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The Royal London Hospital for Integrated Medicine

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Presentation on theme: "The Royal London Hospital for Integrated Medicine"— Presentation transcript:

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 2013

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


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