Positive Health Online

The Aim of Healthy Bristol

Healthy Bristol was started in April 2001 by Dr Rosy Daniel and a group of influential supporters with the aims of making Bristol's large resource of complementary therapies, psychological support services and self-help approaches accessible directly to the general public, and to the medical profession, care agencies and residential institutions for use by their patients or clients.

The Healthy Bristol team believe that a great deal of human suffering can be alleviated through the development of integrated medicine (IM) in the city. We define IM as the combination of conventional and complementary medicine services, psychological support and self-help approaches, delivered within the context of the medical setting.

Healthy Bristol Project Launch, 3 October 2001, from left to right: Junichi Imura
(British Johrei Society), Dr Rosy Daniel (HB Project Leader), Susan Osman
(Patron and BBC news presenter), Peter Wallace (Chairman)

The First Healthy Bristol Initiative

The first initiative will be the Bristol Integrated Medicine Project (BIMP), which will undertake to:

* inform and educate conventional and complementary health-care practitioners about existing IM research, treatment protocols and good examples of working IM service delivery models;
* set up pilot IM projects within general practice, hospital settings, institutions such as prisons and residential care homes within Bristol;
* monitor the outcomes of these initiatives and disseminate the evidence gathered.

The work of the BIMP is designed, ultimately, to provide a template for the widespread provision of information, education and research into all complementary, psychological and self-help services, to enable them to become a routine integrated part of NHS care. In this way these resources may become available to all - and most especially to those who are unable to afford them currently in the deprived areas of the city.

The Second Healthy Bristol Initiative

The second initiative will be the Bristol Health Creation Project - bringing the power of the holistic approach to health to bear in preventing illness in the community by setting up Health Creation initiatives.

The major degenerative illnesses of our time are all preventable. Cancer, heart disease and many lung, gut and musculoskeletal problems can be prevented or reversed given the right level of information, personal guidance, resources and most crucially, psychological support. Changing our lifestyles and habits does not happen as a result of information alone - however frightening that information may be. It is vital that we are encouraged, motivated and lifted emotionally for sustainable, healthy change to occur. By adding the great potential of the holistic self-help and support approaches to the city's conventional health promotion efforts, assisted by the local media and the setting up of Health Creation Centres within the community, the vision of a 'Healthy Bristol' can eventually become a reality. The Bristol Health Creation Project will commence in June 2004 and will not be described fully in this article.

Healthy Bristol will aim to bring help and healing into the heart of Bristol's inner city communities, bringing new hope and encouragement to thousands who have reached the limits of what the more conventional health-care systems have to offer. It will also foster a positive, proactive approach to Health Creation for all that live in the city.

The Bristol Integrated Medicine Project

The Support for the Project

The project has the support of His Royal Highness the Prince of Wales and his pioneering organization The Foundation for Integrated Medicine (FIM). It is supported locally by the MPs Jean Corsten, Dawn Primorolo and Valerie Davey, the Director of Public Medicine, Dr Kieran Morgan, and the Chairman of the North Bristol General Practice Primary Care Group, Dr Will Warin. The research is supported by the Faculty of Health and Social Care at the University of the West of England, Bristol, by Professor Steve West, and by the Faculty of Health and Community Studies at De Montfort University, Leicester, by Professor Mike Saks.

The project has been designed by Dr Rosy Daniel, former Medical Director of the Bristol Cancer Help Centre, with assistance from complementary medicine researcher and publisher Eleanor Lines.

The Context

The founder of Healthy Bristol, Dr Rosy Daniel, became aware first as a GP in Bristol in 1988, then as Medical Director of the Bristol Cancer Help Centre, both of the power of the holistic approach to health to relieve suffering and sickness and of the extreme inequity of access to the city's holistic health resources. She is concerned that many of her GP and consultant colleagues in Bristol are unaware, on the one hand, of the holistic resources that are available and, on the other, of the extensive new scientific evidence validating the use of complementary and mind-body approaches. It is also clear that for many people the block to accessing helpful therapies, support and self-help instruction is purely financial.

She is now committed to rectifying this situation through the Healthy Bristol Project, helping through information, education, research and the setting up of practical integrated medicine projects throughout the community of Bristol to begin to iron out this inequity of access to our city's valuable holistic health resource.

Spurred on by a two-year consultative process for the FIM, Dr Daniel now plans to help make the possibility of IM a reality for the city of Bristol. This project is a first in Great Britain. No other project has worked at a local authority level to bring holistic services to a whole city.

