Health CommitteeWritten evidence from Dr Peter Fisher, Royal London Hospital for Integrated Medicine and Professor George Lewith, University of Southampton (LTC 07)

Summary

The rising prevalence of long term conditions (LTCs) is the greatest single challenge to public health in the UK. The main categories are psychological (including depression, anxiety and insomnia), musculoskeletal (including back pain and osteoarthritis), chronic pain (various conditions) and metabolic conditions (including diabetes). With advances in treatment, formerly life-limiting conditions including coronary heart disease and cancer are increasingly becoming LTCs.

The most important correlates of LTCs are age and socio-economic deprivation. The most important complicating factors are multimorbidity (many people with LTCs have more than one) and polypharmacy (the use of five or more drugs at once with some drugs given to counteract the adverse reactions of other medicines). Polypharmacy is common in people with LTCs and associated with greatly increased risk of adverse drug reactions. Antibiotic resistance is often a consequence of polypharmacy.

LTCs, multimorbidity and polypharmacy challenge the single disease model on which most current health care, beast practice, research, and education is based.

The effectiveness and cost-effectiveness of care for LTCs could be greatly enhanced by integrating Complementary Medicine (CM) and other patient-centred self-care and enabling approaches alongside conventional therapy. This is termed Integrated or Integrative Medicine (IM), defined by the Consortium of Academic Health Centers (53 centres in North America, including some of the most prestigious) as: “the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing”.

There are a range of therapies and service models, but these approaches have in common that they are safe, increasingly of proven effectiveness, attractive to patients and cost effective in the community. They empower people with LTCs, improve symptoms, underlying disease processes and quality of life while reducing requirement for secondary care and drugs. We cite examples of successful NHS implementation of IM.

There is a need for research and development on these interventions including their safety, effectiveness, modes of delivery and integration into NHS services.

The scope for varying the current mix of service responsibilities so that more people are treated outside hospital…

1. IM enhances individualised care of patients and facilitates therapeutic relationships centred on individual need. There is good evidence that it enhances the quality of both primary and secondary care, improves adherence to treatment, reduces emergency admissions and improves outcomes.

2. It is important that care is truly integrated so that secondary care, investigation or intervention is available if required, and to meet the needs of those have complex problems. Training, supervision and support of service providers are essential to ensure high-quality services and require a degree of centralisation.

3. A number of UK healthcare providers are fostering such initiatives. The Royal London Hospital for Integrated Medicine (RLHIM) is a centre of excellence and has developed a number of safe, evidence-based IM service models for LTCs in the NHS.

4. Service models include:

(a)High volume group acupuncture clinics for various painful conditions have proven benefits including pain relief, reduced need for knee replacement surgery and cost savings to the NHS in both primary and secondary care.

(b)Integrated services for chronic back pain, chronic fatigue syndrome and insomnia.

(c)Programmes using mindfulness, relaxation, cognitive behaviour therapy, hypnotherapy and related approaches for variety of clinical conditions including cancer, anxiety, depression and pre-clinical distress are of proven effectiveness. Many such programmes can be delivered through internet-based applications or DVDs/CDs with limited face to face contact. They enhance self-care, reduce polypharmacy and demand for NHS services.

5. There are many other areas of potential interest, for example:

(a)Tai Chi appears to reduce falls in the elderly and improve symptoms of Parkinson’s Disease.

(b)Aromatherapy may be helpful for behavioural and psychological symptoms of dementia., Antipsychotic drugs, sometimes used to treat such symptoms are associated with increased mortality.

(c)Antibiotic resistance is now a major threat: herbal remedies may have potential to replace the need for antibiotics while homeopathy is associated with reduced use of antibiotics in children’s upper respiratory tract infections, an important source of inappropriate use of antibiotics.

The readiness of local NHS and social care services to treat patients with long-term conditions (including multiple conditions)….

6. Divisions between primary, secondary and social care are reflected in treatment of LTCs and multimorbidity. Expert assessment requiring specialised facilities is most effectively provided in secondary care, but treatment generally involves long term management and medical, social and self-care, most appropriately provided locally.

7. Even when there is clear evidence of cost effectiveness (as for acupuncture in a variety of chronic painful conditions) it is often not “heard” by commissioners.

