A Model of Integrated Primary Care: Anthroposophic Medicine January 2001 Jane Ritchie National Centre for Social Research Jane Wilkinson Madeleine Gantley Gene Feder Yvonne Carter Juliet Formby Department of General Practice and Primary Care St Bartholomew’s and the Royal London School of Medicine and Dentistry Queen Mary, University of London Participating practices: Blackthorn Medical Centre, Maidstone Camphill Medical Practice, Aberdeen Helios Surgery and Therapy Centre, Bristol Mytton Oak Foundation, Shrewsbury Park Attwood Clinic, Bewdley St Luke’s Medical and Therapy Centre, Stroud Wallis Avenue Surgery, Maidstone Department of General Practice and Primary Care St Bartholomew’s and Royal London School of Medicine Queen Mary, University of London London E1 4NS 020 78827957 (telephone) 020 78826396 (fax) [email protected] © 2001 ISBN 898661 59 6 Department of General Practice and Primary Care 1 CONTENTS Project Team 3 Acknowledgements 3 RESEARCH SUMMARY 4 PREFACE. 11 PART I THE STUDY AND ITS CONTEXT 13 1 INTRODUCTION 14 1.1 NHS developments and their implications for primary care 14 1.2 The study 18 PART I I ANTHROPOSOPHIC MEDICINE AND ITS DELIVERY 21 2 THE PRACTICES 22 2.1 A profile of the practices 22 2.2 The development of anthroposophic medicine within the practices 25 2.3 Funding 28 2.4 External liaison 30 3 THE PRACTITIONERS 32 3.1 New options for primary care – where does anthroposophic medicine lie? 32 3.2 General features and philosophies of practice 33 3.3 The general practitioners 36 3.4 Therapeutic teams 37 3.5 Teamwork, supervision and support 39 3.6 Professional networks 40 4 REFERRALS 42 4.1 Sources of referral to anthroposophic practices and practitioners 42 4.2 Process of referral to anthroposophic practices and treatments 43 4.3 Process and criteria for assessing the suitability of patients for anthroposophic treatment 45 4.4 Strategies for encouraging the take-up of anthroposophic treatment 49 5 MEDICAL CARE 53 5.1 Provision of medical care 53 5.2 Medication 56 5.3 The perceived benefits of anthroposophic prescribing 64 5.4 Anthroposophic nursing 65 5.5 Specialist medicinal treatments 66 6 MASSAGE, EURYTHMY AND COUNSELLING 68 6.1 Massage 68 6.2 Eurythmy 73 6.3 Counselling 76 7 ART, MUSIC AND OCCUPATIONAL THERAPIES 81 7.1 Art and sculpture therapy 81 7.2 Music Therapy 86 7.3 Occupational and social therapies 89 2 Department of General Practice and Primary Care 8 THE PATIENTS 93 8.1 Profile of patients receiving anthroposophic treatments 93 8.2 Awareness and understanding of anthroposophic practice and its origins 98 8.3 Aspects of patient care 100 8.4 Responses to anthroposophic medicine and treatments 108 PART III CLINICAL OUTCOMES AND THEIR MEASUREMENT 115 9 THE OUTCOMES OF COMPLEX INTERVENTIONS 116 9.1 Sources of information 117 9.2 The classes and categories of outcomes 121 9.3 Problems of outcome measures 129 10 EVALUATION OF ANTHROPOSOPHIC TREATMENT PROGRAMMES IN THE UNITED KINGDOM 131 10.1 The need for research on effectiveness of anthroposophic medicine and complementary therapies 131 10.2 Research on complementary medicine in primary care 132 10.3 The need for primary health care service research and development 134 10.4 Understanding, assessing and improving quality in primary care 134 10.5 Addressing co-morbidity and professional Issues 135 10.6 Methodological and capacity developments 135 10.7 Future research on anthroposophic medicine in the United Kingdom 136 10.8 Evaluation of effectiveness 136 10.9 Is a randomised controlled trial feasible in anthroposophic practices? 137 10.10 Beyond trials 138 APPENDICES 139 I DESIGN AND CONDUCT OF THE RESEARCH 140 II STUDY DOCUMENTS 147 REFERENCES 158 Department of General Practice and Primary Care 3 Project Team The study was initially designed by Jane Ritchie and further developed with the collaboration of Yvonne Carter, Gene Feder and Madeleine Gantley. Jane Wilkinson was responsible for interviews, other data collection and initial analysis, supervised by Jane Ritchie with the support of Madeleine Gantley. Juliet Formby contributed to the medical records extraction and analysis, under the supervision of Gene Feder. All the members of the team participated in discussion of the results, as well as writing of this report. Acknowledgements This study was funded by the Anthroposophic Medical Trust. Bill Gowans, David McGavin and Frank Mulder were part of the research steering group. They contributed to the logistics of the study and co-ordinated the response of the practices to presentation of the initial results. We are grateful to all the practice staff and patients who gave us their time in the course of the study. Ethics approval was given by the North Thames Multi-centre research ethics committee. This report was printed by Weleda UK. 4 Department of General Practice and Primary Care New Options in Primary Care: Anthroposophic Medicine Research Summary Background The study also takes place against a background of extensive change in the organisation, delivery Anthroposophic medicine is an extension of and governance of primary