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Gatekeepers and the Gateway – a mixed-methods inquiry into practitioners’ referral behaviour to the Gateway Clinic
  1. Jason Unwin,
  2. David Peters
  1. Department of Complementary Therapies, School of Integrative Health, University of Westminster, London, UK
  1. Jason Unwin, The Gateway Clinic, Lambeth Hospital, 108 Landor Road, London SW9, UK; jasonunwin{at}yahoo.co.uk

Abstract

Background: The Gateway Clinic is a specialist NHS service in South London providing acupuncture and Chinese medicine. The clinic receives a diverse range of referrals from an expanding population of local general practitioners (GPs).

Objectives: This study explores the referral behaviour of GPs and other primary care users of the Gateway Clinic.

Methods: A pragmatic mixed-methods approach was used, combining mapping of GPs’ usage of the Gateway as taken from the clinic’s database between the years 2000 and 2005, a questionnaire survey of the referring primary care practitioners in 2005, and data, including a thematic analysis of the interview transcripts from semi-structured interviews of a purposive sample of those GPs who refer.

Results: Doctors in the community refer a wide range of health problems to the Gateway Clinic. The most common referrals were musculoskeletal conditions (38–44%), general and unspecified conditions (11–14%), blood and immune system conditions (6–12%), psychological conditions (8–13%), neurological conditions (6–9%), gynaecological conditions (5–6%) and digestive conditions (5–6%). The health problems referred by local healthcare practitioners correlate strongly with the patient profile seen in private acupuncture practice. Between 2000 and 2005 numbers of healthcare practitioners increased by 218% resulting in a 300% increase in patient referrals made to the clinic; the mean frequency of referral per practitioner increased by 71%. Analysis of the qualitative data suggests that positive clinical experience encourages GPs to increase the range of conditions they refer leading to the development of informal referral guidelines.

Conclusion: The Gateway Clinic has become an increasingly popular referral resource. The influences that drive referral to the clinic are multiple and follow “tacit guidelines”. GPs select patients on the basis of their individual clinical experience, informed by positive patient feedback and often only after more conventional medical treatment options have been exhausted.

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Acupuncture has become the most popular and often-used complementary medicine treatment within the NHS.1 Access to acupuncture from general practice, where it has been estimated that around 34% of general practitioners (GPs) use or refer patients for acupuncture,2 suggests that many GPs are finding ways to provide acupuncture as part of their primary care service.34

Acupuncture services are delivered in two ways within NHS primary care: either “onsite” at a GP health centre by a member of the primary healthcare team, by referral to an NHS physiotherapist department or an attached complementary medicine practitioner; or “offsite” by specialist practitioners within a complementary medicine centre that is funded to deal with NHS referrals. The Gateway Clinic is such a centre, and represents a well-established and increasingly popular “offsite” NHS resource for complementary medicine.

The Gateway represents 16 years of continuous development towards integrated working with Lambeth, Southwark and Lewisham primary care community, and with the Primary Care Trusts (PCTs) that now organise it. Acupuncture is often only available on the NHS as part of the range of therapies used in a pain management service and is therefore not ordinarily available for conditions other than musculoskeletal and neuropathic pain. The Gateway Clinic however receives a diverse range of referrals in addition to those of pain management from an expanding population of local GPs. If, as has been suggested,56 the NHS needs to learn from successful models of integration in order to sustain complementary medicine provision, then the Gateway Clinic represents an important opportunity to understand how and why GPs refer patients. Previous studies have identified key influences that drive referrals to complementary therapies within the NHS.511 We set out to explore why NHS practitioners referred patients to the Gateway Clinic and to develop a conceptual model that might explain this behaviour.

AIMS

Different GPs and primary care users refer different types of conditions to the clinic, and with differing frequency. We wanted to clarify the types of conditions referred, factors that influence referral decisions, the reasons for such a diverse range of referrals, and the attitudes and opinions of those who were referring patients.

