CHAPTER 9: DELIVERY
Current Patterns of Delivery
9.1 The majority of CAM is practised in the private
sector. It is often accessed without referral from a GP, by patients
who have read about treatments or have been told by friends of
a certain practitioner, and who contact that practitioner directly
and pay out of their own pocket. FIM confirmed that this was a
common method of accessing CAM. They told us that "…a
significant amount of complementary therapy is bought privately
by people who can afford to buy it"( Q 109).
9.2 However CAM is also available on the NHS, and
has been since its inception. The Department of Health commissioned
an independent study in 1995 to help develop a picture of CAM
access via general practice[53].
This study reported that 40% of GP partnerships in England provide
access to CAM for NHS patients. But evidence shows that this provision
is very patchy - whether patients have NHS access to CAM is dependent
on the attitude of their particular PCG or Primary Care Trust
(PCT)[54]
(Q 109). FIM told us: "The Foundation's integrated health
awards identified 80 good examples of integration both with primary
and hospital services. It demonstrated that provision is increasingly
becoming available through the NHS but access to such services
is patchy" (P 30).
9.3 The NHS Confederation echoed these sentiments:
They told that they support moves towards integration and that
"This is a process that is already happening and the boundaries
of what is considered "conventional" and "complementary"
are constantly shifting (acupuncture in pain clinics, for example).
Much of its foothold is, however, tenuous"(P 145).
9.4 The reaction of many of our witnesses to the
patchiness of CAM provision on the NHS mirrors that which has
been stimulated in the general public by "post-code prescribing".
FIM told us "…if it is available for some people in
the NHS, it should be available for all people through the NHS"
(Q 111).
Methods of Delivery
9.5 Provision of CAM outside the NHS can be offered
through many different mechanisms, including: access through health
clubs and beauty parlours, over-the-counter self-medication; directly
approaching and paying an independent CAM practitioner; self-referral
to a specialist centre; and obtaining a GP referral to an independent
CAM practitioner or specialist centre, whether paid for directly
or through health insurance.
9.6 Unlike private CAM delivery, all NHS CAM has
to be accessed through a GP or another member of the primary healthcare
team. These methods for NHS referrals are outlined in Box 12.
Currently most NHS CAM is delivered within primary care, although
in some cases CAM is now part of secondary care (see paras 9.15-9.20)
9.7 The Department of Health's evidence to us was
keen to emphasise that CAM practitioners are also welcome to try
to play a role in supporting community health initiatives such
as their Healthy Workplace Initiative, the Healthy Living Centres
and Healthy Schools projects.
Box 12
Methods of Delivery Within the NHS
PATIENT
GENERAL PRACTITIONER (or other member of primary care team)
may provide CAM treatment themselves if trained; or
refer to
(a) A member of an on-site multi-disciplinary team (as in the Marylebone Health Centre)
(b) A specialist CAM centre within an NHS Acute Trust (e.g. London Homeopathic Hospital)
(c) A specialist CAM centre contracted by the District Health Authority (e.g. Centre for Complementary Health Studies in Southampton)
(d) An individual, off-site, CAM practitioner contracted by the Primary Care Group or Primary Care Trust
(e) A secondary care service within the NHS Acute Trust that uses CAM (as in some physiotherapy and orthopaedic clinics)
(f) If patient is terminally ill refer to a palliative care unit which provides CAM
(g) Take advantage of District Health Authority Initiatives that may be piloting CAM projects.
NB: A secondary or tertiary care specialist could also make these referrals.
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Integrated Healthcare
9.8 When designing an integrated healthcare service,
there are some basic questions that need to be considered. We
visited the Marylebone Health Centre, an inner-city NHS GP practice
with a multi-disciplinary team including CAM practitioners (see
Appendix 4). There, Dr David Peters described the six stages of
integrating CAM into general practice and discussed the main questions
to be tackled at each stage. These were:
(i) Practice review - Which needs are being
poorly met?
(ii) Resource assessment - Is CAM relevant? What
is its evidence base? Is integration feasible?
(iii) Designing a service - Asking how will GPs
use the service? What will be its aims? How will complementary
practitioners be integrated into the primary care team?
(iv) Delivering the service - Developing referral
procedures and working on resource monitoring.
(v) Management servicing - Including quality
assurance procedures and evaluating outcomes,
(vi) Modifying the service in response to experience.
(vii) Once modification has taken place the steps
can start all over again so the service is constantly self-monitoring
and improving.
9.9 In terms of step 3 of this model, designing a
service, this is a very important issue for all NHS integrative
healthcare; no matter which delivery model is used it is very
important to decide when GPs should consider a CAM referral. At
the Marylebone Health Centre it was decided that GPs would refer
to a CAM practitioner only for conditions where some evidence
for the efficacy of a particular CAM existed. It was also decided
that referrals would only take place if GPs wanted to refer, and
if complementary practitioners thought they could help.
9.10 The Marylebone Health Centre developed a list
of conditions that they commonly consider for CAM referrals. These
include complex chronic illnesses such as: chronic fatigue syndrome;
stress-related conditions; asthma; irritable bowel syndrome; eczema
and non-specific allergies; back pain and migraine. GPs at the
Centre consider a referral if there is an initial diagnosis of
one of these conditions and if one of the following criteria applies:
(a) conventional medicine has failed; (b) the patient is suffering
side-effects from the conventional treatment; (c) the patient
requests CAM for one of the conditions above; or (d) if the GP
feels it is a complex case where a CAM may help (and having asked
the CAM therapist they, too, feel they may be able to help.)
