Abstract

Graves’ disease in an autoimmune disorder that causes hyperthyroidism in various patient populations.  It is mostly prevalent in Asian and Caucasian women who live in iodine deficient areas but has been found to affect a small number of men and children.  The cause of Graves’ disease is unknown but can be diagnosed by identifying other diseases characteristic of Graves’ disease (thyrotoxicosis, goiters, and ophthalmopathy).  There are various treatment options available, but three main options are utilized in the United States (medication, radioactive iodine, and surgery) that work to put hyperthyroidism in remission and return the body back to homeostasis.  Although research on Graves’ disease has produced any positive outcomes, there are still some areas related to the disorder that are imperative to address such as environmental factors and causation.

Graves’ Disease

Graves’ disease (GD) symptoms were first described by Aristotle and Xenophon in the fifth century after discovering the link between an enlarged thyroid and bulging eye (Gan & Randle, 2019).  Then, in the 19

^th

century, Robert James Graves identified a combination of three medical issues that collectively effected the thyroid (Gan & Randle, 2019; Lowery & Kerin, 2009).  Today, GD is prevalent in 80% of hyperthyroid patients who account for <1% of the United States population, predominantly effecting Asian and Caucasian females (American Thyroid Association, 2019; Gan & Randle, 2019; Menconi, Marcocci, & Marinò, 2014).  The disease has higher prevalence rates in iodine deficient countries, but genetics and environmental factors also play a major role in the development of GD (Franklyn & Boelaert, 2012; Menconi et al., 2014; Wémeau, Klein, Sadoul, Briet, Vélayoudom-Céphise, 2018).  Various treatment options exist in regard to returning the thyroid to normal functioning, with one option removing the thyroid altogether (Franklyn & Boelaert, 2012; Hussain, Hookman, Allahabadia, & Balasubramanian, 2017; Lowery & Kerin, 2009; Menconi et al., 2014).  The following is an overview of GD, its process, causes, and current treatment options within the United States.

Etiology of Graves’ Disease

Research on GD suggests that the underlying cause of the disease is unknown, but it has been identified as a multifactorial autoimmune disease characterized by three associated disorders—thyrotoxicosis, goiter, and opthalmopathy—and is the most common cause of hyperthyroidism (Franklyn & Boelaert, 2012; Hussain et al., 2017; Lowery & Kerin, 2009; Menconi et al., 2014).  Thyrotoxicosis is a disorder characterized by an excess in the thyroid hormone (Franklyn & Boelaert, 2012).  In this disease process, thyroxine (T4) and triiodothyronine (T3) are synthesized and released by the thyroid, with the latter hormone effecting energy productions and metabolic rates that interrupt cardiac, hepatic, and neuromuscular functions in the body (Franklyn & Boelaert, 2012).  Next, goiter is an enlargement of the thyroid follicular cells (Menconi et al., 2014).  Lastly, opthalmopathy (also known as Graves’ opthalmopathy, GO) is thought to be due to an autoimmune reaction against thyroid antigens and orbital tissues (Menconi et al., 2014). This disease process is demonstrated through enlarged eye tissue that have become inflamed, swelling the skin around the eyes as veins become engorged with fluid (Menconi et al., 2014).  Severe GO symptoms occur in approximately 3-4% of GD patients and such severity causes “compression of optic nerves that result in the loss of vision acuity” (Menconi et al., 2014, p. 399).  Symptoms of GO that are often reported include excessive tearing, eye irritation, pain, and blurred vision (Menconi et al., 2014).

Disease Process of Graves’ Disease

GD is characterized by auto-antibodies that emulate the thyroid stimulating hormone (TSH) by binding to the TSH receptor and becoming activated (Lowery & Kerin, 2009; Menconi et al., 2014).  This activation causes the thyroid hormone to increase the synthesis and release process, which creates the hyperactivity of the thyroid gland (Menconi et al., 2014).  The increase in thyroid hormones begins to effect other organs within the body such as the eyes, skin, and joints (Menconi et al., 2014).

GD patients endure a gradual progression of symptoms that transpire as the thyroid becomes overactive.  Patients usually report nervousness, difficulty in sleeping, fatigue, weight loss (despite increased appetite), tremors, heart palpitations, difficulty breathing, heat intolerance, sweating, and increased bowel movements (Menconi et al., 2014).  There are also gender and age differences in symptomology. For example, females experience irregular menses while males experience decreased libido, erectile dysfunction, and gynecomastia (Menconi et al., 2014).  Furthermore, elderly patients with GD do not experience the aforementioned symptoms; rather they report apathetic thyrotoxicosis that includes apathy and lethargy with reports of cardiovascular issues such as atrial fibrillation and congestive heart failure (Menconi et al., 2014).  Moreover, elderly GD patients can experience dermopathy, which is non-pitting edema (the touching of a swollen area with no indentation), and acropachy, the clubbing and swelling of soft tissue of the fingers and toes (Menconi et al., 2014).  Both symptoms are rare occurrences and are usually found in GD patients experiencing GO and pretibial myxedema that have persisted over a long period of time (Menconi et al., 2014).

Risk Factors of Graves’ Disease

Genetic Factors

The literature on gene susceptibility suggested high gene effects with low heritability factors.  Gan and Randle (2019) cited twin studies that suggested that 80% of GD cases were due to genetic factors, whereas heritability of GD is considered to be extremely low with several familial thyroid dysfunctions considered to play a role, but the magnitude is uncertain (Menconi et al., 2914).  In regard to specific gene regions, Menconi et al. (2014) identified immune regulating genes (HLA-DR, CTLA-4, CD40, and PTPN22) and thyroid specific genes (Thyroglobulin and TSHR) as the genes impacting hyperactivity in the thyroid.  Franklyn and Boelaert (2012) also identified CTLA4 and PTPN22 as genes that are linked to GD and suggested that these genes are responsible for encoding proteins involved in immune function and are usually the cause of other autoimmune diseases.  Research on genetic factors should continue to identify a more cohesive understanding of the genetic breakdown and associated factors to GD.

Environmental Factors

As with several medical diseases, environmental susceptibility plays a role in the development and activity of GD.  Factors such as smoking, psychological stress, infections (Yersinia enterocolitica), and low iodine intake have been found to maintain and worsen GD (Franklyn & Boelaert, 2012; Menconi et al., 2014).  For individuals that smoke, the susceptibility to GO increases and this disease process worsens—effecting quality of life and mortality rates—yet research efforts have yet to describe specific reasons why (Franklyn & Boelaert, 2012; Menconi et al., 2014).

