Medicine as if people matter – integration rather than breakdown

Michael Dixon, Chair, College of Medicine

Published in JHH13.1 – Shaping the invisible

Ten years into general practice, I was burnt out. Swamped by patients presenting with a range of problems from chronic tiredness, frequent minor infections, irritable bowel, headaches and back pain to stress, loneliness and sheer misery. Discovering complementary medicine gave me back my professional life and radically altered my views on how to heal and the importance of balancing the perspective of clinician and patient.The College of Medicine advocates an open-minded approach to health and healing that includes complementary medicine and other non-biomedical interventions such as the arts and healthy eating, which are being increasingly offered under the umbrella of ‘social prescription’, which is another college-led initiative.

The problem is that we have established a very linear form of biomedical science that doesn’t fit the real world of patients and their frontline practitioners Click To Tweet

A place for complementary medicine in the NHS?

Ask a conventional scientist or public health physician and the answer to this question would most probably be ‘no’. Patients (at least 75% of them according to a number of surveys, including two by the BBC) appear to disagree and say that complementary medicine should be offered on the NHS. Meanwhile, clinicians are split in their opinions. Is there any room for compromise?

Many conventional scientists and medics would say that the issue can be resolved with high quality comparative cost effectiveness evidence showing if and where complementary medicine (CAM) might offer better value than currently provided conventional treatment. Therein lies a problem. That is because the much-needed studies – pragmatic service-based comparative trials of cost effectiveness – have seldom been done in an NHS that spends 0% of its research budget on complementary medicine. So such evidence is unlikely to be available in the near future, and this lack of funding for research leaves complementary medicine in a cleft stick and largely excluded from the NHS. It has to be said that there is more than a trace of hypocrisy in this, given that much conventional primary care (25% by conservative estimates) also lacks an evidence base. However, a forthcoming scoping study supported by the Department of Health is looking into the potential role of complementary medicine. Led by Bristol Professor of Primary Care Debbie Sharp, it could, if it produces a case for greater research investment for complementary medicine, in time redress the balance.

Double standards

Yet the NHS’s double standards prevail even when complementary medicine research has produced an evidence base. Take for example the much reported NICE guidelines (now under revision) which include acupuncture, chiropractic and osteopathy for persistent back pain. Most clinical commissioning groups (CCGs), despite their statutory responsibility to innovate, have continued to withhold funding for these options on the basis that they do not have enough money for engaging new services. Perhaps, given the current state of our cash[1]strapped NHS – which can barely meet demands for standard treatments – we should sympathise.

Clinicians and CM

If commissioners and central government seem negative then what about clinicians, many of whom already provide complementary medicine as part of their NHS service? That includes 50% of physiotherapists who offer acupuncture. An unknown number of GPs offer acupuncture or hypnotherapy, homeopathy or (a meagre few) even osteopathy and other complementary techniques. They do this because they have found these skills help relieve patient suffering where conventional medicine fails. As just such a clinician myself, I have found that using these approaches in my everyday clinical work increases patient (and my own) satisfaction. Furthermore it gives me something extra to offer while reducing my referrals and overall patient costs. In addition we now have some complementary practitioners on site, and this has led most of my GP partners (believers and non-believers) to recognise their value. In a few cases these practitioners have been the early detectors of serious problems in patients referred to them: among my own patients, melanoma, temporal arteritis and spinal secondaries.

 Integrated services

A decade ago, this kind of integrated service was less of a rarity than now. And, since it can add so much value on so many levels – not least economic – it is curious to say the least that the many integration innovations of the 90s and noughties have withered away. Yet there are a few staunch innovators left, such as Whitstable GP John Ribchester. The triaging service for people with musculoskeletal problems which John has developed, offering acupuncture and chiropractic, has shown significantly reduced secondary care referrals and overall costs over several years.

Fundamentalism in science

Yet tolerance of clinical opinions outside the box is now under threat. The Council of the Royal College of General Practitioners recently voted against GPs providing home[1]opathy. There is growing hostility towards clinicians who do not fit a ‘conventional norm’: the government plans to blacklist the use of homeopathic medicines by GPs – a decision hardly based upon economics for the total cost of these medicines is only £110,000 a year (approximately £10 per GP practice). Nor apparently is it even founded on principle but, allegedly, on fear of legal action from those who oppose complementary medicine. Homeopathy may in clinical and public eyes be less credible than many other complementary therapies but surely it does not justify what seems dangerously akin to a McCarthy-like purge?

What do patients want?

If the NHS is institutionally biased against complementary medicine and its practitioners are to be ostracised, then what about patient opinions? Are we to say that conventional scientists must be right and that therefore patients’ experience is worthless? But the ground that fundamentalists stand on appears to be moving. The Rotherham Clinical Commissioning Group does not directly commission complementary medicine but it has introduced social prescribing. This initiative, directed at the 2/3% patients who use hospital services the most, enables them to access a range of extended services they believe might be helpful. This has substantially reduced their hospital use and overall costs and notably one of the most common requests has been for complementary medicine. By default and by a process of subversive patient-led sub-commissioning, the health service is once again paying for complementary medicine. If this is a way of saving costs and meeting patients’ needs, this trickle of change through the dam of prejudice could, as personal budgets come on line, become a flood.

