A short history of non-medical prescribing

It had long been recognised that nurses spent a significant amount of time visiting general practitioner (GP) surgeries and/ or waiting to see the doctor in order to get a prescription for their patients. Although this practice produced the desired result of a prescription being written, it was not an efficient use of either the nurses’or the GPs’time. Furthermore, it was an equally inefficient use of their skills, exacerbated by the fact that the nurse had usually themselves assessed and diagnosed the patient and decided on an appropriate treatment plan.

The situation was formally acknowledged in the Cumberlege Report (Department of Health and Social Security 1986), which initiated the call for nurse prescribing and recommended that community nurses should be able to prescribe from a limited list, or formulary. Progress was somewhat measured, but The Crown Report of 1989 (Department of Health (DH) 1989) considered the implications of nurse prescribing and recommended suitably qualified registered nurses (district nurses (DN) or health visitors (HV)) should be authorised to prescribe from a limited list, namely, the nurse prescribers’formulary (NPF). Although a case for nurse prescribing had been established, progress relied on legislative changes to permit nurses to prescribe.

Progress continued to be cautious with the decision made to pilot nurse prescribing in eight demonstration sites in eight NHS regions. In 1999, The Crown Report II (DH 1999) reviewed more widely the prescribing, supply and administration of medicines and, in recognition of the success of the nurse prescribing pilots, recommended that prescribing rights be extended to include other groups of nurses and health professionals. By 2001, DNs and HVs had completed education programmes through which they gained V100 prescribing status, enabling them to prescribe from the NPF. The progress being made in prescribing reflected the reforms highlighted in The NHS Plan (DH 2000), which called for changes in the delivery of healthcare throughout the NHS, with nurses, pharmacists and allied health professionals being among those professionals vital to its success.

The publication of Investment and Reform for NHS Staff –Taking Forward the NHS Plan (DH 2001) stated clearly that working in new ways was essential to the successful delivery of the changes. One of these new ways of working was to give specified health professionals the authority to prescribe, building on the original proposals of The Crown Report (DH 1999). Indeed, The NHS Plan (DH 2000) endorsed this recommendation and envisaged that, by 2004, most nurses should be able to prescribe medicines (either independently or supplementary) or supply medicines under patient group directions (PGDs) (DH 2004). After consultation in 2000, on the potential to extend nurse prescribing, changes were made to the Health and Social Care Act 2001.

The then Health Minister, Lord Philip Hunt, provided detail when he announced that nurse prescribing was to include further groups of nurses. He also detailed that the NPF was to be extended to enable independent nurse prescribers to prescribe all general sales list and pharmacy medicines prescribable by doctors under the NHS. This was together with a list of prescription-only medicines (POMs) for specified medical conditions within the areas of minor illness, minor injury, health promotion and palliative care. In November 2002, proposals were announced by Lord Hunt, concerning ‘supplementary’prescribing (DH 2002).

The proposals were to enable nurses and pharmacists to prescribe for chronic illness management using clinical management plans. The success of these developments prompted further regulation changes, enabling specified allied health professionals to train and qualify as supplementary prescribers (DH 2005). From May 2006, the nurse prescribers’extended formulary was discontinued, and qualified nurse independent prescribers (formerly known as extended formulary nurse prescribers) were able to prescribe any licensed medicine for any medical condition within their competence, including some controlled drugs.

Further legislative changes allowed pharmacists to train as independent prescribers (DH 2006) with optometrists gaining independent prescribing rights in 2007. The momentum of non-medical prescribing continued, with 2009 seeing a scoping project of allied health professional prescribing, recommending the extension of prescribing to other professional groups within the allied health professions and the introduction of independent prescribing for existing allied health professional supplementary prescribing groups, particularly physiotherapists and podiatrists (DH 2009).

In 2013, legislative changes enabled independent prescribing for physiotherapists and podiatrists. As the benefits of non-medical prescribing are demonstrated in the everyday practice of different professional groups, the potential to expand this continues, with consultation currently under way to consider the potential for enabling other disciplines to prescribe.

Migraines could be a headache of the past

Is there hope for the many millions of migraine sufferers in the United Kingdom and around the world? Researchers at King’s College Hospital certainly believe that this is the case. While they are cautious about the findings of their latest research, the results certainly are one that point towards optimism for migraine sufferers.