Diagnostic Process for Graves’ Disease

GD is diagnosed by laboratory findings that identify other diseases that makeup the disorder.  First, thyrotoxicosis is found in elevated T4 and T3 serum levels and undetectable TSH serum (Menconi et al., 2014).  This screening procedure is the first line of the diagnostic process, but it is suggested that measuring free T4 and free T3 can give a more comprehensive evaluation (Menconi et al., 2014).  Antibodies that fight against the TSH receptor, called TRAb, are also found in the serum collected in the laboratory and are present in 98% of undiagnosed GD patients (Menconi et al., 2014).  Next, radioactive iodine uptake (RAIU) is completed by administering a dose of radioiodine into the patients’ systems.  For GD patients, RAIU levels are expected to be low or absent which is indicative of hyperthyroidism and other forms of thyrotoxicosis (Menconi et al., 2014).  Another diagnostic tool is the thyroid ultrasound. Although it is not a required tool for identifying GD, it has been found to improve the likelihood of identifying pertinent symptoms that verify the presence of the disorder (Menconi et al., 2014).  This process is helpful in identifying the size of the thyroid and detecting nodules that are not profound during a physical examination (Hussain et al., 2017; Menconi et al., 2014).  The last screening method is the color flow doppler that is used to estimate blood flow, which increases within the thyroid of GD patients (Menconi et al., 2014).  This is a substitute diagnostic tool if GD patients are pregnant or when radioactive iodine uptake is unavailable (Menconi et al., 2014).  Overall, diagnostic procedures for identifying GD are profound and highly effective which assists in identifying the most effective treatment method/s for individual patients.

Treatments

Treatment protocols for GD vary by location and depend on patient preference and severity of symptoms.  In the United States GD treatment begins with a medication regimen intended to return the thyroid to its normal functioning (euthyroid).  If patients are unsuccessful with medication, the next step is radioiodine treatment which is expected to restore euthyroidism.   If radioiodine treatments do not resolve the issue, the final option is a partial or total thyroidectomy by an experienced surgeon.  The following outlines each treatment option in further detail and includes the current research findings on the effectiveness of the treatments.

Medication

Anti-thyroid (ATD) medications are the first line of treatment when managing hyperthyroidism and are sometimes used in preparation for a more definitive treatment with radioactive iodine or thyroidectomy (Gan & Randle, 2019; Laurberg Wallin, Tallstedt, Abraham-Nordling, Lundell, and Tørring, 2008; Kotwal & Stan, 2018; Sugino, Nagahama, Kitagawa, Ohkuwa, Uruno, Matsuzu…Ito, 2019).  The goal of ATDs is to control hyperthyroidism and induce remission of GD by inhibiting thyroid peroxidase enzyme and thyroid hormone synthesis (Kotwal & Stan, 2018).  Remission can be seen within the first six weeks of administration and is expected to fully present after three months (Gan & Randle, 2019; Laurberg et al., 2008; Kotwal & Stan, 2018; Sugino et al., 2019).  Remission rates range between 50-60% after 12 months of medication compliance, but no significant improvements in remission have been found after 18 months of administration (Gan & Randle, 2019; Laurberg et al., 2008; Kotwal & Stan, 2018; Sugino et al., 2019).

When GD patients are prescribed ATDs it is important for physicians to initially assess thyroid function every four to six weeks to ensure a decrease in thyroid activity is present while also watching for a hypothyroid state (Gan & Randle, 2019).  A dose reduction should begin once remission has been identified and at this point, biochemical changes can be monitored every two to three months (Gan & Randle, 2019).  It is imperative to note that treatment failure in GD patients is due to noncompliance of medication regimen and is cause for more invasive treatment options (Gan & Randle, 2019).

There are two ATD medications that are currently prescribed for GD patients and their use is dependent on severity of GD, comorbidity with other diseases, pregnancy, and compliance concerns (Gan & Randle, 2019; Laurberg et al., 2008; Kotwal & Stan, 2018; Sugino et al., 2019).  Physicians are expected to inform GD patients of effectiveness and risks associated with each drug while collaboratively identifying which ATD will be most advantageous (Gan & Randle, 2019; Laurberg et al., 2008; Kotwal & Stan, 2018; Sugino et al., 2019).  The following briefly outlines the two commonly used ATDs, methimazole and propylthiouracil.

Methimazole

Methimazole (MMI) is the recommended medication for treating GD in the United States (Franklyn & Boelaert, 2012; Gan & Randle, 2019; Laurberg et al., 2008; Kotwal & Stan, 2018; Sugino et al., 2019).  MMI has been identified as the most effective medication in terms of restoring patients to a euthyroid state and has the highest compliance rate due to low dosage and prescribed amount (10-20mg/once per day) (Franklyn & Boelaert, 2012; Gan & Randle, 2019; Laurberg et al., 2008; Kotwal & Stan, 2018; Sugino et al., 2019).  As with all medications, MMI produces several side effects such as agranulocytosis, rashes, sore throat, fever, and cholestatic hepatitis (Franklyn & Boelaert, 2012).  According to Franklyn and Boelaert (2012), these side effects are more common among patients who are prescribed higher doses, such as 30 mg, at the onset of medication treatment, and physicians are urged to warn GD patients of these potential effects so they can be properly monitored during treatment.  If patients do experience adverse effects to MMI, there is another medication option available to treat GD and hyperthyroidism called Propylthiouracil.

Propylthiouracil

Propylthiouracil (PTU) has the same mechanism of action as MMI, but also inhibits the conversion of T4 cells to active T3 cells (Gan & Randle, 2019; Laurberg et al., 2008; Kotwal & Stan, 2018; Sugino et al., 2019).  Although it has a similar purpose to MMI, PTU requires a higher dosage of 50-100 mg two to three times per day, which impacts patient compliance due to having to take it several times as opposed to once. PTU is prescribed for women who are pregnant or plan to become pregnant within six months of treatment, women who are breastfeeding, GD patients who report side effects to MMI, and those for whom radioactive iodine and/or surgery is not an option (Franklyn & Boelaert, 2012).  Major medical risks are associated with consuming PTU such as agranulocytosis, toxic hepatitis, liver failure, and antibody-positive vasculitis which increases as duration of medication treatment increases (Franklyn & Boelaert, 2012).

Radioactive Iodine Treatment

The next form of treatment for GD is radioactive iodine (RAI) treatment which was created by Dr. Saul Hertz in 1941 (Kotwal & Stan, 2018).  According to Kotwal and Stan (2018), Dr. Hertz was the first to administer iodine-130 and iodine-131 to GD patients in Massachusetts which damaged thyroid follicular cells and caused a reduction in thyroid hormone levels (Kotwal & Stan, 2018).  This form of treatment has become secondary to ATDs but can be utilized as a first line treatment for patients who choose a more definitive treatment method (Gan & Randle, 2019; Laurberg et al., 2008; Kotwal & Stan, 2018; Sugino et al., 2019).  Patients also choose RAI over the surgical route if they prefer nonsurgical treatment, are high risk due to already having had neck surgery, do not plan to become pregnant within six months of treatment, or there is limited or no access to a surgeon who performs thyroidectomies regularly—at least 25 surgeries per month. (Gan & Randle, 2019; Laurberg et al., 2008; Kotwal & Stan, 2018; Sugino et al., 2019).  70% of patients that receive RAI treatment become euthyroid within four to eight weeks and can expect full remission within six months (Gan & Randle, 2019).  The risks associated with RAI include development or exacerbation of GO, salivary gland dysfunction, thyroid, stomach, or kidney cancer, and radiation thyroiditis (Gan & Randle, 2019; Kotwal & Stan, 2018).