Fully human medical science

The Rotherham example suggests that something has gone wrong in the system elsewhere. The problem is that we have established a very linear form of biomedical science that doesn’t fit the real world of patients and their frontline practitioners. It doesn’t even conform to good science, but demands instead the narrowest possible definition of what is real and true according to experiment: a version of science that views human nature, the mind–body connection and therapeutic relationships as nuisance elements. Consequently, many patients and quite a few frontline practitioners who take human factors very seriously, and who integrate them into their work, are finding better solutions than current science is prepared to embrace. This response does not disregard science but demands that science widen its scope to embrace the real world of experience. Integrated clinical science includes a patient’s history, culture, beliefs, and aspirations; it factors in psychosocial as well as mere biological considerations; it tries to balance the realities of individual differences with the validity of traditional averaged out population[1]based evidence.

Individualised medicine

In the same way that genetic mapping and the very latest focused treatment of cancer aims to fit the individual patient, so the art/science of treatment generally, but especially in primary care, needs to become more specific for each individual patient. It also needs to become more generous and understanding. Conventional science would say, for instance, that if a trial of a given therapy produced negative results for those that didn’t believe in it and positive ones for those who did, then the treatment did not work and should not be funded. That is not a logical scientific conclusion: surely it would be justifiable to offer such a treatment to those who believe in it, as long as costs are saved. To say otherwise is to deny a treatment that works for some and will make more resources available for others.

It’s complicated

This takes us to the heart of the issue. Increasingly, the mainstream view of medicine confines it to applying experimental and population-based research; hopefully (but not necessarily) delivered in a compassionate environment. But good medicine is more complex, artistic, subtle and intelligent. In real life many symptoms are metaphors: the headache or chronic tiredness that represents an accumulation of negative features in a patient’s life; the pains in back, guts or genitals that arise from chronically held tensions whose back-stories can’t be told; the chronic diseases rooted in lifestyle or environ[1]mental pollution. Additionally the beneficial effects of some treatments may derive from some cultural or personal symbolic significance. How else to explain the greater use of acupuncture in China or suppositories in France? Medicine must not be dumbed down to the mindless application of biological guidelines doled out by practitioners who have become coerced medical clones. Patients (and most doctors) know there’s more to medicine than this, but the corporate NHS it seems, prefers to ignore it – because of course, it complicates things.

Is there a way forward?

While the NHS examines the potential role for complementary medicine (and hopefully supports some proper cost-effectiveness evidence with which to judge it) clinicians and commissioners should be encouraged to try out the intelligent introduction of complementary therapies because we need to find out what they can achieve in real world situations rather than atypical experimental settings. The question is, are they cost[1]effective with typical patients in typical clinical settings, and can we show – through audit and comparative pragmatic studies – that they are helping patients and saving money. Whitstable and Rotherham are leading the way. There, clinician and the commissioners, though agnostic on the complementary versus conventional issue, have been free-thinking and innovative enough to enable local clinicians and patients to find their own solutions.

Additionally the beneficial effects of some treatments may derive from some cultural or personal symbolic significance

 Courage, collaboration and confidence

We need more of this kind of courage if we are to re-humanise primary care. There can be no doubt that high-tech secondary care using population-based research has conquered some of the high ground: cancer, heart disease and a number of life-threatening conditions. But where long-term disease and less serious conditions are involved, complementary approaches and lifestyle interventions and mind-body medicine may prove cheaper, safer and more satisfactory to the patient than expensive conventional treatment. More often than not, it seems that providing patients with a choice may lower costs. Perhaps it is time for scientists, commissioners and clinicians to trust better the judgement of their own patients and research the outcomes and implications of letting them decide.

Healthcare is in a crisis. Intolerance, conflict and faction-fighting won’t help us find ways out

Indeed, if we do take the rhetoric of a ‘patient-centred’ NHS seriously then we clinicians, rather than foisting our narrow ‘scientific’ opinions and beliefs on them, should see ourselves as their servants. Patients deserve a voice, and a voice that must now be taken seriously by NHS commissioners and clinicians. Now is the time for a more mature and curious attitude to complementary medicine, and for its leaders and clinicians to feel less bullied by the lobbying and aggressive anti-CM voices and their mysterious agendas.

Healthcare is in a crisis. Intolerance, conflict and faction-fighting won’t help us find ways out. Though some bloggers still like to amuse themselves by stoking CM controversies, and a few pundits have built careers on these flimsy foundations, actually these people are just climbing up the signpost. For CM controversies actually tell us a lot about what’s gone wrong with medicine. Understanding, open-mindedness and tolerance are what we need, not just for CM but for the very idea of medicine as an art as well as a science.