The Demand for Complementary Therapies, Support and Self-help Approaches Nationally

Public interest in complementary therapies (CTs) has grown rapidly since Dr Daniel started in general practice in 1985. A recent BBC survey revealed that 1 in 5 respondents had used CTs in the past year and that 4 out of 5 believed that the popularity of these therapies would increase.[1] Earlier Mintel market research information in the mid-1990s showed that 30% of those interviewed used CTs and self-help approaches but that 75% would use them if they were freely available on the NHS.[2] This indicated that CTs are highly valued by the public but that cost and the fact that most CTs are only available privately are huge barriers to accessing them for the majority of people.

The public demand for access to CTs within mainstream health-care settings has largely been blocked by the medical profession because of a perceived lack of evidence for CTs, combined with differences in philosophy and practice from conventional medicine and the lack of medical education on this subject. Variable training standards within complementary and alternative medicine (CAM) have compounded the problem. There has also been a lag in the new findings from the field of mind-body science (psycho-neuro-immunology or PNI) being incorporated into medical practice. The results of such research underline the vital importance of psychological support and self-help approaches in the treatment of many conditions.

Currently much time is demanded of GPs to manage social and psychological problems that could more effectively be delegated to those offering psychological and social support services. In addition, it is now clear that a large number of physical conditions are greatly relieved by psychological intervention and mind-body, self-help approaches.

The Royal College of General Practitioners has estimated that approximately 50% of problems presented to GPs are purely social, 25% psychological, and that of the remaining 25% of physical complaints, half are psychosomatic. This indicates that proper use of psychological support systems and self-help approaches aimed at strengthening the coping mechanisms of individuals could greatly reduce pressure on GPs and hospital services. It would also help to stop many psychological and social problems becoming 'medicalized', incurring inappropriate and costly use of medical investigation and treatments. Even in the remaining 12.5% of truly physical complaints, relief of suffering, palliation and health promotion can be offered through psychological and self-help techniques.

Obstacles to the Integration of Medicine

The lack of knowledge of research evidence, differing philosophies and training standards, plus a lack of medical education for conventional practitioners in complementary medicine, has led to a very low rate of NHS referrals to CTs within mainstream health-care settings.

The FIM[3] has identified the major obstacles to the integration of medicine as being:

* The relative lack of high quality CAM research evidence;
* The lack of dissemination of existing CAM research evidence;
* The lack of clarity about training standards and professional accountability within the various complementary medicine training schools and support agencies;
* The lack of education of conventional medical practitioners about the values, theory, practice and evidence associated with holistic medicine approaches;
* The lack of education of complementary practitioners about medical values, safe practice, reflective practice and inter-professional communication;
* The cost of complementary health care;
* The lack of inter-disciplinary meetings between complementary, support and orthodox health-care practitioners.

However, the last decade has seen important steps being made towards rectifying this situation, with the evolution of a rapidly growing body of high quality scientific evidence for CAM, PNI and IM approaches. Work on the regulation of practitioner training and practice has also begun and this is bringing clarity to the different qualifications and training of practitioners and the scope of their practices.

Both the public and the medical profession are now increasingly aware of the value, benefits and need for a holistic approach to health. The public is in favour of the integration of care for their spiritual and psychological needs with the medical help they receive as well as choice and involvement in their own health-care management.

GPs in innovative practices have already demonstrated the cost-effectiveness and labour-saving potential of providing access to support, self-help and complementary services for their patients.[4] There is clearly a need to facilitate the access of the general public to these services.

Healthy Bristol is seeking to address and help eliminate these obstacles to the integration of medicine in order that individuals may have the best level of health care as well as appropriate involvement in and responsibility for their own health and its management.

Now a period of mutual education, trust building and transparency is needed, through the provision of information and education for medical health-care practitioners about the values, science and theory underpinning the use of appropriate holistic approaches to health. Simultaneous education of CAM practitioners in the values and practice of medicine is also needed, in order to foster a climate for the evolution of a truly integrated approach to medicine. Only if this can happen will the general public receive the best of both worlds - orthodox and complementary - with all sources of possible relief for their problems from any culture or belief system being considered.

How the Need for Integrated Medical Help is Currently Met in Bristol

Within the city of Bristol there are estimated to be 40 complementary therapy centres with a range of practitioners, of which the best known is the world famous Bristol Cancer Help Centre, specializing in the holistic approach to cancer. There are an estimated 3,000 complementary practitioners in the city and many more who provide psychological support and self-help instruction. This compares surprisingly with the number of doctors within the city of Bristol, which is approximately 1,000, made up of 667 GPs and its hospital doctors.

