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Complementary practice at Phoenix surgery: First steps in cooperative inquiry
Abstract
This paper reports briefly on a cooperative inquiry into collaboration between general and complementary practitioners at Phoenix Surgery in Cirencester. From the experience of the co-researchers it is clear complementary practices have a place in primary health care, and that time and energy need to be devoted to developing communication and understanding for a full benefit to be realized.
... [14][15][16][17][18][19][20] Active 'bottom-up' requests from patients for T&CM delivery puts integration onto the management agenda. [21][22][23][24] Enhancing the patient-centredness of healthcare services represents an important incentive for organizational and management support for developing integrative services. 12,[25][26][27][28][29] Proposing the use of T&CM for managing conditions for which conventional medicine has little to offer (e.g. ...
... 11 Last but not least, interprofessional education between T&CM and conventional clinicians is critical for mutual referral and teamwork. 23,27,30,44,45,57,[65][66][67] For conventional clinicians, lack of knowledge is one of the most cited reasons for disapproving T&CM. 20,24,33,34,37,40,50,53,55,65 Patient referral to T&CM practitioners is very unlikely unless conventional clinicians are willing to gain a better understanding of T&CM and to incorporate such learning into clinical decisionmaking. ...
... At clinician level, co-location is critical for fostering trust, as well as developing a sense of partnership between T&CM and conventional clinicians. 7,19,23,32,33,56,64 At an operational level, co-location facilitates efficient referral, feedback, communication, chart sharing and access to conventional testing facilities. 7,25,30,49,57,64 However, these benefits should be seen as being potential rather than guaranteed; this is because other factors may influence the collaboration process. ...
Background
The World Health Organization advocates integration of traditional and complementary medicine (T&CM) into the conventional health services delivery system. Integrating quality services in a patient-centred manner faces substantial challenges when T&CM is delivered within a health system dominated by conventional medicine. This review has synthesized international experiences of integration strategies across different contexts.
Sources of data
Publications describing international experiences of delivering T&CM service in conventional healthcare settings were searched. Backward and forward citation chasing was also conducted.
Areas of agreement
Capable leaders are crucial in seeking endorsement from stakeholders within the conventional medicine hierarchy and regulatory bodies. However, patient demands for integrative care can be successful as demonstrated by cases included in this review, as can the promotion of the use of T&CM for filling effectiveness gaps in conventional medicine. Safeguarding quality and safety of the services is a priority.
Areas of controversy
Different referral mechanisms between conventional and T&CM practitioners suit different contexts, but at a minimum, general guideline on responsibilities across the two professionals is required. Evidence-based condition-specific referral protocols with detailed integrative treatment planning are gaining in popularity.
Growing points
Interprofessional education is critical to establishing mutual trust and understanding between conventional clinicians and T&CM practitioners. Interprofessional communication is key to a successful collaboration, which can be strengthened by patient chart sharing, instant information exchange, and dedicated time for face-to-face interactions.
Areas timely for developing research
Research is needed on the optimal methods for financing integrated care to ensure equitable access, as well as in remuneration of T&CM practitioners working in integrative healthcare.
... Acupuncture and self-management may also have wider benefits than pain reduction. Patient outcomes and experience data suggest that acupuncture may also improve patients' quality of life and well-being, reduce medication use, and improve coping/self-management24252627. Additionally, high levels of GP and patient satisfaction are often reported with services that include acupuncture24252627. ...
... Patient outcomes and experience data suggest that acupuncture may also improve patients' quality of life and well-being, reduce medication use, and improve coping/self-management24252627. Additionally, high levels of GP and patient satisfaction are often reported with services that include acupuncture24252627. Self-management has also been shown to have wider benefits, such as improvements in self-efficacy and cognitive coping, better energy levels and emotional well-being, reduced fatigue, and increased daily functioning16171819. ...