It is estimated that the number of migraine attacks everyday in the UK number over 190,000. This figure was estimated by the Migraine Trust, and it was probably obtained by taking a sample size of the population, taking into account the number of migraine attacks experienced within that group and then multiplying it by the general population in the United Kingdom. This of course means two things: firstly, the figure was proposed by a group that has an interest in promoting awareness about migraines and is hence slightly biased, probably over-estimated. Secondly, bearing in mind that the UK population is over 66 million, and it is unlikely that the Trust surveyed 1 million people – or even anywhere near that – any differences could have been amplified by over 66 times.

What is the difference between a migraine and a normal headache? A migraine is a headache which happens frequently. Migraines themselves are classed as two types. Headaches which happen more than 15 days a month are known as chronic migraine, while episodic migraine is a term used to describe headaches which happen less than fifteen times a month.

The research uncovered that a chemical in the brain was involved both in the feeling of pain and sensitivity to sound and light. This chemical is known as calcitonin gene-related peptide, or CGRP. If CGRP is neutralised, or if part of a brain cell which it interacts with is blocked, then pain receptors are dulled and migraines are reduced.

There are currently four drug companies in the race to develop a CGRP neutraliser.

Race is an accurate term, for the company that develops and trials the drug successfully may win the patent for developing and marketing the drug over twenty years. Drug companies or pharmaceuticals are normally granted that period to reward them for the time and cost invested into research.

One such company, Novartis, trialled an antibody, erenumab on episodic migraine sufferers. Those who took part in the trial suffered migraines on an average of eight days a month.

955 patients took part in the trial and half of those who received injections of erenumab successfully halved their number of migraine days per month. 27% of patients also reduced their number of migraine days without treatment. The results suggest that the drug was successful, particularly as it worked for over 450 people, and that if it were used for those with chronic migraine it might be equally successful. Even if the same percentage were maintained (50% vs 27%), the number of working days saved by migraine prevention could have significant savings for the economy.
Another pharmaceuticals company, Teva, produced another antibody, fremanezumab, and trialed it on 1130 patients. Unlike Novartis’s trials, the participants in Teva’s were those with chronic migraine, with over 15 or more attacks each month. In the Teva trial, 41% of patients reportedly halved the number of days that they suffered migraine attacks. 18% reported the same effect, so the confidence interval in the trial is pretty high and suggests a high degree of positive use.

The study is very important and useful because of the understanding it offers in treating migraine, and the medical products can reduce the frequency and severity of headaches. It makes for fewer days lost to the disease and more positive, functioning people.

Besides CGRP antibodies, there are other current treatments for migraine such as epilepsy and heart disease pills. Even botox is sometimes used. However, all three come with side-effects and are not necessarily the best for everyone.

The hope is that CGRP antibodies, which are traditionally more expensive to manufacture, will in the long term be available at a more affordable cost, and would benefit those who currently get no benefit from existing therapies.

If the estimation that one in seven people live with regular migraine is accurate, migraine reduction could have significant life-improvement effects for humans. Chronic migraine is in the top seven disabling conditions and improvements in understanding it and how to manage it would not only improve the quality of life for those who suffer with it, but also in reducing the number of work days lost for the economy. But the benefits do not just remain with migraine sufferers. Having to live with chronic disabling conditions often leads to other symptoms such as depression. Who knows? Perhaps CGRP antibodies may even negate the effect of depression, resulting in a secondary effect. It may be possible that those who suffer from migraine alongside depression may even not require treatment for the latter if the CGRP antibodies prove to be effective.
Can you imagine a world without anti-depressants? At the moment millions live on some pain-relief medication of some sort. It would be great if they could be phased out. Although it might not be so great for the economy!

Should we be excited about the results? Well, yes. The combined large sample size of both studies, of over 2000 migraine sufferers showed that there was some weight behind the study compared to if – for example – it had been done only on one hundred participants. Secondly, while the research was undertaken by pharmaceutical companies, the outcome was actionable, meaning that it produced a result that was useful, rather than one that merely formed the prelude to a more extensive study. In previous posts I demonstrated how some – such as the coffee umbrella review – did not produce any significantly useful outcome. But we know from this particular research that it may work to neutralise either CGRP, or lessen its interaction with the particular brain cells in order to lower the effect of migraine.

Did the media have a field day with this? Unsurprisingly, no. You see, good research does not lend itself to sensationalist headlines.

Is there any truth about the benefits of Classical music?

