4.  ADVANTAGES AND DISADVANTAGES
OF PROVIDING COMPLEMENTARY
MEDICINE IN GENERAL PRACTICE


Although many patients appear to have benefited considerably from the complementary health service, it also has to be recognised that integrating complementary medicine into general practice can be demanding, particularly since there are no obvious sources for the funding of such a service, and it can make considerable demands on the administration of the practice. Providing an effectively integrated service requires a strong commitment of time and effort, both from the general practitioners and the complementary practitioners, including time to meet together, find out about each other's practice, and iron out any difficulties that might arise in the service. On the other side of the equation, however, the availability of complementary medicine does provide patients and GPs with a wider range of treatment choices, which can be particularly helpful in situations in which conventional treatments have been found to be ineffective. It also, potentially, relieves demand on other health services.

In this section, the demands made by the service on the practice are initially outlined, followed by an assessment of the benefits in terms of savings on other kinds of service provision.


4.1 Funding a complementary health service

The practice in which the service described took place is not a fund-holding practice, and there were no immediate means, within existing budgets, to fund complementary medicine sessions for patients. Initially, a pilot service was funded out of research funding from Somerset Health Authority and evaluated in very broad terms; a further research grant was then obtained for three years, under which a much more thorough evaluation took place. Although the outcomes of this evaluation were generally positive, and the overall costs of the service were low (£17,000 per annum), it was not possible to obtain ongoing funding when the research grants came to an end.

This meant that other ways had to be found to enable the service to continue. Two mechanisms were established for this purpose. First of all, patients began to be charged £6 a session for treatment; the price was set as one which was felt to be manageable by the majority of patients, although below the actual cost to the practice for providing these therapies (which cost between £9 and £12 a session). In addition, a charitable trust was established, with the help of a number of patient trustees, to raise money to make up the difference between the income from patients and the full cost of running the service. This trust has been successful in raising funds for at least one year from local sources, and has attracted a number of patient members, who receive a regular newsletter. Establishing a trust and trying to raise funds from charitable sources has been time consuming for those involved, notwithstanding the dedication and efforts of the trustees themselves.


4.2  The administrative demands of the complementary health service

4.2.1  Managing the appointment system

Running a complementary health service alongside other primary health care activities does place a not inconsiderable burden on the administrative resources of the practice. In the Glastonbury service, the appointment system could not easily be accommodated within existing reception arrangements, and a special system had to be established.

The difficulties in relation to appointments arose from the fact that the number of sessions available each week for each therapy, were quite limited. Each complementary practitioner was only available for half a day each week, with the number of sessions in their therapy varying between 8 a week for the herbalist, to 4 for the massage practitioner. As sessions became booked up quickly, it was decided at the start of the project to allocate appointments on a block basis, of between 4 and 6 sessions at weekly intervals, ensuring that patients had continuity of treatment once this had been started. This presented something of a challenge to the normal reception service and to the computerised appointment system, so one administrator was made responsible for handling all appointments, including the sending out of appointment letters, handling patient queries, and cancellations. These activities took around half a day a week of her time.

At a later stage in the project, the computer appointment system was adapted and a terminal set up in the complementary practitioners’ room, which meant that they could now make appointments with their patients themselves. However, the waiting lists still had to be managed by the administrator, who sent out appointment letters for initial sessions when spaces became available, and also attempted to fill spaces when there were cancellations. Last minute cancellations, and patients failing to turn up for appointment were a continual difficulty, not because the number of ‘no shows’ were higher than for any other service provided at the practice, but because the sessions themselves were somewhat longer: a gap left by one patient in a half day session meant a considerable waste of a scarce resource, unless another patient could be found at short notice to fill the space.

4.2.2  Managing the waiting lists

The popularity of the service, both with patients themselves and with the GPs, resulted in lengthy waiting lists building up, particularly for osteopathy and acupuncture. Patients sometimes had to wait for up to four or five months for appointments, which made referral for short-term problems difficult. Although there was a priority system for ‘acute cases’, this simply added to the length of the wait for patients with less urgent problems, and this tended to discourage GPs from referring patients with acute problems. This was particularly unfortunate, since the research indicates that patients with shorter-term problems show the greatest improvement following treatment (Table 18).

Various steps have been taken to reduce waiting lists, including closing the lists for a couple of months when they become too long. More recently, the ending of the research grant and the imposition of charges for treatments did initially lead to a rapid reduction in waiting lists, although these built up again as the new system became accepted, but not quite to the same level. The introduction of a more flexible appointment system does not appear to have led to any marked change in the number of sessions given to individual patients, although it does allow for sessions to be spread over a longer period.


