Glastonbury Health Centre Medicine Service - Case Study Example

Academia-Research d 19th May 08 Evaluation Strategy Topic:  Analyse and systematically critique the evaluation of Glastonbury Health Centre Complementary Medicine Service Introduction Glastonbury Health Centre provided opportunity of complimentary health services since 1992 to patients suffering from chronic and severe health conditions particularly related to muscles and joints and who normally failed to respond to conventional treatment. They wanted to learn about the benefits the service provided to patients and the contribution it made to the overall running of practice.. 600 patients were referred during 1992 and 1997 with chronic symptoms of disease. There was systematic evaluation of the treatments meted out to patients and the results of the treatment and therapies. The evaluation tried to find whether the service had any real contribution to the running practice in the line. Complementary therapies are age-old practiced by many parts of the world. This therapy has been very effective in treating patients suffering from musculo-skeletal and psychosocial problems and improving the general well being of patients. The Glastonbury Health Centre is very much convinced about this complementary therapy and integrated this into primary health services as their main aim. According to Dr. Wellford primary care and complimentary practitioners have much in common as far as both are concerned about caring the patients rather than just curing them. They have clear guidelines and referral protocols to identify those patients who are most in need of a particular therapy and most likely to benefit. The service is regularly evaluated and adapted to new conditions and experiences. Evaluation of the service has noted 17% of patients recovering after treatment most commonly from musculoskeletol problems and majority report improvements. Modus Operandi The basic complimentary service was framed with selection of five major therapies of osteopathy, acupuncture, herbalism, massage and homeopathy. Six qualified practitioners were assigned the task of providing the services to patients. Patients from the primary section were referred to the complimentary section for treatment. All referrals were made via GPs only but later the practioners were flexible to have their own appointments as well. SF36 is used which is quality of lifecycle to assess the difference in patient’s conditions after treatment. In order to focus on the patients on treatment and to know how the service was performing the objective of the research was set to find the answers of the following questions: 1.  What contribution can complementary medicine make to primary health care? 2.  Which patients can benefit from complementary medicine? 3.  What are the advantages and disadvantages for the practice of having a complementary health service? 4.  Can such a service be cost-effective? The objective set seems to be very limited in scope. To be really consumer-oriented the area of focus should have been increased as given here: *What types of complimentary services people are using? *How many people are using these services currently *What are the health outcomes of patients? How much they are satisfied? *The pattern of use of complimentary services, whether jointly with conventional treatment or used independently. *How do patients gain access to the complimentary treatment? *What is the venue for treatment for complementary treatment and who treats them? Should the complimentary treatment be given in the primary health care centres or should it be given independent of it? * What contribution Complementary medicine gives to primary health services? *Why do people prefer complementary treatments? * Whether the treatment is cost effective. The selection of doctors for undertaking the responsibility of providing the services of complimentary health care is not commendable since they had part time assignments only. No practitioner had full time assignments for the whole week. Homeopath service was just casual. Perhaps the centre was not sure about the flow of patients or they had little funds to make the section viable or they wanted to make the project cost-effective at the cost of the service. The research methodology included a number of different sources of data. These included: - Referral forms on all referrals to the service filled in by GPs and complementary practitioners, - Questionnaires filled in by patients on referral to the service, on completion of treatment and six months after referral, and - Interviews with a sample of patients, and with practitioners and other health service staff. The data source by above mentioned research methodology adopted by the current research has left many other data sources that are more comprehensive and universal. The search centred round small intervention group of people as done in pilot projects. This complimentary health care services is not a local service but spread to large areas of the countries and the world. Therefore sources to search data should have been widened to cover Internet, services of search engines and questionnaires sent to more people by telephones, emails, through networking at conferences, educational institutions, private clinics, health centres, individual therapists, health institutions and websites in wider spectrum of society related directly or indirectly with the complimentary health care services. The objective of adopting method or methods of data collection from different sources is that it must be effective within each evaluation irrespective of the constraints or advantages the method adopted has. A combination of methods is more effective to answer several questions by the evaluation process. The combined system is complex to analyse but is robust enough to withstand analysis from other sources on the same topic. No repeat measurements: In the evaluation process of a very small and constant sample there was need for repeat measurements of the changes before and after the treatment but this not done in this case. This is a more precise method to register precise change in patients. In the evaluation process qualitative approach has not been used aggressively. This approach enables researchers to explore the delivery of the programme and its efficacy better and deeper by providing detailed exploration of the factors that underpin participants’ experience of the programme. Particularly this approach is very useful for small number of evaluators engaged for small sample. Quantitative analysis cannot go deeper with why and