Is there any truth to the commonly accepted notion that listening to classical music improves mental capacity? Somehow it has been accepted in modern society that classical musicians have larger frontal cortices, better mental reasoning powers and perhaps intelligence quotients. Over the last two decades or so this idea has fuelled a rise in the number of pregnant mothers listening to classical music – whether or not they like it – and parents enrolling their children into music classes. The music of Mozart, in particular, has enjoyed a resurgence as its classical form is deemed to be more logical and organised, compared to music of other periods, assisting in triggering patterns of organisation in the brain amongst its listeners.

How did this idea about Classical music come about? In the 1990s scientists conducted a series of experiments where one group of students were played one of Mozart’s piano sonatas before a spatial reasoning test, while another group sat in silence. The group that was played the music beforehand performed better on that task than the control group. The effect on the control group was temporary and only lasted fifteen minutes, meaning that after the fifteen minute mark the disparities between the results were minimal and statistically the same. The results of the group found also that while music primed the individual particularly for mathematical tasks, after an hour of listening to Classical music, the effect on the brain was lost.

That piece of research was pounced on by the media and other individuals and seemingly perpetuated to promote the listening of Classical music. One governor of the state of Georgia even decreed that newborn babies be given a copy of a CD of Mozart’s works upon leaving the hospital. The Mozart Effect, to give it its common name, was written about in newspapers and magazines, and this began the spur of Mozart-related sales of music as well as the trend of mothers playing such music to their children in and out of the womb.

The most important question we need to ask is whether there is any truth in such research, and whether it can be corroborated.

We know that some forms of music has a soothing, calming effect on individuals. Playing the music to the students may have calmed that so they were not nervous, allowing them to perform better on the task. However, relaxation need not take them the form of Classical music. Any activity that promotes calm before a task – reading a light magazine, playing computer games, talking with a friend – can also hence be said to have the same effect as the classical music that was played.

What if the students in the group had read a joke book or comic beforehand, been less worried about the test and scored better? It might have prompted a deluge of articles claiming “Reading Archie (or The Beano – insert your own title here) improves your IQ”.

Or if the students had been offered a protein drink beforehand, it would not be inconceivable that someone would latch to that piece of research and declare that “Protein Drinks not just good for your body, but for your brain too”.

Mozart’s music has been said to embody the elements of classical music as we know it. Organised formal structures, chords and harmonies through related keys, use of contrasting tunes, contrasts in volume all feature in his music. But the music of other composers have such features too. Imagine if the composer Josef Haydn had been the lucky beneficiary of the experiment and his music had been played instead. The sales of his music catalogue would have hit the roof!

Subsequent scientists all found that listening to music of any form caused improvements, and the genre of music – whether rock or Classical – was irrelevant. But studies today still quote Mozart.

Is it ethical that the media promotes unsubstantiated research by reporting without closer scrutiny? As we have seen in previous blogs posts, the media reports on things without necessarily scrutinising the evidence, and entrusts so-called experts to corroborate the evidence, while it fills column inches and air time with modal auxiliary verbs? Huh? In simple terms, it means that if there is a sniff of a link between A and B, the media reports that “A could cause B”. Never mind whether it does or not, there is always the disclaimer of the word “could”.

In this instance, students performed better on a spatial reasoning task after listening to Mozart; hence the headline “Mozart could improve mental powers”. Diluted over several recounts, you could get “According to XXX newspaper, Mozart improves brain power” before arriving at “Mozart improves brain power”. Unfortunately, this is when the headline is then pounced on by anyone who would stand to profit from espousing this theme.

Who would profit from this? The Classical music world – performers, writers, musicians – can use this “research” to entice people into taking up lessons and buying CDs and magazines. If you read any music teacher’s website you may find them espousing the benefits of learning music; it is rare if you find one that advises it is a lot of effort.

The media will profit from such “research” because it means there is an untapped well of news to report and bleed dry in the quest for filling column inches and air time. News exclusives will be brought out, and so-called experts will also profit for appearing on the news and programmes, either monetarily or in the form of public exposure.

One must question the ethics of incorrect reporting. Unfortunately unsubstantiated research leads to more diluted misreporting, which can then form the basis of new research – research that uses these claims as the groundwork for investigation.

It is scary to think that all the medical research that has been done into effect of music and health could be biased because of the so-called effect of classical music. Could musical activities such as learning the piano help reduce Parkinson’s disease? Could listening to the music of Beethoven reduce the incidence of higher cases of Alzheimer’s disease? Could it all be wrong – have we all been sent down the wrong tunnel by an avalance of hype reporting?

