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Dr Peter FisherDr Peter Fisher
Integrating Homeopathy into the Integrating Homeopathy into the
National Health Service: National Health Service:
the UK experiencethe UK experience
Expert Advisor on Expert Advisor on
Complementary and Complementary and
Alternative Medicine to Alternative Medicine to
the National Institute the National Institute
for Health and Clinical for Health and Clinical
Excellence (NICE)Excellence (NICE)
University College London
Hospitals
•• One of largest academic medical centres in UKOne of largest academic medical centres in UK
•• Medical school and specialist institutes, linked to Medical school and specialist institutes, linked to
University College LondonUniversity College London
•• 7 hospitals:7 hospitals:
•• University College Hospital (general/acute)University College Hospital (general/acute)•• University College Hospital (general/acute)University College Hospital (general/acute)
•• Eastman Dental HospitalEastman Dental Hospital
•• Elizabeth Garret Anderson Elizabeth Garret Anderson
(gynaecology, obstetrics, children)(gynaecology, obstetrics, children)
•• Heart HospitalHeart Hospital
•• Hospital for Tropical DiseasesHospital for Tropical Diseases
•• National Hospital for Neurology and NeurosurgeryNational Hospital for Neurology and Neurosurgery
•• Royal London Hospital for Integrated MedicineRoyal London Hospital for Integrated Medicine
The Royal London Hospital for Integrated Medicine
What is
Integrated/-ive Medicine?
‘…restoring medicine’s focus on health and healing,emphasising the importance of the doctor-patientrelationship and the use of all appropriate therapeuticapproaches, healthcare professionals and disciplinesto achieve healing and optimal health.to achieve healing and optimal health.
Patients are active participants in their health care andillness is approached by inducing and supporting selfhealing processes before high-impact, high-costbiomedical interventions.’
Integrated/-ive medicine
in USA
• Consortium of Academic Health Centers for Integrative
Medicine
• 46 academic medical centers
• Stanford, Yale, Johns Hopkins, Harvard, Mayo etc • Stanford, Yale, Johns Hopkins, Harvard, Mayo etc
• ‘to help transform medicine and healthcare through
rigorous scientific studies, new models of clinical care, and
innovative educational programs that integrate
biomedicine, the complexity of human beings, the intrinsic
nature of healing and the rich diversity of therapeutic
systems.’
Royal London Hospital for Integrated
Medicine
Why integrate medicine?the dialectics of integration
• pandemic of chronic conditions v
pandemic of iatrogenic illness
• Reduce medication
• fiscal imperatives v
expensive diagnostics & treatmentsexpensive diagnostics & treatments
• Effective economical whole person treatment
• greater duration of life v
greater duration of poor quality later life
• Safe whole person long term treatments
Royal London Hospital for Integrated Medicine
Dialectics of integration 2
• high-tech, high impact, high-cost interventions v
caring, commitment, compassion
• Revive the art of medicine
• concordance v
efficacy
• Patient-friendly treatments
• dependency on drugs and medical services v
disillusionment and medical counterculture
• Restore faith in medicine
Royal London Hospital for Integrated Medicine
History of Royal London Hospital
for Integrated Medicine
• 1849: founded as London Homoeopathic Hospital
• 1947: ‘Royal’
• 1948: joined National Health Service (NHS)
• 2002: joined University College Hospitals (UCLH)• 2002: joined University College Hospitals (UCLH)
• 2005: complete refurbishment
• 2010: Became Royal London Hospital for Integrated
Medicine
• Approx 30,000 patient appointments/year
The Royal London Hospital for Integrated Medicine
Moving from a socialist
model to patient choice
Secondary care
Department of
Health
Primary Care Trusts
Tax revenue
General
Practitioners (GPs)
Patients
= Funding Referral =
Who controls referral?
PCT ?
Or GP/patient ?
Health and Social Care Bill
2011
• Abolish PCTs
• ‘No decision about me without me’
• Patients will have access to information they want to
make choices about their care. make choices about their care.
• Patients will have choice of any provider
• Patients to rate hospitals and clinical departments
• Focus on personalised care
• Strengthen collective voice of patients and public
Patient
feedback:
NHS
Choices
websitewebsite
The Challenges:
• PCT ‘Low priority’ treatments
• evidence of clinical/cost effectiveness limited
• grommets, tonsillectomy… varicocoele, refashioning
scars….scars….
