Pile them High and Sell them Cheap: Cardboard cut outs and Medical Extensivist’s

A bit of a late start today. Last night I was celebrating Burns Night with some friends from Scotland who know how do so in style. In England, and post Francis, Berwick and Keogh, the demand for more nurses is growing. From my point of view, as an educationalist, it’s difficult in some areas of the UK to see where extra students might be found. Now I don’t do predications but I have a feeling health care educators are soon going to be designing programmes to support the two new additions to the health care workforce announced this week. Up here in sunny Salford (Manchester), the supermarket giant Morrison’s (there are other supermarkets available for your weekly shop) recently ran an initiative that used life size cardboard cut outs of Doctors and Nurses in their stores to encourage customers to shop for healthier foods.

In the study commissioned by the National Obesity Forum, life size images of real doctors and nurses who worked in the local area were placed in the store alongside ‘Lets Shop Healthier’ messages. The trial appeared to be a success. Over the 15 weeks of the trial, customers bought 20% more fresh fruit, 5% more canned fruit and 10% smoked fish. It’s suggested that if the scheme was extended to supermarkets nationally, it could improve the health of the two thirds of the population who currently don’t eat their five daily portions of fruit and veg.

I think this is an idea that could definitely catch on with Universities and educational commissioners alike. We recruit 660 pre-registration nurse students a year in to our School. They all need uniforms, email addresses, Disclosure and Barring Service checks, we need to find them placements, train their practice mentors, invest in expensive simulation laboratories and deal with national student survey results, and rigorous programme approval processes. The UK Government has to find £8.350 a year to pay for each student nurse, so large savings are possible by replacing actual students with cardboard cut outs.

Likewise, it’s estimated that it costs £500.000 to educate and train a doctor. The Government could also make a huge saving by reducing the number of actual medical students by 10% a year, replacing them with cardboard cut outs of the most successful doctors to be found. The idea would work for NHS Trusts struggling to find enough doctors and nurses to staff wards. Why go to the expense of recruiting doctors from Greece and nurses from Spain, when a quick 30 minutes on eBay could secure you half a dozen of each profession for a fraction of the cost.

There is another alternative, which is the so called Medical Extensivist. An import from the US, that’s sure to be a hit with those responsible for community and primary care services. A Medical Extensivist is a clinician, such as an Advanced Practitioner who extends their scope of practice outside the hospital and into the home or other community settings. They tend to work with people with chronic illness and help reduce admissions to hospital. In the US the employment of Medical Extensivists is also aimed at reducing attendances at Emergency Care services by providing routine and regular skilled nursing home visits. Given the current difficulties nationally of educating, training, recruiting and retaining Community and Practice Nurses, this might be just the answer.

If we were able to successfully bring together the Morrison’s Cardboard cut outs model with the US Medical Extensivists model, it seems to me we could have the beginnings of a new form of innovative integrated care being made possible. Let me know what you think. 

The Internal v External Debate: Raising a Glass to Julian Rotter

Possibly because I was unwell at the time but I missed the news that Julian Rotter had died on the 6th of January this year. His work in both defining and developing social learning theory transformed behavioural approaches to personality and clinical psychology. He first published his ideas in his book Social Learning and Clinical Psychology in 1954, a year before I was born. However, he was perhaps best known for his construct of the idea of a Locus of Control of Reinforcement.

The locus of control refers to an individual’s perception about the underlying main causes of events in their life. Rotter’s view was that an individual’s behaviour is largely guided by ‘reinforcements’ (rewards and punishments) and through the experience of feeling rewarded or punished, individuals develop beliefs about what caused these actions. In turn, these beliefs shape what kinds of attitudes and behaviours people adopt over how much power individuals believe they have over events in their lives. The locus of control construct is a belief about whether the outcomes of an individual’s actions is contingent on what we do (internal locus of control) or on events outside an individual’s personal control (external locus of control).

Generally, an internal locus of control is thought to promote better mental health and well-being. Men tend to be more internal than women, the older people become the more internal they become, and individuals holding senior positions in organisations tend to be more internal in orientation. However, those individuals with an internal locus of control need also to be competent and have a well-developed sense of self-efficacy in order to be able to successfully experience a sense of personal control and responsibility. Those individuals, who lack competence efficacy and perhaps opportunity, can become anxious and or depressed. 

Interestingly, the Level of Care Utilization System, another LOCUS, is in the US at least, a widely used tool for determining the appropriate level of service intervention for individuals with a mental health problem. It is an approach that was developed by the American Association of Community Psychiatrists for psychiatric and additions services. Of course thinking about how the 'internal' can help with the external has a long history.

A glass of gin was once ‘prescribed’ to ward off the plague, a glass of wine to’ defend the body from corruption’ and a sip of absinthe to cure the body of round worms (Ok, the last example is the internal curing the internal). When I trained as a nurse, patients were still being prescribed a bottle of stout a day, and there would always be a bottle of brandy in the medicine cabinet. These days our understanding of the harm alcohol has on both the individual and society as whole has meant that it has been removed from prescription pads.

Over the years the Royal Colleges (of Psychiatrists and Physicians) have been free with their advice as to how much we should all drink and in so doing how we might avoid the harm caused by alcohol. I am not sure what Julian Rotter would have said about such advice, although there is a Drinking Locus of Control Scale developed by Keyson and Janda back in 1972. Me, well I have a bottle of sparkling Shiraz cooling in the fridge ready to sip at dinner, and I will raise a glass to Julian! 

