16 Issue 106 October 2013 InternatIOnal therapIst www.fht.org.uk

Healthcare | GP referrals

We speak to FHT members who receive

GP referrals

Building bridgesA number of our members work in GP

practice, receiving referrals from GPs to treat patients in their own private therapy practice or within the GP surgery; as part of a multi-disciplinary group in a palliative care setting, such as a hospice or hospital; or via other organisations providing support services for chronic health conditions. Helping to build the bridge between conventional healthcare and complementary therapies, this line of work is an invaluable step in the right direction towards integrated healthcare. Here, we take a look at the results of our survey into FHT members who treat clients via GP referral…

Promise for integrated healthcareAlthough as therapists, we know first-hand the therapeutic benefits of complementary and sport therapies and that there exists a growing evidence base to increasingly support our work; we are also aware that the lack of research in this field potentially

hinders developing working relationships with GPs, who value the importance of evidence-based practice.

However, a number of our FHT members are encountering a more positive response from GPs, with some of our survey respondents commenting on a marked increase in GP referrals, particularly by those GPs receiving positive feedback from patients. Interestingly, a study has suggested most patients in primary care want a GP who listens, inquires about CAM and, if necessary, refers to or collaborates with CAM practitioners. The researchers concluded that to meet the needs of patients, primary care disease management would benefit from GPs actively informing

patients about CAM and referring to CAM practitioners, where appropriate.1

When asked how our members got involved with GP referrals:l 31 per cent of respondents said that they

were initially contacted by the GP;l 49 per cent were contacted by the patient;

andl 26 per cent of respondents contacted the

GP practice. Out of those who responded to the survey, the treatments most typically referred to were:l massage therapy (70 per cent); l reflexology (45 per cent); l sports massage/therapy (45 per cent); l aromatherapy (28 per cent); l Indian head massage (28 per cent); and l reiki (18 per cent).

A great support toolAs conventional healthcare practitioners value evidence-based practice, this may explain the higher number of GP referrals for

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GP referrals | Healthcare

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I work as a complementary therapist as part of a multi-disciplinary team at rowcroft hospice, where Gps can refer patients – and their primary carer – for complementary therapy if the patient is already known to the specialist palliative care service. In terms of the referral process, we have a referral form, or the Gp can phone our hospice referral line. We also inform Gps when their patients are referred by another source, such as a hospital consultant, or if patients self-refer for treatments, and we will inform the Gp of any outcome or discuss any current issues or concerns (with the client’s consent).

there’s a range of therapies available at the hospice, from massage, aromatherapy and reflexology, to shiatsu, reiki, relaxation techniques and mindfulness-based stress reduction. the main reasons for Gp referrals to complementary therapy are for support, to enhance relaxation, reduce anxiety, provide stress relief, improve well-being, relieve tension and help with symptom control, such as pain and sleeplessness.

some people who have struggled with conventional treatments have accessed the complementary therapies alongside them, and if there is fear around coming to the hospice, complementary therapy can be the first contact with the specialist palliative care service and a gentle approach to the services on offer.

people with advanced, progressive illness often forget they can ‘feel well in the moment’; instead they may focus on their diagnosis, and as anxiety and stress can exacerbate pain, relaxation and support may help them cope in a different way. Funding is one of the big challenges; we are a very busy service and there are four paid part-time therapists and 12 or more volunteers. We typically offer patients and carers up to six free treatments, and we cover an area of 300 square miles (the hospice catchment area). Our volunteer therapists are very valuable to us, seeing patients in their own homes, within their local area.

although there are research papers out there supporting the benefits of complementary therapies, the lack of research and information available may affect Gp referrals. We have a hospice information leaflet about the complementary therapy service and we are careful how we offer therapies; the main intention being relaxation and an increased sense of well-being, which may help with symptom control.

referrers can trust that we work within guidelines and a protocol for each therapy, and we maintain professional boundaries. patients who have given feedback to their Gps about their positive experience may explain the increased number of referrals. It is very rewarding to be part of a fully-integrated, dedicated, multi-disciplinary team at the hospice. the complementary therapy team attend the multi-disciplinary team meetings and have access to supervision, support and training.

