Summary of the impact

Over the past 25 years Professor David Peters has developed a model for successfully incorporating complementary therapies (CT) for musculoskeletal pain into the NHS. Research began in the 1990s. The growth in use of CT (osteopathy and acupuncture) in musculoskeletal service innovation in the NHS, is to a large degree a legacy of Peters work. His integrative model was adopted in GP practices nationally including Glastonbury Health Centre, Blackthorn Centre in Maidstone, Lewisham Hospital Trust, and the Liverpool Centre for Health. NICE subsequently included acupuncture and osteopathy in its guidelines for managing musculoskeletal pain.

Underpinning research

Professor Peters first published papers on the feasibility of collaborative working with complementary practitioners in NHS general practice in the early 90s (Reason, Peters et al. 1991), while at the Centre of Community Care and Primary Health, which was affiliated with the University of Westminster. Peters then came to the University of Westminster in 1992 as a senior lecturer, where he further developed his musculoskeletal work/integrative model around acupuncture and osteopathy (Peters & Davies 1994). The integrative model he pioneered from Westminster, starting at the Marylebone Health Centre (MHC) in the 1990s, had a national influence. Other groups subsequently established versions of his integrative model in their own areas (e.g. Healthworks Newcastle, Cullompton Integrated Medical Centre) (Peters et al. 2003). The model was considered in the inquiry undertaken by the House of Lords Select Committee in 2000, which influenced the recommendations of its report (http://www.publications.parliament.uk/pa/ld199900/ldselect/ldsctech/123/12326.htm).

• 1991-1994 Developing a model for the Extended Primary Care team incorporating complementary practitioners. Exploring the feasibility of using complementary therapies in NHS primary care. Produced papers on the model itself and a feasibility study on NHS osteopathy.
• 1995-2002 Consolidating the model and developing audit and outcomes evaluation systems. This phase of work produced a workbook for emulating the model. (Involving qualitative and action research, consensus building, pragmatic outcomes collection, development of databases and audit systems).
• 2002-5 The increasing popularity of these approaches in the NHS made it necessary to develop clinical governance guidelines (Involving action and qualitative research and Delphi exercises).
• 2006-12 New services of osteopathy and acupuncture for pain were established by the University of Westminster in the NHS, e.g. Victoria Medical Centre, Kensington & Chelsea PCT (and evaluated by Professor Damien Ridge, Dr Marie Polley and Dr Anna Cheshire, at the University of Westminster). For example, integration for musculoskeletal pain in an NHS GP surgery: In terms of effectiveness, comparisons between pre and post-treatment revealed a statistically significant improvement in MSK pain (p < 0.0001) and quality of life (p < 0.0001), and a statistically significant reduction in medication use (p < 0.0001). Qualitative analysis found that patients reported improvements in their MSK pain, mobility, other physical health conditions, well-being and self-management of their MSK problem. (see: http://www.biomedcentral.com/1471-2296/12/49).

Reason P, Peters D et al. A model for collaboration between conventional and complementary pract Journal of the Royal Society of Medicine, April 1991

Peters D, Davies P. A study of one year's referrals to an osteopathic clinic in general practice. Jour Roy Coll GP. Jan 1994

Peters D (foreword in) Ong C-K, Banks B. 2003. Complementary and Alternative Medicine: the consumer perspective. The Prince of Wales's Foundation for Integrated Health. London

References to the research

Grants 2002-12

Sept 2002-3 Consolidating a CT clinical governance network (Kings Fund £26000 over 12 months)

Mar 2003-4 Developing online pilot care pathway: back pain (Dept of Health £30000)

Jan 2004-5 Consolidating consensus on clinical governance of CAM ((Dept of Health £30000)

Aug 2005-6 Developing clinical placements for complementary therapy students (HEIFE 2 £10,000)

Jan 2008-9 The Midlife Lifecheck. Developing item content for DoH website. Evans P, Clow A, Peters D (£70, 000 over 12 months funded by Department of Health)

Jan 2008-10 Developing a self-care information online library (£90k of £500k from DH 2 years)

Jan 2009-10 Developing GP MSK service (£99, 000 12 months funded by Barcapel, an independent charity)

Oct 2010-11 Developing PCT MSK service (£263,490 15 months. Kensington & Chelsea PCT)

Details of the impact

The integration of non-conventional treatment methods such as osteopathy and acupuncture into mainstream public sector primary care has been a gradual process. A small number of early adopters piloted NHS services in the 1980s. Peters, who was Director of the Complementary Therapies team at the Marylebone Health Centre (MHC) played a leading part after Dr Patrick Pietroni gained the necessary funding (£750,000) to inaugurate the St Mary's Medical School/Waites' Project (extended primary care team project) in1988 and appointed Peters as Senior Research Fellow. Peters co-authored a paper on the feasibility of collaborative working in an extended primary care team that included complementary practitioners in NHS general practice in 1991 (Reason P, Peters D et al 1991 ibid). Peters and Davies published a preliminary description of the MHC musculoskeletal acupuncture and osteopathy service in 1994 (Peters D, Davies P 1994 ibid), and in the same year provided a chapter on the benefits and challenges of doctors and complementary practitioners sharing responsibility for patient care.

