Man is a social animal depends on relationships for survival. Social system acts as cushion in stress, supports and enhances wellbeing. Social isolation is a state of loneliness experienced by non-participative individuals in the society. It is characterized by lack of social belongingness, engagement with others, minimal public contacts and satisfying relationships. Absence of meaningful relations is common in mental health settings which significantly impacts recovery and wellbeing of the client Hence, the significance of this issue shouldn’t be undervalued. It is considered to be a current issue but actually it has always been thriving in the corridors of our society requiring comprehensive efforts for its resolution. Therefore, this paper will focus on the concern of social isolation among mentally ill clients, its consequences and few strategies to surmount it.

Mentally ill clients are the most stigmatized members of the society. In eastern countries like Pakistan, these people are publicly and culturally grabbed by the stigmatization and inequity which carries the burden of human distress thus resulting in social isolation. Myths like psychiatric clients are cursed by God, are major contributors to stigma. These people fear refusal from others that socialization may devastate them, so they favor avoiding contacts. Isolation leads to less-productivity, loss of social roles, and inability in fulfilling society’s expectations. Absence of social contacts develops triviality and low self-worth which leads to depression and promote alcoholism or suicide in some cases. Even if death does not frightens them it disrupts them in their social association which leads to guilt, sustained silence and withdrawal.

During a clinical rotation at St. Vincent Old age Home, I encountered a 67 years old widower client with psychological history of depression and medical history of osteoporosis. She received twelve years of education and had earned her living by working in the community center. When her two sons went abroad, she joined this old age home to continue her living. She never shared her feelings with anyone, remained isolated and scolded whenever I tried to call her for group activities. Her secluding attitude made me wonder that if she remained the same, nobody will discern her thoughts which would eventually hinder her recovery. Later with time and motivated efforts of our group she started talking, involved herself in social activities and shared her feelings through songs.

Furthermore, links social isolation with physiological problems like poor physical-health, impaired sleep, hypertension altered immunity and. Also, cognitive decline, nutritional risk.

Roy’s Adaptation Model, a theoretical model in nursing practice can be incorporated to social isolation. Roy suggests that client is a bio-psychosocial individual who frequently mingles and adjusts with the varying surroundings which ultimately affects an individual’s basic needs of survival i.e. growth, reproduction and self-mastery. The model explains the environment as the situation and circumstances surrounding the individual, while health is defined as the purpose of the person’s performance and adjustments. The outcome is the adaptive or maladaptive behavior of the individual. The adaptive performance is exhibited in four ways that are physiological, self-concept, role-function, and interdependence. However failure to adaptation can result in weak self- concept, weak interdependence, and ineffective interpersonal relationships ultimately resulting in social isolation.The nurse acts as an assisting individual in adaptive process by identifying the coping resources and developing coping mechanisms. Nurses are the only ones that drop a line to isolated clients thus it is essential to identify psychosocial issues that increase health risks to these clients. As a student nurse, I focused on client-centered interventions for the promotion of adaptive responses such as encouragement for the verbalization of feelings through therapeutic communication, involvement in group activities, thus re-establishing the adaptive modes of behavior for improving the wellbeing.

Absence of social association might be a reason or a result of mental illness. Mental illnesses such as , depression, schizophrenia, bipolar-affective-disorder leads to social cut-off. Nature of mental illness can be an additional cause of social isolation. Societal phobias like agoraphobia, or severe anxiety or depression frightens the client to endeavor into society. Moreover, it brings feelings of hopelessness and helplessness which secludes them in their rooms. The strong correlations link social isolation with negative health consequences (Nicholson, 2009).We can analyze social separation in relation to mentally ill patients as general problems of discrimination, minimal social-role, negligible social participation and disability. On analysis of the scenario, it is evident that the client wasn’t socializing due to her mental illness. Additional factors may include, loss of spouse, lack of family support, diminutive social networks, and recurring rejection are supplementary factors that take part in this issue

Social reintegration can be an essential component of recovery for mentally ill clients. Strategies to surmount social loneliness could be separated into three stages; individual, group and institutional. At individual stage, I encouraged the expression of feelings and emotions, identified personal reasons for non-indulgence, involved the client in mind-diversion therapies. However coping resources and coping mechanisms could be identified to enhance wellbeing. Secondly, at group level, I admired and highlighted patient’s strengths and participation that is singing of songs in group activity to improve her self-esteem. A constructive student nurse-client relationship provided inclusion in the group which helped her break the ice. Moreover , communities can identifying cases of mental illness and provide appropriate referrals for the treatment. It can play fundamental role in developing support groups and implementation of psychotherapies to improve socialization among these clients. Additionally, small campaigns can aware the communities about mentally ill clients, the cause of their separation from society and the ways of dealing with these clients. Lastly, at institutional level, media can play an important role to aware public about psychiatric illness and the consequences of social segregation. Furthermore, institutions can conduct conferences to develop staff’s competency

