Anne Woodham,
Health editor,
Good Housekeeping,
London
Hilary Bower,
Freelance health and science journalist,
London

Do you know of a surgery, clinic, or hospital where conventional and complementary practitioners work well together? They could win £5000 in the Guild of Health Writers' Award for Good Practice in Integrated Healthcare, organised in association with the Foundation for Integrated Medicine.

Entry details from:
Stephanie Cargill,
12 Conway Walk,
Hampton, Middlesex TW12 3YF.
Tel/Fax: 0181 941 2977.

The award is sponsored by Candis Magazine, Cigna Healthcare, Kellogg's, and Nelsons Homoeopathic Medicines, with a special contribution from Peter Black Healthcare.

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Taking the best from both worlds

Anne Woodham and Hilary Bower take a look at integrated medical practices and how they benefit their patients

Eleven years ago, when Patrick Pietroni (now professor of community care and primary health at Westminster University) broke new ground in establishing the first NHS general practice with complementary practitioners on site in the crypt of St Marylebone Church, the move was seen as dangerously alternative.

 

"Bodywork and masage reach everyone and are a healing thing to offer" Photo: Damien Lovegrove/SPL

Today such "integrated" health care - the combination of conventional and complementary healthcare disciplines working together - is moving rapidly towards the mainstream. A 1995 survey from Sheffield University showed that almost 40% of general practices now offer some form of complementary treatment on the NHS, either from the doctors themselves or from a practitioner within the practice or closely connected to it. Even more recently - on 2 October - researchers at Birmingham University who contacted all practices in Birmingham Health Authority found that half of the 175 practices offered patients access to complementary treatments. Of these, 44 practices offered an in house service, usually provided by a general practitioner. Other surveys show that 30-50% of the population has used complementary medicine at one time or another.

Over the past 18 months there has also been a surge of awareness from the upper echelons of medicine that this is a trend that could enrich all participants - doctors, practitioners, and patients - a sentiment reflected in the huge turnout to a conference recently convened by the Foundation for Integrated Medicine, the organisation set up by the Prince of Wales to drive forward standards and research in the area.

But what does it mean to offer "integrated medicine"? And is it a real option or just a touchy feely exercise of the late 20th century?

"I couldn't work without complementary therapies now," says Sue Morrison, one of the general practitioners at the Marylebone Health Centre. "Bodywork, and massage in particular, reaches everyone and is a wonderful comfort and healing thing to offer. We have a big multi-ethnic group of patients, and it can help break through language barriers and help those with emotional as well as physical problems in a very short time."

The centre's team comprises four full time general practitioners, two part time doctors, an osteopath, a homoeopath, a naturopath, a acupuncturist, a massage therapist, and a counsellor (all part timers).

Conventional medicine is still the foundation of the practice, and every new patient sees one of the doctors for diagnosis and referral. Complementary treatments are regarded as an adjunct and the doctors remain the gatekeepers, suggesting a treatment if they consider it appropriate for the patient's condition and personality. "We tend not to get on so well with the devotees of complementary medicine," says Morrison. "If someone registered just because they want homoeopathy, I would feel impotent as the doctor, and the whole point is that we work together."

Good organisation and communication are vital to making integrated care work, and the practice holds weekly lunchtime clinical meetings plus a 90 minute monthly meeting with all staff. Doctors and practitioners also write in the same set of notes.

Irritable bowel syndrome, asthma, migraine, eczema, arthritis, and chronic fatigue syndrome - the chronic disorders that conventional doctors find so difficult to deal with - are those conditions for which complementary medicine seems to offer most relief.

Evidence is now accumulating from controlled trials to show which techniques benefit particular conditions, says David Peters, director of complementary therapies at Marylebone Health Centre and chairman of the King's Fund working party on the effective delivery of integrated medicine. Osteopathy and chiropractic can relieve back and neck pain, hay fever responds to homoeopathy, and nutritional medicine may alleviate eczema and rheumatoid arthritis.

"With asthma, for example, you would always rely on conventional medicine to treat an acute attack," he explains, "but you could try complementary therapy such as nutritional medicine, homoeopathy, and acupuncture to reduce medication and the frequency of attacks."

