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 Peters.

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:

Massage Therapy

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.

Homeopathy

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.

Acupuncture

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 before referral

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 other problems.

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 inform it.

Discussion

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.