Visit to the Marylebone Health Centre,
12 April 2000
|Members present:||Earl Baldwin of Bewdley
|Lord Perry of Walton
|Lord Walton of Detchant (Chairman)
On arrival at the Health Centre the members of the Sub-Committee
were welcomed by the staff, who included:
Dr Tania Eber GP
Martin Gerish practice manager
Dr Goodstone GP
Gerry Harris acupuncturist
Chrissie Melhuish massage therapist
Dr Sue Morrison GP
Dr Richard Morrison GP
Dr David Peters osteopath
Gabrielle Pinto homeopath
Dr Sue Morrison described Marylebone Health Centre (MHC). The
health centre was started 12 years ago by Dr Patrick Pietroni
and Dr Derek Chase. The original objective was to "explore
and evaluate ways in which primary healthcare can be delivered
to a deprived area in addition to the General Practice component.
The approach is to include an holistic component comprising an
education self-help model and a complementary healthcare model."
The primary focus of the practice is collaboration
with many types of healthcare professionals including complementary
therapists. There is also a focus on internal collaboration with
patients and a big issue for the practice is power sharing; there
is a patient partnership group and patients are involved in the
strategy forming group. The practice aims to be a model that can
be useful in other NHS centres.
MHC has a local catchment area like any other NHS
practice and it does not offer private treatment. To access CAM
services, patients must be referred by one of the GPs at the practice.
It has been found that some patients register purely to get access
to CAM, and this is discouraged as it is thought preferable for
the patient to have built up a relationship with a GP before in-house
referral. The demographics of the patients of the practice are
characteristic of an inner city GP practice. However it is a very
mobile population due to a high proportion of students, homeless
people and political refugees. The practice has a high turnover
rate of 50% per annum.
Introduction to Integrative Approaches - David
David Peters discussed research at the centre. MHC
is a multidisciplinary practice with an emphasis on inter-professional
learning. It is linked to the University of Westminster Centre
for Community Care and Primary Health, which is interested in
integrating relevant aspects of complementary therapy appropriately
into multi-disciplinary mainstream NHS Care. He explained that
the two organisations work together and that, in a sense, MHC
is laboratory of the university.
He discussed how integrated medicine is an emerging
field and that therefore they had had to develop intuitively in
response to patients' and practitioners' needs. However, their
research has also had to try and address the Cochrane Questions
such as: Can it work? Does it work in practice and Is it worth
it? He explained that one of the challenges in the area of integrated
medicine is that it is about more than just combining orthodox
medicine and CAM therapies, it is about emphasising health promotion
and self-care and about collaboration between practitioners and
developing the practitioner-patient relationship.
He discussed the history of research at MHC. Between
1987-1992 the Centre was part of the St Mary's-Waites project
and the main questions they were looking at were whether integrated
healthcare had a role in primary health, and whether it was an
acceptable and appropriate area to encourage. In the 90s they
have moved on to investigating the best methods for integrated
delivery. Now (under a new grant) they are looking at specific
intake criteria and outcome measures. These changes in research
focus have been developing at the same time as a change in UK
medical attitudes towards CAM, which he summarised as having gone
from the idea of CAM as fringe, to alternative, to complementary
and now to integrated.
Dr Peters described the six stages of integrating
CAM into general practice and discussed the main questions to
be tackled at each stage. These were:
|1)||Practice review - what needs are being poorly met?
|2)||Resource assessment - is CAM relevant? what is its evidence base? is integration feasible?
|3)||Designing a service - asking how will GPs use the service? what will be its aims? how will complementary practitioners be integrated into the primary care team?
|4)||Delivering the service - developing referral procedures and working on resource monitoring.
|5)||Management servicing - including quality assurance procedures and evaluating outcomes,
|6) ||Modifying the service in response to experience.
Once modification has taken place the steps can start all over
again, so the service is constantly self-monitoring and improving.