Case study one: Julie Milton, FFHT

mental health conditions,* pain, cancer,2-4 and musculoskeletal complaints; conditions for which there is a growing evidence base supporting the benefits of certain therapies. In our survey, the majority of GP referrals to complementary and sport therapists were for stress, anxiety and depression – 63 per cent – followed by referrals for patients with cancer (28 per cent); multiple sclerosis (25 per cent); and cardiac problems or stroke (20 per cent). Although under no circumstances should complementary therapies replace orthodox medicine, they can provide a great deal of support to people, particularly those with chronic health conditions or who are in palliative care.5

When asked why patients are generally referred to members by GPs, 85 per cent of our survey respondents said it was to support clients and assist with symptom management, while 52 per cent said it was to relieve anxiety. The main symptoms that members help these clients to cope with are pain and soft tissue/muscular complaints – 78 per cent of respondents received GP referrals for both symptoms, respectively. Interestingly, the National Institute for Clinical Excellence (NICE) states that patients suffering from persistent, non-specific low back pain should be offered ‘one of the following treatment options, taking into account patient preference: an exercise programme, a course of manual therapy [including massage] or a course of acupuncture’.6 Healthcare professionals are advised to consider offering another of these options if the chosen treatment does not result in satisfactory improvement.

This perhaps suggests why referrals for pain and soft tissue complaints are so high, particularly as almost 10 million Britons

I was employed by a Gp practice to handle all of their sports massage and sports therapy referrals, which originally came about via dropping leaflets into the Gp practice and treating the Gp’s secretary and practice manager’s wife. the practice manager then called me for an interview to discuss the possibility of working together; he wanted to know what I could offer to his practice and which symptoms I could potentially help.

Funding was secured for six month’s work and I was based in the Gp surgery one day a week, although ended up working longer hours and occasionally extra days due to the popularity of the service. I offered a therapy service combining soft tissue release, muscle energy techniques, massage, ice massage, corrective exercises and gait and posture correction advice, as well as nutrition advice, when needed.

the Gps had referral forms – in most cases, the Gps had tried pain medication and exhausted all other avenues. In order to maintain a good working relationship, I continually updated the Gps on client progress and discussed any referrals to other healthcare specialists that I felt were necessary, such as the podiatrist or for MrI scans for knee injuries.

For me, the benefits of working in a Gp practice included the security of regular work and income; I could see more clients in a day

as I was based in one place; I could also use the room (when available) for private clients; it helped boost my reputation locally; and because I was seeing more clients from a concentrated area, this meant more referrals.

the only disadvantages were that clients expected you to work around their schedules, often not turning up if it did not suit them, and being constantly pressed for time. the funding has recently changed and I am now registered to supply2health (nhs) which sends out information on tenders and when an aQp (any Qualified provider) with your relevant skills is required you can apply, and are then called to attend the tender process with other providers. this has the benefit of all Gp practices being able to refer directly to you, rather than just the ones you directly work with.Editor’s comment: for more information about AQPs, visit www.supply2health.nhs.uk

Case study: Marcus Croman, MFHT

suffer pain almost daily resulting in a major impact on their quality of life and time off work,7 and it is estimated that four out of every five adults will experience back pain at some stage in their life.8 There is a number

of promising studies suggesting that certain therapies, such as massage therapy, shiatsu, acupressure, and Alexander technique may be useful in cases of non-specific low back pain, pain associated with conditions such

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Healthcare | GP referrals

as dysmenorrhoea, and musculoskeletal and psychological pain.9-11

Other symptoms that survey respondents were helping GP referred clients to cope with included headaches (55 per cent) – which complementary therapies have been recommended in the treatment of 12,13 – general anxiety (50 per cent), and poor sleep (48 per cent).

Different aspects of GP practiceOur survey results reveal that GP referrals may include referrals to members working within a multi-disciplinary team, such as in palliative care settings, hospices and hospitals; organisations that provide healthcare services to people with chronic health conditions; and independent members who work in private practice. The four case studies in this article illustrate some of the different aspects of members working in these contexts….

In my private therapy practice, I do not get any referrals from Gp practices; however, as a trustee, service facilitator and therapist working as a volunteer for a registered charity, I see a number of referrals coming directly to the charity from Gps. ICher (the Institute of Complementary healthcare, education and research) is a registered charity, which offers complementary therapies, including aromatherapy, remedial massage, Dr Bach consultations and remedies, counselling, healing, reiki, and reflexology, to anyone with a long-term illness who lives on the Fylde Coast.

We do not have any external funding, and the service is run entirely by our volunteers, using the donations given by our clients. the trustees lease premises in a building, which has four therapy rooms available. We have been in operation for seven years, and the referrals received from Gp practices, as well as community mental health teams and other healthcare practitioners, has increased markedly. We obtained our Gp referrals by targeting the practices with leaflets, information and by giving talks.

