1. The Royal London Hospital for Integrated Medicine
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)

2. 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

3. 10 leading causes of disease burden 2004 & 2030 (WHO)
WHO: The global burden of disease: 2004 update (2008)

4. Prevalence of mental disorder
Annual population prevalence in EU 38%: 165m people
anxiety disorders (14%)
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 Eur Neuropsychopharmacol. 2011;21:655-79

5. ...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 7
Statistics Canada: Canadian Community Health Survey 2010

6. Multimorbidity is common
40 morbidities ⅓ population of Scotland
42% > 1 morbidity
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
Highest
socio-economic quartile
Lowest socio-economic quartile
Barnett K et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet May 2012 DOI: /S (12)

7. Adverse drug events (ADEs)
Common
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
/1000 between
Expensive
Prolong hospital stays, increased resource utilization

8. 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 –910.

9. Increasing costs, more complex morbidity
A perfect storm?
Aging population
Chronic/multi
morbidity
Increased treatment
Increased ADEs
Increasing costs, more complex morbidity

10. 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

11. 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

12. The NHS hospital most recommended by its own patients: NHS Choices website

13. The Royal London Hospital for Integrated Medicine: clinical services
Acupuncture
including high volume & training clinics
mostly western, some TCM
Allergy
Children
Chronic Fatigue Syndrome/ME
Complementary Cancer
General medicine
Including inflammatory and functional bowel
Podiatry
Royal London Hospital for Integrated Medicine 13

14. RLHIM: clinical services 2
Weight loss
Insomnia
Integrated facial pain
Integrated antenatal
Musculoskeletal medicine
Rheumatology
Skin
Stress & mood disorder
Women's
Royal London Hospital for Integrated Medicine 14

15. RLHIM: innovation 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

16. 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 32
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.

17. 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:

18. The Royal London Hospital for Integrated Medicine: therapies
acupuncture
mostly western, some TCM
aromatherapy
autogenic training
cognitive behaviour therapy
cranio-sacral therapy
graded exercise
homeopathy
nutritional medicine
exclusion, supplements, nutraceuticals
Royal London Hospital for Integrated Medicine 18

19. Royal London Hospital for Integrated Medicine
RLHIM: therapies 2
lifestyle management
occupational therapy
physiotherapy
phytotherapy
standardised extracts
western mixtures
Chinese an aspiration
shiatsu
spinal manipulation
sublingual immunotherapy
wet needling
Royal London Hospital for Integrated Medicine 19

20. 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 20

21. Dimensions of integration: professionalism

22. Dimensions of integration: information and education
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 22

23. Dimensions of integration: hands-on training

24. Complementary and Alternative Medicine Library and Information Service (CAMLIS)

25. Royal London Hospital for Integrated Medicine
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 25

26. 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 26

27. High volume acupuncture clinic for
knee pain 27

28. Constraints to Integration
Coordinated hostile media campaign
NHS provision
Regulation
Scepticism
colleagues, particularly academic and older
Financial
but often saves money 28

29. 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

30. 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

31. 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

32. 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
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 32

33. Low Back Pain Care Pathway
Royal London Hospital for Integrated Medicine
Low Back Pain Care Pathway
Complies with NICE Guideline CG88 Low Back Pain
Revised October 2012

34. Irritable bowel syndrome Care Pathway
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

35. category 2: Not requiring prior approval, not guideline based
Royal London Hospital for Integrated Medicine Complementary Cancer Care Pathway
category 2: Not requiring prior approval, not guideline based

36. 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

37. ‘Musculoskeletal other’ approval criteria
Commissioners will only fund Integrated Medical treatment for Musculoskeletal and Rheumatology
pain and/or disability significantly restricting work, everyday living
AND
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

38. Summary Responsive to need Integrated in depth
services offering range of therapies
Integrated in depth
Dimensions
Service models
Guidelines, evidence, pathways
Patient preference

39. The Royal London Hospital for Integrated Medicine
Keys to success
Patient-centredness
Quality & Safety
practitioners, medicinal products, processes
quality assurance: audit, governance
Innovation
responsive to need, guidelines etc
Integration
best of complementary and conventional
The Royal London Hospital for Integrated Medicine

40. International Congress for Complementary Medicine Research London April

41. International Congress for Complementary Medicine Research
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 April 2013

42. Thank you for your attention peter.fisher@uclh.nhs.uk