4.3  Meetings between complementary practitioners and other health care staff

In the initial stages of the project neither the complementary medicine practitioners, nor the GPs, were very familiar with one another’s work. In order to facilitate referrals, each practitioner wrote a brief note about his or her therapy, and the conditions for which it was particularly appropriate. In addition to this, a regular lunch time meeting was set up at which practitioners and GPs could meet; these took place every three months. These meetings were particularly important, since it was often difficult for GPs and practitioners to find time to meet face to face to discuss particular patients, which meant that much of the exchange took place through written notes.

The main focus of these meetings was the administration of the service, and any research activities attached to this, although there was some opportunity for professional exchange. Professional exchange was particularly valued by the practitioners, who welcomed the opportunity to talk to the GPs about the needs of particular patients, and to compare different approaches to health problems. However, administrative and research issues often left little time for case discussion, so occasional evening meetings were set up specifically for professional exchange. These were found very useful by those who attended them.

Finding time for meetings of this kind was, however, often difficult both for the GPs and the complementary practitioners, most of whom had practices elsewhere on the days when they were not providing sessions at the Health Centre, Yet even within the constraints of time, and the limitation of the meetings, they remained an important part of the running of the service.

"I do miss the meetings. They are a good opportunity for exchange, but there is a feeling of time pressure, a lot of business to get through, it is hard to build a team spirit with business meetings, there needs to be more unstructured time." (Practitioner)


4.4  Relieving the pressure on other health services

Although the running of the complementary health service made demands on the time of GPs and administrative staff at the practice, it was also felt to be beneficial, not only in terms of providing patients and GPs with additional treatment options, but also in reducing some of the pressure on other services. Testing this out systematically, using the research data available, became an important part of the evaluation.

This proved to be far from easy to accomplish: many changes had been taking place during the period during which the service had been running, which were having a simultaneous impact on the demand for service. Demand for health services, particularly in primary eare, was steadily increasing throughout the country, influenced by the restructuring of the health service, changes in GP contracts, and the introduction of the Patients’ Charter. The size of the Glastonbury practice increased by around 42% during the time that the service was being evaluated, from 2800 in 1992 to over 4000 by 1997.

However, it was possible to undertake a limited exercise, using the health records of a small sample of patients, to see what difference use of the complementary health service had made to their usage of other services. A second exercise was undertaken to examine changes in the rate of referrals to secondary care during the years that the service had been in operation (Hills with Welford 1997).

4.4.1 Use of other services prior to and after treatment by a patient subsample

A group of patients who had been referred to the complementary health service for longer-term health problems were selected for this exercise. All 41 had been with the health centre at least three years, had had their health problem for over a year and had completed their complementary medicine treatment at least a year prior to the exercise being undertaken. Nearly half the group had received conventional treatments which had failed to produce a significant improvement; in this and most other characteristics they were broadly representative of patients using the service for longer-term health problems. Examination of their health records showed that many of these patients bad a number of health problems, so comparison of other health services in the year before and after receipt of complementary therapies was confined to the particular problem for which they were referred.

Following their initial complementary medicine treatment, there was for most of this group a marked reduction in the use of other health services for the problem referred. The largest reduction occurred for those who had been the heaviest users of other services prior to referral.

Visits to GPs dropped by around a third (Table 26), with the largest reduction coming from the 11 patients that had been the most frequent visitors to their GP prior to referral. For low users of GP service the difference was less marked, particularly as some revisited their GP after an initial course of treatment, to request a further referral.

Table 26  Visits to GP for problem referred

	In year prior to treatment		In year after treatment
Visits to GP for problem referred	Number of patients	Total number of prescriptions	Number of patients	Total number of prescriptions
0-3 visits	30	43	33	31
4-7 visits	6	29	4	21
8-11 visits	3	25	2	18
12 or more visits	2	31	1	18
Total	41	128	41	88

The reduction in the number of prescriptions required by this group was even more marked. Two thirds of the group had required prescriptions for their problem in the year prior to referral, usually for analgesics. Nine of the patients between them accounted for over three-quarters of all the prescriptions. Again it was for this group of high users that the largest reduction took place, with only 5 of the whole group requiring more than four prescriptions in the year following treatment, and the overall number of prescriptions nearly halved (Table 27).