Thyroidectomy

When GD was first identified in the late 1930s, thyroidectomies were the only treatment method used, but with the invention of ATDs and RAI surgery became the final form of treatment for the disease in particular patient populations (Kotwal & Stan, 2018).  Thyroidectomies can be partial or full, and this decision is based on patient preference, severity of symptoms, and lack of effective treatment with ATDs and RAI (Gan & Randle, 2019; Laurberg et al., 2008; Kotwal & Stan, 2018; Sugino et al., 2019).  Partial thyroidectomies have proven to be ineffective due to low remission rates, instability of thyroid function, and costs associated with lifelong follow-up and continuation of other treatment strategies such as ATDs (Sugino et al., 2018).  Subsequently, a full thyroidectomy removes the thyroid gland—the source of hyperactive production of TSH— and produces a higher success rate in GD patients, especially women who plan to become pregnant within six months, patients with comorbid thyroid dysfunctions and/or disorders, large goiters, and active GO patients (Kotwal & Stan, 2018).  The research also suggests that GD patients under 40 years of age are preferred candidates for thyroidectomy, especially children, due to the inconsistencies with taking medications as prescribed and increased rates of recurrence with RAI treatment (Gan & Randle, 2019).

While this surgical procedure produces high rates of success, there are associated risks and contraindications to a thyroidectomy.  For instance, GD patients that are pregnant are only considered for surgery if ATDs are ineffective and the need to control thyroid activity is higher than usual (Kotwal & Stan, 2018; Moleti, Mauro, Sturniolo, Russo, & Vermiglio, 2019).  Other associated risks include vocal cord paralysis caused by laryngeal nerve injury and hypoparathyroidism that Sugino et al. (2018) suggested are caused by inexperienced surgeons (Kotwal & Stan, 2018; Sugino et al., 2018).  As surgeons become experienced in performing such an arduous surgery, technological advances are being considered to improve the surgical process.

Garstka, Kandil, Saparova, Bechara, Green, Haddad, Kang, and Aidan (2018) conducted a study on a futuristic surgical approach of robotic-assisted thyroidectomy.  They conducted studies in the United States and Europe to identify the feasibility and safety of using robotic-assisted surgery to complete thyroidectomies compared to surgery as usual (Garstka, Kandil, Saparova, Bechara, Green, Haddad, Kang, and Aidan, 2018).  According to their findings, GD patients in the United States face similar risks if their thyroidectomy is completed with robotic assistance as compared to surgery as usual, especially when conducted by a high-volume surgeon (Garska et al., 2018).  Although their findings suggest effectiveness of both surgical options, more research needs to be conducted with a higher and more heterogenous sample size to account for various patients affected by GD (Garska et al., 2018).  Overall, patient remission is achievable through various treatment options that are individualized.

GD effects >1% of the American population and is most prevalent in Asian and Caucasian women in iodine deficient areas.  While research efforts are being made to identify a cause of GD, there are currently other diseases associated with the disorder that improve the chances of GD being diagnosed.  There are several treatment options available, with ATDs, RAI, and thyroidectomies being the top three in the United States that work to reduce hyperactivity of thyroid through various mechanisms of action.  Future research efforts should focus on identifying causes of GD and possible preventative methods that could decrease chances of developing the disease, while also considering explanations to environmental factors that attribute to the cause and maintenance of the disorder.

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C3 (4.1) – Describe continuing professional development (CPD).

A CPD stands for Continuing Professional Development as it refers to the process of tracking and documenting the skills, knowledge and experience that practitioner tend to gain formal and informal as practitioner will be working alongside. CPD mean that professional are getting training within you job roles as recording and reflecting on learning and development, it help you to manage your skills and qualities ongoing it focus on learning form experience, reflective learning and review also it help you to set your own development and objectives, it is overview of the professional development to date and it help you with your career development. CPD give better opportunities and increased knowledge it is important to have CPD because it keep your training up to date, can prevent the risks of not knowing certain information, CPD it is essential in the healthcare because we are working with vulnerable children and adults. There are different types of CPD such as first aid training, safeguarding training, mental capacity training and prevents duty training (CPD).

Staying up-to-date with sector/ developments/ action setting

Staying up to date with the sector it is important because you will have the understand and knowledge what action  should be taken and also it is good professional if you are up to date with sector has it show that you are being professional and welling to learn, it show that you are responsible in your role. Staying up to date with sector you would know exactly what to do in certain situation it is important to ensure that you are aware of the service policies and procedures it will help you to gain experiences and identify opportunities for your career. It is important to stay up to date with sector mainly in healthcare you most stay up to date because you are working with vulnerable people, different organisation and other healthcare organisation it help you to be up to date with you knowledge and experiences it reflect on the outcomes of learning and to keep a record for example stay up to date would prevents you from risks.

Development is when you get train and learn new skills it allow you to maintain to develop your own learning and growth throughout about your career. It help you to understand the role of the healthcare service for example nurse  must be trained and qualified to be fully qualified for the nursing role also they need to have training in health and social care or have degree in healthcare (Health Careers 2019). Having development in healthcare because wee most be train before we can provide care and support for the vulnerable people not only you have experiencing in that role but also gaining knowledge about how you prevent upcoming risk so it do not harm the environment and the people that are around us. Development is when you understand the concept of the healthcare needs and it allow you to have communication skills, self-awareness.

Action setting is a goals to help to ensure that they are very important to you and the service for example the Equality Act 2010 say that everyone should be treated equally and should have the right facilities for the disable people has the goal is to treat everyone right by providing lifts and ramps in the building. It is way to achieve something that you want and to identifies what action are needed to get there and how to achieve the action plan, for example What, How, Where, When, Why also it can say that with whom are going to achieve this plan it is important to plan the action setting because it will prevent the risk of accidents and harms (Seek Learning 2019).

C4 (4.2) – Outline sources of support for learning and development. A minimum of four sources of support for learning and development must be outlined.

Formal/informal support

Formal support is when healthcare practitioner is practicing their nursing at hospital which is professional and you must maintain obey the rules, and on the other hand informal support is when you have CPD training it can be physical, social. Informal and formal support can be long term and short it depends what professional it is, the CPD training can be informal because when you are commencing with them, having a social interaction, having an eye contact, a formal support is when the practitioner identifying the problem and providing them with the support such as helping their family and friends with the problems that they are having.