Dr Peters discussed the question of how to decide when GPs should
consider a CAM referral. At MHC it was decided to do this only
for conditions where some evidence for efficacy of a particular
CAM existed. It was also decided referrals would only take place
if GPs wanted to refer, and complementary practitioners thought
they could help and had an interest in helping. They have now
developed a list of conditions that they commonly consider for
CAM referrals. These included complex chronic illnesses such as
chronic fatigue syndrome; stress-related conditions; asthma; IBS;
eczema and allergies; migraine. GPs consider a referral if there
is a new diagnosis of one of these conditions and one of the following
criteria applies: (a)r orthodox medicine has failed; (b) the patient
is suffering side-effects from the orthodox medicine; (c) the
patient requests CAM for one of these conditions; or (d) if the
GP feels it is a complex case where CAM may help (and having asked
the CAM therapist they, too, feel they may be able to help.)
Dr Peters finished his talk by describing how research has the
capacity to serve both practitioners' and patients' needs. For
example, audit ensures quality assurance, research through qualitative
methods increases understanding of the patient's experience, action
research promotes service and professional development and case
studies illustrate best practice models. In this way practice-based
research promotes quality and understanding.
Demonstration of Use of IT System for Quality Assurance Audit
- Gerry Harris
Gerry Harris, an acupuncturist at the practice, demonstrated how
patients are referred to complementary therapists at the practice,
and how the complementary therapists record the progress of their
treatment package in a way that makes clinical audit possible.
Patients at the practice can only see complementary practitioners
if they are referred by one of the GPs. The practice has two forms
for such referrals - one with the basic referral information and
the other a Measure Your Own Medical Outcome Profile (MYMOP).
The MYMOP form describes what each patient's primary and secondary
(and if applicable subsequent) complaints are and the patient
has to rate how much they are suffering. The information from
the MYMOP is put on a specially designed computer programme. Each
time the patient goes to their complementary therapist they rate
how they are feeling and this is entered into the computer with
other relevant information. This creates a log of the progress
of the referral and the computer generates graphs logging improvement
(or lack of it) in each patient.
Demonstration of Complementary Therapies.
The Members of the sub-committee were invited to watch patients
being treated by one of the complementary therapists present.
The demonstrations provided were:
Chrissie Melhuish, a massage therapist, treated a patient with
whiplash complicated by sports injuries and chronic stress. The
practitioner was a trained nurse, with experience of both osteopathy
and sports medicine. She described her approach to patients with
stress-related problems: long sessions (1 hour), with time to
talk; and self-help, involving exercises and stress-management
techniques. She expressed doubt whether the ITEC qualification
was adequate in itself for safe practice.
Gabrielle Pinto, a homeopath, treated a patient with a history
of Irritable Bowel Syndrome and panic attacks. The practitioner
had being seeing the patient for about 18 months. She explained
that the first few sessions with a patient usually involves finding
the right remedy for that patient and this may take a while. If
the patient is taking a lot of orthodox medical drugs, she often
starts by recommending herbal medicines before moving onto homeopathic
remedies. Once the right therapy is found patients can often self-medicate
at home, but if they have relapses or need high-potency remedies
they come back to see the homeopath. The patient present at this
demonstration reported improvement with both her complaints and
she attributed this to homeopathy. She claimed her homeopathic
treatment has allowed her to stop being reliant on the drugs her
GP had been prescribing, which had included Colepermin and Beta-Blockers.
She also felt she did not need to visit GPs so often now she was
seeing the homeopath. When asked if she would have gone to a homeopath
herself if she had not been referred on the NHS, she said she
would have if she could have found an affordable one but that
would have been unlikely.
Gerry Harris, an acupuncturist, treated a patient with multiple
problems (including leukaemia) for which she was also receiving
orthodox treatment. The patient felt the acupuncture helped to
'keep her balanced' throughout her illness. Gerry Harris described
how she leaves the needles in patients for about 20 minutes and
therefore if two treatment rooms are available she can treat two
patients at once, thus improving her treatment rate.
