Dr Mike Kirby describes how his practice set up a well man clinic that focuses on improving the health of men in middle age
Men's life expectancy is, on average, 5 years less than that of women. The average life expectancy in the UK is currently 74.5 years for men and 79.7 years for women. This difference has been termed 'the gender gap'.
For many years this phenomenon has been attributed to some intrinsic difference in overall disease susceptibility between the sexes. Of late, however, it has become apparent that some of the difference in life expectancy between the sexes reflects the fact that men look after themselves much less well than do women.1 For example, 40% of men will only go to see their GP if told to do so by their partner.
Men's greater susceptibility to heart disease has generally been ascribed to lack of the protective effect of oestrogen. However, most of the preventable risk factors for myocardial infarction or stroke, such as smoking, central obesity and hypertension, are considerably more common in men than in women.
Men in the UK visit their doctor four times less often than women on average, and as a result are less likely to have hypertension, diabetes or hyperlipidaemia diagnosed and treated.
Running a well man clinic in primary care is just one of a number of ways of tackling these problems. In 1998 we decided to use the skills that our practice nurses and health visitor had developed in running our well woman clinic to target men's health.
For the first meeting a SWOT analysis (to agree Strengths, Weaknesses, Opportunities and Threats) was undertaken (see Figure 1, below). The practice already had considerable expertise in men's health, having run a pilot screening project for the early detection of prostate cancer in 1992 and published a book on the shared care management of prostate disease in 1994.2
|Figure 1: SWOT analysis in the development of a well man clinic|
Nurses attended courses on prostate disease, erectile dysfunction, hypertension, diabetes and osteoporosis in men.
A literature search was undertaken and relevant and key papers regarding men's health were circulated to all team members to meet their educational needs. Team meetings were held regularly to discuss the results of audit and review progress.
The goals were:
- To provide accurate and thorough current health information to men
- To search systematically for disease where early detection is important
- To monitor and adjust for chronic conditions and monitor borderline abnormalities.
In order to focus on men's health it is important for members of the team to have a shared understanding. This was promoted initially by a brainstorming session at which key areas of men's health were suggested and discussed. This helped to raise awareness of the diseases that affect men.
A team protocol was then constructed and agreed (see Figure 2, below), and an action plan developed (see Figure 3, below). In addition we established an associated website www.healthformen.co.uk
|Figure 2: Sample protocol for a well man clinic|
|Figure 3: Action plan|
1. Agree the partner or colleague for the project
2. Define practice priorities in terms of which services need to be provided and which disease areas are important
3. Arrange literature search and future meeting to present results of this
4. Establish who will do what, where and when
5. Agree timing of clinics and provisional start date
6. Define patient target group, e.g. for men aged 45-60 years
7. Estimate numbers of patients attending the clinic
8. Define length of appointments
9. Clarify how staff can get access to a doctor if questions arise during consultation or prescriptions are needed
10. Inform patients about the clinic:
11. Make arrangements for appointments and recall, systematic or opportunistic; make a decision regarding whether non-attenders will be reappointed
12. Are there any cultural or language implications?
13. Specific approach to men with learning difficulties?
14. Get approval from the Health Promotion Committee
15. Develop an audit trail
The cost of running such a clinic also needs to be taken into consideration (see Figure 4, below). We estimated the cost to be £1800 for nursing time (£36 x 50 weeks), excluding pension and superannuation. Consumables, post and urinary dipsticks add up to another £200 annually. The annual payment for a health promotion programme for a GP with an average list size (1884) is £2615. This is adjusted pro rata for other list sizes.
|Figure 4: Costs of setting up and running a well man clinic|
The costs that need to be taken into consideration include:
A source of income for running such clinics obviously needs consideration and this potentially can be derived from health authority fees, item-of-service fees, sponsorship, commissioning, medical audit advisory group support and patient charges (i.e. private clinic).
The clinic has been supported by a touch-screen information programme on prostate disease and in-house expertise for patients with cardiovascular disease, which includes ambulatory blood pressure monitoring, home blood pressure monitoring, event monitoring and echocardiography.
Men with risk factors for male osteoporosis have been identified and investigated by the use of dual-energy X-ray absorptiometry (DEXA) scanning, and facilities for managing men with erectile dysfunction have been provided.
The practice computer generated a list of 1000 men in the target age group (45-60 years). They were invited by post to attend a regular Tuesday clinic held in the middle of the day by two practice nurses and the health visitor. An open access prostate assessment clinic run by the urology specialist nurse is also available.
The postal invitation resulted in a 60% attendance rate. Non-responders were given a second opportunity to attend at a later date. The clinic is also advertised on the practice nurses' notice board and in the practice leaflet. Men identified opportunistically during the course of normal consultations were also filtered into the clinic.
A clear protocol is necessary for agreed procedures and guidelines. We found that it took the nurses 30 minutes on average to work through the protocol, and each clinic session lasted 3 hours.
The GPs are available during the clinics to provide advice. Patients who have abnormalities detected are invited to make another appointment with their GP for any necessary examinations and investigation after an appropriate time interval.
Audit and re-audit are taken seriously to try to assess the value of the clinic.
During the second year, 270 men attended the clinic compared with 101 during the first year. Some of the headline findings were as follows:
- 39% of the men attending needed further action to be taken.
- 26% were current smokers
- 47% were overweight
- 7 men had osteoporosis diagnosed
- 6 men were found to have Type 2 diabetes
- 24% of men had lower urinary tract symptoms
- 24% had a blood pressure >140/90mmHg
- 15% had evidence of coronary artery disease, and 1 in 13 of the smokers had evidence of vascular disease.
- Of those men who had depression, 29% also had erectile dysfunction.
Clearly, running such a clinic generates a considerable amount of extra work for the practice. This includes repeat blood pressure checking and follow-up of abnormal biochemistry such as blood lipids and glucose.
The prostate touch-screen programme was a useful source of advice and information, and approximately one-fifth of the patients with lower urinary tract symptoms needed to see their GP for further advice.
The first 100 patients attending the clinic were sent a questionnaire. Of these, 50 were completed and returned. Of those who returned the questionnaires:
- 50% said they had reduced their intake of animal fat and were taking more exercise
- 25% said they had reduced or stopped smoking, and a further 25% said that as a consequence of attending the clinic they had seen their GP for advice about a medical condition
- 90% thought the information given to them at the clinic was about right
- 88% said they would recommend the clinic to a friend
- 3% said they would have preferred a full medical.
There are major opportunities for improving the health of men in middle age during a well man check in primary care. Clearly, too, many men with existing medical problems value the chance to spend time with an experienced healthcare professional.
A well man clinic also provides important opportunities for all the medical staff to learn more about men's health and to become more knowledgeable about the diseases that afflict men in middle age. Many of these medical conditions contribute to the gender gap and have a significant impact on the quality of life of those affected.
- Kirby M, Farah R. Men's Health Text Book. Oxford: ISIS Medical Media, 2000.
- Kirby M, Fitzpatrick J. Shared Care for Prostatic Diseases. 2nd edn. Oxford: ISIS Medical Media, 2000.
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