• Complementary medicine of all types
• ‘Referral management’
• Slow, bureaucratic, often refused
Responses: innovation
• 1950’s 1st NHS Complementary Cancer Service
• 1977 1st NHS Acupuncture Service
• 1995 1st NHS Musculoskeletal medicine service
• 2005 1st NHS Group acupuncture service
• 2005 1st UK course on Integrated Medicine for doctors• 2005 1st UK course on Integrated Medicine for doctors
• 2006 1st NHS Integrated antenatal service
• 2007 1st Integrated allergy service
• 2008 1st NHS Herbal clinic
• 2009 1st Integrated weight loss service
• 2010 1st Integrated insomnia service
What problems do GPs face?
Effectiveness Gaps
• A clinical area where available treatments are not fully effective or satisfactory, for any reason.
• Never previously researched
Top 5 EGs % GPs reportingTop 5 EGs % GPs reporting
Musculoskeletal problems 91
Depression 45
Eczema 36
Chronic pain 32
Irritable bowel syndrome 32
Fisher P et al. Effectiveness gaps: A new concept for evaluating health service and research
needs applied to complementary and alternative medicine. J Alt Comp Med, 2004;10:627–632.
The Royal London Hospital for
Integrated Medicine:
clinical services• Acupuncture
• including high volume & training clinics
• mostly western, some TCM
• Allergy
• Children• Children
• Chronic Fatigue Syndrome/ME
• Complementary Cancer
• General medicine
• Including inflammatory and functional bowel
• Podiatry
The Royal London Hospital for Integrated Medicine
RLHIM: clinical services 2
• Weight loss
• Insomnia
• Integrated facial pain
• Integrated antenatal
• Musculoskeletal medicine • Musculoskeletal medicine
• Rheumatology
• Skin
• Stress & mood disorder
• Women's
The Royal London Hospital for Integrated Medicine
The Royal London Hospital for
Integrated Medicine: therapies
• homeopathy
• acupuncture• mostly western, some TCM
• aromatherapy
• autogenic training• autogenic training
• cognitive behaviour therapy
• cranio-sacral therapy
• enzyme potentiated desensitisation
• graded exercise
• nutritional medicine • exclusion, supplements, nutraceuticals
The Royal London Hospital for Integrated Medicine
RLHIM: therapies 2
• lifestyle management
• occupational therapy
• physiotherapy
• phytotherapy• standardised extracts • standardised extracts
• western mixtures
• Chinese an aspiration
• shiatsu
• spinal manipulation
• sublingual immunotherapy
• wet needling
The Royal London Hospital for Integrated Medicine
Dimensions of integration
• System
• Normal NHS system
• Common electronic patient records
• Governance and evaluation
• professionals trained in CM, subject to discipline
• Culture of evaluation
• Guidelines
• eg National Institute for Health and Clinical Excellence (NICE)
guidelines for low back pain recommend acupuncture and
manipulation
The Royal London Hospital for Integrated Medicine
Dimensions of integration:
professionalism
Dimensions of integration:
information and education
• Education and training: integrated and ‘hands-on’
• Specialist advice
• NICE NHS Evidence – complementary and alternative medicinemedicine
• NHS’s official CAM knowledge website
• Complementary and Alternative Medicine Library and Information Service (CAMLIS)
• Physical and online
The Royal London Hospital for Integrated Medicine
Dimensions of integration:
hands-on training
Complementary and Alternative Medicine
Library and Information Service (CAMLIS)
www.cam.nhs.uk
All 48
Pubmed
listed CAM
journals
online
Models of integration
• Fully integrated:
• integrated Chronic Pain Service with neurological and dental
hospitals
• integrated antenatal service with UCLH midwives
• Unique services: Allergy and Chronic Fatigue Syndrome
• UCLH’s only services for under-provided conditions: all
treatments guideline recommended treatments & CM.