National estimates of the number of complementary practitioners now in practice, calculated from the 2nd Exeter University Report suggest there are about 60,000 practitioners and possibly another 20,000 statutory health professionals using CTs in the UK, compared with 30,000 GPs.[5] These figures suggest that Bristol has an above average density of holistic health practitioners.

The complementary therapy centres in Bristol are nearly all situated within the affluent north-west of the city, with only six or so outside this area in the east and south. Most of these offer accommodation for rent to practitioners to practise on a freelance basis as opposed to offering employment. It appears that by far the majority of practitioners practise currently from their own home or personal private practice premises. Practitioners estimate that over 90% of the usage of these services is private and self-initiated by the general public. Of the group who use this resource, approximately 75% are women.

The CTs for which there are most GP referrals are osteopathy and chiropractic. This is followed by acupuncture, herbal medicine and homeopathy. A survey in 1986 demonstrated a surprisingly large interest in CAM among GPs in the Avon area.[6] Standard medical referrals to medically qualified colleagues had been made by 76% of GPs in the previous year, while 72% had referred to non-medically qualified practitioners. Despite this high reported level of referrals to non-medical colleagues, the perception is that most GPs are largely unaware of existing CAM centres and practitioners in their areas. They are particularly unaware of the existing psychological and self-help agencies, which could help their patients and significantly reduce the non-medical aspects of their work.

Until recently the Bristol Council for Voluntary Services (BCVS) existed, which aimed to gather and disseminate information about the city's voluntary services. Since then attempts to organize information in this area have been taken up by VOSCUR (The Voluntary Organizations' Standing Conference of Urban Regeneration) and the Care Forum. Whilst these agencies do a great deal to get appropriate help to those who need it they are not currently including the holistic services of CAM, psychological and self-help services within their directories, other than in a very patchy way.

Within general practice in Bristol there is one dedicated complementary GP practice specializing in Anthroposophical Medicine and the provision of allied complementary, psychological and self-help support services. There is also a practice in North Bristol with two practising homeopaths and other practices with GPs who themselves offer a range of skills such as acupuncture, osteopathy and hypnotherapy. Currently very little is known directly about GP attitudes towards and use of IM approaches. The impression of low usage by GPs of existing resources comes directly from the CAM practitioners and holistic support agencies that report high levels of self-referral and a predominance of white, middle-class patients. It is not clear how many Bristol GPs or hospital units employ the services of CAM or support practitioners. There is, however, a well-established NHS homeopathic hospital in Bristol, staffed by medically qualified homeopaths with a high level of GP referrals.

Previously, fundholding policy gave GPs more freedom to be able to employ non-medical support practitioners if they were perceived as being of value. However, the advent of Primary Care Groups (PCGs) has largely removed this flexibility in the use of practice budgets and the fundholding practices have had their funds for CTs withdrawn; CTs have received lower priority in the new administrations, which are keen to restructure their conventional services first. In a system intolerant of inequities, it has been difficult to establish CAM provision on an equal basis throughout the regions and, as a result, it has frequently not been provided at all.

Only one-fifth of PCGs in the UK have any CAM policy in place, and these are mostly only continuing existing provision on a provide-and-review basis. There is currently neither a centralized initiative within Avon Health Authority to evaluate the role and benefits of IM nor any policy towards the development of Integrated Medical Services.

The most active attempts to develop IM within the city to date are currently being undertaken by the Bristol Cancer Help Centre, which is working with GPs to integrate holistic cancer help services into their surgeries.

In terms of any organized attempts to develop IM within general practice, there is the Complementary Medicine Special Interest Group in the North Bristol PCG which has begun to disseminate useful information on the use of CTs to GPs. The Department of General Practice (University of Bristol) is developing holistic medical education modules for GPs in training.

The Healthy Bristol project will gather information and inform the local health authority about high quality physical, social and psychological services in the area. It will fill an information gap for both the medical profession and the general public. Its outreach work to the medical profession, complementary practitioners, the public and the local health authority will create a network to facilitate policy changes that will ultimately allow the integration of holistic health services within the NHS and so foster the development of IM.

