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Set up an outcomes-focused acupuncture service

Dr Mark Bevis explains how an acupuncture service has benefited 80% of local knee pain patients and saved thousands of pounds

Dr Mark Bevis explains how an acupuncture service has benefited 80% of local knee pain patients and saved thousands of pounds

These days, more patients and practitioners are looking at alternative treatments to manage conditions. But although the public might want access to treatments such as acupuncture, not everyone can afford to pay for them and the NHS rarely provides them. Many clinicians are sceptical about such approaches, and when faced with limited funding for new services, will opt for what is proven rather than what is different.

I prefer to keep an open mind. As clinical lead for St Albans and Harpenden Musculoskeletal Clinical Assessment and Treatment Service (MSK CATS), I'm constantly on the lookout for different ways to provide support for patients who would otherwise be referred to secondary care.

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So when GPs from the Parkbury House and Midway surgeries in St Albans wanted to set up an acupuncture clinic for patients with knee pain, I felt it was worth doing. This was on the proviso that it was on a pilot basis, that there were strict criteria to determine who was eligible for treatment and that its progress was closely monitored.

This approach has paid off, with 80 of the 100 or so patients seen since the scheme began in 2008 responding to acupuncture treatment. This means they have not been referred for knee surgery, which costs about £6,000 per patient, as opposed to the £20 the clinic receives for each patient's individual acupuncture sessions. The clinic has also received national acclaim, winning in 2008 a Prince's Foundation Integrated Health Award as well as an NHS Alliance Acorn Award in the integrated and complementary healthcare category.

our assessment service

St Albans and Harpenden PBC group (STAHCOM) gave the go-ahead to MSK CATS to commission this service, as it fitted in with the group's PBC vision. STAHCOM, which has 13 practices covering about 180,000 patients, seeks to ensure the provision of easily accessible, equitable services to patients in the community.

These same values were behind STAHCOM's decision to commission the MSK CATS service in 2006. The PBC group recognised the service would reduce referrals and costs and has subsequently been involved in similar redesigns with ophthalmology and dermatology. MSK CATS was one of the first services of its kind in the country to triage MSK referrals with the aim of managing as many as possible within a primary care setting. Practices within STAHCOM are encouraged – but not required – to send their musculoskeletal, rheumatological and orthopaedic referrals to the MSK CATS team.

I was keen to lead the service, having developed a special interest in rheumatology when I entered general practice 15 years ago. Shortly after becoming a GP, I began working one session a week as a hospital practitioner in the rheumatology department at the Queen Elizabeth II Hospital, part of East and North Herts NHS Trust. As a GP with a specialist interest in rheumatology, I head up the MSK CATS team, which includes a consultant orthopaedic surgeon from the local hospital, an osteopath, several physiotherapists with extended skills and another GP with an interest in musculoskeletal medicine. Patients are referred to us for the most appropriate treatment, which could be anything from advice regarding self-care to physiotherapy to surgery. As a result of the MSK CATS service, about 60% of all GP referrals are kept in primary care and – at a conservative estimate – at least £300,000 savings each year have been achieved by avoiding secondary care referrals.

A pragmatic approach

Our team is always seeking ways to improve care pathways for patients, but they need to be cost-effective. In 2007, Dr Jonathan Freedman, a GP at Parkbury House surgery, along with GPs Dr James Ferguson and Dr Michael Cannell from Midway surgery, presented me with a proposal to set up an acupuncture clinic for patients with knee pain and disability secondary to advanced osteoarthritis. I saw the potential, but wasn't totally convinced of the value of acupuncture – the evidence base is sparse and somewhat contradictory. The proposal was an opportunity to offer an alternative approach to managing pain, and potentially a way of avoiding performing surgery on older people with all its associated risks and complications, as well as a means of cutting costs. The service would be set up by doctors who were all qualified acupuncturists and had been providing services to patients for a number of conditions, from back pain to pregnancy sickness, for many years.

Although I was in favour of offering an alternative therapy to patients, I didn't want to commission a general acupuncture service for which demand could become overwhelming. So I suggested the entry criteria should be restricted to patients with knee pain who would otherwise be referred for surgery. I also felt that to test the service's effectiveness, it would be best to do a six-month pilot, and that outcomes should be closely monitored.

Making the business case

Dr Freedman and I then presented our case for an acupuncture service to the STAHCOM commissioning board. We acknowledged the project was controversial but stressed it should have clear aims and objectives. These included looking at whether patients with osteoarthritis of the knee who are on the threshold of being referred to surgery can have their pain adequately controlled by acupuncture. We also pointed out the service had the potential to save thousands of pounds by avoiding expensive surgery.

Faced with such persuasive arguments, STAHCOM agreed to the pilot project.

Armed with well-defined criteria and objectives, Dr Freedman and his colleagues were also able to convince St Albans and Harpenden PCT. STAHCOM then authorised funding so MSK CATS could commission Dr Freedman and his colleagues to set up a six-month pilot scheme in 2008.