In conclusion, psychiatric nursing practice requires the idea of social integration to enhance physical and psychological wellbeing of socially secluded clients. The adoption of adaptive modes of behavior through Roy’s Adaption Model directs the nurse in defeating social isolation. For that reason, suitable steps at individual, group and institutional levels could be effective in preventing social aloneness. Once the objective is accomplished, healthcare contributors will be able to increase a person’s quality of life and prevent the worsening.

Access to healthcare for disabled people in the UK is not as straight forward as it can be. Disabled people face serious barriers to accessing care including structural, financial and attitudinal barriers among others (Zaide, A., Burchardt, T., 2005). While some argue that disabled people must have full access to healthcare due to their disability (Braitwaiste, J. and Mont, D. 2006), others highlight that accessing health care is much difficult for the disabled because their needs are not fully understood (Papworth Trust, 2016).

This essay will explore in detail the factors that affect the disabled from accessing healthcare fully in the UK. Evidence will be taken from academic books; peer review journals, searches on the internet on published journals and working papers.

Socio-economic status is connected with degrees in health category and needs for health care. Many evidences from source shows that people of all ages with lower socio-economic status are more likely to die, suffer from specific diseases, or to experience illness or disability. The meaning of disabled people has drastically changed over the years in our society. Disabled people were a group of people who appeal pity and were the subjects of charitable movement, but they are now more likely to be the focus of equal rights legislation.

(Punch, S., Harden, J., Marsh, I. and Keating, M. 2013).

Disability is very common in the UK population. According to the Equality Act 2010, a person with physical or mental impairment that has substantial and long -term negative effect on their daily lives is classified as a disabled. In the UK, there is a good evidence, long-standing inequalities both in terms of access to health care, unmet needs, and health outcomes. However, only limited information about access to healthcare for people with disabilities is there. The available information shows that people with disabilities report worse access (such as physical access into buildings) to services and worse satisfaction with provided services. Their needs are not recognised, they generally face several barriers, structural (such as lack of transportation), financial and cultural (e.g., misconceptions about disability). Many studies have shown that disability is an added impediment in accessing health service. Disabled people are restricted in accessing healthcare and report less satisfaction with their medical care. Some of the barriers to healthcare access include lack of transport and inaccessible buildings. Disabled people often report that their needs are not understood, or they are treated as patients of low priority (Papworth T, 2016).

The delivering of equal access to healthcare for all has been built by the British National Health Service (NHS). Wenzl et al (2015) said, the NHS is expected to work towards greater access to healthcare and reduction in health inequalities. However, through the establishment of tangible policies, the extent that has either been realised or operationalised should be debatable. Powell & Exworthy (2003) argue that most of the NHS policies that are aimed to provide an equitable service focus on service availability rather than on any other dimension of access and concluded that there is “…discrepancy between the ‘paper’ aim of equal access and the operational aim of equal provision” (p 59). The 2010 Equity and Excellent document put service accessibility at its core but failed to either acknowledge people’s disparities demands to healthcare or the different resources that people have at their disposal.

Popplewell, et al (2014), found out that people with severe disability are the ones most likely to have an unmet healthcare need. Almost 7.2 times more disabled are more likely to have an unmet mental healthcare need due to the cost, than people with no dis ability in the UK. Popplewell et al, 2014, demonstrated how adults with physical disability in England report wore access to primary care, while Allerton & Emerson (2012) found similar inequalities in the UK national study with people with chronic conditions or impairments. Some research from UK has also shown that people with disabilities report wore experiences of cancer care (bone, A., McGrath-Lone, L. Day, S., et al 2011-2012)

Drainoni, M., et al (2008) emphasizes that, people with disabilities face structural, financial and attitudinal barriers when they seek to access healthcare. Disabled people in the UK faces difficulties in accessing healthcare that is caused by lack of transport, inaccessible buildings and inadequate training of healthcare professionals, among other factors. People with disabilities usually reports that they feel their needs are not understood, they feel they are not heard, and they are patients of low priority due to their pre-existing condition. Such difficulties can be further compounded by the systematic ban that people with disabilities normally face, such as lower rate of employment, lower income levels of poverty than general population. People with disabilities often have greater healthcare needs and therefore may need to access healthcare services more that the general population (Braitwaiste, J. and Mont, D. 2006).