Independent study

Independent study is when individual have their choice to study on your own without people being around them and individual will know what to do. Most pupils tend to find independent study very help because they know their weak points also  no one can disturb them for example people with anxiety tend to be alone or not being around other people it is important that college and school provide them with right support that they need in their education. Each person has a different level of understanding and processing information it is massively important to notice individual with their learning and providing the support they need it is a choice when individual choose to study independently rather being in group for example their confidence and motivation will increase and having time freely without anyone pressuring them to finish something quicker  it is important to give each  person the time they need to improve their learning in order to achieve their goals.

Work experience

It is important to have work experience in order to understand when start to work in your career also work experiences give person a confidence and it motivate them to work. It has many different types benefits and it will help individual with their communication not only support individual with their work but also it show their weaker point for example they may choose somewhere to work and they did not like due to staff. It give individual  the opportunity to explore  the working environment  also it give them opportunity  that they can be successful in their job, it help them to be prepare for work and develop basic knowledge about the healthcare environment  or how each person should treated. It is about gaining experience that will help to be organise in their workplace it show that individual have motivation and commitment in their role or professional, when individual have work experiences individual will know that what are their skills and qualities for example healthcare practitioner needs to show empathy and have communication in order to understand the problems (All About Career 2019).

Feedback

Feedback support individual with their learning and it will help to know what things are there that they struggle with the most so they can improve in the future this is mainly one or one comment also it is private. It is valuable information that many practitioner would use in to make an important decisions having a feedback in the workplace will improve their working relationship it show that individual are very organise and commitment to the work you have put on if you have feedback it will show your growth for example teacher is giving proper feedback rather than putting everything in the details (t-three 2019). It help people to learn from their mistake and build their confidence sometime give negative feedback can put down the person confidence and might feel that they are being judged you need to make sure that you don’t write something that will hurt them and low their self-esteem.

B2 (4.3) – Explain why continuing professional development is integral to the role of a health and social care practitioner.

Up-to-date knowledge and practice

Staying up to date knowledge and having practices it will be easy for the practitioner to be up to date most healthcare service mostly changes their polices and produces and if the staff are not up to date with the new rules they can’t be able to inform clients. It is important that staff provide best and high quality care and to meet their needs, it is about the changes must be made to improve the practices for example teacher must have training each year to maintain their professionalism, having an important knowledge and understanding of how to provide a learning opportunities for vulnerable people to achieve their health also the healthcare practitioner should work in the team identifying opportunities for working with colleagues sharing the development of effective practice with them it show that practitioners are willing to share their ideas with them also it show that you are interesting by showing attention. For example healthcare professional must be up-to-date in order to have an understanding about the healthcare sector it is important for the practitioner to have knowledge about health and social care as the practitioner will be providing health support for the vulnerable individual.

Continuous improvement

This is when individual are showing improvement in their work environment by making their work outstanding so it stand out in the front of people. Continuous improvement is when CPD training allow individual to have more knowledge it give person opportunities to wider their professional skills if individual take break having continuous improvement will allow the person to improve their own skills and qualities it allow that if you make any changes it won’t effect on your role. Continuous improvement mean that the manager wants the service must provide the best care for the patients and they want the service to be outstanding it is about providing quality and safety for the patients as they are vulnerable, it is about empowering the staff to deliver safe and high quality care and it must be reliable this is also for the patients and the service, because if the service do not provide the high quality care not only it is affecting on the person health but also on their service has they are not provide vulnerable people with a good care which they need (Kia Partners 2019)

Regulatory requirements

This is major roles that play in the healthcare industry because it protect the public from health risk has it ensure that they provide a safe health care to every individual who needs support and help. It is about reporting incident and risk so it do not harm the people around the environment  this is an check-up in case if you an illness most people don’t tend to have check because they think they are healthy such as regulatory when we go to doctor for a check-up it is the law rule that must be follow if you are in the health care professional such as code of conduct, polices and procedure, compliance, guideline, rules  they all comes in the regulatory requirement for example a nurse must be train and have qualifications in the nursing industry and most obey all the rules. The regulatory requirement is to protect the environment, keeping public confidence in the career and holding the professional standards having to protect the everymen from the harm it is important because it show that you care for the people and by keeping clean and helping the vulnerable to have their check-up and providing them with their support, medication and care.( Professional standards authority 2019)

Reflective practitioner

A reflective practitioner is when a healthcare practitioner know their strengths and weakness it is about improving their experiences and to improve their working environment it allow the practitioner to build their confidence and becoming more proactive professional. It allow the healthcare professional are continuing with their daily learning and it will allow them to improve their practices to fully qualified as practitioner this will be a skills and quality that the healthcare practitioner will develop when they are taking training. It is an opportunity for the healthcare practitioner to develop their self- awareness, it will help the practitioner with their personal growth and professional growth, in healthcare it is important for the practitioner to have reflective because it them a feedback it them to understand their skills. (PMC 2019)

Application of learning.

An application of learning when individual  collect a lots of information for the date to improve the application of learning such the patient’s records, medical report and other stuff that is related to their health it the service to make their decisions. This when a service allow you to provide them with individual personal details in order for them to register you in their service for example NHS would tell you to provide them with all of personal detail such you medical reports if individual had any illness that they must be aware of, in the healthcare it is important to each person right details this will prevent individual when the patients is at risk and someone needs to contacted for them to know about the patients situation

A*1 (5.1) – Describe the role of reflection within continuing professional development. Examples may be used to support the description.

Self-awareness

Self-awareness it is massively important because it practitioner to have training in CPD individual must know what skills and qualities. It individual allow to be  aware of their weakness and strength it help the practitioner to develop their confidences and having to aware of self-awareness it is important for the individual  treat themselves with care and should maintain their health and wellbeing. Self-awareness is about understanding and having be able to work on self-awareness and to be happy also people may have judgemental mind which it is important that it doesn’t not affect on the mental health. Positive self-awareness is about having a positive thinking and having a better knowledge about your development also it can increase your ability to achieve the goal having self-awareness will help you to maintain your social development. (Better Health Solution 2019)

Positive Outcomes

Positive outcomes are when practitioner success in something within CPD it is important to have an positive outcome to make sure that it will be benefit for the patients as well as the practitioner. It is about making sure that every stages of treatment or support they are providing must be effective and appropriate to their needs for example having to provide staff with training to increase their knowledge and to maintain their professionalism in order to provide care for the patients. To have a positive outcomes individual must promote by having to take good care of the patients and staff having CPD training will allow the staff to give feedback whether they would recommend this training to other staff or in the future.

Planning for development

Planning for development will help practitioner to maintain their training in the CPD, because it give the opportunity to plan their active before and it will allow to be organised in the workplace not only it keep the practitioner to be organised but it is help practitioner to maintain their healthcare professional role having to plan for development will increase the knowledge about that individual may not know also this will be benefit yourself and the service. Creating plan it is important in the healthcare service because practitioner need to plan their work before they can treat patients with medical care, also it is about ensuring that the planning for the development has been develop with care and it is not harmful for the patients also the people that are in the CPD training. (TJ 2019)

Ongoing review

Ongoing review within CPD is when practitioner will get  a feedback from other professional it give the idea if professional are doing something right or wrong it is important get ongoing review to maintain individual development. It is where goals and target can be easily observed and closely it and will build confidence by making sure that the target are met on time it also involve different CPD professional to achieve something that they want, this will keeping each practitioner motivated and engaged within CPD it is about the perform level and ongoing review should be positive rather than negative.

