Ten tips on developing
an Integrated Medicine Service

From GP Magazine

Your partners may need some persuading but some useful arguments are:

One in five of our patients already use complementary therapy each year. By linking in with complementary practitioners we can ensure comprehensive care for our patients. We can influence the quality and safety agenda for complementary therapy. We can further the research and development of complementary medicine. We will have a wider range of therapeutic options for our patients irrespective of their ability to pay

Patients are, quite rightly, expecting to be involved in decisions about their care and they are increasingly selective regarding the merits of conventional medicine. Many patients are expressing reservations about the safety of our treatments and are less happy to accept our reassurances. They wish to make informed choices, and to include in their choices the appropriate use of complementary medicine. We need to be able to participate in those decisions.

Establishing an Integrated Medicine Service is not an easy option. In the current climate the most important asset is enthusiasm. Time, as well, will be in short supply and will have to be found. Funding and finance will need energy and commitment, and you will find there will inevitably be more meetings (groan!).

At times you may wonder why you are bothering, with so much else to do, and you may feel quite lonely, but there are a number of fellow enthusiasts out there, so donít despair. You can applaud yourself for endeavouring to develop a more complete and holistic approach to your patientsí needs – and your patients will acknowledge this and express sincere appreciation (well, some of them will!).

The next step is to decide which therapies you plan to offer. In our practice we offer the major complementary medicine specialities – osteopathy, homeopathy, herbal medicine, acupuncture and massage. Together these account for over 70% of CAM consultations in the UK today, they provide a significant amount of health care (especially worldwide), they have in part established a degree of proven efficacy and are generally considered safe.

Other complementary medicine specialities which provide services in primary care are chiropractic, spiritual healing, aromatherapy, hypnotherapy, anthroposophical medicine, eurythmy, yoga to name but a few!

It is extremely important to ensure any integrated service is properly run. Any practitioners we affiliate with should be able to demonstrate a sound training, with accreditation to a professional organisation which is open, accountable and subject to scrutiny.

In future, integrated medicine will have to conform to standards of clinical governance, ensuring safety and quality of care, in line with all health professionals. This is a necessary and healthy expectation – standards of practice in CAM (as with other health professionals) can vary widely.

All practitioners should be covered by professional indemnity insurance. (Medically-qualified CAM practitioners are of course already subject to GMC registration as a pre-requisite of practice).

Funding of an integrated medicine service is the biggest bugbear. With the demise of fundholding, any NHS funding will have to come from the PCG for which hard work and persistence will be required.

All PCGs/PCTs will shortly be receiving an information pack from the NHS Executive advising on the various mechanisms for establishing an integrated medicine service. Get hold of a copy, discuss with your PCG Chairman how any proposal may be formulated, incorporate evidence of CAM, effects on waiting lists, relevance to HIMPS, implications for patient choice, universal access to heath care. You may wish to promote your practice as a PCG referral centre.

Other ways of funding the service could be via a practice based charity (as in our case for the past 3 years), or through the National Opportunities Fund for Healthy Living Centres.

Canvass your colleagues for support and seek support from your patients, and the Community Health Council.

Communication within the practice and within the project is vital for success.

All the practice must feel involved, including administrative staff. Appointment systems can prove frustrating and time consuming, and waiting lists need careful supervision.

Meetings between partners and practitioners are essential to liaise, to discuss problems, to share clinical management and to learn and develop mutual respect.

Comprehensive referral and feedback forms are a good way to formalise communication, especially if the service is off-site.

Deciding who and how to treat can prove difficult. We are aiming to offer a holistic, person-centred approach not simply a disease focused therapy. However we need to be pragmatic and realistic regarding which patients may benefit in our project. We refer according to three levels of priority:

Priority 1. Evidence based effectiveness such as osteopathy in acute back pain.
Priority 2. Conditions in which evidence is supportive or good Ďanecdotalí evidence of benefit, perhaps from the patient, eg acupuncture in frozen shoulder.
Priority 3. Conditions which the doctor and patient agree may benefit from a trial complementary therapy, eg herbal medicine in chronic fatigue.

Demand for the service may easily outstrip supply and controlling a limited resource can prove very difficult.

Prioritising referral will help control demand and limiting treatment courses to a specified number of sessions (eg six), will prevent clogging of the system. Many patients will have chronic illness which may benefit from prolonged treatment, this is unlikely to be available with limited funds, although we are able to cater for repeat courses with some patients where strongly indicated.

Evaluation of outcome is important in this new area of patient care. We need to learn about how we are doing – are patients getting better, and if so do we know why (or why not). Incontrovertible evidence in CAM (as in many areas of medicine) is much needed. Matched case controlled trials are the ideal way to evaluate CAM interventions but difficult to implement. Research is accumulating, and a clearer picture will emerge, assisted by sensible outcome evaluation.

Finally it is important we share our successes, our failures, our hopes and our fears with other colleagues. We need to network and link up.

There are various organisations facilitating and exploring the role of integrated medicine and these will prove a useful resource. Internet addresses which could be helpful are:

Foundation for Integrated Medicine – www.fimed.org
Faculty of Homeopathy – www.trusthomeopathy.org
Centre for Complementary Health Studies – www.ex.ac.uk/ehs