Complementary Medicine Research Unit: School of Medicine, University of Southampton.

Professor Arthur, Head of School of Medicine

Professor Arthur, Head of the School of Medicine, welcomed the Committee and explained that the research structure was developed 'from the ground up' from 1990. Their research concentrates on areas of expertise which are: human genetics; infection, inflammation and repair; cancer services; foetal origins of adult disease; and community clinical services. The medical school is the second smallest in the country but was rated in the top ten in the research assessment exercise and scored well in the quality assessment exercise.

Dr George Lewith

Dr George Lewith, doctor, researcher and CAM practitioner, discussed his work as Head of the Complementary Medicine Research Unit where he works for half a day per week. The unit was set up in 1995 and is situated within the infection, inflammation and repair unit of the research division of the medical school. The unit is financed by 'soft money' rather than by the medical school. Its main funding source is a grant from the Laing Foundation (which also funded much of the work the Committee saw at Exeter), which has covered all their administrative costs since May 1995 to May 1998 with a further three years support promised until May 2001. They have also received money for research from the Wellcome Trust and the British Medical Association as well as some money from industry for commercial research.

The aim of the research unit is to evaluate the clinical effects of complementary medicine and investigate the scientific basis for its mechanisms. They believe that 'these innovative techniques should be rigorously assessed and, where appropriate, integrated into mainstream conventional medicine.'

The research that they do falls into five main headings: rheumatology and rehabilitation work, respiratory disease, cancer, fundamental research (including health psychology and research on the effects of attitudes on outcomes), chronic fatigue syndrome and miscellaneous projects.

Dr Lewith highlighted some of the lessons that they had learnt in their work at the unit. Firstly, large, good quality clinical trials can help uncover information that even people working as practitioners had not thought about. Secondly, having a CAM research unit within an undergraduate medical school provides a clear research structure as well as administrative and research support, and working in an NHS environment provides access to patients as well as providing credibility for the unit. Thirdly, designing and carrying out rigorous trials in CAM is more intellectually challenging than orthodox medicine research: it can be done but it is not easy. Dr Lewith's final point was that setting up a research unit and carrying out good quality research in the CAM area takes a long time. They found that it took four to five years of hard work before they had good quality, interesting papers coming through.

Overview of various trials

The next set of presentations was given by some researchers and students who worked within the unit. Dr Lewith said the Unit had made an effort to show a cross section of studies including ones with positive and negative results and ones in progress as well as ones completed. The studies included work into acupuncture for chronic neck pain, work on the relationship between patients' attitudes to CAM and the outcomes of their treatment, the proving of Belladonna in homeopathic dilutions, electrodermal testing for allergies and acupuncture in stroke rehabilitation.

Questions

When asked if the level of funding the unit got from its NHS region was unusual, George Lewith said it was but he believed part of the reason for this is that they submit unusually high-quality proposals and they take account of any criticisms their proposals receive during peer review and re-submit accordingly. He also mentioned that NHS review can be useful even if the NHS region can not afford to fund the project. If the NHS peer review says it is a good quality proposal, the Unit can use that recommendation to get support from charities which are too small to have their own peer review panels but want validation of a proposal before they fund it.

However Professor Arthur noted that Southampton has recently changed NHS regions from the South West to the South East region and since this change they have noticed a drop in medical school funding (not just for CAM proposals) because the South East is a more competitive region.

Education

Dr Chris Stevens gave a brief overview of the medical school curriculum. It is a five year undergraduate course with optional modules (one option being in CAM) available in year three and an in-depth research study unit in year four. In year five students take up placements across the region.

Dr David Owen, a local homeopathic physician and President of the Faculty of Homeopathy, is the course tutor for the CAM module. This covers eight half days and is a familiarisation course, not a training one. It covers questions such as: which therapies can be used for which conditions? and, what is CAM appropriate and inappropriate for? The main therapies the students come into contact with, and consider evidence about, are acupuncture, homeopathy, chiropractic, osteopathy and herbal medicine.

Dr Owen said the course is centred around the question: "If you had a loved one who was suffering from an illness not well treated by orthodox medicine, what would you want their doctor to know about CAM?" The course involves complementary practitioners in the local area and offers medical students an opportunity to experience CAM as practised in the community. The course is in great demand, with numbers limited by places, not by the amount of interest shown by students.

The learning objectives for the course have been developed by the teaching team, with input from medical students studying the module:

• To have examined (constructively and critically) the merits and claims of different complementary medicines.

• To describe the concepts of individualisation and holism, and to give examples of when different CAM treatment approaches are used to treat different patients with the same diagnosis.

• To have examined the students' own attitudes towards complementary medicine and reflect on the variety of attitudes that exist among patients, health care practitioners and providers.

• To be able to assess and advise patients who enquire about or benefit from CAM.

• To have participated in consultations and discussions to identify how patients perceive different treatment approaches and the role patients play in healing themselves.

• To state the basic principles and evidence for complementary medicine. To describe the context in which it is practised in the community and how to obtain more information, including key points on training and regulation.