how that is possible in qualitative evaluation. The focus of this research was to examine the role of complimentary therapy within general practice and not as an independent entity. This limits the efficacy of this age-old practice. There are chances for biased opinions and pressures in this type of research within the limitation of another competing services (in the future) though complimentary today. In workshop organized by Dr. David Peters of Marylebone Health Center about the range of complimentary therapy at the center it was generally felt that there was limited scope for complementary medicine within the new NHS and that the role of ‘champions’ who could provide leadership and share good practice was particularly vital. Effectiveness of the evaluation The effectiveness of complementary services should be determined independently. In order to make the search more relevant the findings must be compared with the other researches, which are widely available. This is true that researches in this area have time and resource constrains but they have to be meaningful for the targets. Pilot studies on problems that are on short terms have valid roles in setting up broader issues and in establishing a valuable dialogue in between the practitioners and consumers. It should be applied to larger areas to get broader outlook of the objective. Designing the sample population has some serious shortcoming first because of a very small sample of 600 and second for division of that sample by ‘above and below 40 years of age’. Women who assessed themselves to feel greater level of change after treatment have not been given a separate and deeper evaluation. These variations have not been recorded in SF36 results. Therefore there was need for qualitative assessment of the women sample by interviews or group discussions to go in detail about their self-assessment standing. No attempt has been made to know what is the population percentage that uses complimentary treatments. The evaluation is concentrated to the Glastonbury health centre only whereas the problem pertains to the whole society. There should have been attempts to find the number of visits by each patient to practitioners for one or more therapies. Need for Independent Process Evaluation In order to know how the programme operates on the ground process evaluation need to be used, which verifies about the programme to know whether or not it is delivered as intended to the targeted recipients. This defines the aspect of research and the type of information about the aspects to be collected to present the clear picture about the targets. Process evaluation tends to be carried out independently of service delivery and is normally carried out by evaluation specialists. For practical reasons, it is normally separate from day to day programme management and monitoring. In this case study of research the evaluation is done by the practioners themselves who may be biased in presenting the facts. Outcomes with support of counterfactual evaluation needed Outcomes of a research are the principle objective. These are factors that the programme is likely to have an effect. In case of impact evaluation, which is to measure the impact of a policy or programme on the defined outcome measures it is very crucial to define the outcomes of interests precisely and in advance. Everyone is interested to know about the impact the policy or programme of a research has in terms of outcome. The answer best lies on what would happen if the programme is not in the place working. This is counterfactual that is not adopted by the present evaluation process. The research should focus on both the elements of process or impact of the policy for the evaluation to be effective. The research has used before-after study to measure the impact of complimentary health care services to cure patients. In this method the outcomes are measured on the population eligible for the programme both before the programme is implemented and after it is. The difference between the two measures is considered to be the impact of the policy or programme. These Before-After studies are conducted for research when the policy is implemented on national basis and not just on the pilot stage as this research is. Therefore there is not justification for using this method. Problems of size of the intervention group were often faced in the analysis. Small number of patients from specific disease and the conditions of the disease could not be brought on the scale of analysis. This problem was acute in case of small number of patients with emotional disease since they were insignificant in number to be put on tests. The limitation of impact analysis was further felt because of group-wise analysis divided into several groups as women group, older group below 40 and above 40-child group out of total size of 600 patients only. Had the size been bigger the analysis would have been far meaningful and representative. The Cost-Benefit analysis is done with a view to identify all the costs and benefits arising from a programme. This presents an overall view and assessment of the impact of the policy. The objective is to know if the benefits provided is more than the cost involved in the programme and that in other alternative schemes. This is a valuable guide to continuance of the programme on cost effective basis individually or relative to other schemes. The cost-benefit analysis requires identifying the impact of the policy or programme on the eligible population. In case of the research in our sample the same cost-benefit analysis with assessment of impact evaluation is done. The evaluation has noted the savings made by the group of patients in the year following complementary medicines more or less covered the cost of the complimentary medicine provided. It has also been noted that complimentary health services has made a considerable contribution to the reduction in referrals to secondary care and is more than covering its costs from savings elsewhere in health service provision Who paid for the services? The evaluation report is not clear specifically about who pays for the complimentary health care services. Whether NHS pays 100% or the patients also pay a portion. In which cases patients have to pay full. The report is also not clear about the availability of private clinics in the area of complimentary medicines that existed in the place. Secondly the research is not clear about who paid the practitioners and how since they were all partly engaged on time basis. The report indicates about the gross cost that is involved in