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Dr Peter Fisher Clinical Director Director of Research Expert Advisor to National Institute for Health and Clinical Excellence (NICE) The UK experience:

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Presentation on theme: "Dr Peter Fisher Clinical Director Director of Research Expert Advisor to National Institute for Health and Clinical Excellence (NICE) The UK experience:"— Presentation transcript:

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2 Dr Peter Fisher Clinical Director Director of Research Expert Advisor to National Institute for Health and Clinical Excellence (NICE) The UK experience: The Royal London Hospital for Integrated Medicine

3 University College London Hospitals One of largest academic medical centres in UK One of largest academic medical centres in UK Medical school and specialist institutes, linked to University College London Medical school and specialist institutes, linked to University College London 8 hospitals: 8 hospitals: University College Hospital (general/acute) University College Hospital (general/acute) Cancer Centre Cancer Centre Eastman Dental Hospital Eastman Dental Hospital Elizabeth Garret Anderson Elizabeth Garret Anderson (gynaecology, obstetrics, children) (gynaecology, obstetrics, children) Heart Hospital Heart Hospital Hospital for Tropical Diseases Hospital for Tropical Diseases National Hospital for Neurology and Neurosurgery National Hospital for Neurology and Neurosurgery Royal London Hospital for Integrated Medicine Royal London Hospital for Integrated Medicine The Royal London Hospital for Integrated Medicine peter.fisher@uclh.nhs.uk

4 10 leading causes of disease burden 2004 & 2030 (WHO) WHO: The global burden of disease: 2004 update (2008)

5 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 2010. Eur Neuropsychopharmacol. 2011;21:655-79

6 ...and Medically Unexplained Physical Symptoms (MUPS) 20052010% change Chronic Fatigue Syndrome 333,816413,37024% Fibromyalgia389,782446,58615% Multiple Chemical Sensitivities 598,585784,79831% Target Population27,125,06528,890,7107 Statistics Canada: Canadian Community Health Survey 2010

7 Multimorbidity is common 40 morbidities 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 Barnett K et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet May 2012 DOI:10.1016/S0140-6736(12)60240-2 Lowest socio- economic quartile Highest socio- economic quartile

8 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 9 17/1000 between 1995-2005 Expensive Prolong hospital stays, increased resource utilization

9 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. 2010 19 901–910.

10 A perfect storm? Aging population Chronic/multi morbidity Increased treatmentIncreased ADEs Increasing costs, more complex morbidity

11 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

12 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

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

14 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

15 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

16 RLHIM: innovation 1950s 1 st NHS Complementary Cancer Service 1977 1 st NHS Acupuncture Service 1995 1 st NHS Musculoskeletal medicine service 2005 1 st NHS Group acupuncture service 2005 1 st UK course on Integrated Medicine for doctors 2006 1 st NHS Integrated antenatal service 2007 1 st Integrated allergy service 2008 1 st NHS Herbal clinic 2009 1 st Integrated weight loss service 2010 1 st Integrated insomnia service 2012 Complementary Cancer Care in UKs largest cancer centre

17 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 91 Depression45 Eczema36 Chronic pain32 Irritable bowel syndrome32 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.

18 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;11:243-248.

19 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

20 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

21 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

22 Dimensions of integration: professionalism

23 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

24 Dimensions of integration: hands-on training

25 Complementary and Alternative Medicine Library and Information Service (CAMLIS) www.cam.nhs.uk

26 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 UCLHs only services for under-provided conditions: guideline recommended treatments & CM. Royal London Hospital for Integrated Medicine

27 Models of integration 2 Colocated services: in UCLHs 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

28 High volume acupuncture clinic for knee pain

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

30 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

31 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

32 NHS Commissioning Category 1 based on authoritative guidelines Stress & Mood DisorderGroup Acupuncture Chronic Headache Non-Organic InsomniaGroup Acupuncture Knee Pain Cognitive Behavioural TherapyPerennial Allergic Rhinitis Irritable Bowel SyndromeHayfever Fibromyalgia SyndromeWeight Loss Chronic Fatigue SyndromeFacial Pain Chronic low back pain

33 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 http://guidance.nice.org.uk/CG88

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

35 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

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

37 NHS Commissioning Category 3 require prior approval AntenatalSkin Mother & babyOsteoarthritis Autogenic trainingMusculoskeletal other Children behaviouralInflammatory arthritis Vulnerable includes some of most popular & innovative services

38 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

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

40 Keys to success 1)Patient-centredness 2)Patient-centredness 3)Patient-centredness 4)Patient-centredness 2)Quality & Safety practitioners, medicinal products, processes quality assurance: audit, governance 3)Innovation responsive to need, guidelines etc 4)Integration best of complementary and conventional The Royal London Hospital for Integrated Medicine peter.fisher@uclh.nhs.uk

41 International Congress for Complementary Medicine Research London 11 - 13 April 2013 www.iccmr2013.com

42 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 11 - 13 April 2013 www.iccmr2013.com

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


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