caused by the inability of the pancreas to produce insulin. Type 1 diabetes is classified as an autoimmune disease, meaning a continuation in which the body's immune system 'attacks' one of the body's own tissues or organs" (Diabetes in Children) Childhood diabetes is not common, but there are marked variations around the world. In England and Wales 17 children per 100,000 develop diabetes each year" (Diabetes in Children). "The last 30 years has seen a three fold increase in the number of cases of childhood diabetes. In Europe and America, type 2 diabetes has been seen for the first time in young people. This is probably in part caused by the increasing trend towards obesity in our society" (Diabetes in Children) The reader can readily discern with the language of the professional experts in stating "probable", which is a little less than emphatic, and maybe, which is highly speculative, one can safely assume that no one really knows what exactly causes either type "1" or type "2" diabetes. 7 Alcohol While moderate alcohol consumption (one or two drinks a day) reduces the risk of CVD, ay high levels of intake - particularly in 'binges' the risk of CVD is increased. The World Health Report 2002 estimates that over 9 per cent of all disease burden in developed countries is caused by alcohol consumption, and that 2 per cent of the CHD, and almost 5 per cent of stroke in men in developed countries is due to alcohol" (WHO 2002) The Government currently advises that regular consumption of between "three and four units a day by men and between two and three units a day by women of all ages will not lead to any significant health risk" (DOH 1995) Consumption by any group which exceeds the government recommended level, is strongly not advisable. Any person who exceeds the established benchmarks is seriously putting themselves at risk "40 per cent of men and 23 per cent of women in Britain consume more alcohol than the recommended daily benchmarks. 27 percent of men and 17 per cent of women in Britain consume more than the weekly recommended levels of alcohol, that is 21 units per week for men and 14 units for women" (General Household Survey 2002) 8 "In every age group men are more likely to exceed the weekly recommended drinking level than women" (GHS 2002). I have selected Alcohol as the featured issue which will be aligned with the nurse practitioner within the GP. Alcohol is clearly a double edge sword, and it represents a challenge for the nurse, because it is socially accepted, up to the recommended government limits, and whenever one ventures beyond the limits, then a very grey area exists. Does education prepare the nurse to handle this grey area in her primary care capacity Is academia even aware of the challenging position which the nurse faces in dealing with consultations of potential problem drinkers in the GP Nurse Practitioner role within GP - Alcohol In a study conducted by Geirson et al, concerning attitudes of general practitioners and nurses to working with lifestyle changes, with special reference to alcohol consumption (early identification of, and intervention for, alcohol related problems) "the nurses rated their potential effectiveness in helping patients change lifestyle higher than that of GPs for all lifestyle behaviours. Nurses receiving more alcohol-related education had mire positive attitudes than nurses with less alcohol related education courses and training" (Geirson et al 2005) 9 The results of this study can be assessed by the amount and level of practical (on the job experience) and the standing levels of pedagogical preparation which has been received by both the GPs and the nurse respondents. There is an existing thesis that to improve alcohol prevention with the assistance of primary health care, it has been suggested that primary care nurses are an under - utilized resource. K. Johansson et al sought to find out under what circumstances are nurses willing to engage in brief alcohol interventions. They invited 26 nurses to participate in focus group interviews; "the nurses considered primary health care to be just one among many sectors within the community with responsibility for alcohol prevention. The role of health care in alcohol prevention was perceived to be important but mainly secondary preventative. Reasons for refraining from alcohol screening and intervention included lack of self-efficacy, time consumption, and a fear of harming their relationship with the patient" (Johannsson et al 2005) Being aware that nurses would in all probability would be willing to take on the responsibility of providing brief interventions for clients with alcohol or drug dependency, K. Grupp sought to devise a strategy for training development for nurses to provide brief interventions in order to reduce hospitalization, morbidity, 10 and mortality. "The short term results included increased knowledge of nurses about AOD assessment" (Grupp 2004) "The long term affects of the Grupp study was assessed by Dunn et al, and they concluded that the "long term results indicated 95 per cent of patients referred to the AOD team were confirmed to have AOD problems" (Dunn et al 1997). The project demonstrates that there is a clear need for nurses to have more knowledge of AOD problems and about intervention techniques. That when they are armed with the proper