It may be fair to say the human impulse is to buy first and consider later, because we are prone to regret. If we have missed an opportunity to improve the lives and abilities of our children, then we will be kicking ourselves silly forever with guilt.

So if you are still not convinced either way about whether classical music – either in the listening or the practice – really does have any effect, you could at least mitigate your guilt by exposing your child to piano music, for example that has predictable patterns in the left hand. Sometimes, listening to structurally-organised music such as from the Baroque may be useful, but it is also good to listen to Romantic music because the greater range of expression arguably develops a child that has more emotionally subtlety and intelligence.

You may find that ultimately, any truth in the research about Classical music and its mental benefits is not due to the blind passive listening, sitting there while the music goes on around your children. It is in the child’s inner drive to mentally organise the sounds that are heard, the trying and attempts to organise background sounds that really triggers the mental activity in the brain. It is more the practised ability in the inner mind to organise musical sounds that causes better performance in related mental tasks.

Physical and Mental Contamination

Is there a need to start worrying about your kitchen? I don’t mean in the home improvement context, never mind that the island unit is looking a bit worse for wear, and that your swanky appliances need upgrading so you can have two ovens to cook for your little army; or maybe you are thinking you could expand beyond the microwave and gas cooker. Or perhaps you are considering the option of creating an open plan kitchen. Whatever the physical changes you are considering, they are beyond the scope of discussion. Danger lurks in your kitchen.

It doesn’t come in the form of masked strangers brandishing kitchen implements. Or ruthless critics in the form of master chefs or children. No, the hidden danger in your kitchen is more subtle, more soft, yet potentially more lethal.

The kitchen sponge.

Scientists estimate that the kitchen sponge contains the highest concentration of bacteria than anywhere in the house. On the face of things, this is not an unrealistic statement. The kitchen sponge is in contact with remnants of food as it passes over the crockery and cutlery, and while the latter are clean, microscopic elements of food have merely been transferred to the sponge. And even if you take the effort to rinse out the sponge, or go a step further by microwaving the sponge, trace elements of food bacteria will remain.

According to the Mail Online, one of the more sensationalist newspapers in the United Kingdom, there are 54 billion cells of bacteria residing on the humble sponge. But of course the Mail Online would say that – it is taking a simple fact and blowing it out of proportion in order to create a purchasing headline. (And what is a purchasing headline? It is one that intrigues you enough to make a financial physical purchase to discover more, or hook you in enough to commit your time to reading more, never mind that the headline was slightly manipulated in the first place.) The fact is, bacteria exist all around us. They are on the surfaces of things around us. But it is important to distinguish between good and bad bacteria. The majority of bacteria around us are harmless. The remaining bacteria can do us harm if they enter our bodies, which is why it is a good idea to wash hands before eating. This ensures the harmful bacteria on our hands, either from touching door knobs or taps or other contaminated surfaces, does not rest on food that we ingest. It is also a good idea to cover up exposed cuts so that bacteria does not enter the bloodstream.

Bacteria is all around us but we can’t live life in fear of it.

Can you imagine if the word bacteria was substituted with the word humans? It would give a better perspective.

The headline would read that something like “A higher concentration of criminals found in [name of city]”. But you can’t live like every human in that city will do you harm. You can only take necessary steps to avoid being negatively affected.

Just like bacteria.

The current guidelines around hand washing recommend that we  our hands with water and soap for at least 20 seconds, after instances such as using the toilet, handling raw food like meat and vegetables. It is advised that we wash our hands before eating or after contact with animals.

Does washing with specialist soaps make any difference? A study by Rutgers University and GOJO Industries in the US found that there was little difference, which suggests the science between Brand X and Brand Y is as manufactured as the products themselves.

The study involved twenty volunteers and examined variables of hand washing such as brand, volume and time elapsed. A non-harmful strain of the bacteria e-coli was placed on the hands of the volunteers and then examined after washing to see how much remained.

The study found that there was little to distinguish between normal soaps and anti-microbial formulations. In fact, as long as volunteers washed their hands with soap for thirty seconds, the difference in results after washing were negligible.

There were a couple of minor limitations to the study conducted by Rutgers and GOJO Industries.

Firstly, that sample size is too small. Secondly, volunteers could not ethically be asked to handle deadly bacteria so the results may have only be applicable to that particular strain of bacteria.

There was a major stumbling block to the research however. GOJO Industries manufactures hand soaps.