... Findings showed that patients using the BBPS experienced improvements in their pain, quality of life, understanding of their pain, levels of physical activity and levels of relaxation, which continued for 3 months after they finished treatment (with the exception of relaxation). These findings demonstrate that this type of service can achieve results in line with other research suggesting that acupuncture and self-management can help with the reduction of low back pain e.g.7891011121316171819, as well as having wider benefits such as improved quality of life, psychological well-being and self-efficacy1617181924252627. Our findings also suggest that providing self-management with acupuncture for patients most at risk of developing chronic pain worked best, particularly 3 months post intervention. ...
Supported self-management, acupuncture and information can help reduce the symptoms of low back pain. These approaches are currently recommended by NICE guidance as treatment options for patients with persistent low back pain. However, there has been no previous evaluation of a service providing them together for this common problem. The purpose of this service evaluation was to report patient outcomes and experiences of the Beating Back Pain Service (BBPS), a pilot service based in a primary and community care setting, delivering acupuncture, self-management and information to patients with chronic low back pain.
Patients completed a questionnaire at three time points: pre-BBPS, immediately post-BBPS and three months post-BBPS. Outcome measures included the Bournemouth Questionnaire (measuring musculoskeletal, MSK, problems), EuroQoL-5D (measuring quality of life), Pain and Self-efficacy Questionnaire, and additional questions on medication use, physical activity, understanding of pain and positive well-being. Additionally, the STarT Back (measuring risk of developing chronic pain) was collected at BBPS information sessions. Non-parametric tests were used to evaluate pre- and post- variables. Questionnaires also collected qualitative data (open-text responses) regarding patient views and experiences of the BBPS, which were analysed using thematic analysis.
80 (out of 108) patients who attended the initial BBPS information session agreed to participate in the service evaluation (mean age 47 years, 65% female). 65 patients attended subsequent BBPS acupuncture and/or self-management sessions and were asked to complete post-treatment questionnaires; complete datasets were available for 61 patients.There were statistically significant improvements over time for pain (p <0.0001), quality of life (p = 0.006), understanding of pain (p <0.001), physical activity (p = 0.047) and relaxation (p = 0.012). Post-hoc analysis revealed that scores improved between baseline and post-treatment, these improvements were maintained at 3-month follow-up (except relaxation). Patients receiving a combination of acupuncture and self-management sessions produced the most positive results. Patient satisfaction with the BBPS was high.
The BBPS provided a MSK pain management service that many patients found effective and valuable. Combining self-management with acupuncture was found to be particularly effective, although further consideration is required regarding how best to engage patients in self-management.
... Both of these appear to increase support for integration amongst policy makers. Active ''bottom up'' requests from patients for integration puts the inclusion of TCAM onto the management agenda of BM institutions[27][28][29][30]. Proposing the use of TCAM for managing conditions for which BM treatment has little to offer (i.e., filling BM's effectiveness gaps) appeared to receive less resistance[20,22,[31][32][33][34][35][36]. ...
... TCAM services are expected to be costneutral, even if they do not actually bring cost savings to the NHS. Thus, many TCAM services operate on a self-financing basis, and even when public funding is available, caps on the maximum number of treatments are often applied[29,36,48]. Under such funding arrangements, the flexibility of TCAM provision may be compromised because services would need to be geared to serving the purpose of cost containment and demand management[25,37]. ...
... Under such funding arrangements, the flexibility of TCAM provision may be compromised because services would need to be geared to serving the purpose of cost containment and demand management[25,37]. For example, patients with acute problems may be given preference over those with chronic problems needing osteopathic treatment since effects will be evident in a shorter time span than for those with chronic diseases[29]. The uneven distribution of TCAM funding amongst population groups and locations has made equity in service access difficult to achieve in most situations[21]. ...
Inteprofessional collaboration (IPC) between biomedically trained doctors (BMD) and traditional, complementary and alternative medicine practitioners (TCAMP) is an essential element in the development of successful integrative healthcare (IHC) services. This systematic review aims to identify organizational strategies that would facilitate this process.