Reflective practitioner

Reflective practitioner is about improving and developing practitioner within the healthcare it is also about making how this could reflect on the individual role it is about increasing the knowledge and experiencing. It give the practitioner to develop new idea and it making sure that you understand the concept of the reflective practitioner. Reflective practitioner it is about improving your own practices and experience to increase the knowledge you are currently developing, this is skills and qualities that practitioner tend to learn while they are practicing for the role it will help them to understand to identifying your knowledge and strength and it is allow you to get feedback and reflective practitioner will guide practitioner make their choices for their learning development.

Develop knowledge and skills

To have the right skills and knowledge will allow the practitioner to understand improve their work and it will allow them to provide high quality care and support for the patients. It give the opportunities to gain for experience and will have more knowledge about somethings. This is important to have and successful role in health and social care for example a healthcare practitioner must know about Person Protective equipment because it can increase the personal knowledge and skills also you will be motived different sector has different knowledge and skills it is important that healthcare practitioner can develop those as soon as possible each can may develop new skills and knowledge they may interact with new people such young people or in an organisation that they are working to more knowledge  and skills practitioner must know role about their roles.

Responsibility for own Learning/professional growth

This is our own reasonability for our learning and professional this is benefited in the healthcare professional it is about recognising your own responsibility within CPD you have the reasonability for your own learning such as planning for development, self-awareness and action you tend to learn the reasonability through your qualification and your achievement or training. CPD is about to practices more and get the skills you want has the professional growths is about gaining experience.

A*3 – Reference Section

• School smart (2019) Benefits of independent learning for students (online) Available at: https://www.school-smart.co.uk/page/independent-learning/[Date Accessed 20/06/19]
• Seeking learning (2019) 7 ways to stay up to date in your industry (online) Available at:https://www.seek.com.au/learning/careers/your-next-job/building-your-career/7-ways-to-stay-up-to-date-in-your-industry[Date Accessed 18/06/19
• Professional standards authority (2019) Professional healthcare regulation (online) Available at:https://www.professionalstandards.org.uk/news-and-blog/blog/detail/blog/2018/04/10/professional-healthcare-regulation-explained[Date Accessed 18/06/2019]
• PMC (2019) reflective practice in health care and how to reflect effectively (online) Available at:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5673148/[Date Accessed 2019]
• Better Health Solutions (2015) Why Self-Awareness is important (Online) Available at:https://www.betterhealthsolutions.org/5-reasons-self-awareness-important/?cn-reloaded=1[Date Accessed 21/06/19]
• Training journal (2019) The importance of learning and development plans (online) Available at: https://www.trainingjournal.com/articles/opinion/importance-learning-and-development-plans [Date Accessed 21/06/19]
• S/NVQ Level 3 Health and Social care (Adults) (Yvonne Nolan with Neil Moonie and Sian Lavers 2005 (Reflective Practice page 135-136)
• Currant Health (2019) using positive patients outcome as a measure of healthcare value(Online) Available at: https://www.curanthealth.com/using-positive-patient-outcomes-measure-healthcare-value/[Date Accessed 27/06/2019]
• Patient information forum (7
  
  ^th
  
  November 2014) Supporting patients to develop knowledge, skill and confidence is central part of achieving person centred care (Online) Available at: https://www.pifonline.org.uk/supporting-patients-to-develop-knowledge-skills-confidence-is-a-central-part-of-achieving-person-centred-care/[Date Accessed 27/06/2019]

Review of literature is an essential component of a worthwhile study in any field of knowledge. It helps the investigator to gain information on what has been done previously and to gain information on what has been done previously and to gain deeper insight in to the research problem. It also helps to plan and conduct the study in systematic manner.

In this chapter, the investigator has presented the available research studies and relevant literature from which the strength of the study was drawn.

1. Studies related to cervical cancer

2. Studies related to HPV vaccination.

STUDIES RELATED TO CERVICAL CANCER

MiocLee,C.(1999) conducted a qualitative study with eight focus groups (number of sample=102) by using eleven question derived from the health belief model. Focus group revealed that there was misinformation and a lack of knowledge about cervical cancer. The women there fore were confused about causative factors and preventive strategies related to cervical cancer. The findings showed that major structured barriers were economic and time factors. The main psychological barriers were fear, denial confusion thinking. Participants stated that medical advice and education would influence them to undergo Pap test. Recommendations were made to reduce certain barrier and to increase knowledge and motivation.

Sheila,Twin. (2005) conducted a study among chinese women from a total sample of 467 in order to identify the knowledge about cervical cancer. Evident suggested that women knowledge about cervical cancer and preventive strategies are significant their screening practices. The need for further knowledge about the cervical screening and preventive measure was demonstrated.

HkoLiou, Xueminling. (2009) conducted cross sectional descriptive design on responses action and health promoting behaviors among rural Taiwanese women with abnormal Pap test. The result shows that nearly 14% were diagnosed as precancerous and underwent further treatment. 24%of the women took no action during the 3 month after receiving the result. As many as 96% were not aware about localized cervical cancer. These analyzed results may prove useful in developing intervention strategies to assist women with positive Pap test results to choose treatment modalities and adopted health behaviors.

STUDIES RELATED TO HPV VACCINATION

Kwan,T, et .al. (2007) conducted a cross sectional community based study to explore Chinese women’s perception of human papilloma virus vaccination and their intention to be vaccinated . A total of 1450 ethnic chinese women aged 18 and above who attended the health centers. The result shows about 38% of participants (n=527) had heard of HPV and about 50% (n=697) had heard of vaccination against cervical cancer. 88% of the participants(n=1219) indicate that they would likely to be vaccinated. Majority of the participants believed that sexually experienced women should be vaccinated; while27%opposed vaccinating sexually naïve women. study suggested that HPV infection was perceived to be stigmatizing to intimate family and social relationships, despite misconception and a grossy inadequate knowledge about HPV and HPV vaccination,

NubiaMunoz, et .al. (2007) conducted study among 17, 622 women aged 15-26 years who were enrolled in one of two randomized, placebo-controlled, efficacy trials for the HPV6/11/16/18 vaccine (first patient on December 28, 2001, and studies completed July 31, 2007). Vaccine or placebo was given at day 1, month 2, and month 6. All women underwent cervico vaginal sampling and Pap testing at day 1 and every 6-12 months there after. A result shows that vaccination was up to 100% effective in reducing the risk of HPV16and 18 related high-grade cervical, vulvar, and vaginal lesions and of HPV 6 and 11-related genital warts. In the intention-to-treat group, vaccination also statistically significantly reduced the risk of any high-grade cervical lesions (19.0% reduction; rate vaccine = 1.43, rate placebo = 1.76, difference = 0.33, 95% confidence interval [CI] = 0.13 to 0.54), vulvar and vaginal lesions (50.7% reduction; rate vaccine = 0.10, rate placebo = 0.20, difference = 0.10, 95% CI = 0.04 to 0.16), genital warts (62.0% reduction; rate vaccine = 0.44, rate placebo = 1.17, difference = 0.72, 95% CI = 0.58 to 0.87), Pap abnormalities (11.3% reduction; rate vaccine = 10.36, rate placebo = 11.68, difference = 1.32, 95% CI = 0.74 to 1.90). Conclusion of the study is High-coverage HPV vaccination programs among adolescents and young women may result in a rapid reduction of genital warts, cervical cytological abnormalities.