Dr Owen also outlined some issues that had arisen when deciding how to design the course. These included:

• Which CAM therapies to teach

• Whether to include clinical attachments

• How to develop common objectives with courses at other medical schools

• What methods to use in assessment

• Limitations of the module structure

• Funding

• Post graduate teaching

Other healthcare practitioners training at Southampton (e.g. nurses) can attend the course as can students from the Bournemouth College of Chiropractic who may want to learn about other CAM therapies. This encourages interdisciplinary learning and understanding.

Aside from the CAM module several of the medical students have been involved with the unit through pilot research projects on CAM issues during the research part of their course in the fourth year). The medical school also runs lectures in the second year of the curriculum on acupuncture and pain management.

Dr Owen also mentioned his work outside Southampton. He has done some work on Continuing Professional Development in CAM for doctors; he has found the postgraduate course in homeopathy at the Glasgow Homeopathic Hospital is the most popular postgraduate course for doctors in Scotland.

Centre for the Study of Complementary Medicine

Introduction and Background

After lunch the Committee visited the centre for the Study of Complementary Medicine where they were welcomed by Jacqueline Tuson, Practice Manager. She introduced the other members of staff who included:

• Dr George Lewith - GP, CAM practitioner and joint partner in the centre

• Dr Michael Clerk - GP, CAM practitioner and joint partner.

• Maureen Middleton - Nurse manager

• Val Hopwood - Physiotherapist, CAM practitioner and researcher

• Alan Mills - practitioner

Ms Tuson described the background of the Centre. The Centre was set up in 1982 by Dr Lewith and a Dr Kenyon. The partners are all medically qualified practitioners who previously worked as orthodox GPs and hospital doctors. They also use a range of qualified CAM practitioners alongside the partners to complete the range of therapies they can offer. They have built up their reputation so that they now have 4000 patients on their current database and the doctors see up to 20 patients a day from across the British Isles and Europe. They also have a smaller sister clinic in Upper Harley Street.

The conventional medical background of the doctors and practitioners is an important element to the Centre as it gives the public confidence in their abilities and improves relationships with local GPs, resulting in more referrals. It is also important that all the practitioners are multi-skilled and are not limited to the use of one CAM therapy so that they often use a mixture of therapies in one treatment plan.

They have their own dispensary and qualified nurses who provide advice and support for patients. This is part of the Centres emphasis on a team based approach. They have a nurse advice line for patients with worries as well as a web-site with information on treatments.

The fact that they have the phrase 'for the study of' in their title means they get numerous phone calls from people who do not realise they are a clinical practise. The reason they keep this title is because historically they did a great deal of training and research from the Centre. However they do not currently offer training courses but they keep their title because providing information is part of their mission.

A survey of the Centre which was published in the BMJ shows most patients come with very long term problems (average duration 10 years). Currently patients most frequently present with the following conditions: irritable bowel syndrome, migraine, eczema, non-specific allergy, back pain and chronic fatigue. The staff continuously audit their practice, and results for 1999 show impressive outcomes for a lot of patients suffering from chronic conditions such as IBS and ME.

The Dorset NHS Contract

The Centre for the Study of Complementary Medicine is primarily a private practice but it has a history of providing NHS care too. Until recently this was provided under the fund-holding scheme for local fund-holding practices. Other practices in the area were able to refer patients through the Health Authority, and these patients had to meet stringent criteria. This system led to a difference in availability between those practices which were fund-holding and those which were not. The abolition of fund-holding has meant that patients in the Southampton area can usually obtain referral to the Centre if their GP thinks it would be the best treatment for them.

As well as their relationship with the local PCGs the Centre has a separate NHS agreement with the Dorset Area Health Authority. This is a unique contract within the NHS for CAM services. It operates in two parts. The first is an integrated medicine unit which operates for one day per month at a GP practice in Dorset. GPs in this clinic and in other local clinics are able to refer patients with any of six specific conditions to this clinic. These conditions are: chronic fatigue syndrome, IBS, migraine, child behavioural problems, eczema and non specific allergy. There is a waiting list of around three months for this clinic; at times this has been as long as nine months. Prescriptions are limited to what is available on the NHS unless patients are willing to pay for medicines themselves.

The second contract with the Dorset Area Health Authority allows patients to travel to the Centre in Southampton for their treatment. Last year this resulted in 600 consultations. This system provides for the same six conditions as the first contract although there is some flexibility. This service is quite popular with GPs as they can send patients who are difficult and who they have been unable to help. This is a more comprehensive contract as the range of treatments they can provide at the Centre is greater and the nurses and dispensary can be used. The contract is very easy to administer as it provides for 6 appointments for the specified condition with the only formality being a letter of referral. The contract also requires a letter of progress be sent to the referring GP. The six appointments can be extended if the GP writes to the Health Authority for permission. The Centre makes a conscious effort to make sure GPs are always kept up to date about their patients' progress and treatment. This contract has allowed interested GPs to become fully informed about the Centre's methods and they see this as being of long term benefit to the NHS.

Case Studies

The Committee were then introduced to a patient who had received treatment at the Centre and had the opportunity to ask questions about how they had viewed their treatment and what they felt about their experiences.

Therapeutic Demonstrations

The Committee were given the opportunity to participate in or watch demonstrations of the Alexander Technique and Acupuncture, and to ask questions of the practitioners involved.