We searched 4 international databases for qualitative studies on the theme of BMD-TCAMP IPC, supplemented with a purposive search of 31 health services and TCAM journals. Methodological quality of included studies was assessed using published checklist. Results of each included study were synthesized using a framework approach, with reference to the Structuration Model of Collaboration.
Thirty-seven studies of acceptable quality were included. The main driver for developing integrative healthcare was the demand for holistic care from patients. Integration can best be led by those trained in both paradigms. Bridge-building activities, positive promotion of partnership and co-location of practices are also beneficial for creating bonding between team members. In order to empower the participation of TCAMP, the perceived power differentials need to be reduced. Also, resources should be committed to supporting team building, collaborative initiatives and greater patient access. Leadership and funding from central authorities are needed to promote the use of condition-specific referral protocols and shared electronic health records. More mature IHC programs usually formalize their evaluation process around outcomes that are recognized both by BMD and TCAMP.
The major themes emerging from our review suggest that successful collaborative relationships between BMD and TCAMP are similar to those between other health professionals, and interventions which improve the effectiveness of joint working in other healthcare teams with may well be transferable to promote better partnership between the paradigms. However, striking a balance between the different practices and preserving the epistemological stance of TCAM will remain the greatest challenge in successful integration.
... Both of these appear to increase support for integration amongst policy makers. Active ''bottom up'' requests from patients for integration puts the inclusion of TCAM onto the management agenda of BM institutions27282930. Proposing the use of TCAM for managing conditions for which BM treatment has little to offer (i.e., filling BM's effectiveness gaps) appeared to receive less resistance [20,22,313233343536. ...
... TCAM services are expected to be costneutral , even if they do not actually bring cost savings to the NHS. Thus, many TCAM services operate on a self-financing basis, and even when public funding is available, caps on the maximum number of treatments are often applied [29,36,48]. Under such funding arrangements, the flexibility of TCAM provision may be compromised because services would need to be geared to serving the purpose of cost containment and demand management [25,37]. ...
... Under such funding arrangements, the flexibility of TCAM provision may be compromised because services would need to be geared to serving the purpose of cost containment and demand management [25,37]. For example, patients with acute problems may be given preference over those with chronic problems needing osteopathic treatment since effects will be evident in a shorter time span than for those with chronic diseases [29]. The uneven distribution of TCAM funding amongst population groups and locations has made equity in service access difficult to achieve in most situations [21]. ...
... Information about the relationship between evaluations and funding is missing for several services (either known or suspected as discontinued) operating in the 1990s (Rydings Hall, 12 West Yorkshire, 32 GP based purchasing, 20 Sydenham, 5 Phoenix, 22 Leyton Green 6 ). Thirteen of the 25 services (Glastonbury, 15 Newcastle, 27 Liverpool, 17 Sheffield Menopause Clinic, 28 CHI, 18 CHIPS, [7][8][9] Helios, 26 Get Well UK, 35 St. Margarets, 11 Cullompton, 13 ROMANS, 33,34 CHOICE, 36 Marylebone 21 ) still operate. ...
... integration experiences suggested that interprofessional education between BMD and TCAMP is critical for mutual acquaintanceship , and subsequent referral and teamwork373839. Nevertheless, stakeholders from Hong Kong seemed to be uncertain about its feasibility. For BMD, lack of knowledge is one of the most cited reasons for disapproving TCAM [40– 42]. ...
In Hong Kong, statutory regulation for traditional Chinese medicine (TCM) practitioners has been implemented in the past decade. Increasing use of TCM on top of biomedicine (BM) services by the population has been followed; but corresponding policy development to integrate their practices has not yet been discussed. Using focus group methodology, we explore policy ideas for integration by collating views from frontline BM (n = 50) and TCM clinicians (n = 50). Qualitative data were analyzed under the guidance of structuration model of collaboration, a theoretical model for understanding interprofessional collaboration. From focus group findings we generated 28 possible approaches, and subsequently their acceptability was assessed by a two round Delphi survey amongst BM and TCM policy stakeholders (n = 12). Consensus was reached only on 13 statements. Stakeholders agreed that clinicians from both paradigms should share common goals of providing patient-centered care, promoting the development of protocols for shared care and information exchange, as well as strengthening interprofessional connectivity and leadership for integration. On the other hand, attitudes amongst policy stakeholders were split on the possibility of fostering trust and mutual learning, as well as on enhancing innovation and governmental support. Future policy initiatives should focus on these controversial areas.
