For many years, the NHS has found complementary medicine an uncomfortable bedfellow - at best regarded as 'fringe' and in some quarters as 'quack'; never viewed as a substitute for conventional medicine and rarely as a genuine partner in providing therapy. But at last there are signs of a genuine partnership developing as more and more NHS professionals and complementary therapists find themselves working alongside one another.
The distinctly tepid response sixteen years ago when, as President of the British Medical Association, I first broached the subject of integrated medicine was ample evidence of the uphill struggle ahead.
I took some encouragement from conventional medicine's rather warmer reception for a discussion I convened three years ago to look at practical steps to move forward the agenda.
Doubtless the public's rapidly growing interest in complementary medicine in the intervening years had played a part (one result of which was the BMA's publication of Complementary Medicine, New Approaches to Good Practice. This went so far as urging doctors to find out more on the subject, if only to be able to field their patients' questions).
In 1997 the steering group of The Foundation for Integrated Medicine (FIM), of which I am proud to be president, published a discussion document 'Integrated Healthcare - A Way Forward for the Next Five Years?'
Mindful of criticisms and caveats from sceptics in orthodox medicine, the resulting recommendations for action identified five key areas necessary to encourage co-operation: better education and regulation of complementary practitioners to ensure high standards of safety; evidence-based research and development: delivery and information.
That patients are interested in complementary therapies is undeniable. A recent BBC poll revealed that one in five Britons now opt to use complementary therapies. Nearly 80% of those asked believed that these therapies were becoming increasingly popular.
Yet we have a situation in which substantial numbers of people are looking beyond the NHS for health care, indeed are using complementary and alternative medicine in parallel with conventional provision, and - if continued demand is any indication - are presumably satisfied with the results. All well and good, perhaps, but if there are advantages in this approach, clearly they should not be limited only to those who can pay.
This interest in non-conventional approaches is far from one-sided. According to a survey by Birmingham University in 1998, about half the family doctors who responded provided access to one or more complementary therapies, either by practising a non-conventional therapy themselves, or by suggesting their patients go to local complementary practitioners.
The response to the recent Guild of Health Writers' Award for Good Practice in Integrated Healthcare, held in association with FIM, suggests that integrated medicine is far more widespread than expected. To qualify for entry, the integrated healthcare team had to include at least one conventional health professional. The number of entries - 81 to be precise - far exceeded expectations and the sheer diversity, the quality of work and the real integration of disciplines was astonishing. Even more remarkably, the majority were operating within the NHS.
Homoeopaths, osteopaths, reflexologists, acupuncturists, T'ai chi instructors, art therapists, chiropractors, herbalists and aromatherapists: these practitioners were working alongside NHS colleagues in acute hospitals, on children's wards, in nursing homes and in particular in primary healthcare, in GP practices and health clinics up and down the country. There were entries from integrated teams in physiotherapy, mental health care, maternity care and from specialist integrated teams focusing on cancer, AIDS, multiple sclerosis, epilepsy and postnatal depression.
What the best demonstrated was that integrated medicine - the collaboration of two seemingly opposed disciplines for the benefit of patients - was not only possible, but actually worked.
There was little that was haphazard or ad hoc about these teams. According to their entries, most of the practitioners fulfilled the criteria that FIM has established: they were trained and qualified by reputable organisations, they took into account the evidence available when introducing therapies, and they worked as professionals in teams of mutual respect.
The second important revelation was that, by dint of intensely hard work and innovation, many of the entrants had found ways to research and prove the effectiveness - and cost effectiveness - of complementary therapies. It has been a common criticism that the research for integrated medicine is at best flimsy, at worst non-existent. One of the obstacles always raised is that it is very difficult to trial complementary therapies in the rigorous randomised way that mainstream medicine deems to be the gold standard. This is ironic as there are, of course, un-evaluated orthodox practices which continue to be funded by the NHS.
The winner, Complementary Therapies within Cancer Services at the NHS Hammersmith Hospitals Trust, was outstanding for the sheer depth of its integration in offering massage therapy, reflexology, aromatherapy, relaxation training and art therapy to cancer patients at Charing Cross and Hammersmith Hospitals. The service is literally embedded within the orthodox matrix and has engendered a very real degree of professional respect at every level.. It is continuously evaluated and regularly audited and shows consistently increasing referrals from mainstream medical staff. Several pilot studies are underway but records indicate that complementary therapies have significantly decreased palliative drug use among radiotherapy patients.