How the service works

It took about six months to get the service off the ground, which mainly involved meeting with the acupuncture team and agreeing the specifications for the service.

The way the service works is that patients with known osteoarthritis of the knee on the point of being referred for surgery are referred by practices within STAHCOM to MSK CATS. They are then offered the option to receive a course of acupuncture. Those who wish to have treatment are given a leaflet about what it involves. The patient receives four weekly sessions of acupuncture and monitors the effectiveness of treatment and how much their pain has eased, using a ‘Measure Your Own Medical Outcome Profile'

scoring tool. Patients are then judged to be either ‘responders' or ‘non-responders'. After four sessions those who are not responding go on to the stronger electroacupuncture. Responders will then have top-up treatment every six weeks or so to control their pain, whereas non-responders return to the original care pathway and may be referred for total knee replacement surgery.

Acupuncture is delivered at either the Parkbury House Surgery or the Midway Surgery by nurses qualified in acupuncture. Sessions are held weekly and carried out on up to six patients at a time. Carrying out treatment collectively is an added bonus in that it lets patients, many of whom are over 70, get together and support each other.

Although both the PBC and PCT have been supportive of the scheme, not everyone was convinced of its value. Some GPs are sceptical about acupuncture, regarding it as a placebo and not the best use of NHS funds. By having a clearly designed pilot and good outcomes we hoped that, even if GPs didn't believe in acupuncture, they would put those feelings to one side, recognise the benefits and acknowledge the results. It's about taking a pragmatic approach – and as GPs we are all used to making decisions for our patients and acknowledging when something works, even if we don't always know why.

Outcomes

After four sessions, 80 out of the 100 or so patients treated to date have reported a significant reduction in pain, increased mobility, a greater ability to do daily activities and an overall improvement in quality of life. This has meant the patients have not required the surgery that was previously planned.

However, for these improvements to continue, acupuncturists say that patients need to receive treatment every six weeks. That means the numbers of patients needing treatment will grow, so we will need to put financial boundaries on this, or we will need to access the savings made from the service to help continue to fund it.

Another difficulty is that although we initially established strict entry criteria, as with any new service, GPs occasionally referred patients who didn't necessarily meet them, such as the older, housebound patient who had knee pain but was not fit for surgery. We decided that to deny them acupuncture would be unethical and so we have agreed to treat some patients who do not meet our criteria on a case-by-case basis as a possible way to ease their suffering.

To those looking to replicate the scheme, I would advise enlisting the support of their PBC group and their PCT, by making sure they present a clear, unambiguous case and that their project is as focused as possible.

The pilot scheme was extended to 12 months to allow further evaluation of the results and, following a successful evaluation, has now been incorporated into the range of services offered by MSK CATS. The recent NICE guideline supporting the use of acupuncture in low back pain presents a possible opportunity to extend acupuncture further.

No matter what we achieve, I'm sure some GPs will still think acupuncture is nonsense, while others will be convinced of its value. The rest of us will take the middle ground and look at its possibilities, even if we don't understand why it works. If keeping an open mind means patients' pain can be managed so they don't have to have risky and expensive surgery – well, that's an outcome that's hard to argue with.

Dr Mark Bevis is clinical lead for the MSK CATS service operating in the St Albans and Harpenden SHA, and a partner at The Lodge Surgery, St Albans, Hertfordshire

The provider perspective

GP Dr Jonathan Freedman gives his take on setting up the service

For the past 15 years I have been practising acupuncture on a voluntary basis, and during that time I've been trying to get some sort of NHS funding to develop a service.

PBC with its ‘invest to save' principles seemed like a good route and I, along with other GPs practising acupuncture at the Midway surgery, hoped that by investing in a low-cost acupuncture service we could save STAHCOM a significant amount of money.

With the support of MSK CATS and by highlighting the potential savings to be made by having the clinic, we convinced STAHCOM to approve the service.

Start-up costs were kept to a minimum. We persuaded the PCT to purchase six electroacupuncture machines, which cost £325 each. MSK CATS pays us £20 per patient per acupuncture session, which has to cover all costs including admin and nursing time. Three nurses qualified in acupuncture deliver the service. Marion Richardson, who co-founded the clinic, is a senior lecturer in western medical acupuncture at the University of Hertfordshire, Steph Martin-Smith is employed as a practice nurse by Parkbury House and Pam Richmond works for the PCT as a district nurse and runs the Midway Surgery clinic. On average they work three sessions a week in total, and treat around 30 patients a week.

Running this clinic is a labour of love and a chance to show how acupuncture can encourage a shift in services from secondary to primary care. But establishing the service has been challenging, for as well needing to persuade the PBC group about its value, we have also faced scepticism from local GPs.

The way to convince clinicians is to spend time talking to them about the significant evidence that acupuncture works (see references below).

Now our clinic is up and running, sceptics can see patients are happy with the service, because it relieves their pain and means they don't have to have surgery. And their happiness is the most important indicator of the clinic's success.


Nurses qualified in acupuncture provide the service at two GP practices nurses providing acupuncutre 60 second

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