Case study: Susan Smith, MFHT Funding was the main challenge that our

survey respondents faced, and therefore it was no surprise that only a small minority (eight per cent) of participants stated that the GP practice or organisation paid for treatments, compared with 79 per cent that stated treatments were paid for by the patient. Other challenges faced by members in this field was a restricted number of treatments available (37 per cent), time restraints, lack of research to support treatments, and treatment adaptations for health conditions (26, 24 and 21 per cent, respectively).

A number of survey respondents indicated that they have found it difficult to receive GP referrals in the first place, regardless of whether they contacted them or even rented a room in the GP surgery, as many GPs still appear to lack an understanding of complementary therapies and others appear sceptical due to the limited evidence base. Many therapists commented that it was GPs who have had a personal experience of the benefits of complementary therapies that are more open to their potential benefits and more likely to refer.

Janet Lindop, MFHT, provided therapy treatments, relaxation techniques, and related advice for a number of years within

Rewards outweigh the challenges

I provide complementary therapies to clients in my own practice via referrals from a Gp who I have provided reflexology treatments to for 13 years. typically receiving two clients a month, I provide these clients with a range of therapies – from aromatherapy, reflexology and massage therapy, to Indian head massage, reiki and healing.

the Gp tends to refer clients who have expressed an interest in CaM and

would potentially gain a benefit from complementary therapies, to support them and help them to manage their symptoms and relieve anxiety.

the conditions clients typically suffer from include stress, anxiety and depression; cancer; muscular and joint problems, usually neck, shoulder and low back pain; high cholesterol; high blood pressure; sleep problems; and frequent headaches.

Case study: Juliette Boekhoff, MFHT

a local PCT (primary care trust) centre, a local community well-being clinic and the NHS, plus was involved in a number of health strategies, such as stop smoking incentives (massage was used to reduce stress and provide an incentive for those quitting smoking), improving the health of deprived communities and attending events to promote healthy living. Janet says that funding is a real issue for integrating complementary therapists who work privately and independently into GP practice, and believes that unfortunately we are still some way from being truly accepted within mainstream medicine or receiving appropriate remuneration.

Although throughout her career Janet has seen that some GPs have demonstrated the confidence to allow therapists to treat their patients; it is interesting that when the service is provided for free, it becomes a more readily valued form of healthcare.

However, by allowing therapists to deliver therapy services, this can help to educate mainstream medicine about the effectiveness and overall benefits that complementary therapies can bring to GP practice. Janet does believe there are some GPs that would welcome the support of complementary therapies but are restricted by budgets, while others are unaware of the health benefits and potential savings, thanks to fewer prescriptions and GP visits.

Yet despite proving to be a challenging environment in which to work, the benefits appear to outweigh the challenges, with a number of respondents commenting that making a difference to clients’ lives is a very rewarding aspect of this work. Working with other healthcare professionals in this capacity brings many members a sense of achievement and self-esteem, and the satisfaction in knowing they are contributing to the progress towards integrated care.

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References

GP referrals | Healthcare

1 Jong MC, van de Vijver l, Busch M, Fritsma J, and seldenrijk r (2012). Integration of complementary and alternative medicine in primary care: what do patients want?, Patient Education and Counseling 89(3): 417-22. source: pubMed (www.ncbi.nlm.nih.gov/pubmed/23031611).

2 Quattrin r et al (2006). use of reflexology foot massage to reduce anxiety in hospitalized cancer patients in chemotherapy treatment: methodology and outcomes, Journal of Nursing Management 14: 96-105.

3 Wilkinson sM et al (2007). effectiveness of aromatherapy massage in the management of anxiety and depression in patients with cancer: a multicenter randomized controlled trial, Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology 25(5): 532-539.

4 Wilkinson s, Barnes k and storey l (2008). Massage for symptom relief in patients with cancer: systematic review, Journal of Advanced Nursing 63(5): 430-439.

5 Improving Supportive and Palliative Care Services for

Adults with Cancer (2004). national Institute for Clinical excellence (www.nice.org.uk/nicemedia/pdf/csgspmanual.pdf).

6 nICe (http://publications.nice.org.uk/low-back-pain-cg88).

7 the British pain society (www.britishpainsociety.org).8 Back Care (www.backcare.org.uk/factsandfigures)9 The 2009 Annual Evidence Update on CAM for Low

Back Pain, the national library for health. source: nhs evidence (www.evidence.nhs.uk).

10 Furlan aD et al (2008). Massage for low-back pain, Cochrane Database of systematic reviews (online) 4: CD001929. source: pubMed (www.ncbi.nlm.nih.gov/pubmed).

