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The UK experience:
The Royal London Hospital for
Integrated Medicine
Dr Peter Fisher
Clinical Director
Director of Research
Expert Advisor to National Institute for Health and
Clinical Excellence (NICE)
University College London
Hospitals
• One of largest academic medical centres in UK
• Medical school and specialist institutes, linked to
University College London
• 8 hospitals:
• University College Hospital (general/acute)
• Cancer Centre
• Eastman Dental Hospital
• Elizabeth Garret Anderson
(gynaecology, obstetrics, children)
• Heart Hospital
• Hospital for Tropical Diseases
• National Hospital for Neurology and Neurosurgery
• Royal London Hospital for Integrated Medicine
The Royal London Hospital for Integrated Medicine
[email protected]
10 leading causes of disease burden
2004 & 2030 (WHO)
WHO: The global burden of disease: 2004 update (2008)
Prevalence of mental disorder
• Annual population prevalence in EU 38%: 165m people
• anxiety disorders (14%)
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insomnia (7%)
major depression (7%)
somatoform (6%)
alcohol and drug dependence (>4%)
ADHD (5%)
Dementia (1-30%, depending on age)
• 27% of total disease burden
• Undertreated
Wittchen HU et al. The size and burden of mental disorders and other disorders of
the brain in Europe 2010. Eur Neuropsychopharmacol. 2011;21:655-79
...and Medically Unexplained
Physical Symptoms (MUPS)
2005
2010
% change
Chronic Fatigue
Syndrome
333,816
413,370
24%
Fibromyalgia
389,782
446,586
15%
Multiple Chemical
Sensitivities
598,585
784,798
31%
Target Population
27,125,065
28,890,710
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Statistics Canada: Canadian Community Health Survey 2010
Multimorbidity is common
• 40 morbidities ⅓ population of Scotland
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Highest
socioeconomic
quartile
Lowest socio42% > 1 morbidity
economic quartile
23% multimorbid
increases with age but absoute number higher in younger
onset earlier in deprived areas particularly including mental
health
• Challenge single-disease framework
• Personalised, continuity of care especially in deprived areas
Barnett K et al. Epidemiology of multimorbidity and implications for
health care, research, and medical education: a cross-sectional study.
Lancet May 2012 DOI:10.1016/S0140-6736(12)60240-2
Adverse drug events (ADEs)
• Common
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In USA 4.6% of deaths, top 5 causes of death
Hospitalized 6.5% , almost double risk of death
4,335,990 outpatient attendances
107,468 hospital admissions in 2005
9 17/1000 between 1995-2005
• Expensive
• Prolong hospital stays, increased resource utilization
Adverse drug events (ADEs)
• Associated Factors
• age
• number of medications
• female gender
Bourgeois FT et al. Adverse Drug Events in the Outpatient Setting: An 11-Year National Analysis
Pharmacoepidemiol Drug Saf. 2010 19 901–910.
A perfect storm?
Aging population
Increasing costs, more
complex morbidity
Increased ADEs
Chronic/multi
morbidity
Increased treatment
Why integrate medicine?
• chronic & multimorbid conditions v
pandemic of iatrogenic illness
• Reduce medication, treat person not disease
• fiscal imperatives v
expensive 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
Why integrate medicine?
• high-tech, high impact, high-cost interventions v
caring, commitment, compassion
• Revive the art of medicine
• concordance v
efficacy
• Patient-friendly, culturally appropriate treatments
• dependency on drugs and medical services v
disillusionment and medical counterculture
• Restore confidence in medicine
The NHS
hospital most
recommended
by its own
patients:
NHS Choices
website
The Royal London Hospital for
Integrated Medicine:
clinical services
• Acupuncture
• including high volume & training clinics
• mostly western, some TCM
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Allergy
Children
Chronic Fatigue Syndrome/ME
Complementary Cancer
General medicine
• Including inflammatory and functional bowel
• Podiatry
Royal London Hospital for Integrated Medicine
RLHIM: clinical services 2
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Weight loss
Insomnia
Integrated facial pain
Integrated antenatal
Musculoskeletal medicine
Rheumatology
Skin
Stress & mood disorder
Women's
Royal London Hospital for Integrated Medicine
RLHIM: innovation
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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
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
2012 Complementary Cancer Care in UK’s largest cancer centre
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 reporting
Musculoskeletal problems
Depression
Eczema
Chronic pain
Irritable bowel syndrome
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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.
Why do patients come to Royal London
Hospital for Integrated Medicine?
(925 responses from 493 patients)
Sharples F, Van Haselen R, Fisher P. NHS patients’ perspective on
complementary medicine. Comp Ther Med 2003;11:243-248.