... 29 Earlier studies state that communication is central and working in the same premises is the most successful way to achieve quicker and better outcomes at a lower cost. 4,5,16,19,[30][31][32][33] To our knowledge, this is the first trial that has evaluated the effects of combined manual therapy performed under own diagnostic, treatment and management responsibility, for patients with musculoskeletal disorders in outpatient orthopedic waiting lists. Further research is required to establish clinical guidelines for different musculoskeletal disorders and to investigate to what extent manual therapy may reduce orthopedic outpatient waiting lists and to perform cost analyses. ...
Traditionally, orthopedic outpatient waiting lists are long, and many referrals are for conditions that do not respond to interventions available at an orthopedic outpatient department. The overall objective of this trial was to investigate whether it is possible to reduce orthopedic waiting lists through integrative medicine. Specific aims were to compare the effects of naprapathic manual therapy to conventional orthopedic care for outpatients with nonurgent musculoskeletal disorders unlikely to benefit from surgery regarding pain, physical function, and perceived recovery.
Seventy-eight patients referred to an orthopedic outpatient department in Sweden were included in this pragmatic randomized controlled trial. The 2 interventions compared were naprapathic manual therapy (index group) and conventional orthopedic care (control group). Pain, physical function, and perceived recovery were measured by questionnaires at baseline and after 12, 24, and 52 weeks. The number of patients being discharged from the waiting lists and the level of agreement concerning management decisions between the naprapath and the orthopedists were also estimated.
After 52 weeks, statistically significant differences between the groups were found regarding impairment in pain, increased physical function, and regarding perceived recovery, favoring the index group. Sixty-two percent of the patients in the index group agreed to be discharged from the waiting list. The level of agreement concerning the management decisions was 80%.
The trial suggests that naprapathic manual therapy may be an alternative to consider for orthopedic outpatients with disorders unlikely to benefit from surgery.
Treatment for musculoskeletal disorders in primary care in Sweden is generally initiated with advice and medication. Second line therapy is physiotherapy and/or injection and radiography; third line therapy is referral to an orthopedist. Manual therapy is not routine. It is a challenge to identify patients who benefit from treatment by different specialists. The current referral strategy probably contributes to long waiting lists in orthopedic departments which is costly and implies prolonged suffering for the patients. The aim of this health economic evaluation is to compare costs and outcomes from naprapathic manual therapy (NMT) with orthopedic standard care for common, low prioritized, non surgical musculoskeletal disorders, after second line treatment.
Diagnose Related Groups (DRG) were used to define the costs, and the SF-36 was encoded to evaluate the outcomes in cost per quality adjusted life years gained (QALYs).
Results from a 12 months' follow-up showed significantly larger improvement for the NMT than for orthopedic standard care , significantly lower mean cost per patient; 5 427 SEK* (95% CI; 3,693-7,161) compared to14 298 SEK (95% CI; 8,322-20,274), and more gains in QALYs per patient (0,066 compared to 0,026). Thus the result is "dominant".
It is plausible that improved outcomes and reasonable cost savings for low prioritized non surgical outpatients would be attainable if NMT were available as an additional standard care option in orthopedic outpatient clinics. *) Price level 2009; 1 Euro=10,6213 SEK; 1 US Dollar=7,6457 SEK.