The Organization of Healthy Bristol

The Bristol IM programme will run for three years. Initially doctors and those providing complementary support services in the city will be surveyed to assess their current usage of and attitude towards IM. The complementary practitioners and providers of psychological and self-help services will be invited to have their service assessed for inclusion in the Bristol Integrated Medicine Directory. Doctors will be invited to set up IM pilot projects with our help and support, which we will then also help them to monitor for research purposes. We will aim to set up a minimum of one pilot project in:

* a general practice setting;
* a hospital setting;
* a prison; and
* a residential care home;

At the end of the three-year period, an assessment will be made to evaluate the progress and results of the IM pilot projects. We will then be able to assess the need for continuation of the pilot programme. It is hoped that, by this point, the value of the IM approach will have been demonstrated sufficiently well to justify financial support from Avon Health Authority and/or the Primary Care Trusts.

The functions of Healthy Bristol have been focused into seven project groups, each of which has external professional advisors, in the areas of:

* Information;
* Education;
* Research;
* Integrated medicine service delivery;
* Fundraising;
* Publicity;

all of which are dependent on

* The Healthy Bristol Network.

Information

The Information Project provides the foundation for Healthy Bristol, by producing a directory of quality-assured holistic services available in the Bristol area. Complementary practitioners and those offering psychological, social and self-help services as well as mainstream medical practitioners who are (or wish to be) involved in IM will be invited to take part in the project. The skills and qualifications of IM practitioners will be measured against quality criteria agreed between the Healthy Bristol Project and the medical profession locally, with additional advice from the FIM. The description, cost and scope of services provided will also be included in the directory.

The resulting Bristol Integrated Medicine Directory will be continuously updated and members will be asked to renew their entry on an annual basis. It will become available during the three-year duration of the project:

* as a paper-based directory;
* on the Healthy Bristol website;
* on the Avon Health Authority website, available to both the public and medical profession;
* as part of the Care Forum's DISS directory.

The Information Project will also serve to provide back-up information to the medical profession on the qualifications and training of complementary practitioners. It will also help to compile the Bristol Integrated Medicine Evidence Directory and the Bristol Integrated Medicine Treatment Guide - which will also be available through the above channels.

Education

The Education Project outreach work will:

* familiarize conventional medical professionals with the facts about IM research and practitioner training and help disseminate the research information compiled by the Research Project held in the Evidence Directory mentioned above;
* instruct conventional medical practitioners on the philosophies and science underlying IM therapies as well as describing the practical ways in which conventional and complementary teams can work together;
* instruct holistic/complementary practitioners on the requirements of the medical profession in order for them to enter into the development of integrated medical services;
* provide access to high-quality IM training for conventional health-care teams so that they can provide additional services within their existing practice;
* Set up multi-disciplinary integrated medicine case conferences within normal medical teaching environments.

Research

The Research Project will:

* conduct research into the current usage and attitudes towards IM in Bristol;
* provide summaries of the evidence base for the use of complementary therapies for specific medical conditions which will form the basis for the Bristol Integrated Medicine Evidence Directory. This information will be supplied to the medical profession both in the form of paper summaries, via the Healthy Bristol website and through meetings with health professionals (see Information and Education Projects);
* help set up outcome measure studies in the pilot integrated health-care projects that become initiated. Outcomes will be measured in terms of effectiveness, safety, cost effectiveness and patient satisfaction, quality of life and well-being.

Integrated Medicine Service Delivery

The Integrated Medicine Service Delivery Project will assist orthodox practitioners to establish IM pilot projects within their current practice, hospital, institution or care setting. Drawing on the latest scientific research and examples of existing models of good integrated health-care practice already described by FIM and others, this project team will facilitate the development of a wide range of integrative practices such as:

* introducing spiritual healing in GP practices for chronic, degenerative conditions;
* providing massage for the elderly in residential care;
* establishing meditation in prisons;
* using herbal or homeopathic support to speed recovery from surgery;
* introducing support and yoga groups into the community to help the anxious;
* offering nutritional education and cooking skills for the socially disadvantaged.

Individually tailored models may be developed, as appropriate.

Fundraising

The Fundraising Project will identify suitable funding partners in the Healthy Bristol work and will raise funds both for:

* the core funding and set-up costs of the central office; and
* the Healthy Bristol Fund, which will be used to fund selected IM pilot projects and the associated research within the community (where funds are not available within the host organization) so that services may be provided free at the point of delivery. The fund will be focused on the areas of highest health need in Bristol.

Publicity

The Publicity Project will be fundamental to the success of the Healthy Bristol work. This group will work to raise vital awareness in the city of the huge potential of the BIMP - aiming to get the city to take ownership of the project at every level.

