1 Executive Summary
The public pays the NHS piper through their taxes, so they should call the tune on the treatments offered. Polls show that 3 out of 4 patients want Complementary and Alternative Medicine (CAM) free on the NHS (1). The Prince of Wales’ Foundation for Integrated Health (FIH) has been advocating integration of CAM for a decade.(1) However, clinician resistance (who wrongly regard CAM as quackery practiced by charlatans) has prevented CAM integration hitherto, condemning patients to Hobson’s choice of treatment – conventional only - usually drugs with side effects and unsafe adverse reactions.
This paper promotes a Department of Health (DoH) initiative – innovation – which gives a new window of opportunity for overcoming clinician resistance, and implementing the integration of CAM. The Darzi report of 2008 stressed the importance of creating a culture of innovation in the NHS to promote quality of care and cutting waste and errors. ‘Care’ means not just in treating illness, but also in promoting interventions to prevent long term conditions from developing. This is CAM’s strong suit, so the time for CAM integration into the NHS has now come.
The mechanism by which it would work is as follows. CAM practitioners in every town would group themselves into social enterprise companies, perhaps called ‘Social Enterprise Alternative Treatment Companies’ (SEATCs) Legally they would be set up as ‘Alternative Providers of Medical Services’ (APMS) The SEATC would be commissioned by the PCT to provide CAM treatment services under a Service Level Agreement (SLA) for 3 years.
Patients seeing their GP would then have the choice of whether to have conventional treatment (probably drugs) or alternative treatment (probably in the form of a voucher to take to their local SEATC centre, see a ‘gatekeeper’ who would advise them on a CAM care pathway). Both treatment options would be free to patients, and the CAM practitioner would be paid by the PCT via the SEATC.
Every Strategic Health Authority (SHAs) has been given a statutory duty (and £20 million over 5 years) to promote innovation. Academia has been mobilised, and ‘Health Launchpad’ has been established to provide an incubator for new born schemes which are fragile, and need help to develop. The PCTs will get paid extra for innovative schemes. These are new ‘big guns’ which can help patients, patient groups (eg Local Involvement Networks (LINks) and CAM therapists get CAM integrated into the NHS, as described below.
2 Promotion of innovation by SHAs and Launchpad
The Department of Health recently held a conference called ‘Innovation Expo - Innovation for a Healthier Future’ at the Excel exhibition centre in London (18-19th June). It was attended by 6,000 people, including me. A document called ‘Innovation for a Healthier Future’ was handed out, from which the following quotations are taken.
The Darzi report High Quality Care for All (HQCfA) in 2008 called for a reformed system that supports quality improvement by innovation. This is defined as the exploitation of beneficial ideas to the public. Accordingly, the Strategic Health Authorities (SHAs) have been given a legal duty to promote innovation, and £220 million over the next 5 years. Every SHA has appointed directors and managers of innovation to implement this policy, and their record will be monitored annually.
Their role is to create the right context and reinforce the right leadership behaviours to stimulate innovation in frontline organisations, such as PCT commissioners and their providers. The new Commissioning for Quality and Innovation (CQUIN) scheme includes goals of safety, effectiveness, patient experience, and innovation, together with an incentive payment framework to reward projects that achieve this. Academic Health Science Centres (AHSCs) have also been established to foster world-class partnerships between research, teaching and patient care organisations so that developments in research can be more rapidly translated into benefits in patient care.
For example, the National Endowment for Science, Technology and the Arts (NESTA) have got together with the Young Foundation to create Health Launch Pad (www.healthlaunchpad.org) as an incubator for innovative projects. They offer support to social entrepreneurs who approach them with promising ideas. Their goal is to make a lasting impact on people’s health and wellbeing. They note that 45% of the adult population has a long standing illness, which accounts for over 80% of NHS spending. They ask: ‘have you a solution to a problem? If so we hope that Launchpad can join with you, so together we can play a major role in solving it.’ This paper is my contribution, and I hope to start a SEATC in my community of Brighton and Hove, around an alternative health centre called ‘Revitalise’ which I founded in 2003 under the name of ‘Planet Janet’. I have called a public meeting there to discuss this on 21st July.