METHOD

We used a pragmatic mixed-methodology approach, which has been used in other studies to examine GPs’ clinical decision-making. The approach combined quantitative and qualitative research along the lines recommended in the House of Lords Select Committee Report on Complementary and Alternative Medicine.1213

Clinical database service evaluation

The Gateway Clinic’s database contained information for a 4-year period between 2000 and 2005 (data for 2003 being unavailable). The types of condition referred to the clinic were categorised using the International Classification of Primary Care (ICPC).14 Given the annual number of referrals made to the clinic, the annual number of primary care users referring patients, and the annual mean average of referrals made per primary care user, we were able to distinguish groups for Rare Users (1 referral per annum), Occasional Users (1–6) and Frequent Users (>6).

Questionnaire followed by semi-structured interviews

A questionnaire was sent out to a random sample of 175 (56%) of the 314 practitioners who had referred patients during 2005. The questionnaire comprised five short-answer questions asking how often the respondent referred to the Gateway, the types of conditions they tended to refer, any comments regarding their experience of referring, and whether they would be willing to participate in a 15–20-minute interview. The returned questionnaires were then grouped according to whether the respondent was a Rare, Occasional or Frequent User. Interviewees were selected purposively from each of these groups and seven semi-structured interviews were conducted. The transcribed interviews were put through NVivo-2 Qualitative Research Software to generate a thematic analysis.

RESULTS

Database data

The seven most common conditions referred to the clinic were: musculoskeletal conditions (38–44%), general and unspecified conditions (11–14%), blood and immune system conditions (6–12%), psychological conditions (8–13%), neurological conditions (6–9%), gynaecological conditions (5–6%) and digestive conditions (5–6%). Figure 1 and table 1 show the frequency of conditions referred for each of the available years 2000–2005.

Figure 1 International Classification of Primary Care categories of referrals made to the Gateway Clinic in 2005.
Table 1 International Classification of Primary Care (ICPC) categories of referrals made by all practitioners to the Gateway Clinic for each year of clinical records (2000–2005)

The six most commonly referred conditions to the clinic are compared in table 2 to a recent national survey of 9408 patients seeking care from private acupuncture practitioners.15 The conditions treated in private acupuncture practice show a high degree of correlation with those referred to the Gateway Clinic by primary care users. A higher number of Blood and Immune system conditions are seen at the Gateway because the Gateway Clinic has particular experience in the treatment of patients with HIV or Hepatitis C. The overall similarity in figures suggests that the Gateway Clinic is meeting the same need in NHS primary care as is met nationally by private acupuncture practitioners.

Table 2 Comparison of Gateway Clinic referral statistics (2000–2005) and a national survey of private patients seeking care from acupuncture practitioners in the UK

Table 3, which gives the number and frequency of referrals made by all users (predominantly GPs), shows that there has been a 300% increase in the number of referrals made to the clinic, and a 218% increase in the number of primary care users referring to the clinic in the course of the 5 years.

Table 3 Gateway Clinic statistics for the number and frequency of referrals made by practitioners for each year of clinical records (2000–2005)

Questionnaire data

The questionnaires prompted 53 responses comprising 47% Rare Users, 38% Occasional Users and 15% Frequent Users. By comparison, the clinic’s referral figures for 2005 showed the whole population to comprise 57% Rare Users, 40% Occasional Users, and 3% Frequent Users. Each of the three respondent groups was well represented by the sample, with frequent users being slightly over-represented and rare users being under-represented, as would be expected. Written comments were given by 26 of the respondents (23% Rare Users, 46% Occasional Users and 31% Frequent Users). Whereas only positive comments were given by the Frequent and Occasional User groups, more critical comments were made by the Rare User group. All these comments provided initial insight into attitudes and opinions of referring practitioners and helped shape the semi-structured interview questions.

Major themes from interviews

Seven of the respondents agreed to be interviewed: one Rare User, six Occasional Users and (surprisingly) no Frequent Users. Themes developed from these interviews are described below and are included in the thematic model diagram (fig 2).

Figure 2 A thematic model of the influences informing general practitioners’ referrals to the Gateway Clinic.