The Royal London Hospital for Integrated Medicine
Models of integration 2
• Colocated services: in UCLH’s main centres
• cancer
• children
• Cost effective services for ‘effectiveness gap’ conditions:• Cost effective services for ‘effectiveness gap’ conditions:
• group acupuncture
• OA knee, low back, headache, facial pain
• Informal: Contacts, ad-hoc referrals etc
The Royal London Hospital for Integrated Medicine
High volume acupuncture clinic for
osteoarthrosis of knee
Constraints to Integration
• Coordinated hostile media campaign
• NHS provision
• regulation
• Scepticism
• colleagues, particularly academic and older
The Royal London Hospital for Integrated Medicine
Patient
feedback:
NHS
Choices
websitewebsite
Responding to challenges:clinical pathways & exceptionality
• Based on guidelines or strong evidence
• therefore outside LPP
• Predefined exceptionalities
• to de discussed• to de discussed
• heavy user of services
• adverse effects
• personal preference(?)
NICE Guideline Low Back Pain
May 2009• 1.4 Manual therapy
• 1.4.1 Consider offering a course of manual therapy, including spinal manipulation, maximum of 9 sessions over up to 12 weeks
• 1.5 Other non-pharmacological therapies
• 1.5.1 Do not offer laser therapy
• 1.5.2 Do not offer interferential therapy• 1.5.2 Do not offer interferential therapy
• 1.5.3 Do not offer therapeutic ultrasound
• 1.5.4 Do not offer transcutaneous electrical nerve simulation (TENS)
• 1.5.5 Do not offer lumbar supports
• 1.5.6 Do not offer traction
• 1.6 Invasive procedures
• 1.6.1 Consider offering a course of acupuncture maximum of 10 sessions over up to 12 weeks
• 1.6.2 Do not offer injections of therapeutic substances
http://guidance.nice.org.uk/CG88
Acupuncture High volume group
acupuncture 6-8 sessions
Physical activity Exercise as advised
by physio Pilates Class 6-8 sessions
Patient referred with Low Back Pain Initial assessment by Musculoskeletal physician
Assess red and yellow flags Relevant investigations as required
Oswestry Disability Questionnaire 1
Capacity 40 new patients/month If poor response, major psychological element
Physical and psychological treatment
Lifestyle – bio-psychosocial approach exercise 6-8 sessions
CBT/Medical Hypnosis 6-8 sessions
Management Education, advice on self care
treatment choices and agree with patient
Royal London Hospital for Integrated Medicine
Low Back Pain Care Pathway
GP
review/discharge
6-8 sessions
Other therapy assessments As required including Podiatry and OT
6-8 sessions Occupational Therapy Supportive therapies e.g. Reflexology and
Aromatherapy 2-3 sessions
If overweight Weight loss
clinic
Musculoskeletal physician reassessment Assess red and yellow flags
Relevant investigations as required Oswestry Disability Questionnaire 2
Musculoskeletal specialist treatment
Manual therapy 6-8 sessions, Individualised
acupuncture/deep needling Complementary therapies
Complies with NICE Guideline CG88 Low Back Pain
Created Dr Peter Fisher January 2009, Revised Dr Adam Ward February 2011
Royal London Hospital for Integrated Medicine
Services, therapies & care pathways
Homeopathy ������������ �������� ������������ ������������ �������� ������������ ������������ ������������Homeopathy ������������ �������� ������������ ������������ �������� ������������ ������������ ������������
Acupuncture �������� ������������ �������� ����
Manual
medicine������������
Iscador ������������
EPD ���� ��������
Nutrition ���� ���� �������� �������� ���� ������������ ����
Lifestyle
management
/CBT
�������� ������������
Summary: Integrated Medicine
• Integrated medicine
• supports healing
• doctor-patient relationship
• uses all resources • uses all resources
• active patients
• Is important because
• chronic conditions
• iatrogenesis
• patient satisfaction
Summary: RLHIM
• Responsive to need
• services offering range of therapies
• Dimensions
• system, professionalism, education & information, • system, professionalism, education & information,
governance
• Service models
• Fully integrated, unique, colocated, cost-effective
• Guidelines, evidence, pathways
• Patient preference
Keys to success
1) Patient-centredness
2) Patient-centredness
3) Patient-centredness
2) Quality & Safety
practitioners, medicinal products, processes
4) Patient-centrednessassurance: audit, governance
3) Innovation
responsive to need, guidelines etc
4) Integration
best of complementary and conventional
The Royal London Hospital for Integrated Medicine