MHC's inter-professional learning and multidisciplinary primary care team model became the focus of academic study with the establishing of the Centre for Community Care and Primary Health at the University of Westminster. The collaborative model had national influence. Other groups subsequently established versions of the integrative model in their own areas (in particular Liverpool Centre for Health, Lewisham Hospital NHS Trust Complementary Therapy Centre, Glastonbury Health Centre, Healthworks Newcastle, Cullompton Integrated Medical Centre). Then, as GP fund-holding was succeeded by PCT multi-funds in the mid-90s, a community-based version of the MHC model made acupuncture and osteopathy available PCT-wide via the Westminster PCT Complementary Therapies Service.

This in turn acted as a model for PCTs nationally: a national survey conducted in 2002-3 (to which 66% of PCTs responded) showed that 30-63.2% of the responding PCTs declared they were providing community access to complementary therapy services (Wilkinson J, Donaldson J, Peters D. 2004 ibid). The House of Lords Science and Technology subcommittee on Complementary Therapies took on the integrative model as one of its key case studies.

Peters work was written up in a workbook published in 2002 (Peters et al. 2002) which was well-reviewed (e.g. by Lewith, Freshwater, Dijkstra), and attracted praise even from those who have reservations about integrating complementary therapies into mainstream healthcare (Ernst 2002). The demonstrable and growing presence and popularity of osteopathy and acupuncture in the NHS led to the inclusion of osteopathy in the 2001 RCGP guidelines on low back pain. Subsequently, the 2009 NICE guidelines on early intervention in acute low back pain included osteopathy and acupuncture (see http://www.nice.org.uk/CG88).

Subsequently, we set up and tested the model in various NHS settings. It was evaluated and shown to be effective through research at the Victoria Medical Centre by the University of Westminster (http://www.biomedcentral.com/1471-2296/12/49). Out of this work, another service for musculoskeletal pain was established for Kensington & Chelsea PCT in 2010-11. The Kensington & Chelsea Beating Back Pain Service (BBPS) was a pilot service for patients with persistent low back pain. An evaluation, conducted by Ridge, Cheshire and Polley found 38% of patients experienced a clinically significant improvement in their pain at 3-month follow-up (in press, http://www.biomedcentral.com/bmccomplementalternmed/). As a consequence of having led these developments in NHS care, Peters was invited to participate in the ARC symposium on research priorities on the role of complementary therapies in MSK disease in 2009, and in 2012 he gave evidence to the House of Commons Health Select Committee on workforce planning in relation to CM in the NHS (http://www.parliament.uk/business/committees/committees-a-z/commons- select/health-committee/news/12-01-19-etwp-ev3/). The team at Westminster are now involved in commercializing this work in the new NHS commissioning environment, for example, developing an online self-care library (http://selfcare-library.info/) which presents the evidence-base for the use of CT and self-management options. Additionally, the recent establishment of the Westminster Centre for Resilience at the University will research the use of non-pharmacological interventions in long-term chronic conditions.

Peters D, Chaitow L, Morrison S, Harris G. 2002. Integrating Complementary Therapies: A Practical Guide for Primary Care. Harcourt Brace. Edinburgh.

Dijkstra PU. Review Manual Therapy Vol 7 No 2 (2002)

Lewith G. Review. Complementary Therapies in Medicine, Vol 10, No 1, March 2002

Freshwater D. Review. Complementary Therapies in Nursing and Midwifery. Vol 8, No 3, Page 173, August 2002

Ernst E. Review. Focus on Alternative and Complementary Therapies, Vol 7, No 2, page 206, June 2002

Sources to corroborate the impact

• The National Clinical Commissioning Board & NHS Alliance
• Bristol Primary Care, Medical School
University of Bath
• Southampton University
• House of Lords Science and Technology — Sixth Report 2002
• http://www.publications.parliament.uk/pa/ld199900/ldselect/ldsctech/123/12326.htm
• http://www.parliament.uk/business/committees/committees-a-z/commons-select/health- committee/news/12-01-19-etwp-ev3/