We have already examined in the past how it is not a good idea if pharmaceutical companies run their own tests because the authenticity cannot be guaranteed completely if there is a bias from the outset. If a pharmaceutical company or any other manufacturing company is going to invest time, money and effort into production, it is going to choose results which have a positive bias, rather than those with a negative one which either force further research, impacting on production time and costs, or one that cause the complete abandonment of results.

Is there anything we can trust anymore? The dilemmas we have are that the media distorts reporting, and research is funded with an agenda which produces an expected outcome. It is difficult to secure funding for research if there is no meaningful purpose behind it beyond sales.

Returning to the original issue of bacteria, as long as we take necessary precautions, that is the best we can do. These precautions include replacing the sponge regularly, and not leaving unwashed dishes in the kitchen, and washing our hands to avoid contamination.

And take in what you read and hear about health and news with a pinch of objectivity. Avoid contaminating your mind too!

Set aside time and space for your own mental health

Work places huge demands on modern living. It goes without saying that over generations work demands have increased. For example, generations ago the concept of a traditional job for most people was a five-day working working week. The song “9 to 5” by Dolly Parton more or less captured the essence of work at the time. (Unfortunately, it is still fairly often played, to the point that people in non-Western societies assume we still only work eight hour days, five times a week, and spend our free time sunning ourselves on the beach.) Nowadays people have to work longer hours, and travel further for work. The total time spent each day traveling and working each day could easily amount to twelve hours, and it is not like the commute is down time – we still have to catch up on emails, admin, and type away busily on the laptop. We could easily spend sixty hours doing work-related things.

And the weekends? Forget the weekends. These days there is no distinction between a weekday and a weekend. Work has steadily grown its talons and where an hourly-rated individual used to get 1.5 or two times the normal rate for working on a weekend, these days it is the same. Employers realise that in an economy with job shortages, they can get away with offering less rates but will not be short of takers.

The problem with all this is that we don’t really have much of a choice when it comes to establishing our work boundaries or exercise or rights when we realise we are being pushed beyond our work boundaries. We’re made to feel that in these times, we are lucky to hold down a job, and if we complain about the increasing demands of it, and how higher managers try to force more work on us without increasing our pay, we might get told to take a hike and end up in a more difficult situation of having no job, commitments to uphold and having to start out again. There are lots of people trapped in jobs where they have to take on more and more as the years go by, and have every ounce of work and free hour extracted from them for little pay. This places increasing mental demands on the individual not just in having to cope with work demands, but the possibility of being made redundant if he or she shows weakness by having to admit an inability to cope any more. It is a no win situation.

Is it a surprising statistic that mental health illness is on the rise? Hardly.

Nowadays people are working more to live and living to work more.

What can you do to preserve some semblance of mental health?

The first thing you can do for yourself is to establish boundaries within the home. Establish a space where work does not intrude. A good idea is often the bedroom, or even have a rule that you will not work on the bed. If you end up working on your laptop in the bed, it will not do you any good – keep at least a certain physical space for yourself.

Also try to set aside a time each day for yourself if possible. It is possibly unrealistic to say an hour each day in the modern life climate, but something like twenty minutes to half an hour would be a good idea. Use this time to wind down in your personal space doing something you enjoy, that is different from work. You may think you cannot really afford that time, but it is important to disassociate yourself from work for the sake of your long-term longevity. Think of it as enforced rest. If it works better for you, take your enforced in the middle part of the working day. You don’t necessarily have to be doing something, use it to rest or catch a power nap.

Every now again, such as on a weekend, do something different from work. Do a yoga class, learn an instrument like the piano, or play a game of tennis. The possibilities for leisure are endless. But don’t bring your work approach to your leisure. Don’t start charting your tennis serve percentage, or do anything that makes your leisure activity appear like work in a different form. The only thing you must do with a businesslike approach is to meet this leisure appointment so that your life does not revolve around a continuous stretch of work.

We can moan about it but the nature of work will never revert back to how it was in the past. Those of us who long for the good old days will only make our own lives miserable with wishful thinking. Those of us who insist on working five-day weeks will find it is insufficient to maintain modern living in the twenty-first century. We will all end up working longer and harder in the current economic climate, and even if times improve, employers will be unlikely to go back to pre-existing forms of remuneration if workers have already been accustomed and conditioned to work at a certain level, because it is more cost effective to hire fewer employees who do more work than have the same work done by more employees. Employees have to recognise that adapting to increasing work loads are a working life skill, and that taking steps to negate increasing pressures will also be an essential part to maintaining our own mental health and well-being.