Health after work

1
Health after work

• Dr M Feldman
• Petersfield Screening

2
Who am I ?

• Senior partner general practice
• Trainer in general practice
• Petersfield Screening
• Occupational health

3
Life and Death
Genetics
Infection
Decline and death NOW
Trauma
IDEAL
Cancer
Autoimmune
Endocrine
Vascular
Drugs
4
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

5
What is Health?

• A healthy person is one who has been inadequately
  investigated

6
What is Health?

• WHO definition
• a state of complete physical, mental and social
  well-being and not merely the absence of disease
  or infirmity

7
The Four Cornerstones

• Psychological
• Social
• Spiritual
• Physical

8
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

9
Stress

• Negative aspects of too much or too little
  pressure

10
Pressure or stress
11
Pressure or stress two types of people
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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 syndrome
• 1Alarm reaction - defence mobilisation -
  lowering of resistance
• 2Stage of resistance - coping mechanisms
  resistance restored
• 3Stage 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 -gt
  appraisal of ability to cope -gt stress reaction

15
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 retirement

• Short Term
• Fight or flight
• Long Term
• Physical - Many different body systems affected
• Social - Work and home - Stress Spiral
• Psyche - Anxiety / Depression

18
Long Term Physical

• Cardiovascular
• Gastrointestinal
• Respiratory
• Skin

• Reproductive
• Neurological
• Immune

19
Long Term Psychological

• Addiction
• Insomnia
• Depression / anxiety

20
Social

• Marital Problems
• Relationship Problems
• Stress Spirals

21
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!!

22
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.

23
Spiritual Health

• No values conflict
• Behaving as you believe is right
• Values conflict ? stress
• Belonging
• Faith

24
Physical Health
25
Life Expectancy UK Men

• Best
• Chiltern 78.4
• East Dorset 77.9
• Ryedale 77.9
• Wokingham 77.8
• Fareham 77.6
• South Norfolk 77.6
• South Oxford 77.5

• Worst
• Glasgow 68.4
• Inverclyde 69.2
• W Dunbarton 69.1
• Manchester 70.1
• Eilean Siar 70.9
• Merthyr Tydfil 71.1
• Liverpool 71.2

26
Deaths per 100,000 UK and Developing countries

• UK
• Heart attacks 234
• Stroke 124
• Cancer lung 46
• Pneumonia 34
• Chronic Bronc 28
• Cancer colon 25
• Cancer stom 21

• Abroad
• 87
• 71
• ---
• 95
• 46
• ---
• ---

27
Deaths per 100,000 UK and Developing countries

• UK
• RTA 19
• Suicide 17
• Diabetes 15
• Diarrhoea --
• Perinatal --
• TB --
• Measles --
• Malaria --

• Abroad
• 19
• ---
• ---
• 71
• 57
• 47
• 26
• 21

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Leading causes death UK

• Circulatory disease
• IHD
• CVA
• Cancer
• Colon / Stomach
• Lung
• Breast
• Prostate

29
Causes of Disease

• Circulatory
• Family History
• Hypertension
• High Cholesterol
• Diabetes
• Smoking

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Hypertension

• Incidence about 25
• Predisposes to
• Stroke
• Heart attack
• Heart failure

31
Hypertension

• Management
• Weight Loss
• Low salt diet
• Exercise

32
Hypertension

• Reduce alcohol if excessive
• Medication if gt160, and/orgt100 or 30 risk
  of heart attack at 10 yrs
• Diurectics
• B Blockers
• Calcium antagonist
• ACE / Angiotensin II inhibitors

33
Raised Cholesterol

• May be hereditary
• Related to Genes / Weight / Diet
• Predisposes to
• Heart disease
• Strokes
• Furring up of arteries

34
Raised Cholesterol

• Average British Cholesterol 6.2 mM/L
• Desirable Cholesterol lt 5.2 mM/L
• Good and bad types
• Good should be gt 0.9 HDL
• Bad should be lt 3 LDL
• Ratio of total to good should be less than 4

35
Diabetes Mellitus

• Insulin dependent
• In young people
• Presents with
• Thirst
• Weight Loss
• Tiredness
• Relatively rare about 2-3 per 1000 people

36
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

37
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

38
Diabetes Mellitus

• Treatment
• Weight loss
• Low fat diet
• Oral medication
• Insulin

39
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

40
Osteoarthritis

• Prevent by
• Avoiding excessive weight
• Not overstraining joints
• Symptoms
• Pain
• Reduced movement

41
Osteoarthritis
42
Osteoporosis

• low bone mass Bones thin and spongy
• 1/3 of all womengt60
• 1/12 of all men gt 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

43
Osteoporosis

• Osteoporosis spongy bones
• Can effect back, hip and wrist
• Back
• Wedging is seen

44
Osteoporosis
45
Osteoporosis

• Osteoporosis symptoms
• Height loss
• Protruding abdomen
• Dowagers hump
• Reduced Lung capacity
• Oesophageal reflux

46
Osteoporosis

• Causes
• Premature menopause
• Alcohol
• Steroids ( prednisolone gt 7.5 mg per day)
• Thin BMI lt 19
• Family history
• Low calcium intake
• Smoking

47
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

48
Osteoporosis Prevention

• Exercise in youth builds bone mass
• Calcium Supplements if -
• Deficient in diet
• On steroids
• Postmenopausal gt 5 yrs and thin
• Vitamin D Aids calcium absorption assimilation
• 800iu per day or from fish oil/milk/egg etc
• HRT