Infectious Disease Obstetric Gynecology journal. (2006) suggested that Vaccines which protect against infection with the types of human papillomavirus (HPV) commonly associated with cervical cancer (HPV 16 and 18) and genital warts (HPV 6 and 11) are expected to become available in the near future. Because HPV vaccines are prophylactic, they must be administered prior to exposure to the virus, ideally during preadolescence or adolescence. The young age of the target vaccination population means that physicians, parents, and patients will all be involved in the decision-making process. Research has shown that parents and patients are more likely to accept a vaccine if it is efficacious, safe, reasonably priced, and recommended by a physician. Widespread education of physicians, patients, and parents about the risks and consequences of HPV infection and the benefits of vaccination will be instrumental for fostering vaccine acceptance.

Andrea Licht,S, et. al. (2009) conducted study on HPV vaccination. The aims of this study were to assess HPV vaccination rates and to examine whether knowledge and risk perceptions regarding HPV were associated with the reported use of the HPV vaccine among female college students. A cross-sectional design was used among 406 women aged 18-26 years were recruited at two public universities and completed a self-administered survey. Respondents who reported having received at least one dose of HPV vaccine were classified as ‘vaccinated’ (n=177, 43.6%). Responses, stratified by the receipt of HPV vaccine, were compared using descriptive statistics and multivariate models. Results based on multivariate logistic regression modeling, 18-year-old women were approximately four times more likely to report use of the HPV vaccine compared with respondents aged 19-26 years. Respondents who correctly indicated that HPV caused genital warts were 1.85 times more likely to have received at least one HPV vaccine. African American and Asian women were each less likely to be vaccinated compared with white women. Risk perception was not significantly associated with vaccine uptake, however, the majority of respondents failed accurately to recognize their high risk of both acquiring and transmitting HPV. These findings suggest knowledge deficits and misperceptions about HPV risk as potential themes for educational campaigns encouraging the greater use of the preventive HPV vaccine among this subgroup

Allison Friedman,L. (2004) suggested that genital human papilloma virus (HPV) infection is the most common sexually transmitted virus in the united States, causing genital warts, cervical cell abnormalities, and cervical cancer in women. To inform HPV education efforts, 35 focus groups were conducted with members of the general public, stratified by gender, race/ethnicity, and urban/rural location. Focus groups explored participants’ knowledge, attitudes, and beliefs about HPV and a hypothetical HPV vaccine as well as their communication preferences for HPV-related educational messages. Audience awareness and knowledge of HPV were low across all groups. This, along with an apparent STD-associated stigma, served as barriers to participants’ hypothetical acceptance of a future vaccine. Although information about HPV’s high prevalence and link to cervical cancer motivated participants to learn more about HPV, it also produced audience fear and anxiety. This research suggests that HPV- and HPV-vaccine-related education efforts must be approached with extreme

Raley, JC. (2004) suggested that Human papilloma virus (HPV) is the causative agent of cervical neoplasia and genital warts. A vaccine has recently been developed that may prevent infection with HPV. Vaccination for HPV may become a routine part of office gynecology. Researcher surveyed members of the American College of Obstetricians and Gynecologists (ACOG) to determine their attitudes to HPV vaccination. A survey was sent to Fellows of ACOG to evaluate gynecologists’ attitudes. Vaccine acceptability was analyzed by using 13 scenarios with the following dimensions and respective attributes: age of patient (13, 17 and 22 years); efficacy of vaccine (50% or 80%); ACOG recommendation (yes or no); and disease targeted (cervical cancer, warts or both). Each scenario was rated by means of an 11-point response format (0 to 100). Responses were evaluated using conjoint analysis. Results of 1200 surveys that were sent out, 181 were returned and included in our analysis. ACOG recommendation was considered the most important variable in vaccine distribution (importance score = 32.2), followed by efficacy (24.5), age (22.4) and, lastly, disease targeted (20.9). Of these variables, higher efficacy was favored; preference was given to age 17 years, with a strong disinclination to vaccinate at age 13 years; and protection against cervical cancer, or genital warts, or both. Demographic characteristics of the gynecologists (i.e., age of physician, gender, and practice setting and community size) did not play an important role in the decision to recommend vaccination. Professional society recommendation is important for acceptability of a potential HPV vaccine. Gynecologists are willing to include this vaccine in their practice.

Chun Chao, et. al (2007) conducted study among 34,193 female who initiate HPV vaccination. The aim of the study was to examine the rate and correlate the completion of HPV vaccination. The result shows that the completion rate was 41.9% among age group between 9- to 17-year and 47.1% in the 18- to 26-year. Black race – 95% confidence interval and lower neighborhood education level were associated with lower regimen completion. A history of sexually transmitted diseases, abnormal Pap test results, and immune-related conditions were not associated with HPV vaccination regimen completion.

Caron, et. al. (2008) conducted a cross sectional study among college women, the study reveals that cervical cancer is primarily caused by the human papillomavirus (HPV) and is the second most common cause of cancer-related mortality among women. Purpose: College women may be at risk for contracting HPV based on their sexual behavior. An exploratory analysis was conducted, following the release of the HPV vaccine, Gardasil[R], the am of the study is to (1) determine awareness of HPV and Gardasil[R], (2) assess attitudes, behaviors, and beliefs about the HPV vaccine, (3) identify information sources that college women are accessing. Methods: A cross-sectional study of college women (n=293) enrolled in a Northeastern university voluntarily completed a self-administered questionnaire regarding knowledge, attitudes, behaviors, and beliefs about correlations, and paired sample t-tests. Results: Sexually active respondents would recommend the HPV vaccine to others and disagree that HPV vaccination would encourage risky sexual behavior. Yet, “need more information” is the predominant reason respondents would not get the HPV vaccine if it were offered for free. Discussion: Correlations are identified on how self-reported knowledge influenced attitudes, behaviors, and beliefs regarding the HPV vaccine. These findings should assist health educators in developing integrated public health education efforts for HPV vaccination that are targeted towards this at-risk population.

This student written literature review is published as an example. See

How to Write a Literature Review

on our sister site UKDiss.com for a writing guide.