care services. conventional medicine that aims to provide a means by which people can develop their own Study design latent capacities to address physical, psychological and spiritual aspects of illness. It involves the use The study was largely qualitative in design in of a variety of therapies, including art, music, order to understand the nature of eurythmy (movement therapy), massage, and anthroposophic medicine in general practice and counselling as well as anthroposophic medicines. the outcomes that result from anthroposophic Opportunities for social rehabilitation and work treatments. The research undertaken had three may also be offered as part of the therapeutic main components: process. Anthroposophic medicine is most widely • A medical record analysis in which 492 developed in Germany, the Netherlands and records were analysed to provide a profile of Switzerland although there is now growing patients receiving anthroposophic medicine interest in many other countries, both in Europe in the study practices; and elsewhere. • In depth interviews with patients (30) and various professionals (40) involved in the delivery of anthroposophic medicine to Within the UK, there are six general practices (five provide documentary evidence of the NHS and one Primary Care Group based charity) approach; and a 16 bedded residential unit offering • Case studies of patients currently anthroposophic treatments as an integrated part of undergoing treatment (20) in which patients the care they provide. In 1996, the practices and their GPs and therapists were wanted systematic answers to questions about the interviewed to explore the impact and effects impact, effectiveness and durability of different of the treatments received. Two patient treatments across a range of medical conditions. centred outcome measures were also They also wanted to understand how the process completed which use self generated of delivering anthroposophic medicine might be symptom indices or effects of illness as the unified or enhanced, through collating learning basis of assessment. from each of the practices. The study practices Aims of the research The seven practices in which the research took place are: The research addressed three questions: Blackthorn Medical Centre (4 GPs) situated at • What is anthroposophic medicine as the north-western edge of Maidstone, within a understood and interpreted by doctors, nurses largely middle income community. and therapists working within general Wallis Avenue Surgery (Single handed) also in practice? Maidstone, sited on a council estate. • How is anthroposophic medicine organised Helios Surgery and Therapy Centre (3 GPs) and delivered within primary care settings in located in a residential, high income area in the the UK? north west of Bristol. • What impact does anthroposophic medicine St Luke’s Medical and Therapy Centre (3 GPs) have on patients, both in terms of clinical situated in Stroud in Gloucestershire, with a outcomes and patient responses? branch surgery in Gloucester. Mytton Oak Foundation (1 GP) a charitable The central issues explored by the study are ones Foundation sited on the Western edge of which lie at the heart of much contemporary Shrewsbury adjacent to a six-partner NHS socio-medical research. There has been increasing general practice where the Foundation doctor is interest in attempting to define different forms of also a GP. general practice and the nature of the roles that Camphill Medical Practice (1 GP) sited within GPs play within it. Similarly, there is now one of the Camphill communities on the edge of widespread interest in how to provide ‘evidence’ the City of Aberdeen. about plural and more delicate interventions. Department of General Practice and Primary Care 5 Park Attwood Clinic a 16-bedded residential unit owned by the charitable foundations, and the situated on the outskirts of Bewdley in NHS practice, where this is linked, rents space in Worcestershire. Four doctors work at the clinic, the building, thus generating additional NHS two of whom are GPs. funded income for the Trust. All of the practices, except Wallis Avenue, accept referrals from outside of their lists for Defining anthroposophic medical practice anthroposophic treatments. All the practitioners were firmly committed to working within mainstream general practice. The organisational structure of the centres is such There was an equally universal view about the that, technically, five of the six primary care limitations of orthodox clinical practice and a practices are NHS general practices and one, desire to push the boundaries to include both Mytton Oak, is a charitable trust. All but one of psychological and spiritual dimensions. Most the NHS practices also provide most of their crucially there was felt to be value in ‘having a anthroposophic treatments through a linked foot in both camps’, both for patient care and for charitable trust. The residential clinic is a professional development. charitable company limited by guarantee attached to a ‘general practice’ with a small temporary list.