8. Other examples include

(a)An insomnia service incorporating online education and treatment resources, group and individual consultation provided by the RLHIM. Specialist back up is required for patients who have complex problems (for instance sleeping tablet dependency).

(b)Penny Brohn Cancer Care has developed a Treatment Support Clinic for cancer patients undergoing chemotherapy and radiotherapy at the Bristol Haematology and Oncology Centre. This provides emotional and physical support, and lifestyle advice. Evaluation shows an improvement in survivorships and self-help skills.

The practical assistance offered to commissioners to support the design of services….

9. NHS contracting arrangements can result in a lack of cooperation between commissioners, primary and secondary care providers. Limited scientific information on IM is available to the commissioners and preference for existing local and conventionally based services makes it difficult for those offering an IM approach to LTCs.

10. The report of the recent EU research collaboration CAMbrella highlights the need for more comparative effectiveness research into IM. If we are to provide sustainable solutions to healthcare provision for an aging population suffering from LTCs we must examine the potential of IM rather than continuing to invest in specialised secondary care and increasing polypharmacy. There is promising preliminary data on the potential of IM, but without more detailed evidence expensive and inappropriate “managed” choices for patients with LTCs will continue. Evidence must include informed patients’ perspective. Commissioners and patients should become active and informed stakeholders in the development of research strategy.

11. The RLHIM is has many years of experience and could be an important agent in supporting and advising on the design and implementation of IM, including training and Continuing Professional Development.

12. The cost-effectiveness of such services is greatly enhanced by close integration with NHS and social care. Difficulties in agreeing contracting arrangements between commissioners and care providers and lack of familiarity with IM have constrained wider provision of such services.

The ability of NHS and social care providers to treat multi-morbidities and the patient as a person…

13. The NHS is weak in the treatment of multimorbidity, which is now highly prevalent. NHS secondary care services are often specialised so there may be little holistic overview of the patient. Multimorbidity is frequently compounded by polypharmacy which, in turn, is frequently associated with adverse drug reactions. Fragmentation of clinical care through specialist services may result in lack of awareness of drugs prescribed by different doctors. 50% of UK care home residents take six or more drugs daily; this is associated with a very high risk of adverse drug reactions.

14. While attention has been given to reducing drug consumption (for instance by regular review of medicines, an area in which the UK is weak); much less attention has been given to developing and implementing effective non-drug treatments with long term safety and high patient acceptability.

15. Most complementary therapies treat patients rather than diseases. This means that several, nominally separate, conditions coexisting in one patient, may be targeted by a single treatment. This may be the result of the patient centred approach or specific effects of treatment, or both. High quality clinical studies and qualitative research suggests that it is powerful and effective.

16. For instance a large study of acupuncture (18,000 patients) showed it to 50% more clinically effective than conventional care for painful musculo-skeletal conditions and headache and. Other studies show it to be cost effective.1

Obesity as a contributory factor to conditions including diabetes, heart disease…

17. Obesity is a very major contributor to these and other conditions such as arthritis and back pain. Obesity is best tackled in an integrated manner including dietary advice, lifestyle and psychological support provided across health and social care, combined with appropriate backup including bariatric surgery in extreme and intractable cases.

18. Specific dietary interventions are of proven value for various conditions including high cholesterol. Unlike drugs, their collateral effects are positive. Type 2 diabetes is associated with consumption of sweetened beverages (including “diet” drinks). Dietary interventions should be more widely used in the NHS.

Current examples of effective integration…

19. The College of Medicine supports, encourages and disseminates good practice this area.2 Examples of IM included in their innovations network include:

20. “Altogether Better” an evidence-based approach to engaging, training and supporting individuals in communities to become volunteer Community Health Champions. A preliminary evaluation of this approach suggested substantial social return on investment (SROI).

21. Wester Hailes Health Agency works within a disadvantaged community in Edinburgh. It offers a range of integrative services including green gyms, exercise, community gardening, time banking, complementary therapies and counselling.

22. Freshwinds Integrated Medicine Programme, based in the community in Birmingham provides integrative care for adults and children with life-threatening and life-limiting conditions. The multi-disciplinary team includes doctors, complementary therapists and researchers. Programmes include outreach CM for adults receiving end of life care and a “Personal Budgets” complementary therapies project for people living with LTCs. Interim analysis suggests a reduction in hospital admissions.