Meeting with Practitioners and Patients
The Sub-Committee were introduced to seven patients who had received
complementary therapies at the Centre, many of whom were members
of the patient-partnership association. Each of these patients
had suffered from very different complaints including asthma,
back pain (following a car accident where vertebrae were broken),
cancer, recurrent urinary tract infections and chronic rhinitis.
All the patients had tried a variety of orthodox treatments before
being referred to complementary therapists at the practice, and
all felt that they had benefited from CAM. Many claimed it had
reduced their reliance on the orthodox medicine they were using
Evidence-based Practice - David Peters
David Peters discussed the applicability research to real-life
practice. He suggested that, although RCTs and meta-analysis of
RCTs are valuable, in that they provide certainty about the efficacy
of a medication for a particular condition, real-life primary
care does not mirror the way illness and treatment are defined
in such research. He explained patients do not come to their GPs
with specific, well-defined conditions but the intake for most
trials eliminates all but the most clear-cut examples of a condition.
He suggested that this was especially a problem for CAM as the
GPs often referred the more complicated patients who had chronic
complex conditions. Often these patients were not suffering from
a single problem, although a particular condition may have been
the reason for referral but further discussion often unveiled
He also discussed the problem of how to shape outcome criteria
for research into CAM. The complementary therapists at the practice
had considered a number of instruments for evaluating outcome.
These included questionnaires such as the SF36. However, many
of these instruments required a lot of time and thought from the
patients so the MHC had decided to opt for the MYMOP form. They
are piloting this form but say that using any standard instrument
is hard as they get such a variety of patients.
In summary David Peters suggested that a variety of research methods
should be used for CAM. RCTs should be used as they have a high
standard of rigour but outcomes research can complement RCTs and
can be designed in a way that has more relevance to primary care.
Together he believes it is possible to build an evidence 'mosaic'.
They are making efforts to create their own research, and early
results show that many patients are doing well. Dr Peters feels
that it is possible to create rigorous data within a patient-centred
practice with vague entry criteria. Their eventual aim is more
rigour in their research methods, for example through randomising
patients to different treatments.
Practice-based Evidence - Dr Sue Morrison
Dr Sue Morrison started her talk by saying that the issues of
evidence-based practice and practice-based evidence were related.
She moved on to describe the status of the practice which is a
PMS Pilot, and therefore it is on a devolved budget. However Dr
Morrison suggested that their PCG is moving towards a PMS-type
structure and if they had known this was going to happen then
they may not have taken up the offer of the PMS Pilot.
Although their status on the PMS pilot means that MHC is different
from the rest of their local PCG, they are trying to stay integrated.
Dr Morrison herself is on the board of a sub-group of the PCG
that is looking into opening up CAM provision to the whole of
the PCG. This plan is currently only in development but they have
decided that GPs and complementary practitioners will only be
able to refer into the service if they have been on a course about
integration which is being developed.
Dr Morrison explained that as a practice they have always been
in favour of rigorous clinical audit and they are using data from
their audits to develop a manual of integrated care for other
practices to use. However she described some limitations to their
data, such as the fact that some patients self-select to MHC in
order to access CAM, and therefore wider information is needed
from across the PCG on what patients want.
She finished her talk by saying that although the practice has
been dutiful to NHS policy they are also hoping to be able to
Many questions about research were discussed. These included points
on the problem of how to randomise for time spent with patients,
and how to take account of a variety of possible confounding factors
such as whether a patient pays for the service and how this may
affect their reaction to a treatment. One point that was emphasised
was that research involving CAM must ensure that the CAM practitioners
involved are properly trained as there is a mix of training standards
in the area. The staff at MHC are talking about developing a research
management group to tackle such issues. However some worries were
aired that the future of services like those provided at MHC may
be in danger during the first few years of PCGs when money is
tight, and those in management are anxious and have a big enough
task just managing orthodox medical services.