steelweaver's picture
Community Acupuncture - an ongoing mutation

The Challenge: 

The Question: 

How do we provide accessible, affordable post-industrial healthcare to the community?

The Problem: 

Healthcare is getting more expensive, more energy-intensive, more ecologically damaging, more isolating and inhumane.

The Solution: 

As part of a broader shift in healthcare provision and practice, traditional acupuncture provision through community and multibed clinics.

Channels: 

Having worked at SourcePoint Community Acupuncture on Dartmoor in the South-West of the UK last year, I'm currently in the process of setting up my own clinic in a town nearby.

Community/multibed acupuncture, if you are not familiar with it, is a new model of acupuncture provision based on the multibed model common in China and Japan. Costs are lower because multiple patients can be treated at the same time, in the same space (in the US, reclining garden chairs are commonly used to keep equipment costs even lower, as in the picture above). This is possible because this style of acupuncture mostly uses distal points on the arms and legs (no undressing required) and, after insertion and manipulation, the needles are left in to continue working for 20 minutes while the next patient is seen.

[And if you are unfamiliar (or dubious) about what traditional acupuncture can treat, here are some research summaries from the British Acupuncture Council.]

This area of the UK has a lot of rural poverty. The town in question used to be a centre of the textiles industry and still has associated businesses, but now is mostly well-known for being poor, backward and depressed in comparison to nearby Exeter or Taunton. A walk down the high street reals the unholy trifecta of economic malaise, high levels of obesity, ill-health and disability, and that indefinable loss of spirit in a town that convinces every young person of passion or ambition to leave the area at the earliest opportunity.

The main message is that Community Multibed Acupuncture can be an incredibly powerful intervention in an area like this. The effect seems to come from a combination of:

1) Effective health care - I've lost count of the number of patients who have come in with stories of months or years of expensive National Health Service treatments that made no difference to their conditions, who then see a large reduction in their symptoms after only one or two acupuncture treatments. (Moves to provide acupuncture on the NHS over the last decades have been faltering and half-hearted, and are now suffering from a pushback against anything considered 'alternative' or 'optional' - which is a shame, as it could save the NHS millions).

2) Humane treatment - unlike the increasingly isolating and interventionist treatments common in industrial healthcare, the effectiveness of traditional acupuncture shows patients that good health can often be achieved through minimal intervention, through working with the body rather than against it, through self-help, and lifestyle and dietary changes. Demonstrating that a more humane approach to health is possible starts people thinking about what else they need to question.

3) Collective treatment - something about the nature of receiving shared treatment with other people seems to have an effect on people. Perhaps it cuts through the common Western idea of illness as something private, secret and shameful - whatever it is, sharing one's vulnerability and the act of seeking support and help with other community members seems to have a profound psychological charge.

4) Affordability - although health care is free ('at the point of use') in the UK, it is, in effect, rationed; waiting lists are getting longer again, and many NHS trusts are effectively bankrupt. C&MACs offer a form of healthcare without the expensive pharmaceuticals, electronics and salaried consultants. Most either offer a reduced rate (e.g. £20) or a sliding scale (e.g. £10-30, where you pay what you want). [I've found problems with both models - resistance to the idea of a sliding scale is very common, and often leads users to undervalue what is being offered. Given that it has taken the District Council 2 months (at this time of counting) to respond to what should be a simple request for licensing, and given that the licence terms for this district are insanely onerous, I have found a degree of freedom and enjoyment in simply offering treatments for free and explaining to patients what sort of average donation is necessary to keep the clinic open.] If all kinds of healthcare were funded equally, acupuncture would prove massively more cost-effective than many 'mainstream' modalities - not to mention less energy-intensive and ecologically-damaging.

5) Knock-on effects - people who come to the clinic see flyers and posters for other events while they are there. They buy a coffee in the cafe upstairs and bump into other people they know. They go into other shops seeing as they are in town already. People who had given up on the town are excited that something like this would happen there. Maybe some people even wonder whether there is something they could do to get things happening in the local area. These are effects that are common to any community venture, many of which other ERs have mentioned elsewhere. As with education, art, reskilling, etc, the fact that users of the service are making positive changes in their lives, and are already feeling the benefit of being involved, seems to snowball this effect even more strongly.

Comments

"Community"

Alberto's picture

Hello @steelweaver, welcome back! It's been a while. 