The Healthy Bristol Network

The success of Healthy Bristol depends on its ability to reach members of the public in all areas of the city and to help change NHS practice and medical thinking at local level. The process of this change requires the direct involvement of community members and their politicians, and that the local Health Authority purchasers and providers, health educators, health-care practitioners, managers of the large institutions and care homes, the business community and the media all play a part. The role of the Community Link Manager will be to establish this network of stakeholders and to ensure up-to-the-minute information flow from the community to Healthy Bristol and from Healthy Bristol back to the community.

Professional Goals

Within the first three ambitious years of the BIMP we will aim to have:

* identified a membership of the high quality complementary, psychological and social support and self-help services within the Bristol community;
* created an evolving Bristol Integrated Medicine Directory of these resources;
* informed every health-care professional in the city about the directory and given guidance on its usage;
* informed interested Bristol health-care professionals about the existing evidence base for the use of complementary, psychological and self-help approaches in medicine;
* offered every health-care practitioner within the city the opportunity to receive education and guidance in the use of integrated medicine approaches;
* offered every complementary and support practitioner in the city the opportunity to learn about the requirements of medical colleagues in order to work in partnership with them;
* offered all interested health-care practices guidance in the development and setting up of IM services;
* informed the public about how to access and use high quality complementary, psychological and self-help approaches to manage and improve their health;
* helped to build a picture of current attitudes towards and usage of integrated health-care approaches in Bristol;
* defined some of the most effective usages of IM practice in order to contribute to the adoption of appropriate practices on a larger scale within the city and nationally;
* have created a new formulation for the development of integrated medical services within a city, which will help benchmark future applications to health authorities countrywide.

Who Will Benefit?

The project will benefit members of the general public in Bristol who have reached the limits of what conventional medicine is able to offer them. It will be aimed particularly at those who cannot access IM approaches for practical or financial reasons. The range of medical conditions to be targeted are:

* anxiety and depression and other forms of psychological distress;
* long-term chronic disabilities such as chronic bronchitis and physical disability;
* inflammatory conditions that are not responding to treatment such as asthma, eczema and rheumatism;
* bowel or reproductive dysfunction;
* life-threatening conditions.

The BIMP will also be able to respond to specific requests for treatment protocols for doctors working with any condition or patient group.

Bristol's doctors and health-care practitioners will also benefit from this project as they will be given support to offer relief to their chronically ill patients, which will take a burden from them emotionally, as well as saving them time and the cost of repeated medical testing and treatment.

The Funding of the BIMP

Healthy Bristol is currently seeking charitable status as, to date, there is no statutory funding of any sort available for this project. A total of £600,000 is required to fund the three-year project, of which £150,000 has already been donated from the Japanese Johrei Society. Once this core funding has been raised, Healthy Bristol is seeking to create a Healthy Bristol Fund through which to help participants in the project provide complementary medicine services, free at the point of delivery within the four pilot projects and thereafter to other suitable IM projects initiated within medical health-care settings. If we are successful in raising funds it will also be possible for individuals to apply to this fund for support in obtaining integrated medical help if their doctor is not participating in the BIMP.

Membership of Healthy Bristol

The first priority for Healthy Bristol is to build our:

* general membership - of those who wish to support the project financially and politically - from within and outside Bristol;
* practitioner membership - of those individuals and organizations offering complementary, psychological and self-help services within Bristol who wish to have their services assessed for inclusion in the Bristol Integrated Medicine Directory;
* patient membership - known as the Patient Voice of Healthy Bristol - of those who have directly experienced the benefits of holistic approaches to health and would like to add their voice to the political lobby for the development of IM within Bristol;
* medical membership of doctors, nurses and other health-care practitioners who would like to support the evolution of IM in Bristol.

If you would like to become a member of Healthy Bristol please contact us by e-mail at admin@healthybristol.co.uk, by letter to Membership, Healthy Bristol, 77a, Alma Rd, Clifton, Bristol, BS8 2DP, by phone on 0117 9493366.

References

1. BBC Radio 5 Live/ICM Research Ltd. 1999.
2. Mintel. Report on Alternative and Complementary Medicine. 1997.
3. FIM. Integrated Healthcare - A Way Forward for the Next Five Years? The Foundation for Integrated Medicine. ISBN 1 85717 173 X.
4. Pietroni and Pietroni. Innovation in Community Care and Primary Health: the Marylebone Experiment. ISBN 0443 052964.
5. Mills Simon and Budd Sarah. Professional Organization of Complementary and Alternative Medicine in the UK 2000. 2nd report to the DH. Centre for Complementary Health Studies, University of Exeter. 2000.
6. Wharton R and Lewith G. Complementary Medicine and the General Practitioner. BMJ. 292: 1498-500. 1986.