General satisfaction

The interviewed users were very satisfied with the service received and comments included:

  • “we are very keen on it” (Interview 2)

  • “I’m glad we’ve got it, I hope it stays and expands as I do feel there are avenues that can’t be provided by conventional medicine” (Interview 3)

  • “I would definitely recommend it and tell everyone about it” (Interview 4)

  • “people seem very satisfied” (Interview 7)

Dissatisfaction

Comments related to the long waiting list for treatment at the clinic:

  • “the problem with the long waiting list is you may have to prescribe medication — which may work…and is probably a good thing……then they will not look for the alternative — [but] in the long term however the medication may not be the answer” (Interview 4)

Influences that lead a user to make a referral to the clinic

The exhaustion of other therapeutic strategies is the strongest influence driving referral to the clinic:

  • “Exhausted other treatment approaches and just wanted to try it” (Interview 1)

  • “After unsatisfactorily exploring other treatment routes, patients tire of medical interventions, different tablets etc … patients asking for acupuncture or something different” (Interview 3)

  • “People who are not altogether happy with the medication they’re taking, they are perfect for offering an alternative” (Interview 4)

  • “When patients become desperate after other modalities have failed the patient” (Interview 5)

  • “I think if patients aren’t keen on Western treatment and want to try something else” (Interview 6)

Positive feedback

Further referrals follow after positive feedback from patients’ experiences.

  • “Fairly large numbers of patients with very positive experiences” (Interview 1)

  • “Good feedback from patients” (Interview 2)

  • “People who have been negative but have gone along and come back looking for a new referral” (Interview 4)

  • “Patients seem to be fairly positive about their experiences” (Interview 5)

  • “Patients who have valued the treatment” (Interview 7)

The evidence base

Only one interviewee commented on the need for research-based evidence as a driver for referral. In general, referral was made on a more pragmatic and investigational basis.

  • “Practitioners tend to develop their own in-house evidence, based on their own patient experiences coupled with any other scientific information they require” (Interview 1)

  • “a referral is more likely to depend on the practitioner’s feeling that the therapists at the clinic can effectively treat the condition” (Interview 3)

  • “Anecdotal evidence of a patient improving then I would refer” (Interview 3)

  • “I would suggest the referral to the patient if they were even partially open to it … for any condition I believed may be worsened by the patient’s mental state” (Interview 4)

How practitioners are informed about the clinic

The clinic has become well known to particular GP practices and practitioners. It seems that information about the clinic is passed on by word of mouth between patients, practitioners and their colleagues. Patients often initiate the referral and inform their practitioner about the clinic. Limited amounts of information sent out from the Gateway Clinic had influenced some practitioners and practices to refer patients. Mention was made of the complexities faced by GPs who refer patients to complementary and alternative medicine (CAM) services even though other members of a group practice have differing opinions about the therapeutic value of this treatment: “we never talk about CAM, we all have to kind of find out for ourselves” (Interview 3). This is a reminder that GPs differ significantly in their knowledge about CAM, holding different opinions about its usefulness and their willingness to use it.11

Influences that lead a user to diversify the conditions they refer to the clinic

Patients’ positive experience and the lack of other acceptable treatments lead GPs to increase the range of conditions and frequency with which they refer.

  • “good patient feedback… [has led me to] extend the number of condition I might refer” (Interview 2)

Additionally, two practitioners acknowledged that after receiving treatment as patients themselves at the clinic, they had increased the frequency and diversity of conditions they would refer.

  • “I have received treatment at the Gateway Clinic myself” (Interview 1)

  • “After having first hand experience of being treated with acupuncture for migraine headaches and back pain” (Interview 4)

Additional/secondary themes

Information

There was a near unanimous call among the interviewees for more information from the Gateway Clinic — both for themselves and for their patients — about what happens at the clinic. A simple leaflet outlining what the clinic does, opening times, and how treatments are carried out, was requested. The idea was suggested of making a display stand for GPs’ waiting rooms, explaining the Gateway Clinic’s role to patients. GPs also said they would value more structured, regular information on whether patients had attended and how they had progressed.

Waiting list

It was felt that the length of the waiting list caused some patients to lose interest in the clinic as an alternative to conventional medicine: “Sometimes you are referring someone who is particularly bad at that time, and having to wait 12 weeks is a long time” (Interview 2). One user interpreted the clinic’s limited publicity as a tactic to prevent the clinic being overrun. This interviewee expressed his concern about “opening up the floodgates to the clinic” (Interview 5) and wanted assurance that it would be able to deal with an increased referral load.

