Health after work
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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 12 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 13 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 16 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 18 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 ----- Deaths per 100,000 UK and Developing countries UK RTA Suicide Diabetes Diarrhoea Perinatal TB Measles Malaria 19 17 15 ------ 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 • • • • 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) • • • • • • • 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 – – – – 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 • • • • • • • • 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 – – – – – 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 • • • • • 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 - 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 – – – – 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 • • • • • 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 Health After Work The End