The connections between disability, socio-economic condition, and gender affect access to healthcare. According to (Zaidi, A., Burchardt, T. 2005), shows that access to healthcare is mediated by the type of health service provider, which is in turn interceded by income. People with disabilities are normally excluded from the job market and they also have a higher daily living costs, for instance, increase heating costs if they spend more time at home or out of pocket payment for equipment. They often cannot afford to pay for private coverage or out of pocket payment for medication. In Beatty et al (2003) studies found out that people with the poorest health and with the lowest incomes are the least likely to receive all health services needed. Low income can affect access to healthcare in various ways through, such as, reduced access to suitable transportation and reduced ability to pay for medication or make out-of-pocket payments. This has a gender dimension too, with women consistently reporting worse access to healthcare.

Women with a disability are more likely to have an unmet healthcare need than any of the other groups, for example, they are 7.2 times more likely to have an unmet mental healthcare need due to the cost if compared to men without disability, and by men with a disability they are almost four times more likely to have an unmet healthcare need due to the cost of prescribed medicines (Gideon, J. 2012). There is a gender differences in barriers to healthcare. One of the reasons for this may be the invisibility of the wider social dimensions of gender within the healthcare system, including the NHS. Healthcare systems usually do not recognise the additional obstacles that women may face when they seek healthcare, such barriers may be due to lower income or higher caring responsibilities compared with men (Gibson, BE., Mykitiuk, R. 2012).

The fact that these results come from UK, a country with a national, public free at-the-point-of- access healthcare system (apart from prescriptions), is particularly worrying. The NHS aims to provide equal access to the population, but this does not seem to be distributed equitable, especially when we consider the use of service and do not their availability. This shows how the interaction of disability and gender can create a structural disadvantage for disabled women who report the worst access to healthcare from any other group (Smith, DL. 2006). To develop effective policies to move towards a more equitable healthcare access, it is important to explore in detail the reasons behind the worse access to healthcare services for people with disabilities, acknowledge how the significance of gender in any exploration of access to services. It is also important to acknowledge how multiple factors, such as disability, gender and the social and financial realities that are implanted affect access to healthcare (Gibson, J., O’Connor, R. 2010). It is vital to determine the actual accessibility of healthcare rather than expected access based on the availability of services or the provision of health reporting, which do not always acknowledge people’s specific needs (eg, transportation needs to reach a healthcare facility). It is also equally important to understand that health inequalities are largely based on disparities in wider determinants and therefore, policies aimed at achieving a more equitable distribution of health, need to address broader socio-economic inequalities (Morris, S., Sutton, M. and Gravelle, H. 2005).

In conclusion, people with disabilities report worse cases every day for access to healthcare, with transportation, cost, buildings and long waiting lists being the main problem. It is very worrying as they illustrate that a section of the population, who may have a higher healthcare needs, faces an increased problem in accessing health care services.

References

• Allerton, L., Emmerson, E. (2012):
  
  British Adults with chronic health conditions or impairments face significant barriers to accessing health services.
  
  Public Health. Elsevier. UK
• Angus, J., Seto, L., Barry, N., et al. (2012):
  
  Access to cancer screening for women with mobility disabilities
  
  . J cancer Educ. Springer, New York.
• Braithwaite, J., Mont, D. (2009):
  
  Disability and Poverty
  
  : a survey of World Bank Poverty assessments and implications. ALTER-European Journal of Disability Research. Elsevier. UK
• Beatty, P., Hagglund, H., Neri, M. (2003
  
  ): Access to health care services among people with chronic or disabling conditions
  
  : patterns and predictors. Arch Phys Med Rehab. Elsevier. UK.
• Bone, A., McGrath-Lone, L., Day, S., et al. (2011-2012):
  
  Inequalities in the care experiences of patients with cancer
  
  : analysis of data from the National Cancer Patient Experience Survey. British Medical Journal Open. UK.
• Department of Health. (2010):
  
  Equity and Excellence
  
  : Liberating the NHS. Norwich. The stationary Office. [online] http.www.tsoshop.co.uk Accessed on 23/10/2018.
• Drainoni, M., et al. (2006):
  
  Cross-disability experiences of barriers to health care access.
  
  J Disability Policy Studies.
  
  United Kingdom.
  
• Gibson, BE., Mykitiuk, R. (2012
  
  ): Health care access and support for disabled women
  
  : falling short of the UN Convention on the right of persons with disabilities. Women’s Health Iss. Canada.
• Gibson, J., O’Connor, R. (2010):
  
  Access to Healthcare for Disabled People:
  
  asystematic review
  
  .
  