Table 27  Prescriptions for problem treated

	In year prior to treatment		In year after treatment
Number of prescriptions	Number of patients	Total number of prescriptions	Number of patients	Total number of prescriptions
0	15	0	23	0
1-3	17	21	13	19
4-7	6	28	5	29
8-11	1	10	0
12 plus	2	29	0
Total	41	88	41	48

There was a similar reduction in the numbers of further referrals, tests and other treatments required by the group for the condition referred. (Table 28), with the largest reductions taking place in referrals for physiotherapy and X-rays.

Table 28  Other services used, for problem referred

Referrals and other services used	In year prior to treatment		In year after treatment
	Number of patients	Number of referrals/treatments/tests	Number of patients	Number of referrals/treatments/tests
Consultant referrals	6	7	5	5
Hospital visits	2	3	1	1
X-rays	8	8	4	5
Other tests (blood etc.)	4	5	3	4
Physiotherapy	7	7	2	2
Counselling	2	2	0	0

4.4.2  The effect of the complementary health service on referrals to secondary care

The drop in referrals to secondary care revealed in this subsample of patients suggested that it would also be useful to look for evidence that the service was impacting more broadly on referrals to secondary care. Since the service had been set up in 1992, it had received around 1000 referrals, the majority of these (around 650) for musculo-skeletal problems, with a further small but significant group (around 120) with psycho-social problems. The most common referrals for patients with these kind of problems outside the practice were for physiotherapy, to consultants in orthopaedic surgery and rheumatology, and to the community mental health team.

Referrals of this kind were quite high from the Glastonbury practice on the whole, (There were, for example, a very high proportion of patients suffering from depression in this practice.) However, examination of records revealed that referrals for orthopaedic surgery and physiotherapy had reduced since the setting up of the complementary health service, while psychiatric referrals, after an initial increase, had levelled off. Rheumatology referrals increased, but the overall numbers were so small that these give very large annual variations (Table 29).

Table 29  Referrals from the practice per 1000 of patient population *

Referrals	1991/2 (before)	1993/4 (after)	1994/5 (after)	1995/6 (after)
Orthopaedic surgery	23	17.9	24	19
Rheumatology	2.2	4.3	2.1	6.6
Physiotherapy	41.6	40	44.3	38
Psychiatry (including referrals to community mental health team)	26.1	39.1	39.3	37.4

* Figures for 1992/3 are not included as the project was set up part way through this year

This decrease, or lack of increase in referrals contrasts favourably with the rise in referrals of this kind elsewhere. For example, two recent studies of counselling and physiotherapy in general practice (Somerset Health Authority 1996) indicated a marked increase in referrals from a set of control practices while referrals in the intervention practices fell (Table 30).

Table 30  Level of change in rate of referrals in other Practices in the county *

Type of referral	Other practices: change between 1993/4 and 1995/6	Change in Glastonbury between 1991/2 and 1993/4	Change in Glastonbury between 1993/4 and 1995/6
Rheumatology	+48%	+95.5%	+5.3%
Orthopaedic	+28%	-22.1%	+6.1%
Physiotherapy	+22%	-2.8%	-15.7%
Psychiatry	+64.7%**	+46.8%	-4.3%

*  The comparison practices were those used as control practices in the studies of counselling and physiotherapy in general practice (Somerset Health Authority 1996)
** This increase was only for consultant psychiatry, not for referrals to the community health team, for which separate computerised records were not available.

Some of the Glastonbury increases would have been accounted for by the increase in size of the practice. When these are adjusted for, it can be seen that the numbers of referrals, by 1996, were considerably lower than they would have been if they had continued to rise at the same rate as they had at similar practices elsewhere in the county (Table 31).

Table 31  Hypothesised levels of referrals, with attached costs

Type of Referral	1991/2 actual referrals	1995/6 actual referrals	1995/6* hypothesised referrals at % rate of increase of control practices	Difference between actual and hypothesised referrals
Orthopaedic consultations	74	76	146.9	70.9
Rheumatology consultations	7	26	18.6	-7.4
Physiotherapy	134	150	241.7	91.7
Totals	215	252	407.2	155.2

* These figures are adjusted for the increased size of the practice population between 1991/2 and 1995/6

This change in external referrals supported the findings from the analysis of usage of services in the subsample; i.e. that the availability of complementary medicine had reduced demands on other health service resources. In section 5 we examine what implications these changes in demands on other services had, in terms of the cost-effectiveness of complementary medicine provision.

NEXT PAGE