Summary points

  • The Gateway Clinic receives an increasing number of referrals for acupuncture from primary care

  • Patients are generally referred after failing to respond to conventional treatment

  • Decisions to refer are based on anecdotal evidence from patient reports

  • Users request more information about the service

Other opinions

The Gateway was regarded as an important example of a CAM provider within the NHS that represented a model that if more widely distributed, could reduce NHS expenditure by making a specialist NHS CAM unit available to local primary care teams. One gastroenterologist specialising in the treatment of patients with Hepatitis C used the Gateway Clinic to provide an integrated approach to treatment: “I don’t have a problem with someone having acupuncture and herbal medicine alongside Western medical treatment, I don’t believe they are exclusive of each other, I think they are quite complementary” (Interview 6). One GP felt that the impact of HIV could be mitigated by Chinese medicine and that these treatments should not be overshadowed by more expensive retro-viral medications: “there is a role for keeping people off retro-viral medication until they are really needed… the Gateway Clinic should promote HIV treatments”. He went on to comment that people seemed very willing to travel considerable distances to receive Chinese medicine on the NHS, “including patients with chronic fatigue which is amazing” (Interview 7).

DISCUSSION

The Gateway’s service statistics testify to its growing popularity among local primary care team members: a 218% increase in GP users, a 300% increase in total patient referrals to the clinic, with the mean GP referral rate to the clinic increasing by 71% over a 5-year period while the profile of conditions referred to the clinic has remained stable.

This study’s findings suggest that positive feedback from patients can encourage GPs to increase the range of conditions they refer. This experience leads to the development of what amounts to informal referral guidelines based on their clinical experience. While similar findings have been described by other authors,711 this study, set in a busy NHS “offsite” acupuncture and Chinese medicine facility, updates and extends these findings.

There are limitations to this study. First, our sample of 175 was intended to represent all referring practitioners. However, after reconfiguring the clinic’s database, the true number of primary care team members who had referred patients over the entire period was found to be 720. Among them, 314 were actively referring patients in 2005, and the selected survey sample is representative of the three referring groups, albeit slightly biased in favour of the Frequent User group. Second, we were unable to sample as purposively as we had anticipated, because no Frequent Users came forward for interview, and the seven primary care team members we recruited were either Occasional or Rare Users of the clinic. Nevertheless, the interviewees expressed a wide range of experiences and views.

A recently published ethnographic study of how one team of GPs handle and integrate evidence into their practice as part of their decision-making processes describes how clinicians rely on “mindlines”.16 Mindlines are defined as “collectively reinforced, internalised, tacit guidelines, formed through interaction with each other and wider networks of ‘communities of practice’”. Our research suggests that primary care practitioners using the Gateway Clinic have been developing similar “mindlines”, which in the absence of research-based evidence to guide them, or other treatment options, function as tacit guidelines when making decisions about referring a patient to the Gateway Clinic.

In conclusion, the Gateway Clinic has become an increasingly popular referral resource among GPs in the South London NHS Trusts of Lambeth, Lewisham and Southwark. The range of conditions being referred to the Gateway Clinic by primary care users is diverse and closely resembles the profile treated in private acupuncture consultations. The influences that drive referral to the clinic are multiple and follow “tacit guidelines” shaped by clinical experience and patient preference. GPs select patients on the basis of individual clinical encounters, are informed by positive patient feedback, and often only refer once their more conventional medical treatment options have been exhausted.

Acknowledgments

Thanks to the School of Integrative Health University of Westminster, Charlotte Paterson at the Peninsula Medical School University of Exeter, and all at the Gateway Clinic.

REFERENCES

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Footnotes

  • Competing interests: The author declares employment by the Gateway Clinic subsequent to the writing of his dissertation as a researcher on an NHS funded study.

  • Ethics approval: Approval of this study was given by the Lewisham Local Research Ethics Committee on the 8 May 2006. REC reference number: 06/Q0701/28.

  • This paper is based upon a research project presented as part requirement for the MSc Complementary Therapy Studies degree at the University of Westminster. A secured-time grant from RDC Southwark PCT enabled the writing of this paper.

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