providing the complimentary services. Whether the cost includes the direct cost only or it includes all overhead costs proportionately in the complimentary services. Better comparison can be made if the rates of providing private services in this line and in general health practises are provided. The research should have included all these to clarify everything and all aspects of complimentary services. The evaluation report has touched the reasons for using complimentary services but is not clear whether patients have an independent choice for referring to be treated in complimentary therapy section for comprehensive section of they were simply referred by the GP for their own end. Whether the patients were aware that the GPs were not capable to treat patients with complimentary disease. Whether the patients had any choice when they were treated well and the relationship with the doctors was spoiled. A comprehensive evaluation on this line would have provided a broader picture of the patients’ shifts to complimentary health care. SF36 scale used to score out the difference between the conditions on referral and after treatment was very sensitive and useful for the purpose. The SF36 was better designed tool to measure compared to the self-assessment of change by the patients. Own assessments of change did not provide a particularly useful measure of difference between groups. Patients with different levels of problems –how much chronic, or severe- and different levels of experience about the disease and the complimentary medicine and also their attitude about the health and treatment mattered on the self-assessment. SF36 with use of correlation analysis also was more objective to study the problems and treatment. The SF36 analysis showed that those patients with long-term disease in chronic and severe condition for more than a year did not show improvement but short-term disease for lower than six months did show favourable result on treatment. (Table 20) Patients with different levels of severity of problems showed different results after treatment. On the scale of SF36 it has been shown that more the severe the problem on referral the greater the level of improvement. The conclusion is not very convincing to the common mind. Why this should happen. It may be the case of attitude towards the disease patient has. People with long drawn chronic patients tend to feel negative about their disease and tend to feel that it would not cure. Patients with acute symptom but in short-term remain optimistic about the disease and tend to feel the difference of treatment even if minor. Complimentary treatment is typically used for long-standing illness for more than a year. It is also used for multiple reasons and multi-system conditions particularly recognised by doctors as not or poorly benefiting from the conventional treatments. The finding of SF36 is contradictory here. The role of complimentary therapy in the service to cure severe and chronic patients is growing gradually. By now GPs still have little knowledge about which patients and in which conditions they are likely to respond better to different therapies. The research is still on pilot basis only. The source of information about the disease and treatments are the practioners or the patients or small audits. The patients referred to complimentary care by GPs are the available opportunities for a systematic analysis of patients. This type of research is a small beginning on short-term basis than can be broadened on large scale on medium term basis. Patients are not left on to the care of orthodox treatment but are referred to specialised doctors in the complimentary medicines. The findings provide a useful focus on the need for scientific health care to patients in the specialised category that cannot be cured by the conventional methods and also focus on proper planning and provision for the treatment in this segment. There is indication in the finding that patients are taking more and more responsibility for their own health. The findings by evaluative study may provide opportunity for NHS to integrate complimentary therapy in their folds. Successful treatment by complimentary care may relieve the existing health care system by transferring all patients with chronic and severe nature to them. The complimentary medicine and health care will be able to attract so many patients from the ethnic and economically lower class patients who are not able to afford the western medicines and diverse costly medical tests. Another clear indication trough cost-benefit analysis is given that the complimentary health care services are not burden on others. These services recover through savings gained in reduced use of drugs and diagnosis tests that would have incurred in case of conventional treatment. Though the independence of complimentary health care is a subject to be discussed the services provided at present within NHS is the right strategy at present to enable it to flourish. NHS will be benefited from reduced repeat visits to GPs or fewer referrals for complex diagnostic tests. There are positive benefits to both health care services and the patients. Every patient needs to be cured but some times quality of care by doctors also matters for patients. There is psychological benefit to patients who become satisfied by extras care by doctors and tend to ignore even if there is no permanent cure of the disease. This is possible by complimentary health care only. The policy to integrate the complimentary health care services to the GP taken by the Glastonbury is good decision for the present because this will provide ample opportunity to free up more GP’s time and enable them to concentrate to their medical care better and improve patient-doctor relationship. The economic benefits derived by complimentary therapy can be used to improve the services in the GP by service to more patients in the time saved. This integrated health care service strategy should be extended to more and more centres. This strategy will enable complimentary therapies to stand up on its own one-day or other to provide independent service to the well being of mankind in general. . Barbara Wider. The Department of Complementary Medicine University of Exeter email: b.wider@exeter.ac.uk Complementary and Alternative Medicine: the consumer perspective www.fondazionericci.it/flex/cm/pages/ServeAttachment.php Dr. Hills Dione, Dr.Roy Welford, COMPLEMENTARY THERAPYIN GENERAL RACTICE An evaluation of the Glastonbury Health Centre Complementary Medicine Service http://www.integratedhealth.org.uk/report Read More