skills, they are apt to perform in a professional manner and not adhere to personal feelings. In the UK, GPs and practice nurses selectively provide brief alcohol interventions to risk drinkers. In the case of the GP alcohol intervention is almost always based on the patients characteristics, along with certain structural factors, such as the features of the practice and how it is organized. However. The modifiers which influence the nurses practice are not as clear. C A Lock et al sought to investigate if patient characteristics, nurse characteristics, and practice factors influence provision of a brief alcohol intervention by practice nurses in primary health care. "The multi-level model was unable to identify any independent nurse characteristics that could produce a brief intervention, but indicated significant variation between nurses in their tendency to offer the intervention to patients. 11 No structural factors were found to be positively associated with selective provision. Patient and nurse factors contributed to the selective provision of a brief intervention in primary care" (Lock et al 2004) The Association for Medical Education and Research in Substance abuse found that "because nurse practitioners often do not possess an absolute role legitimacy, as might an OBGYN, the nurse practitioner is more prone to initiate substance abuse information" (Gassman 2003) Psychiatric nurses have a long history of involvement with alcoholic patients. Alcoholic users, mis users, and abusers comprise a significant percentage of the patient load in every specialty and subspecialty of nursing. Stevenson et al assert that, "nursing education has neglected this important area of content in general nursing curricula" They further state that "staff development has not trained mainstream nurses to routinely assess for alcohol problems among hospital patients, and primary care providers have failed to do care case findings" (Stevenson et al 2005) A M Roche et al, in their paper "Brief Interventions": Good in theory but weak in practice (2004), examines the characteristics of brief interventions and their principal delivery agents and explores reasons for the failure to move from efficacy to effectiveness. A key feature of brief intervention delivery also 12 examined the role of GPs versus the less well-explored option of the practice nurse Given the prevention potential that rests with brief intervention, there are crucial questions to be addressed" Boche 2004). A substantial body of research evidence has accumulated in support of the efficacy of brief interventions for a number of alcohol related problem areas. This evidence has been used to exhort a range of professional groups such as general practitioners (GPs) and more recently emergency department hospital staff to engage in brief interventions. Internationally, however, the secondary prevention efforts have largely failed. It is suggested that perhaps the profession has the right vehicle but the wrong driver and until closer scrutiny is made of this issue efforts in this key prevention area will continue to fall short of the optimum level. Alcohol risk assessment is often included in general health screening questionnaires but often little use is made of this information. Alcohol consumption is infrequently included as a focus of health promotion campaigns. Because alcohol intake influences many other health risks, it is logical and practical to include alcohol risk reduction in general in wellness counseling. Incorporating alcohol counseling lowers alcohol risks and lowers the risks of other chronic diseases. It also provides examples of ways nurses and other health professionals can discuss alcohol risk reduction in the context of general health, 13 thus helping to remove the stigma associated with alcohol risk and engage clients in efforts to lower their alcohol risks. N. Skinner et al, conducted a study which was a step beyond any other when they attempted to gauge the effect of role adequacy and role legitimacy on motivation and satisfaction concerning alcohol issues. The findings in the Skinner study have important implications for future AOD development strategies. The Skinner study examined the antecedents of health professionals motivation and satisfaction in responding to Alcohol and drug issues. Building on the seminal work of Shaw et al, the Skinner et al study examined the influence of education, support, AOD experience, and perceptions of role adequacy and role legitimacy. The study involved a national survey of Australian health professionals (N=351) from two occupations: Nurses (N=223) and mental health professionals (N=128). The strongest predictors of role legitimacy and role adequacy were support and the perceived usefulness of education. Satisfaction was predicted by perceived role legitimacy in both samples, and by perceived role adequacy for mental health professionals. Motivation was predicted by perceived role adequacy and perceived role legitimacy in both samples. 14 "Identification of support as a key predictor of role adequacy and legitimacy reinforces the importance of workforce development interventions at an organizational systems level rather than focusing exclusively on knowledge, skills, and experience of an individual worker" (Skinner et al 2005) . 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