Figure 1 National Statistics ( 2001)
Figure 2 shows the ethnic composition of Evington in comparison with Leicestershire. It can be observed that there is a lower percentage of Whites and Black or Black British than the
Leicestershire average and a significant high percentage of Asian or Asian British. Ethnicity can have a significance on the health status (Acheson, 1998) so is regarded as an important factor when conducting a health needs analysis.
Figure 2 National Statistics (2001)
The economic activity related to Evington (figure 3) identifies that compared to the Leicestershire average the area has a low unemployment rate and a higher percentage of retired residents compared to both Leicestershire and England and Wales. This can be linked with the high percentage of people age 60 and over in Evington. There are a low percentage of students in the area compared to Leicestershire. This may be because Leicestershire has 2 universities and majority of colleges and schools are based there. Students from Evington may not necessarily be studying in Evington but elsewhere in Leicestershire or in England and Wales.
Figure 3 National Statistics (2001)
Housing tenure (figure 4) shows a significantly higher percentage of owner-occupiers in Evington than Leicestershire and also England and Wales. A high percentage of home owners do not indicate wealth as homes owned by the elderly may be in need of work and lack basic amenities which could have detrimental consequences on the individual health status (Age Concern, 1999).
Figure 4 National Statistics (2001)
Taking this into account Evington has a Jarman (1991) score of -9.47, which indicates there is little or no deprivation compared to Leicester that has a score of +3.7, indicating it is highly deprived. However the score can be misleading as due to the high number of pensioners in Evington there may be pockets of deprivation.
- Epidemiology
The Health of the Nation (DOH, 1991) and more recently Our Healthier Nation (DOH, 1998), use information from the public health domain to look at trends and set targets for improvement. It aims to secure continuing improvement in the general health of the population by adding years to life and life to years. The four biggest killers are:
- Cancer which kills 127,000 people-target to reduce by a 1/5 in under 75
- Heart Disease and Stroke kill 214,000 people-reduce by 2/5 under 75
- Accidents kill 10,000 people-1/5 and serious injury reduce by 1/10
- Suicide kills 4,500 people-reduce by 1/5
The overall mortality rate in Evington and surrounding areas appears to be the same as the national average (figure 5), however the death rates for people in the age groups, 15-64 years show 11-13% excess, compared with corresponding figures for England and Wales.
Figure 5 Public Health Profile (2004)
The main causes of mortality between the years 2001-2002 among men and women aged 75 and under in Evington and its surrounding areas are presented in figure 6. Even though Coronary Heart Disease (CHD) and Cancer are national targets of health, it can be observed that Evington and its surrounding areas have a problem with this. The predominant causes are malignant neoplasm’s (24% in male and 34% in female) and circulatory diseases (40% in men and 30% in female).
Figure 6 Public Health Profile (2004)
The practice profile (2004) identifies that the overall population of Evington with Type 1 and 2 diabetes (see Appendix 5) is 4.3%, which is higher than the national average of 3% (DOH, 2002). The prevalence of diabetes rises with age (figure 7) and the high percentage of elderly patients could account for this. Evington also has a high population of Asians and Davies et al (1996) suggests that Type 2 diabetes is particularly high in this ethnic group.
Figure 7 Practice Profile (2004)
- Community Facilities
Evington provides the immediate environment for where people live, work and play and for many more vulnerable groups, such as the older people and those on low income, most of their lives are lived solely in this area. Essential local services are provided such as post offices, shops, regular buses and health centres. There are a number of voluntary, statutory and social services available in the area (Appendix 6) that Betty is aware of.
- Needs Assessment
Distinguishing between individual needs and the wider needs of the community is important in the planning and provision of local health services. If these needs are ignored then there is a danger of a top-down approach to providing health services, which relies too heavily on what few people perceive to be the needs of the population rather than what these needs are (Twinn et al, 1996).
- Referral
Betty was referred to the DN on the 19 December 2002 by her General Practitioner (GP). She is seen by the DN for the dressing of 3 wounds on her abdominal hernia. It was decided that Betty would be visited everyday because of her past medical history.
Betty is a non insulin dependent diabetic and has hypertension, both which are controlled by oral medication. 17 years ago she had a hysterectomy where she reports her abdominal hernia developed from. She has fractured both of her wrists and has no sensation of the heat or cold on her hands but can move and use her fingers perfectly fine.
- Health Needs Assessment Tool and Model of Nursing
A health needs assessment tool was used to carry out Betty’s assessment (Appendix 7). A relaxed environment was facilitated in Betty’s home by the student nurse. Open questions were asked to gather as much information as possible to build a holistic picture of Betty, her community and her needs.
The model chosen to assess Betty’s needs was the Roper Logan Tierney (RLT) model (1983) and the actual and potential problems based on the 12 activities of living were highlighted. This model was chosen as Walsh (1998) suggests it is trying to promote maximum independence and meet Betty’s needs. Haggart (1994) suggests the Neuman’s systems model seeks to involve patients in their health care and focuses on prevention. This is congruent with the needs of community nursing. The Orem (1991) model is also valuable for patients with minimal deficits.
- Other Tools
The Waterlow (1985) pressure sore risk assessment was carried out and Betty had a score of 13 (Appendix 8), which identifies she is at risk. A pressure relieving mattress provided by the Red Cross has been used since 2002 and it was decided that because Betty is independently mobile there was no need for other aids.