3 Practice Based Commissioning (PBC)
The legislative framework for this was established in April 2006. The following is taken from a booklet entitled ‘Practice Based Commissioning, a framework for implementation in Brighton and Hove. The gist of it is as follows: (my interpretation and comments are italicised)
PBC means allowing GPs to hold the budget to commission services for their patients from April 2006. The aim of PBC is
• to put GPs in charge of resources (the money follows the patient)
• develop primary and community services closer to peoples homes or in communities. (Alternative therapy centres meet this criterion)
• improve health outcomes in line with strategies (eg supporting people with long term conditions, prevention of illness, reducing hospital admissions, self-responsibility, These are CAM therapies’ strong suit)
• address health inequalities in the city (access to CAM therapy should not be restricted to the rich)
1 Assessment of need (to heal the sick)
2 Identification of the right care pathway (there is nothing in the document saying that CAM therapy cannot be the right care pathways)
3 Redesign of services to achieve that pathway and get the best use of resources (CAM therapy has evidence that it is cost-effective for many conditions, eg prevention of illness, promotion of wellness, back pain, chronic fatigue, palliative care, cancer,)
4 Buying that pathway from the right provider. (there is now an opportunity for alternative therapy centres to become an Alternative Provider of Medical Services APMS)
Holding the budget means being responsible for stages 1-3 above, so that the GPs will make all commissioning decisions. The PCT will continue to hold the actual budget (ie keep the money in a bank account) and will be responsible for developing the detailed service specification documents, securing contracts (service level agreements) on behalf of practices, and for the invoicing and payments ie procurement stage 4. (alternative therapy centres can form themselves into a social enterprise company and negotiate with the PCT and bid for a service level agreement to provide CAM therapies)
Practices will be asked to produce a simple commissioning plan on entering the scheme. This will describe the services for which an indicative budget has been allocated. (I suggest that this should include the following CAM therapies:
Osteopathy, chiropractic, cranio-sacral therapy, acupuncture, homeopathy, yoga, pilates, hypnotherapy, healing, reiki, massage, aromatherapy, reflexology, shiatsu, tai chi, qigong, herbal medicine, flower remedies, healthy diet counselling, astrology, meditation, art therapy, music therapy, family constellation groups. .Courses on Mindfulness Based Cognitive Therapy (MBCT) have been approved by the National Institute for Clinical Excellence (NICE) as an alternative to antidepressants. The new NHS constitution gives the right for every patient to have NICE approved treatments if their GP endorses it, so MBCT should be made widely available for patients on antidepressants (2).
6 World Class Commissioning
This DoH initiative is a statement of intent, aimed at delivering outstanding performance in the way the PCT commissions health and care services. A new film was shown at the conference, which included the following straplines: ‘Adding life to years, and years to life……Intervening early to prevent more serious illness……Getting the best value for the taxpayers money….Maximising health and wellbeing outcomes for local communities……. World class partnerships (of GPs, independent sector, voluntary sector) (CAM treatments meet all of these objectives)
The Brighton and Hove PCT held two big public meetings in Brighton last summer (2008) to consult us on what we wanted to be commissioned in the next 3 years. I told them: ‘complementary and alternative therapies’, and wrote 2 papers for them elaborating on this (2)
The DoH provides practical support for PCT’s world class commissioning in the Framework for procuring External Support for Commissioners (FESC)
7 How can alternative therapists treat NHS patients?
The steps required are as follows:
a) Form a group with other alternative therapists and social entrepreneurs, (eg the therapists working in an alternative therapy centre) to form a social enterprise, not for profit company. Think big (as the PCT does) and offer a wide and comprehensive CAM therapy service for a whole area, eg town. Include a cluster of other alternative therapy centres to widen the scope of therapies and centres in your SEATC and get economies of scale.
b) Get advice on how to form a SEATC from one of the organisations listed below, and from your own local Centre for Voluntary Sector Forum (CVSF) and local business start up advisors.
c) Draft a proposal for NHS Innovation setting out how your SEATC would contribute to the health and wellbeing of your local community.
d) Submit your proposal to your SHA, with copies to the Young Foundation Health Launch Pad team and NCI listed below, local LINk, and ask for their support.
e) Negotiate with your local PCT to commission your SEATC to become a APMS and sign a service level agreement with them for provision of alternative treatment to their patients for the next 3 years, as if you are a hospital.
8 Contact details of advisors
a) Young Foundation / Health Launch Pad, London 0208 709 4820 Rowena Young, Kerry McCarthy, Joop Tanis programme manager, email@example.com
Jaques Mizan, Senior Associate
b) National Centre for Involvement (Warwick University) Institute
c) NHS Institute for Innovation and Improvement www.institute.nhs.uk
(Warwick University 0800 555 550 e mail: firstname.lastname@example.org
d) Future Builders England Newcastle www.futurebuilders-england.org.uk (Social Enterprise companies)
Tel: 0191 261 5200, email: email@example.com
e) South East Coast SHA: Peter Houghton, Director of Innovation, 01293 847039
Dr Alan Kennedy Innovation Manager email: firstname.lastname@example.org
f) Brighton and Hove PCT: Dr Geraldine Hoban, Commissioning Director, Anne Foster, Primary Care Development Manager for Hove and Portslade (West locality) Chris Naylor, Central Brighton, Kathy Felton and Laura Wade jointly for East Brighton.
1 Foundation for Integrated Health www.fih.org.uk
2 See www.reginaldkapp.org 9.28 ‘Improving Health by Ending the Prozac Nation’
and 9.34 ‘NHS Physician Heal Thyself with Meditation’ by John Kapp.
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