Another example, this time in primary care. Glastonbury Health Centre, runner-up in the Award, set out to develop a model of a fully integrated NHS primary care service that could be replicated in other NHS practices. The idea of a GP practice offering complementary practices is not new - but the Glastonbury initiative goes far beyond this in providing a truly integrated service. Patients are offered courses of acupuncture, herbal medicine, homoeopathy, massage therapy and osteopathy in the same way as orthodox practices offer physiotherapy or medication.
The Award judges commented on the clear atmosphere of mutual professional respect among the GPs and complementary practitioners, and the latter's inclusion in practice meetings and access to patients' medical records. No one would deny that there are not considerable hurdles in assimilating systems that in many respects, notably language and philosophy, may seem diametrically opposed. Obviously compromises must be made on both sides.
In common with its fellow pioneer the Marylebone Health Centre in London, the first NHS practice to offer non-conventional therapies, Glastonbury has worked hard at hammering out a modus operandi, indeed a modus vivendi. The GP principals act as 'gatekeepers' for referrals, but these are not made arbitrarily or blindly, as can so often happen. Referral guidelines were devised through many hours of discussion and are regularly re-evaluated. The ongoing informal process of mutual debate and assessment helps the GPs to identify the most appropriate therapy for a patient or a condition.
These consultations have paid off in terms of patient benefits, both subjectively and, it would appear, objectively. Glastonbury carried out an evaluative study between 1994 and 1997. Using established tools, it found that 85 per cent of patients referred to complementary therapies reported some or much improvement. There were also statistically significant improvements in general vitality, social functioning, emotion and mental health in roughly two thirds of patients.
Complementary therapies were shown to be particularly effective for patients with shorter term or more severe conditions on referral, and in relieving pain and physical discomfort for patients with musculo-skeletal problems. The research also suggested that the therapies contributed to relieving social and emotional distress in patients with psychosocial problems.
As well as therapeutic benefits, the patients were able to take advantage of both conventional and complementary routes, without feeling they must exclude or hide either. Many reported that they found the evident co-operation between their GP and practitioners to be reassuring. Indeed, feedback from those patients using complementary therapies was overwhelmingly positive - with some of the warmest comments coming from those whose first experience of non-conventional therapies was through a practice referral.
As an NHS practice, how does Glastonbury Health Centre afford this service? A practice-based charitable Trust enables patients to access the required therapies for the price of an NHS prescription or free of charge if necessary. The practice is keen to pursue further research into cost effectiveness of complementary therapies in general practice, as the (admittedly limited) evidence they have garnered on this issue is tantalisingly promising.
Although providing complementary therapies tends to be slightly more expensive than conventional treatment, patients appear to reduce their usage of other health services such as GP time, prescriptions, x-rays and other tests. This is tremendously important information - not only for the health centre, who hope to prove to their local primary care funders that this care should be provided on the NHS, but for all of us who would like to see the NHS offering a broader kind of care for greater numbers of people.
Some aspects of this could be surprisingly simple, accessible and inexpensive. Complementary therapies afford enormous scope for self care and their very popularity is often attributed to patients' desire to take more responsibility for their own well-being. One of the most appealing entrants in the Guild of Health Writers' Award involved a single intervention with enormous potential.
A team at Queen Charlotte and Chelsea Hospital showed that teaching mothers with post natal depression to massage their babies not only enhanced mother-child bonding, but relieved the mother's depression. If one considers that post-natal depression afflicts 10 per cent of the 70,000 women who give birth in the UK each year, it is clearly a major problem, affecting the mental health of the infants, who often grow up with behavioural problems, or with a reduced IQ, and representing a lifelong financial drain on the NHS and social services. Set against this the sum of £30, the estimated cost of five lessons in infant massage that, with appropriately trained massage therapists, could be provided in any baby health clinic or GP practice.
These are pragmatic examples, with easily quantifiable benefits, of the kind of future that integrated healthcare could provide in the NHS. Complementary therapies are not a woolly cul de sac but a very real option with promising advantages for patient care and primary health group budgets.
Communication is the very oxygen of innovation, but too often ground-breaking initiatives are not well-publicised. With this in mind, The Foundation for Integrated Medicine is establishing an information data base and resource centre for practitioners and professionals who want to develop integrated services. It is no longer a question of hacking a path through unexplored jungle. The way is landmarked, the goals and prizes are visible. All that is needed is courage - and a little imagination.