At the turn of the 21st century, social health inequalities remain to be the key public health problems in advanced European countries. There is strong variation in life expectancy between and within the countries, which has accumulated over the past 3 or 4 decades’ (Fox, 1989; Drever & Whitehead, 1997; Kunst, 1997; Marmot & Wilkinson, 1999; Elstad, 2000; Mackenbach & Bakker, 2002). NHS targeted health inequalities with infant mortality and life expectancy at the core to reduce them by 10 % by the end of 2010. These two health inequalities were announced in February 2001, with the other complementary targets, the areas of smoking and teenage pregnancy. These targets were set to reduce the broad spectrum of inequalities covering the general strategy to address all of the major health inequalities including gender, race, age, etc.’ (DH, 2001).

The secretary of state, nationally announced a comprehensive strategy to reduce health inequalities, challenging the NHS as a key player to live up to its founding and enduring values of universality and fairness to shut the unjustified gaps between individuals with any background, fair NHS services with high quality and good outcomes to everyone’ (Darzi L., 2007).

The independent scientific review of the national health inequalities was published in 1998. This report suggested policy developments to tackle health inequalities. This report showed the increasing gap between the different social groups. This resulted in the consideration of these increasing gaps needed action ‘upstream’ as well as ‘downstream’ (Acheson Inquiry, 1998).

As the NHS and Department of Health continuously poured efforts to reduce the health inequalities. The overall performance can be defined as ‘much achieved more to do’ (DH, 2009).

This review will analyze the role of NHS in tackling health inequalities, as targets were set to reduce infant mortality and to increase the life expectancy in men and women across UK, faster than elsewhere in world.

2.0 Aims:

• To understand health inequalities
• To briefly review of the Acheson Inquiry recommendations
• To study the role of the NHS as a key player in tackling health inequalities in UK.

3.0 Material Methods:

Study will review reports and documents published by the Department of Health and the NHS. Review of literature will be done from the data available on the websites of the Department of Health, the NHS and other government websites. Discussion of role of NHS as key player in tackling health inequalities in UK and a comment on the target achieved over a decade.

4.0 Review of Literature:

In 1980, the United Kingdom Department of Health and Social Security published a report of the Working Group on Inequalities in Health, also known as Black Report. This report showed great extent of of which ill-health and death are unequally distributed among the population of Britain, and suggested that these inequalities have been widening rather than diminishing since the establishment of the NHS in 1948′(Gray AM. 1982). The Black report identified four types of explanations of health inequalities: artefact, selection, cultural or behavioural, and materialist’ (Blane D., 1985). Since then there were many studies contributed to broader understanding of the health inequalities (Smith et al 1990). After 1997 NHS had made clear progress, as in 1997 NHS was in relatively poor health, due to this low investment hampered proper planning. In regards with different health inequalities NHS was not simply big enough or capable enough to meet the expectations of the patients (Darzi L., 2007).

The steepest inequalities health is observed at two stages of the life course: early childhood and midlife. Less inequality is observed in adolescence and in older age (Kuh & Ben Shlomo, 1997). Actual health inequalities were considered and taken note by the scientific independent inquiry called as Acheson Report in November 1998, which reviewed the evidence of health inequalities in UK. Acheson report suggested that, “there is convincing evidence that, provided an appropriate agenda of policies can be defined and given priority, many of these inequalities are remediable (Acheson Inquiry, 1998).

The Acheson report is supposed to be the cornerstone for the policy development over the last 11 years informing action on the national target and the cross-government strategy, the programme of action. The report focused on socio-economic inequalities which showed the increasing gap between different social groups. It suggested almost 39 recommendations (Appendix I).

After considering the all the facts and recommendations, the NHS announced the two national health inequalities targets in February 2001, one relating to the infant mortality and the other to life expectancy. These targets were considered to reflect the efforts taken to reduce the broad spectrum of inequalities at national level across UK. These targets can be formulated under the specific terms – socio-economic groups and geographical areas so that they can cover more general strategy to address all of the major health inequalities including gender, race, age as well as health in specific disadvantaged groups such as lone parents and the homeless (DH, 2001).

England’s new health strategy, like this across the UK, represents a major advance in the vision and remit of public health policy. Protecting and improving aggregate levels of health no longer provide a sufficient justification for investment in public health; this investment must also yield a more equal distribution of health between socioeconomic groups. As a result, public health goals which were previously expressed only in terms of population averages now include a concern with how health is distributed across society. It is a concern summed up in the goal of ‘tackling health inequality’ (Hilary G., 2004).

5.0 Understanding Health Inequalities:

Inequalities are a matter of life and death, of health and sickness, of well-being and misery. The fact that in UK today people in different social circumstances experience avoidable differences in health, well-being and length of life is, quite simply, unfair. Inequalities in health arise because of inequalities in society – in the conditions in which people are born, grow, live, work, and age. So close is the link between particular social and economic features of society and the distribution of health among the population, that the magnitude of health inequalities is a good marker of progress towards creating a fairer society (Marmot, 2010).

The documents on plans, actions and performance standards are designed to spell out what it means to tackle socioeconomic inequalities in health. Their descriptions suggest that it has a variety of meanings. At some points, tackling health inequalities is described as a commitment ‘to break the link between poverty and ill health’ and ‘to improve the health of the worst off ‘ (Milburn, 2001 as Cited in Hilary G., 2004). Health inequalities can be stated as ‘the disparity in health status between rich and poor’ and ‘the health gap between the worst off in society and the better off’ (Wanless D., 2001). At other points, health inequality is a concept which covers the whole population. Health inequality ‘exists between social classes’ and ‘right across the spectrum of advantage and disadvantage’ (Hilary G., 2004).

6.0 Review of Acheson Report:

The Acheson report was published in 1998 from then it has been considered as the corner stone for tackling health inequalities. This independent scientific review considered the developments over the 20 years and identified some possible policy developments to address health inequalities. The report showed the data with increasing gap between social groups, “in early 1970s, the mortality rate among the men of the working age was almost twice as high as for those working in social class V (unskilled) as for those in social class I (professional). By the earlier 1990s, it was almost three times higher.” This resulted in the consideration of this increasing gap needed action ‘upstream’ as well as ‘downstream’ in other words from outside the NHS, as well as within it.

The report also addressed that social determinants affect people’s health across their lives; the early years are a particularly important stage of life, where poor socio-economic circumstances have long lasting effects. Consequently, it gave priority to policies and interventions with the potential to reduce inequalities in access to the determinants of good health among parents, particularly present and future mothers, and children.

It suggested almost 39 recommendations (Appendix I) which focus around the 4 major themes:

The social determinants of health, such as poverty and income, education, employment, environment and housing

The life course, including lifestyle factors such as smoking, nutrition and alcohol consumption

Other dimensions of health inequalities beyond socio-economic status namely ethnicity, gender and age

Measures to improve the effectiveness of the NHS’s systems of care, not least in terms of resources and access to services.