  Social Care and Neurodisability: Pier Professional LTD. University of Cambridge. UK.
• HM Government. (2012):
  
  Equality Act
  
  . The Stationary Office. London.
• Morris, S., Sutton, M. and Gravelle, H. (2005):
  
  Inequity and inequality in the use of Health care in England
  
  : an empirical investigation. Soc Sci Med. UK
• Papworth Trust (2016):
  
  Disability facts and figures
  
  . Papworth Trust. Cambridge UK. Accessed 23/10/2018.
• Popplewell, NT., Rechel, BP., Abel, GA. (2014):
  
  How do adults with physical disability experience primary care?
  
  A nationwide cross-sectional survey of access among patients in England. Cambridge University. UK
• Powell, M., Exworthy, M. (2003):
  
  Equal access to health care and British National Health Service.
  
  Policy Studies. UK
• Punch, S., Harden, J., Marsh, I. and Keating, M. (2013):
  
  Sociology: Making Sense of Society.
  
  Pearson Education limited. Fifth edition. United Kingdom.
• Scheer, J., Kroll, T., Neri, MT., et al. (2003):
  
  Access barriers for person with disabilities
  
  : the consumer’s perspective. Journal Disabilities Policy Studies.
• Smith, DL. (2006):
  
  Disparities in health care access for women with disabilities in the United State
  
  . National Health Survey. Disability Health Journal. USA
• Wenzl, M., McCuskee, S., Mossialos, E. (2015):
  
  Commissioning for equity in the NHS
  
  : rhetoric and practice. Br Med Bull. London
• Zaidi, A., Burchardt, T. (2005):
  
  Comparing incomes when needs differ: equivalization for the extra costs of disability in the UK
  
  . Rev income Wealth. UK

Palliative care is moving through an important period of expansion and development and it upholds a unique position in health care. More people need palliative care than any other health or social care services. This essay will be able to compare and contrast the current practice i.e. hospice and hospital with evidence based research. This essay will explore the history of past present and future of palliative care including the current policy and how palliative care will be in 10 years time. This will also go through the relevance of symptom management and pain control in palliative care.

According to the NHS cancer plan (Department Of Health 2000) every year, over 200,000 people diagnosed with cancer and around 120,000 people die from cancer. Terminal care is an important part of palliative care(National Council for Hospice and Specialist Palliative Care Services (NCHSPC 1995). Palliative care grew from hospice which includes terminal care. The point at which terminal care begins is a subjective decision in the absence of an ability to accurately predict prognosis. How do we distinguish between progression and terminal? The word terminal is negative and passive. Palliative care upholds the principles of life and continuity instead of hailing sadness(Clarck and Seymour1999).

The goal of palliative care is achievement of the best quality of life of the patient and their families(WHO 2005).World Health Organisation (2005) defines palliative as “the active total care of patients whose disease is not responsive to curative treatment. Control of pain ,of other symptoms and of psychological social and spiritual problems is paramount” .The palliative care approach aims to promote both physical and psychosocial wellbeing (Addington and Julia,stated in Fallon M 1996) Palliative care is recognised by individualised, holistic models of care, delivered carefully, sensitively, ethically, and therapeutically by using skilled communication with attention to detail ,meticulous assessment ,and advancing knowledge(Balfour et al 2006).One of the core elements of good palliative care is effective communication, among health professionals and between health professionals and patients (Buckman,1993 wellbeing(Raudonis,1993;Hinton,1998).The essential components of palliative care are effective control of symptom and effective communication with patients and families and others involved in their care(O`Neil and Fallon 1996). The principles of Palliative care states as “Palliative care affirms life and regards dying as normal practice, neither hastens nor postpones death, provides relief from pain and other distressing symptoms. Offers support system to help families of patient’s illness and their own bereavement (Balfour et al,sited in Fallon M et al 2006)