A moving and handling assessment derived by Pilling (1993) was undertaken and a score of 5 was obtained for Betty (Appendix 9) due to her body weight being above 8 stones. Betty is fully mobile and therefore no equipment was needed. Pilling and Frank (1994) report that this is a tool and should not be substituted for professional judgement or knowledge of correct handling techniques.
Betty’s Body Mass Index (BMI) was calculated and she scored 29, which classifies her as being overweight (Appendix 10). The lifespan of an obese person is 9 years less than someone of lower weight (Netdoctor,2004). Obesity causes raised blood pressure and raised cholesterol levels which lead to CHD and stroke. It also fosters inactivity and generally involves an unhealthy diet which together contribute to cancer, diabetes, gall bladder disease, arthritis and musculoskeletal problems. (National Audit Office, 2001).
A in depth wound assessment was carried out (Appendix 11) to promote healing of the wounds and prevent infection. Because Betty has a chronic illness such as diabetes and is overweight these factors contribute to the delay in healing. Her blood sugar level was recorded (Appendix 12) and she had a reading of 7.00mmol on the day of the assessment, which indicates she is in the ideal range (4 - 7mmol) (Netdoctor, 2004). King (2001) suggests people with diabetes experience more wound healing problems however Rosenberg (1990) reported that there is little research conducted in the delay of the wound healing process. A recent study by Brown et al (2004) indicates that majority of people who are obese have some form of skin problems. In Betty’s case dryness, broken skin, red patches and itchiness were identified.
Betty’s pain was assessed using the Numerical Rating Scale (NRS) (Appendix 13) and she reported her pain as being 0 out of 10. Downie et al (1978) described the NRS as either a horizontal or vertical line with ‘0’ indicating no pain and ‘10’ indicating severe pain. The main advantages of using the NRS are its simplicity of administration and scoring and use (Flaherty, 1996).
- Discussion of Role Of Carers
Betty has a number of people that are involved in her care. Her best friend who is a teacher visits Betty every morning at 8am and ensures that she is awake. Betty has a paper delivered every day by the paperboy that she has known for a long period of time. The district nurse visits Betty every morning for half an hour and she has built a relationship with her as they have been seeing Betty for 2 years. Betty has a monthly visit from the pharmacist who delivers appropriate medications and wound dressing materials.
She sees her GP regularly as they live in the same village and has also built a relationship with them who are involved in Betty’s care. A hairdresser visits her on a monthly basis for a trim and perm and a laundry man for her washing. Betty’s family are her main carers. Her daughters visit her regularly and her grandson lives in Evington and takes Betty shopping on a weekly basis. Twigg (1994) suggests that the largest provider of care services in the community is the army of family, friends and neighbours who are reported to number over six million people.
- Policies
The Cumberlidge report (1986) recognised the importance of all nurses in primary care and health needs assessment, including DNs. It identified the aims of community health care and classified health needs as elderly, disabled, chronically sick and terminally ill and preventive care. This report was a nursing contribution to the Tory National Health Service (NHS) and Community Care Act (CCA) (1990). The publication of the NHS and CCA (1990) led the way for a much clearer understanding of how the then government wanted services to be structured and delivered. This act introduced a number of fundamental changes in the organisation and delivery of care, with the internal market and contract culture being key features.
The New NHS Modern and Dependable (1997) was a Green paper formed by the new Labour government. This proposed the abolishing of GP fund holding and the set up of national pilot trials of Primary Care Groups (PCG). They suggest a greater patient participation and public involvement. The Health Act (1999) was the new Labour statute to replace the NHS and CCA (1990) and consolidate the Green Paper (1997). GP fund holding was abolished and PCG’s became Primary Care Trusts (PCT). The PCT’s were the local unit of management, participation and emphasis that were introduced in April 2000.
The NHS plan (2000) was a modernisation strategy where 19 billion pounds has been invested for a ten-year plan 2000-2010. It introduced the National Service Frameworks (NSF), which set national standards and identify key interventions for a defined service or care group, put in place strategies to support implementation and establish ways to ensure progress within an agreed time scale. The plan was developed to shift the balance of power from ‘top down’ to ‘bottom up’ and involve patient participation. Health Action Zones (HAZ) were also introduced to pull together people and the private sectors.
The impact of the policy related directly to patient care is all patients including Betty are entitled to a basic package of care by being a member of a PCT. Betty benefits from an enhanced package of care, as the NSF for older people (2001) and NSF for diabetes (1999) is available. However patients with Multiple Sclerosis on the DN’s caseload in Evington are not benefiting, as a NSF has not yet been produced. Local community facilities such as a library, adult evening classes and voluntary services such as Age Concern are also used by Betty and are highlighted in Appendix 5.
- Conclusion
By conducting a thorough assessment and involving patient participation a satisfactory package of care is available to meet Betty’s health needs. She is fully aware of all the services that are available to her and is capable of making a choice for the ones she is using and others that she did not use at the time of assessment.
From this report it can be identified that assessing the health needs of Betty can be beneficial to her and her community and becoming a member of a PCT entitles her to a free basic package of care with additional NSF for diabetes and a NSF for obesity, which is currently underway.
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