23. The Bromley By Bow Centre (London) and the Culm Valley Integrated Centre for Health (Devon) use Health Trainers and Facilitators These programmes provide a wide range of activities from cooking classes to gym and dance sessions. The programmes also include IM approaches and specialist Health Trainer to support individuals with mental health needs.

24. A project led by Newcastle West CCG is moving away from a disease specific view of LTCs and is developing a social prescribing project. Social prescribing supports GPs to refer and encourage people to take up activities, instead of, or alongside their medical prescription, to improve the quality of life. This initiative should result in substantial cost savings in terms of prescription drugs, outpatients and hospital admissions).

25. Stockport Council is working with Pennine Care NHS Trust to redesign mental health services to discharge people from specialist services to supportive community alternatives. The new pathway is expected to reduce referrals to secondary care by 65%, discharge by 25% and re-presentation rates by 60%, with savings of £1,320–1,880 per patient.

26. Several charities have developed community programmes, for instance Age UK’s Fit as a Fiddle project is designed by older people for older people to help improve their physical health and mental well being. Savings to NHS have been calculated as £3.50–7.00 for every £1 spent.

The implications of an ageing population for the prevalence and type of long term conditions…

27. An influential paper published in The Lancet in 2012 showed that 23% of the population of Scotland is multimorbid, on average those aged 65 or over have two morbidities, those over 75, three. It concluded “Our findings challenge the single-disease framework by which most health care, medical research, and medical education is configured”.3 The single disease framework has delivered dramatic improvements in health care, so much so that it has become a victim of its own success, it has eliminated or controlled large swathes of human suffering. But applying it uncritically in the context of LTCs and multimorbidity may aggravate the situation.

28. There is a strong correlation between ageing, LTCs, multimorbidity and polypharmacy, the problem is compounded because older people are more susceptible to adverse drug reactions. Existing services will struggle to cope, fragmentation of services, particularly when it results in excessive use of drugs, may aggravate the situation.

29. The CAMbrella report shows that IM provision within the EU is widespread but provision at best patchy and regulation poor. This is the case in the UK. Up to 50% of the UK population suffering from LTCs use CM. This has encouraged charities such as Arthritis Research UK to commission reports for patients on CAM as the majority of patients with arthritis are using CAMs in conjunction with their conventional care to self-manage their LTCs.

The interaction between mental health conditions and long-term physical health conditions

30. Poor mental health is strongly associated with physical LTCs, particularly in socio-economically deprived groups. Whole person approaches which do not view physical and psychosocial problems as independent and integration between health and social care an important in dealing with this. Psychological techniques including mindfulness, relaxation, cognitive behavioural therapy and hypnotherapy-based outpatient programmes have been evaluated for various stages of chronic pain, irritable bowel syndrome, headache, asthma and several other conditions. These non-pharmacological self-care approaches have major and sustainable impacts. These techniques are simple to deliver through a combination of web based interventions with minimal (but vitally important for adherence) face to face contact.

31. Application of such approaches to asthma is supported by preliminary evidence and is now the subject of a large NIHR-supported clinical trial.

The extent to which patients are being offered personalised services…

32. Individualisation, choice, respect for patient preference, cultural appropriateness and understanding of the bio-psycho-social factors that underlie chronic illness are key to successful management of LTCs, including cost and the quality of life of sufferers. A large volume of qualitative research shows the central role that IM can play. The value patients place on it is demonstrated by the high proportion of patients with LTCs who pay out of pocket for CAM. They are, in effect, creating their own models of IM. These could be provided more effectively if the models used were evidence informed and in cooperation of health professionals. Regrettably many patients do not tell health professionals about their use of CAM as they believe them to be poorly informed and sceptical.

33. Apart from reflecting a regrettable lack of trust between patients and health professionals, this could be dangerous: for instance St John’s Wort, an effective and widely available herbal antidepressant, interacts with many drugs. The value that patients place on an open and supportive attitude from health professionals is highlighted by the fact that the RLHIM has among the most positive patient feedback of all NHS hospitals.

3 May 2013