The Development and contemporary practice in palliative care

Palliative care has become a public health priority across European countries due to increase in life expectancy and incidence of chronic illness (World Health Organisation(WHO)Europe 2004a; 2004b). Modern palliative care originated in development of St Christopher`s Hospice in London in 1967,recognising the unmet needs of dying patients in hospital (Chiarella 2006). Dame Cecily Saunders established the hospice and, with others, conceived of a comprehensive approach to dealing with the variety of symptom and suffering often experienced by patients with progressive debilitating disease. Careful observation of the use and effect of morphine and similar drugs are also originated in the hospice.(O`Neil and Fallon 1996). In the beginning palliative care was reserved only for those with incurable cancer .Palliative care now provided for other patients such as t AIDS , Neurological diseases including motor neuron disease and multiple sclerosis and some conditions of heart failure rather than concentrating only on cancer patients. ( O`Neill and Fallon 1996). In the past hospices provided only inpatient care and they were isolated from mainstream care. However in the last decades palliative care has gone through rapid changes and growth. In 1985 there were less than 100 hospices in the UK and now there are over 200 with 400 home care teams compared with less than 50 in 1985.(O`Neil and Fallon 1996). Today an impressive and bewildering array of palliative care education is available from short courses to conferences through to diploma first and higher degrees (Richard ,sited in Fallon M, 1996). Whatever the illness or its stage , informed by a knowledge and practice of palliative care principles and supported by specialist palliative care which should be practiced by all health care professionals in primary care , hospital and other settings by focussing on quality of life which includes good symptom control (NCHPCS,1999)District nurses play a vital role in community palliative care settings .Palliative and terminal care is an area of care that encompasses all the skills and knowledge passed by district nurses (Goodman et al ,19998). An example of importance district nurse awareness of service is the Marie Curie community nursing services ,developed to offer bedside nursing care for patients at home (Barnes, 1999).The opportunity to take education and training is important for community nurses when working with patients and families(Wikes et al 1998).The provision of 24hour service is a key component of community palliative care delivery. To improve the quality of care two complimentary models are used in UK. “The Gold standard Frame work -which is a primary care based approach to formalising best practice ,so that good care become standard for all patients every time(Thomas Sited in Fallon M,et al, 2002).The Liverpool care pathway provides multidisciplinary documentation and prompted guidelines towards achieving important goals for patients with cancer and their families in the dying phase (James 2002).Gold Standard Framework is for patients who nearing the end of life and Liverpool Care Pathway is for the last days or the last few hours of life . Presently patients have a choice for their situation.

Careful evaluation is the essential basis for symptom management and is the responsibility preferred place of death rather than spending their last days of life in an unfamiliar of both doctor and nurse. Evaluation is the vital steps in cancer pain (WHO 1998). The most widely accepted definition of pain is that given by the international association for the study of pain (IASP) ‘Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage’ (Woodruff 1996). More practical definition is ‘pain is what the patient says ‘hurt” (woodruff 1996). In the palliative care setting where pain is usually chronic and progressive and of obvious significance to the patient some degree of suffering is common. Symptom should be treated promptly since they more difficult to treat, the longer they are left. Treatment must start as soon as the diagnosis is made. A symptom control is a major gaol with in palliative care and if the success of the goal is to be measured adequate methods of assessing symptom and the distress they cause are required.

The basic science of total pain mechanism is that anxiety fear and sleeplessness feed in to the limbic system and cortex. In turn the brain talks back to the spinal code modifying pain input at spinal levels. This then feeds back to the brain and a loop is established. With effective assessment and a systemic approach to the choice of analgesics using the WHO’s analgesic ladder over 80% of cancer can be controlled with the use of inexpensive drugs that can be self administered by mouth at regular intervals. (Falloon et.al.) According to the WHO pain ladder drugs should be administered in standard dozes at regular intervals in a stepwise fashion.

Patients with cancer should be comforted with maximally achievable pain control and not leave in fear of inadequately treated pain. As survival of patients with cancer becomes longer, reliable pain relief is now a high priority issue that warrants both scientific research and industrial development of new devises and pharmacological agents that would make this pain relief complete safe and lasting.

When we turn in to the future and challenges in palliative care ,and where palliative care will be in 10years time, Palliative care will become more increasingly available to patients with non-malignant disease. Patients will be given more choice for their preferred place of care and where they wanted to be at the end of their life. More government funding, greater commitment, better education, and further research are some of the most important features of future palliative care. Greater political awareness and lobbying will also be needed. Introducing new models of care to bring good quality of care to a wider number of patients. Government offered a 12million investment over 3years to improve care for people coming to the end of their life lives. There will be an increasing number of hospices and will be developed world wide. More government funding are expected .palliative care will be more commonly available for patients with non-malignant disease. Palliative care will become more relevant part of education and public awareness to benefit palliative care for those who needed.

Conclusion

As medical science grows, we can expect the demand for palliative care will increase to a much higher level. And it will be vast growing part of social care around the globe .Palliative care must be considered as a service available routinely within main stream health care. In a world of limited or decreasing resources for health care , government in both developed and developing countries must allocate resources for cancer pain and palliative care in rational way. Increased research in to symptom management and assessment are highly prevalent and devastating clinical complication badly needed.