Dr, I've a problem, erm, you know ‘down there’…

I was poorly last Monday and I spent almost the entire day in bed nursing an extreme cough/cold/flu episode. Over the Christmas and New Year break I had one cold or cough after another, and the last one, just before returning to work, knocked me off my feet completely. So unusually for me, I did the sensible thing and stayed off work for the day.  

Actually, it’s fairly unusual for men in general to do the sensible thing when it comes too their health. Susan Hale and colleagues publishing in the British Journal of Health Psychology, report that unlike women, men are less likely to consult their GP with health problems, make less use of general health checks and screening than women and often seek help for symptoms late in an illness episode, sometimes with fatal consequences. 

Interestingly whilst women still have a higher life expectancy than men, they are more likely to have an illness for which they received medical treatment than men. This doesn't mean that women are not as healthy as men – there is no evidence to suggest this is the case. However, for all kinds of reasons women tend to recognise symptoms much earlier than men and then act more quickly in seeking help in dealing with these and the illness that might have generated the symptoms. Men either don’t recognise changes in bodily sensations as being symptoms or ignore the symptoms until such time as they become publicly revealed.

So I was interested to read of the new guidance released last week by the National Institute for Health and Care Excellence (NICE) for prostate cancer Each year, over 37000 men are diagnosed with prostate cancer and a further 10000 will die from the disease. The new treatment protocol recommends a monitoring approach (‘watchful waiting’ as it’s described in the US) for everything apart from high risk localised prostate cancers. Now don’t get me wrong, I am the first to advocate reducing medical intervention. I'm with Illich in that regard. But is this advice going to work? I doubt it.

There is nothing pleasant whatsoever about the treatment or diagnosis of prostate cancer. Treatments can often result in urinary incontinence and erectile dysfunction. Diagnosis involves a digital rectal examination (DRE) a biopsy and a blood test (PSA). In a study published in Oct 2013, 60% of men over the age of 50 hadn't heard of a PSA test. Although the number of female GPs is growing, it’s still the case that 57% of GPs are men. And as Susan Hale noted there are issues for many men of another man performing a DRE on them. Biopsy’s are painful and can lead to long term complications, and the jury is out on the benefits of PSA.

Indeed in the latest study (2012) which looked at the two major international studies (the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial, and the European Randomised Study of Screening for Prostate Cancer) concluded that for every 1000 men aged 55-69 who are screened every 1-4 years for a decade: 0-1 deaths from prostate cancer would be avoided; 100-120 men would have a false positive test result that leads to a biopsy, and about one third of the men who get a biopsy would experience problems from the biopsy; 110 men would be diagnosed with prostate cancer. 50 of these men would have a complication from treatment including erectile dysfunction (29 men) urinary incontinence (18 men), serious cardiovascular event (2 men) deep vein thrombosis or pulmonary embolism (1 man), and death due to treatment (1 man).

I can’t see the NICE advice appealing to many men – however there is an alternative. An MRI scan can establish with 95% accuracy when a man has got prostate cancer. Scans are cheap to do (£200) compared to a biopsy (£600). Extensive research has found no evidence that the magnetic fields and radio waves use during MRI scan pose a risk to the human body. As a diagnostic procedure it’s no more unpleasant or painful than spending a day in bed with an extreme cold/cough/flu.episode. 

A sense of Déjá vu in this first blog posting of 2014

A Happy New Year to you all. I hope to be able to keep writing a blog every week, and hope you will continue to support me and read each weeks musing. I don’t usually have any problems about what to write, but as I was thinking about this week’s blog, I had a strong sense of having had similar thoughts before. And although it was good to see Fergus was back with his mates last week, spending the winter months in the woods and fields around Rockcliffe, there was something more to this feeling.

Partly this sense of déjá vu was prompted by the weather. In last week’s blog I mentioned about the folks in the South who had suffered power outages and flooding. Well on Friday we had our own flooding here. The high tide was 9 meters, higher than it had ever been in 2013. As the rain fell, and the wind blew, the sea broke through the wall between us and the estuary, and rushed upwards towards the house flooding the fields next door. 

Thankfully we were fine, unlike our friends at the Anchor Hotel. There the sea came right over the wall and straight into their front bar. By yesterday they were back in business operating from the bar with the real log fire at the rear of the pub. 

Also yesterday, I read with interest the Government’s announcement that they were to spend £25 million on placing more mental health nurses in police stations and courts. It’s hoped that the scheme will be fully rolled out to all of England by 2017. I think this approach to ensuring good mental health care is long overdue proper investment. Similar schemes have been operating previously, but have often been limited in scope and reach by a lack of funding. Indeed was part of a Diversion (out of the criminal justice system) when I worked for a mental health trust and sat as a Magistrate in Bolton – and that was nearly 20 years ago.

The Department of Health reports that many people in prison have a mental health problem, a substance misuse problem or a learning disability. One in four lives with a mental health illness such as depression or psychosis. It has been estimated that police officers spend 15%-25% of their time dealing with suspects with mental health problems often with very unsatisfactory outcomes for all those involved.

Whilst having more mental health nurses working in liaison and diversion services will hopefully improve these outcomes it will also help support the polices public protection work. Which is somewhat ironic given that police put on extra patrols at many of the Emergency Departments in hospitals around Greater Manchester over the Christmas and New Year period. In the Trust I am currently involved in there had been 200 assaults reported by staff over the past 24 months. There is both a need for a police and a mental health nursing presence in many A+E departments, which sounds like a scheme waiting to be announced.

And announcements there were aplenty of those who received a New Years Honours. It was great to see David Dalton, Chief Executive Salford Royal NHS Foundation Trust receive a knighthood. Many congratulations to him and all those who received recognition for their contributions to creating a better society.