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Abstract:

This report looks at features for consideration in the implementation of a multi-disciplinary clinic, focusing in certain aspects on the service provided by a homeopath.

1. Introduction:

This report is outlining aspects for consideration in a multi-disciplinary surgery. Focus is taken on a homeopathic clinic. Emphasis is on the benefit to patients that extrapolates from working in a multidisciplinary team. This involves an outline of the advantages seen in a homeopathic treatment, details of a possible implementation of qualitative clinical evaluation and management aspects of referral.

The information for the aspects stated came from reports on the GetwellUK scheme, the Marylebone clinic and the Bounds Green Group Practice, the websites of NICE, SOH and the NHS.

2. The benefits of a multi-disciplinary clinic:

The awareness and responsibility of patients for their own health is growing, and the acceptance and request for treatment methods outside the mainstream practice is increasing. More and more surgeries are extending their range of services available to the patient, empowering the patient to choose, and the practitioner to select and refer to an alternative therapy if so desired or necessary.

The CAM disciplines have largely in common the patient-centred aspect that is lost in the GP practice.  Patient perception of the quality of care and satisfaction with alternative treatment has been shown to be increased as the patient – CAM-practitioner interaction is deeper and of longer duration than that with the GP.

Being in a multi – disciplinary team means to its members that they are given more options to complement their treatment, aimed at providing the patient with the best possible treatment available. Therefore having direct access, on site, to practitioners of different disciplines, may promote specialist diagnosis and expertise, and analysis of the holistic and psychosocial context of the patient [1]. There is an increased possibility of matching the patient condition to the appropriate therapy.

2.1 The benefits of Homeopathy in a multi-disciplinary setting:

Homeopathy has frequently proven successful where conventional treatment has failed to provide a satisfactory result [2]. Homeopathy especially, has become increasingly valued because of the holistic approach it takes to a patients´ infliction with illness.

Not only is homeopathy inherent of a treatment benefit to patients, but it has, in multi-disciplinary settings, contributed to a reduction in the requirement of follow-up consultations [3]. Beyond this, homeopathic practice has reduced costs in comparison to single GP practices [4] [5]. Homeopathy can complement, precede or follow onto other therapeutic interventions.

3. Quality assurance:

Inclusion of Homeopathy in a multi-disciplinary setting should be dependent on assurance and implementation of professional best practice that assumes maintenance of confidentiality, ethicality, quality standards of practitioner qualification and therefore registration with the discipline regulating body. In the practice of homeopathy in the U.K., this can, for example, be with the Society of Homeopaths [6].

4. Inter-disciplinary communication and management of referrals:

The demand for alternative therapies is increasing, and most patients use CAM in conjunction with allopathic treatment. One essential factor emerging out of a practitioner collaboration, as is a multi-disciplinary clinic, is therefore the requirement of intense communication.

4.1 Communication:

The practitioner-patient communication gains importance in a multi-disciplinary setting; practitioners have to have in the least a good awareness and knowledge of other therapies in order to be non-judgmental in their interaction with patients when they request inclusion of or referral  to alternative therapies. The exchange between practitioners is also increased in relevance as there is the requirement of inter-disciplinary interaction aimed at identifying an appropriate treatment option for the patient.

Essential for any participant of a multi-disciplinary team is team compatibility, the collaboration with team members.

4.2 Referrals:

Inter-disciplinary communication is one factor required to accomplish effective patient referral; the exchange and processing of patient details also requests good team-play. It is increasingly becoming common practice to employ electronic systems of referral [7] [8]. The transfer of data is safe, secure and imminent, and it is possible to book appointments then and there in the consultation, in accordance with the patient.  Conventional, paper referral has in the past resulted in delay in processing and was subject to frequent cancellation or alteration of appointments by patients [7].

Reasons for referral range from recommendations due to good reaction to a specific treatment of other patients, conventional treatment being ineffective or producing side-effects to selection of a treatment option to complement another treatment approach. Whilst it is commonly the practitioner referring a patient, patients may self-refer and chose a therapy they feel suits them best. The practitioner selects and recommends a treatment that he considers most appropriate to the patient and his presenting complaint.

4.2.1 Referrals by homeopaths:

Relevant information such as prescribed medication, diagnosis, case-history and symptoms should be contained in a referral form that is to be effectively shared with the selected practitioner the patient is to be referred to [9]. At the same time this information could be printed for the patient if referral is sought with a practitioner outside of the multi-disciplinary clinic, for self-referral of the patient to another practitioner, or upon finalization of treatment for the patients´ own record.

Referral stipulates the transfer of responsibility from one practitioner onto another. The homeopath referring a patient is accountable for selecting a practitioner that is competent and best suited for the patient and his complaint, and he, like the homeopath, underlies regulation by a statutory body [9].

5. Clinical audit and evaluation:

It is necessary to constantly, critically observe and evaluate the service that is provided. In a multi-disciplinary setting this may help monitor not only the quality of the service provided to the patient, but may also give relevant information on the progression and success of the activity within the multi-disciplinary team. Audit is about noticing the need for alterations in a service with the aim of improving the delivery of care to patients [10] [11]. It is a means of measuring development, identifying risks and providing assurance. Audit may collect demographic information, may be qualitative, condition specific, or of general, administrative detail [11].

5.1 Audit in homeopathic settings:

Prime attention should be focused on the well-being of the patient therefore feedback from patients is indispensable. One system utilized to evaluate the service provided to patients is the use of MYMOPS that give insight into the patients´ qualitative perception of their well-being at different stages of their treatment [11]. This system of evaluation should be implemented from the beginning of active practice as it will demonstrate the development and progress consistently.