11 robinson prof n et al (2011). Shiatsu and Acupressure: a review of the effectiveness evidence. source: the shiatsu society (www.shiatsusociety.org/content/research).

12 kumar p. Clark M. Clinical Medicine (sixth edition). published by elsevier ltd, 2005. (IsBn: 978-0-7020-2763-5).

13 nhs Direct (www.nhsdirect.nhs.uk).

the Fht is receiving an increasing amount of calls from members telling us that they have been contacted by commercial advertising companies trying to sell listings on therapist directories and registers. Many of these companies state that their directory/register is used by Gps, Clinical Commissioning Groups (CCGs), the nhs and other government healthcare bodies to access complementary therapists. In many cases the directory/register even has ‘Gp’, or ‘nhs’ in its title.

the Fht believes that there is no evidence that any of these directories/registers have any relationship with Gps, the nhs or any government healthcare body, nor do they have any skill, competency and safety standards for acceptance to the directory/

register. please be extremely cautious when entering into a discussion with these organisations and if you have any doubt, contact the Fht for advice.

there is no single register of complementary therapists that has acceptance or approval by Gps, Clinical Commissioning Groups (CCGs) or the nhs. the only existing relationship between registers of complementary healthcare therapists and these groups are accredited Voluntary registers (aVrs) recognised by the professional standards authority (psa). the Fht is currently undergoing accreditation of its register of complementary healthcare therapists by the psa – see page 41 for more information.

Beware directories promising ‘GP referrals’

Rewards outweigh the challenges

For those members who work in healthcare organisations, such as palliative care settings or organisations providing therapies for people with chronic health conditions, it is rewarding to work within a multi-disciplinary team and improve the quality of life of these clients, helping them to manage their symptoms and offering support at a difficult time.

The move towards integrated healthcare may be a long and often challenging journey but it would seem from our survey that the persistence of our members in building bridges with GPs, developing professional working relationships and gaining excellent results from therapy treatments is going a long way in working towards this goal.

And from the GP’s perspective….Dr Michael Dixon, a practising GP and chair of NHS Alliance and the College of Medicine, told the FHT:‘I am very fortunate at my practice as we have many complementary practitioners offering services to patients within our Integrated Centre for Health. Very frequently, I am suggesting that patients see a number of our complementary practitioners – particularly our osteopath, massage therapist, reflexologist, hypnotherapist or sports therapist – and the referrals to them and their workload has steadily increased as my nine partners have increasingly realised their potential to help patients.

‘They offer a patient-centred service, which many patients find more acceptable than conventional treatment and which is provided with that level of care, compassion and time, which is sometimes all too difficult in the hurried day of a conventional NHS practitioner.

‘For most of us in the NHS, the added value of complementary therapies is to fill the ‘evidence gaps’ in areas where conventional medicine has little to offer. This encompasses a great deal of general practice, such as patients presenting with back pain, depression, anxiety, chronic tiredness, multiple infections, irritable bowel syndrome, fibromyalgia, and much of what we see in general practice.

‘Talking to other GPs, their reticence in referring to complementary therapists is simply their lack of knowledge of those complementary therapies and a fear that they may be blamed if things go wrong. Of course, that is something that has almost never happened but the fear is real and can only be overcome by complementary therapists working closer with conventional practitioners and GPs and enabling them to know more about the complementary therapies being practised, the people providing them and the boundaries of safety within which they practise.

‘Not long ago, I was attacked by someone, who said that I should not allow my patients to be treated by practitioners who did not have medical training. I pointed out that within the last year, our osteopath had sent me three patients; one had a mole that would have killed him had it spread; another had temporal arteritis, which would have sent her blind if I had not been alerted; and a third had spread of cancer, which would

have made her life even worse if it had not been discovered at an early stage.

‘It is certainly time for complementary practitioners and conventional medicine to work closer on behalf of patients, who all too often have to choose ‘either/or’ and who are confused by the division between the two. It is certainly time for conventional practitioners and complementary practitioners to join force on behalf of the patient and allow the latter to have a full range of treatment approaches provided in a safe and coordinated way, which allows us to treat patients to maximum benefit. We can perhaps only create this by abolishing the fundamentalists, who are opposed to all complementary medicine, and those who oppose all attempts at regulation, and encouraging safe practice – whether they be complementary or conventional practitioners.’*visit www.fht.org.uk/rr/complementary/mentalhealth/Pilkington to read about the evidence base for complementary therapies and mental health.

l Forty FHT members completed the survey. Many thanks to all those members who took part.