49
Osteoporosis Treatment

• Calcium Vitamin D ok
• HRT stops the rot
• Biphosphonates a cure

50
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 1500

51
Disease Prevention

• Skin Cancers
• Commonest cancers known in Caucasians
• Related to sun exposure
• Burning
• Family History

52
Disease Prevention

• Skin Cancers
• Solar Keratoses
• Premalignant
• Sun exposed areas
• Non pigmented
• Roughening
• Seek Help
• Treatment liquid nitrogen

53
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

54
Disease Prevention

• Basal cell carcinoma

55
Disease Prevention

• Basal cell carcinoma

56
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

57
Disease Prevention

• Squamous Cell carcinoma

58
Disease Prevention

• Melanoma incidence increasing
• Family History
• Fair skin
• Legs in women
• Back in men
• History of burning ( cf blistering )

59
Disease Prevention

• Melanoma
• Asymmetry
• Varied Pigment
• Change in shape or colour or size
• Bleeding, Itching
• Satellite lesions

60
Disease Prevention

• Melanoma
• Can spread easily
• Early excision can cure
• Prognosis related to depth

61
Disease Prevention

• Melanoma

62
Disease Prevention

• Melanoma

63
Disease Prevention

• Melanoma

64
Disease Prevention

• Melanoma

65
Disease Prevention

• Melanoma

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Disease Prevention

• Weight Apples pears
• Optimal
• Body Mass Index
• 19-24 woman
• 20-25 man gt 25 overweight gt 30 obese
• Incidence
• Overweight 34 women
• Overweight 45 men
• Obese 18 women
• Obese 16 men
• NB fat children ? fat adults look after your
  grandchildren

67
Disease Prevention

• Weight
• Overweight causes
• Diabetes
• Raised cholesterol
• Raised blood pressure
• Joint disease cf hips knees

68
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

69
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

70
Disease Prevention

• Diet
• Low cholesterol
• Animal fats
• Beware Hidden fats biscuits, crisps, cakes
• Beware Tropical fats palm oil, coconut and
  advocado

71
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

72
Disease Prevention

• Exercise
• Reduces cholesterol
• Helps weight loss
• Lowers blood pressure

73
Disease Prevention

• Exercise
• Helps control diabetes
• As good as antidepressants
• Protects bones if weight bearing

74
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

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Disease Prevention

• Immunizations
• Flu and pneumococcal vaccine if gt 65 or
• Asthma
• Diabetes
• Renal disease
• Cardiac disease
• Travel jabs

76
Disease Prevention

• Dental checks
• Optician
• Free glaucoma screen if family history
• Cataracts
• Driving night vision
• VDU, reading glasses

77
Disease Prevention

• Health Screening
• Full History and examination
• Blood pressure
• Exercise stress ECG cardiac risk assessment
• Liver function tests
• Renal function tests
• Thyroid
• Diabetes

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Disease Prevention

• Health Screening
• Visual acuity
• Glaucoma check commonest cause of blindness
• Grip strength
• Hearing
• Prostate Specific Antigen for carcinoma prostate

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Disease Prevention

• Health Screening
• Lung function tests
• Cervical Smear
• Mammography
• Aortic aneurysm gt 55 yrs
• Tropical screening
• Schistosomiasis
• Ova and parasites

80
Disease Prevention

• Health Screening
• Faecal Occult blood if family history bowel
  cancer
• Skin cancers

81
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

82
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

83
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

84
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
• 13 Doctors are planning to retire early

85
The State of the NHS

• Recent BMA survey of all GPs
• 22 380 responded
• 66 of entire workforce
• 86 Voted to hand in resignation next April
  unless working conditions improve

86
The State of the NHS

• The Waiting
• BHB 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

87
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

88
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

89
State of NHS advice to GPs

• 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

90
The State of the NHS

• The solution
• Go 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

91
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

92
Private medical insurance

• Whats covered
• Inpatient costs
• BUT check if ceiling or specific hospitals only
• Outpatient costs
• Vary with policy may even include
• Home nursing
• Psychiatry
• Ambulance

93
Private medical insurance

• Whats 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

94
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 gt 6 weeks 6 week
  plan NU

95
Private medical insurance

• Basic policies
• Little outpatient cover
• WPA Poplar good for 50s
• Includes DXT and chemotherapy and out patients
• Secure Healths 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

96
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

97
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

98
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

99
2000/2001 Couple 57/59 Couple 68/70
Basic
Securehealth Hospital Plan 727 1493
WPA Poplar 680 -
Standard
OHRA Medios Healthcare 1369 -
Comprehensive
Abbey Option2 2666
Clinicare classic 1617 -
NU fair and square 3102
Royal Sun alliance Values1 1703 -
Secure health Executive 1182 2471
100
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?

101
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 lt XS
• Eg WPA with XS Cost couple 57, 59 713
• XSlt50 1500
• Xsgt60 3000
• NB claiming does NOT increase PMI premiums
  claim as often as you like

102
Private medical insurance

• Benedon
• Cheap and cheerful
• 85p per person per week
• No pre existing exclusions
• No increase with age

103
Private medical insurance

• Benedon
• BUT
• Have to be lt 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

104
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

105
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

106
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

107
Health After Work

• The End