In this paper we explore the contribution of work in Human Inquiry to the debate about what might constitute authentic emancipatory practice and about how such an ideal might be approached. We beghin by considering some key values, issues, and commitments which characterise this work and distinguish it from other established research traditions. A number of distinct approaches to the practice of human inquiry have been articulated. These are referred to but it is not our purpose to review particular approaches in detail here. Rather our aim is to move from this overview of human inquiry to consider some important implications for practice. In particular, we look at Bateson's theory of levels of learning and explore ways in which both the intellectual and the more personal frameworks of participants can contribute to, and at times impede, the kinds of mutual learning with which human inquiries are concerned. We illustrate this discussion by drawing on examples from our own work in human inquiry. Here we aim to highlight particular implications and issues that might arise within human inquiries. One source of illustrations is Peter's work with general and complementary practitioners in a primary health care centre, the other is Anne's work with UWE student groups acting as consultants for local community organisations. In each case we consider some origins, forms, and expressions of power differences and show how empowerment can occur as participants learn within and across Bateson's levels as inquiries progress. We conclude by summarising the evidence of and opportunities for empowerment in each case and by showing how a deeper appreciation of Bateson's levels of learning can further understanding of the nature of emancipatory practice. Finally, we make more general suggestions about the role of approaches to Human Inquiry in future emancipatory practice.
The paper focuses on the interprofessional relationships which developed between general practitioners (GPs) and complementary practitioners (CPs) during a pilot project where GPs referred to acupuncturists, osteopaths and chiropractors. It is based on interviews with GPs and CPs, that took place at the beginning and end of an evaluative study on patients referred with musculoskelal conditions. Referrals to hospital orthopaedic outpatients departments and pain clinics were also examined. The most common relationship that developed was where the GP delegated responsibility for treatment to the CP. One CP and GP developed a more interactive relationship which included a shared diagnostic role. The NHS reforms offer opportunities for different types of working relationships to develop between health professionals. They also offer opportunities for professionals who have not traditionally worked in the NHS to do so. The findings discussed here are exploratory. Further research to identify the types of relationships developing between CPs and GPs and to establish whether the type of relationship has an impact on secondary referrals and treatment outcomes is recommended.
To review evaluations of primary and community care complementary therapy services. To explore the impact evaluation reports may have had on funding decisions taken by NHS commissioners.
We collected 32 reports for 25 services, principally in England. Reports were analysed for content using the structure-process-outcome model. Modified BESTCAM guidelines, which came out of a Delphi consensus exercise rating the ability of reports to address commissioners' priorities, were used to address the second objective.
Most commonly, evaluators carried out data extraction of referral forms (10), costings of the service (9), patient satisfaction questionnaires (9) and patient health status questionnaires (8). Five service evaluations addressed NHS cost pressures, with another carrying out a cost effectiveness assessment with QALY.
Addressing commissioners' priorities (e.g. GP consultations rates, prescription rates, secondary care referrals) in complementary therapy service evaluations may bolster chances of securing funding, but are unlikely to be enough on their own.
This book explores research as a collaborative process—researching with and for people, rather than on people. In particular, it addresses the central question: 'What is the nature of participation, and how can participative relationships and processes be established and sustained in human inquiry?'
In the 1st part of the book Peter Reason outlines a theoretical foundation for understanding participation and undertaking participative research. He discusses the emergence of a world-view that is holistic, pluralist and egalitarian, and sees human beings as co-creating their realities through participation. He also stresses the urgency and importance of discovering ways of living in more collaborative relation with each other and with the wider ecology.
The 2nd section presents examples of participative research in action. The contributors give accounts of their processes of research—the aims of the inquiries, the nature of the collaborations that took place, and the particular issues and learning involved. Examples include an evaluation of a prenatal programme by the mothers themselves, an exploration by health visitors of their own professional practice, and a collaborative inquiry into a woman-centred staff development programme in a dominantly masculinist institution.
Addressing both theory and practice, "Participation in Human Inquiry" is [a] sourcebook for students and professionals undertaking research in such fields as psychology, sociology, management and education. It will be of particular interest to practitioners of co-operative inquiry, participatory action research, action inquiry and all forms of collaborative action research. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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