The idea of conventional and complementary practitioners working together seems almost a contradiction in terms. Certainly it is not always easy. "The language of acupuncture and homoeopathy is so different from that of conventional medicine, with terms like 'energy,' 'qi', and 'vital force,' that, with the best will in the world, doctors get in a stew over what the therapists are doing," says Peters, who is a medical doctor as well as a complementary practitioner. "Complementary practitioners are also used to being independent and are unused to working in a team. Regular team meetings and lots of open minded enthusiasm are essential to iron out wrinkles."

The centre is half way through a three year research project to investigate whether patients are satisfied with the use of complementary forms of treatment and whether there is real improvement in their health. "My sense is that patients choose to register with our practice because they like the complementary treatments we offer, but there are many questions unanswered, and we can't move forward unless this is done," says Morrison. "What criteria do doctors use in making referrals, for example? Is it because you have a particular interest in a treatment? Are you more likely to refer to a discipline or to a person? How much has it to do with how tired you are that day and sharing the load? Or with who has free appointments? There are so many variables."

It's not just in London that integrated health care is taking off. Examples can be found across the country, such as at the Phoenix Surgery in Cirencester. Here David Beales is the driving force behind the introduction of complementary treatments. He became convinced of their value when his first wife fought - and sadly lost - her battle with cancer in the 1980s. Today, remarried, Dr Beales's interest in "the whole person, the influence of the mind on the body, what it is that creates health" remains strong.

With local health authority funding, the Phoenix Surgery employed an acupuncturist, osteopath, and homoeopath for a year's trial in 1993. Results in treating back pain, headaches, chronic illness, and other stress related problems were so encouraging that the five general practitioners agreed to continue with the support of the practice's charity, the Phoenix Trust. Patients pay £15 towards a session, or receive free treatment if they are unemployed or on benefit. The trust, funded by patient donations and fundraising efforts, picks up the rest of the bill.

Phoenix's doctors and therapists describe their relationship as one of working "side by side." "The general practitioner makes the initial assessment because it's important not to miss a symptom," explains Beales. "But the complementary therapists look at what might influence someone's condition."

"Attitudes have shifted among the general practitioners," says Meg McDonald, a cranial osteopath who works at the Phoenix Surgery half a day a week. "Admittedly, osteopathy is easier because on the whole it makes sense medically to them, but at first they didn't know what to expect. Now they are better about which patients they refer to us."

But can integrated medicine be cost effective? Marylebone Health Centre has a low referral rate to specialists and a prescribing rate that's half the national average, although until the research project is finished, no one knows how much this is due to the complementary services. Peters reports that when he provided osteopathy and acupuncture for another general practitioner partnership, referrals to orthopaedic and rheumatology consultants fell by 50%.

 

Providing acupuncture for patients has reduced referrals to rheumatology consultants Photo: Damien Lovegrove/SPL

Restricted resources do mean the centre is unable to offer long term treatments, and the average complementary treatment is four to six sessions. "Some people can afford to continue in the private sector and others can't. I do have a question over raising expectations about unfulfillable needs," says Morrison.

Integrated medicine can also be tough on practitioners. Although she is convinced of its benefits, Morrison says it demands an enormous amount of time, communication, understanding, and compromise.

"Team working is extremely difficult. For 10 years we've been exploring why this is, looking at rivalries, power issues, competition issues, and issues relating to loss of a special relationship with the patient when you move them on: let alone whether we can talk to each other in a language we understand. But it has really paid off. We have found we can contain conditions that are usually difficult to look after in normal practice."

Gabrielle Pinto, Marylebone Health Centre's homoeopath, also notes the challenges of bringing together often very different approaches. Many homoeopaths, for example, refuse to work with doctors who prescribe drugs. But, she says, compromise is again the key. "In general practice, homoeopathy can be a support in helping people through a difficult time. If I see patients early enough, especially those with stress related symptoms, they may not require drugs. And even if they do need very strong drugs, you can return later to the underlying problem so that it doesn't raise its head again. I'm beginning to teach the doctors what I can and can't do, and they're beginning to hear me."

Public demand, if nothing else, means that doctors of the future are guaranteed to come face to face with alternative therapies more and more. How much better it must be if the passion and commitment of both sides can be combined to bring the best of both worlds to patients.