The Royal London Hospital for
Integrated Medicine: therapies
• acupuncture
• mostly western, some TCM
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aromatherapy
autogenic training
cognitive behaviour therapy
cranio-sacral therapy
graded exercise
homeopathy
nutritional medicine
• exclusion, supplements, nutraceuticals
Royal London Hospital for Integrated Medicine
RLHIM: therapies 2
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lifestyle management
occupational therapy
physiotherapy
phytotherapy
• standardised extracts
• western mixtures
• Chinese an aspiration
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shiatsu
spinal manipulation
sublingual immunotherapy
wet needling
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
Royal London Hospital for Integrated Medicine
Dimensions of integration:
professionalism
Dimensions of integration:
information and education
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Education and training: integrated and ‘hands-on’
Specialist advice
NICE External Expert Panel
Complementary and Alternative Medicine Library and
Information Service (CAMLIS)
• Physical and online
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
Models of integration
• Fully integrated:
• integrated Chronic Pain Service with dental hospital
• integrated antenatal service with UCLH midwives
• Unique services: Allergy and Chronic Fatigue Syndrome
• UCLH’s only services for under-provided conditions:
• guideline recommended treatments & CM.
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:
• group acupuncture
• knee, low back, headache, facial pain
• group Cognitive Behaviour Therapy, Autogenic Training
• insomnia, chronic fatigue, fibromyalgia
• Informal: Contacts, ad-hoc referrals etc
Royal London Hospital for Integrated Medicine
High volume acupuncture clinic for
knee pain
Constraints to Integration
• Coordinated hostile media campaign
• NHS provision
• Regulation
• Scepticism
• colleagues, particularly academic and older
• Financial
• but often saves money
The Challenges:
• Commissioners ‘Low priority’ treatments
• evidence of clinical/cost effectiveness limited
• grommets, tonsillectomy… varicocoele, refashioning
scars….
• Complementary medicine of all types
• ‘Referral management’
• Slow, bureaucratic, often refused
Commissioning challenges:
clinical pathways
• Category 1 based on authoritative guidelines
• Approximately 60% of patient attendances
• Category 2
• Complementary cancer care
• Category 3 require individual approval
NHS Commissioning
‘Category 1’
based on authoritative guidelines
Stress & Mood Disorder
Group Acupuncture Chronic Headache
Non-Organic Insomnia
Group Acupuncture Knee Pain
Cognitive Behavioural Therapy
Perennial Allergic Rhinitis
Irritable Bowel Syndrome
Hayfever
Fibromyalgia Syndrome
Weight Loss
Chronic Fatigue Syndrome
Facial Pain
Chronic low back pain
NICE Guideline Low Back Pain
• 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
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1.5.1 Do not offer laser 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
Royal London Hospital for Integrated Medicine
Low Back Pain Care Pathway
Complies with NICE Guideline CG88 Low Back Pain
Revised October 2012
Royal London Hospital for Integrated Medicine
Irritable bowel syndrome Care Pathway
Based on NICE Guidelines for IBS in Adults (CG61), British Society of
Gastroenterology Guidelines for Management of IBS (2007)
Revised February 2011
Royal London Hospital for Integrated Medicine
Complementary Cancer Care Pathway
• category 2: Not requiring prior approval,
not guideline based
NHS Commissioning
‘Category 3’
require prior approval
Antenatal
Skin
Mother & baby
Osteoarthritis
Autogenic training
Musculoskeletal other
Children behavioural
Inflammatory arthritis
Vulnerable
includes some of most popular & innovative services
‘Musculoskeletal other’
approval criteria
• Commissioners will only fund Integrated Medical
treatment for Musculoskeletal and Rheumatology
• pain and/or disability significantly restricting work,
everyday living
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• Inadequate response to at least 2 treatments including:
• physiotherapy and exercise, weight loss, simple analgesic, low dose
antidepressant, NSAID, corticosteroid DMARD or biological agent
• Heavy use of health services
• >4 primary and secondary care consultations in previous 6 months,
>6 in previous 12 months
• Medically unexplained physical syndrome after extensive
medical investigations and causing significant distress
Summary
• Responsive to need
• services offering range of therapies
• Integrated in depth
• Dimensions
• Service models
• Guidelines, evidence, pathways
• Patient preference
Keys to success
1) Patient-centredness
Patient-centredness
2) Quality
& Safety
medicinal products, processes
3) practitioners,
Patient-centredness
assurance: audit, governance
4) quality
Patient-centredness
3) Innovation
responsive to need, guidelines etc
4) Integration
best of complementary and conventional
The Royal London Hospital for Integrated Medicine
[email protected]
International Congress for
Complementary Medicine Research
London 11 - 13 April 2013
www.iccmr2013.com
• Global sustainability of healthcare for chronic
conditions
• Global Pandemic of long term conditions:
35/58 million deaths annually worldwide
• 80% of consultations in industrialised countries
• Multimorbidity/polypharmacy/iatrogenic illness.
• Ecofootprint of pharmaceutical industry
• Underexploited resources of
traditional/complementary/integrated medicine
International Congress for Complementary Medicine Research
London 11 - 13 April 2013
www.iccmr2013.com
Thank you for your attention
[email protected]