Health after work Dr M Feldman Petersfield Screening.

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

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?

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 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

Stress

Negative aspects of too much or too little pressure

10

Optimum performance

Burnout /Breakdown

Rustout

HIGH

LOW STRAIN / PRESSURE

pERFORMANCE

Pressure or stress

11

Pressure or stress two types of people

12

Different Perspectives of stress

Stimulus based

Noxious environment - heat, cold, lack of sleep

Social ridicule / failure / bad relationships

13


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


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

19

Long Term Psychological

Addiction

Insomnia

Depression / anxiety

20

Social

Marital Problems

Relationship Problems

Stress Spirals

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

Physical Health

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

Leading causes death UK

Circulatory diseaseIHDCVA

CancerColon / StomachLungBreastProstate

Causes of DiseaseCirculatory

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 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

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 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

Osteoarthritis

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 – spongy bonesCan effect – back, hip and wristBack• 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 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

Osteoporosis Treatment

Calcium – Vitamin D – ok

HRT – stops the rot

Biphosphonates – a cure

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 PreventionBasal cell carcinoma

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 PreventionSquamous Cell carcinoma

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


Can spread easily

Early excision can cure

Prognosis related to depth

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


Fish 3x per week reduces heart

disease

Fibre reduces transit time – and

bowel cancer

To loose weight keep to low fat diet


Low cholesterol

• Animal fats

• Beware Hidden fats – biscuits, crisps, cakes

• Beware Tropical fats – palm oil, coconut

and advocado


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 PreventionExercise

Reduces cholesterol

Helps weight loss

Lowers blood pressure

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


Visual acuity

Glaucoma check – commonest cause of

blindness

Grip strength

Hearing

Prostate Specific Antigen for carcinoma

prostate


Lung function testsCervical SmearMammographyAortic aneurysm > 55 yrsTropical screening• Schistosomiasis• Ova and parasites


Faecal Occult blood if family history

bowel cancer

Skin cancers

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 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 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 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


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 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 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 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 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


What’s coveredInpatient costs• BUT – check if ceiling or specific hospitals

only

Outpatient costs• Vary with policy may even include

– Home nursing– Psychiatry– Ambulance


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


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]


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


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


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


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?


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


BenedonCheap and cheerful –

• 85p per person per week

• No pre existing exclusions

• No increase with age


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


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


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


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

Health after work Dr M Feldman Petersfield Screening.

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Transcript of Health after work Dr M Feldman Petersfield Screening.