The report gave high priority to mothers, children and families. Tackling health inequalities is a complex and long-term challenge, requiring action across the layers which influence the health. The relationship between these layers is shown below in Fig. 1 (an updated version of the Dahlgren and Whitehead diagram that appeared in the Acheson report).

Fig. 1 The main determinants of health:

Source: Barton and Grant (2006) adaptation of Dahlgren and Whitehead (1991) from UN Economic Commission for Europe (2007) Resource Manual to Support Application of the Protocol on Strategic Environment Assessment.

7.0 National Health Inequalities Strategy, Programme for Action:

The national health inequalities target was set in 2001 the aim was to reduce the health outcomes in infant and the overall increase in life expectancy by 2010. The national health inequalities strategy programme for action was built on the board front set out in Acheson, which focused on the importance of the working across government and in partnership both with other service providers and with the local communities’ (DH, 2003).

Four themes of the programme for action:

supporting families, mothers and children – reflecting the high priority given to them in the Acheson report

engaging communities and individuals – strengthening capacity to tackle local problems and pools of deprivation, alongside national programmes to address the needs of local communities and socially excluded groups

preventing illness and providing effective treatment and care – by means of tobacco policies, improvements in primary care and tackling the ‘big killers’ coronary heart disease (CHD) and cancer

addressing the underlying social determinants of health – emphasising the need for concerted action across government at national and local levels up to and beyond the 2010 target date.

Annual status report has to be published throughout the lifetime of strategy, these developments were monitored against the NHS to the wider determinants of health (reflecting Acheson’s proposal for action on broad front), and 82 departmental commitments (DH, 2003)

These Annual status reports showed the improvement in health in real terms across all social groups, against a range of indicators including life expectancy, infant mortality, cardiovascular disease and cancer, and reported on developments against the cross-departmental commitments (DH, 2010).

8.0 Role of the NHS in tackling health inequalities:

As NHS is the key player in tackling health inequalities target set in 2001- ‘By 2010 to reduce the inequalities in health outcomes by 10% as measured by the infant mortality and life expectancy at birth.’

8.1 Life expectancy-

The life expectancy gap between the areas with lowest life expectancy and the national average is caused principally by premature deaths from cancer, circulatory diseases and respiratory diseases with smaller effects from suicide and violence in men. The over 50s contribute 79% of the gap in women and 70% of the gap in men. It follows that the priorities for NHS action which will have the greatest impact on narrowing the gap are:

• addressing cancer and circulatory diseases within manual social groups because these major killers exhibit strong social class gradients.
• Improving the life expectancy of the over 50s
• high quality care in disadvantaged areas, especially primary care.

Key areas of interventions to narrow the gap in life expectancy are: reducing smoking, prevention and effective management of other risk factors in primary care, targeting over-50s, and working pro-actively with partners on issues affecting life expectancy.

8.2 Infant mortality-

Deaths under one year of age total about 3,000 per year. The two major causes of neonatal deaths are ‘immaturity related conditions’ and ‘congenital malformations’ and both show a strong social class gradient. The social class gradient is greater for post-neonatal deaths. Just under 50% of all post-neonatal deaths are accounted for by two causes: ‘signs, symptoms and ill-defined conditions’ (predominantly SIDS) and congenital anomalies.

The underlying determinants of mortality and ill-health in infants include:

• low birth weight
• maternal smoking (smoking during pregnancy)
• paternal smoking
• maternal anthropometry/nutritional status
• failure to breast feed
• quality and quantity of health care
• maternal age
• the physical environment (housing condition)
• the family and social environment

Key areas for interventions to narrow the gap in infant mortality are: reducing smoking in pregnancy, improving nutrition in women, reducing teenage pregnancy, increasing breast-feeding, effective ante-natal care, improving the quality of midwifery, obstetric and neonatal services and high quality family support.

The NHS set to improve the action to address health inequalities (Appendix II):

• Raise the profile of health inequalities and focusing on results
• Making it clear it is not good enough to achieve top line targets at the expense of widening inequalities
• Make health inequalities an integral part of planning, commissioning and delivery
• Promote Health Equity Audit, Local Delivery Plan and its impact on the health inequalities.
• Partnership working and influencing partners to tackle the wider determinants of health and health inequalities
• Progress must be measured
• Use of the Health Care Standards and their underpinning criteria.

The WHO guiding principle, that ‘the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being’, was reiterated in the 1998 World Health Declaration’ (Hilary G., 2004). The report on health profile of England 2009 states there are improvements in number of critical areas eg. Decrease in mortality rates, increase in life expectancy and further reduction in infant and perinatal mortality’ (DH, 2010). These achievements can be defined as ‘much achieved more to do'(DH, 2009). Now the NHS is focusing to be the World Class NHS whom services will be’ (Darzi L., 2007)-

• Fair
• Personalized
• Effective
• Safe

Over recent years health inequalities have increasingly featured as an NHS priority. This has been evident in their incorporation into other Public Service Agreement health targets, and the findings of the Wanless report noted the association between lower socio-economic status and poor health outcomes, and the cost consequences for the NHS’ (Wanless D., 2004).

The contribution of the NHS to the 2010 target was recognized in the Treasury-led cross cutting review (DH, 2002). This review considered the implications of the Acheson report for departments across government and the NHS. It identified NHS interventions as more likely than other interventions to help deliver the short-term target through reducing smoking in manual groups and preventing and managing other risk factors for coronary heart disease and cancer, but it recognised that the social determinants were crucial for a long-term sustainable reduction in health inequalities.

9.0 Discussion:

The Black Report concluded that inequalities in early 1980s were not mainly attributable to failings in the NHS, but rather to many other social inequalities influencing health: income, education, housing, diet, employment, and conditions of work. Then Black Report recommended a wide strategy of social policy measures to combat inequalities in health. After 10 years of Black report the social class differences in mortality were still increasing, after this there were many studies undertaken addressing inequalities in health'(Smith et al 1990). Then Acheson report was published in 1998 an independent scientific review of the inequalities in health, and in 2001 the national targets for tackling inequalities in health were set in which Department of Health and NHS played a key role the success can be stated as the ‘much achieved more to do’ (DH, 2009). The Marmot review recommends ‘action on health inequalities requires action across all the social determinants of health and needs to involve all central and local government departments as well as the third and private sectors. Action taken by the Department of Health and the NHS alone will not reduce health inequalities’ (Marmot, 2010).

10.0 Conclusion:

The above study shows the NHS had played a key role in tackling health inequalities along with the Department of Health over the past decade. This resulted in the highest life expectancy ever in UK and gradual decrease in the infant mortality. Overall development in past decade is shown in Appendix III, which shows factors such as employment, housing conditions, educational achievement, crime and child poverty without which the overall improvement in the health inequalities is not possible. The role of NHS in tackling health inequalities have also improved the overall performance of the NHS itself in and made the NHS a World Class NHS visioning fair, personalized, effective and safe services ahead.