9.11 The other CAM practice we visited, the Southampton
Centre for the Study of Complementary Medicine (see Appendix 5)
was a very different organisation from the Marylebone Health Centre
as it is an independent-provider organisation contracted by District
Health Authorities to offer CAM services for specified conditions.
However, the conditions for which it receives NHS referrals are
very similar to those treated at the Marylebone Health Centre.
9.12 During our visit to Southampton they told us
about a survey of the Centre which was published in the British
Medical Journal which shows that most patients come with very
long-term problems (average duration 10 years). The staff continuously
audit their practice, and results for 1999 show impressive results
for many patients suffering from chronic conditions, especially
irritable bowel syndrome and myalgic encephalitis (ME),
more often called the chronic fatigue syndrome.
9.13 The Southampton Centre for the Study of Complementary
Medicine operates a contract with Dorset Area Health Authority.
This is a unique arrangement within the NHS for CAM services and
it operates in two parts. The first part is an integrated medicine
unit which the Centre operates for one day each month at a GP
practice in Dorset. GPs in local clinics are able to refer patients
with any of six specific conditions to this clinic. These conditions
are: chronic fatigue syndrome, irritable bowel syndrome, migraine,
child behavioural problems, eczema and non-specific allergy. The
second part of the 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 has proved to
be quite popular with GPs, especially as a way of dealing with
patients who are 'difficult' and whom they have been unable to
help. The second part of the contract has been designed so that
it is very easy to administer: it provides for six appointments
for the specified condition, with the only formalities required
being a letter of referral and a letter of progress to 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 that GPs are always kept up-to-date
about their patients' progress and treatment. This arrangement
has allowed interested GPs to become fully informed about the
methods that the Centre employs.
9.14 Both the Marylebone Health Centre and the Centre
for the Study of Complementary Medicine are examples of integrative
healthcare projects that GPs feel have benefited their patients
and themselves. These provide evidence that there is a place for
CAM in primary care, especially in the treatment of chronic conditions
with which GPs often struggle to help their patients.
Primary and Secondary Care
9.15 One of the questions that we have considered
is whether CAM is more suited to primary or secondary healthcare
delivery. Dr Michael Dixon of the NHS Alliance told us that in
the delivery of CAM "…there is clearly a bias towards
primary care… t is firmly in the primary care agenda already.
I think also psychologically there is an empathy there, that is
to say, first of all, both general practice, primary care and
complementary medicine are holistic from their point of view,
they are taking the whole person not just the constituent bits.
Secondly, they are both very committed to the whole idea of self-care
which secondary care often is not, it is often more the passive
act of modern, traditional medicine. Thirdly, I think this whole
concept of a therapeutic relationship is much stronger in primary
than secondary care. There is a natural empathy in primary care"
(Q 1474).
9.16 However, Professor Ruth Chambers, also from
the NHS Alliance, added: "Without doubt we think it should
also be in secondary care. We think it should be offered along
all care pathways… so that the care pathway for back pain
or whatever would automatically have complementary medicine featuring
in the flow of a patient. It would be self-care: coming to the
GP, going to secondary care and back again involving all the therapies.
We think it should be a cost-effective option for reducing in-patient
costs and that is why secondary care would be interested in learning
more about it and adopting it where it fits" (Q 1474).
9.17 There are existing models of CAM being part
of secondary care delivery, but they are limited to three or four
main areas. First, where the manipulative therapies (osteopathy
and chiropractic) have been integrated into orthopaedic care.
Second, where acupuncture (and occasionally some of the relaxant
therapies in Group 2) have been integrated into pain clinics.
Third, where acupuncture and occasionally aromatherapy have been
integrated into some obstetric and cancer services, and into palliative
care, rehabilitation and care of the elderly. And fourth, where
homeopathy is provided within secondary care through the homeopathic
hospitals (see Appendix 6).
9.18 There are many different means through which
CAM may be available on the NHS; definitive judgements cannot
easily be made about which models are best as so little work has
been done on evaluating this area. FIM told us that "…it
is crucial that where there is successful integration of orthodox
and CAM therapies that these projects are carefully evaluated"
(p 30). This would help produce guidelines for future attempts
at integration on issues such as when to refer, how to communicate
about treatment regimes etc. FIM have recently received a small
grant from the Department of Health to undertake some work in
this area (p 30).
9.19 In conclusion, it seems that there are already
several successful models of integration, although current levels
of provision are patchy. In addition, with the recent introduction
of Primary Care Groups and Trusts primary care delivery patterns
are changing (this will be discussed in the next section). It
is probably not necessary to ask which method of integrated healthcare
is best but instead to ask which method of delivery is most appropriate
in which situation? Work needs to be done to evaluate existing
models of integration so that each new project can learn from
those that came before. The anecdotal experiences brought to our
attention seem to suggest that there is a valuable role for CAM
in primary care, especially when provision concentrates on referrals
for those conditions for which, according to our evidence, CAM
helps most (e.g. chronic complaints, allergies).
9.20 We recommend that those practising privately
accessed CAM therapies should work towards integration between
CAM and conventional medicine, and CAM therapists should encourage
patients with conditions that have not been previously discussed
with a medical practitioner to see their GP. We also urge CAM
practitioners and GPs to keep an open mind about each other's
ability to help their patients, to make patients feel comfortable
about integrating their healthcare provision and to exchange information
about treatment programmes and their perceptions of the healthcare
needs of patients.
53 Thomas et al (1995) National Survey of Access
to Complementary Health via General Practice University of
Sheffield. Back
54
A PCT differs from a PCG in that it is legally responsible for
the delivery of primary care services, unlike a PCG which is a
sub-committee of a Health Authority. Most PCGs expect to develop
into PCTs over the next 5 years. Back
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