6. Administrative aspects, marketing and employment or self-employment:

There are two possibilities of employment in a clinical setting of integrated health care. One is in paid employment where the clinic provides the location, pays a salary to the practitioner and provides a reception and personnel that handles patient contacts such as making appointments and handling payments. The other is self-employment, where the practitioner rents accommodation at the clinic, jointly with other practitioners pays administrative personnel, or handles organizational matters personally. Whilst in the former model the practitioner receives a fixed payment for the provision of his service, in the latter the practitioner decides what he charges each patient. A similar structure applies to marketing, publication materials and advertisements. The costs of these expenses are likely to be carried by the clinic where the practitioner is employed, whereas in self-employment these are costs that the practitioner has to invest himself.

6.1 Administrative aspects to running a homeopathic clinic:

Consultations should be regulated to take 1.5 hours for an initial and 45 minutes for a follow-up session. Follow-up sessions take place 4 to 5 weeks after each prior consultation. The suggested patient attendance is for 3 to 6 appointments. Should, after that time, no significant progress be perceivable, back-referral to the GP or another discipline is suggested. The costs of homeopathic remedies are subject to inclusion in the cost of treatment.

Bookings should be made with surgery reception. Staff will add the details into the electronic timetable of the practitioner or shall establish contact with the practitioner.

An emergency contact should be provided with staff at the reception or administration, who may in the case of urgency seek recommendation for the patient from the practitioner.

7. Discussion:

There are challenges to such a model. Although suggestion is that the GP be “gate-keeper”, holder of overall responsibility [12], there may be lack of synergy between disciplines, or competition amongst practitioners. A homeopathic practitioner may experience lack of trust in his discipline and judgment by fellow team-members because of criticism of, or concerns over the evidence base of the efficacy of the discipline. In order to retain this multi-disciplinary model feasible, there is the requirement for interdisciplinary tolerance and good-will.

8. Conclusion:

The therapies of CAM are increasingly valued by patients and practitioners of differing disciplines.  Multi-disciplinary systems are in demand and workable models can provide a service that is beneficial to the patient.

The highest aim of health professionals is to relief human suffering. As no one discipline can claim to be all-ailment encompassing and healing, the multi-disciplinary approach is a construct that aims at providing the best possible service to a patient [13]. Homeopathy is suited to be a rigid part of multi-disciplinary practice.

Acknowledgements:

I should like to express my gratitude for the assistance I have received in the sourcing and collating of information for the conduction of this exercise. Many thanks go to Maureen McElroy and Rehana Banu Issat, for sharing.

References:

[1] Reason, P., Chase, H. D.; Desser, A.; Melhuish, C.; Morrison, S.; Peters, D.; Wallstein, D.; Webber, V.; and Pietroni, P. (1992) Toward a clinical framework for collaboration between general and complementary practitioners [online] last accessed 24.02.2010 at URL http://people.bath.ac.uk/mnspwr/Papers/RSMCLIN.htm

[2] Adams, J. (2003) The positive gains of integration: a qualitative study of GPs’ perceptions of their complementary practice [online] last accessed 24.02.2010 at URL http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=527436

[3] Ward, A. (1996) Report on a practice-based homeopathy project                                 Analysis of effectiveness and cost of homeopathic treatment within a GP practice [online] last accessed 24.02.2010 at URL http://www.homoeopathyuk.org/file/My_research_page.html

[4] Smallwood, C. and FreshMinds (2005) The role of complementary and alternative medicine in the NHS: an investigation into the potential contribution of mainstream complementary therapies to healthcare in the UK [online] last accessed 24.02.2010 at URL http://www.library.nhs.uk/HEALTHMANAGEMENT/ViewResource.aspx?resID=105315

[5] Treuherz, F. (1999) Homeopathy in general practice. A descriptive report of work with 500 consecutive patients between 1993 -1998 Northampton: SOH

[6] SOH (2004) Code of Ethics [online] last accessed 24.02.2010 at URL http://www.homeopathy-soh.org/about-the-society/code-of-ethics.aspx

[7] Dennison, J., Eisen, S., Towers, M., & Clark, C. (2006) An effective electronic surgical referral system [online] last accessed 19.02.10 at URLhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1963768/pdf/rcse8806-554.pdf

[8] NHS (2010) Electronic Referrals [online] last accessed 19.02.10 at URL http://www.wales.nhs.uk/IHC/page.cfm?pid=33626&orgid=770

[9] GMC (2009) Good medical practice: Working with colleagues [online] last accessed 24.02.2010 at URL http://www.gmc-uk.org/guidance/good_medical_practice/working_with_colleagues.asp

[10] Scrivener, R.; Morrell, C.; Baker, R.; Redsell, S.; Shaw, E.; Stevenson, K.; Pink, D.; and Bromwich, N. (2002) Principles for best practice in clinical audit [online]last accessed 24.02.10 at URL http://www.nice.org.uk/media/796/23/BestPracticeClinicalAudit.pdf

[11] Russo, H (2006) Shining lights: A practical guide for integrating health care [online] last accessed 24.02.2010 at URL http://www.fih.org.uk

[12] Pietroni, P. (1992) Beyond the boundaries: Relationship between general practice and complementary medicine [online] last accessed 24.02.10 at URLhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1883275/

[13] Cohen, M. (2004) CAM practitioners and “regular” doctors: is integration possible? [online] last accessed 24.02.2010 at URL http://www.mja.com.au/public/issues/180_12_210604/coh10215_fm.pdf

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