I am not sure about acupuncture as such. On the other hand, I am very intrigued by what your model adds to acupuncture. You add:

  • Humane treatment. On this I have to disagree with Steven Novella. He says: "All good doctors are empathetic and patient-centered." And this is true, but it misses the point. Because most doctors work in systems which are not humane at all – and can't be, because they run on an industrial age paradigm. They derive efficiency from scale and standardization, and that requires patients are treated as production batches in manufacturing. Many doctors absolutely hate this, but it's the only game in town. Acupuncture is out of this system, and therefore it can afford to at least try to be humane.
  •  Collective treatment and destigmatization. No brainer.
  • Affordability – always a good thing.

It seems to me these are tenets of anything we can rightfully call open care. 

Another interesting data point you have found is about licensing and regulation. Is two months a long time to get a license in the UK? If so, what do you think is going on, and how could it be fixed?

(I don't buy knock-on effects really, because you'd have them also if you administered any other treatment than acupuncture (as well as not delivered in the patient's home). 

No Humane ghost in the machine

Rune's picture

Hello @steelweaver and @Alberto, the reflection about ‘good doctors’ and ‘systems’ triggered me to exemplification.

We often simplistic talks about good doctors. They have suffered the longest & toughest study and taken the Hippocratic oath. Only good people invest their intelligence and life so ‘insanely’, instead of pursuing personal wealth. Lately I’ve been several times patient(ly) at (4) hospitals.

95 % of the time you wait, pay tickets, try to get the right documents and wait for someone to (re)-type (using only the indexfinger) your anagraphical details (already electronically registered).

5 % of the time a healthcare professional is actually seeing you. That time is again divided into

20% waiting for the doctor to read your documentation and check that you paid the ticket etc.

10% the actual examination/intervention

60% waiting for the DOCTOR to TYPE (with maybe 2 index fingers) your diagnosis/report in the secret language: docterish

10% where (s)he explain/discuss with you.

 

0.5% (10%*5%) of the time you feel some human treatment!!!

99.5% (100%-0.5%) you are just frustrated waiting for your final hour.

 

  • I wonder: Before computers the doctors had a secretary doing paperwork and the doctor used his expertice 100% to speak and treat the patient. Who remembers if this is true?

  • claim: doctors are equally frustrated because they are not typists or bureaucrats and wants to do what they are trained to do. Cure

  • I accuse: Technocrats that have made healthcare more ‘efficient’ by buggy information technology. Legislators by substituting common sense and the hippocratic oath with rules, disclaimers, useless consent forms, lawsuits and barriers between professionals.
    US ALL for electing the people continuing this process of alienation of the patient and healthcare providers.   

  • I support: incubating open care initiatives

@Rune, I've lived in 8

Natalia Skoczylas's picture

@Rune, I've lived in 8 countries in the past few years, mostly in Europe. I've been to doctors in all of them. And there were no computers to assist the doctors, mostly they had a person to do the written documentation. Which didn't change the fact that even if they had theoretically more time to spend on approaching me as a patient, they would mostly limit their help to examination and writing a prescription. Rarely they bother talking to me and try to figure out the reasons for the problem. It happened a lot with dermatologists, who basically just give you a prescription for some external treatment, very expensive, and ask you to try it out. None of their recommendations ever helped me. 

Last times were absurd to an extent that the doctor wouldn't even tell me what he thinks is wrong until I asked - and then the questions about medication followed, with an ironic response: oh, so you're interested in drugs? 

I don't know what these doctors are actually frustrated with. I guess an inhumane amount of patients to see every day might be one of the reasons. Still, I would suggest there is a huge lack of empathy training during their studies and work, and maybe this is why they're incapable of approaching their patients in a more personal, compassionate manner. 

Extremely interesting

Rune's picture

Hmm, @Natalia Skoczylas, I'm impressed about your international experience. It could be extremely interesting analyzing those 8 countries, comparing them with other peoples experiences (I've only lived in DK,UK,NL & IT). With the free movement of labour and free choice of public health provider (HCP) it could be interesting to have a sort of 'google maps' scoring system of satisfaction. People could score the on a couple of dimensions ....is that networking stuff @Alberto?

Great idea

Alberto's picture

... and great discussion. Something to think about for the second year of OpenCare. A collaborative map of waiting vs. being given health care and empathy? Nice artifact.

The idea of "rules instead of Hippocratic oath => bad" is intuitively very appealing. I think @teirdes has some structured thoughs and experience. 

Also: studying interventions for increased empathy

Noemi's picture

I would be interested to see if some interventions can trigger more emphatetic treatments and how that affects patient wellbeing. Things like "Hello my name is..." campaign for practitioners to be more humane, or the other day I was reading about inserting empathy in the medical studies - "What Medical Residents Learn from Art Museums".  These things don't feel too sophisticated things to do for apparently very high returns. We all seem to agree that "more empathetic" is better for patients wellbeing, not just satisfaction which is more obvious. 

ask you to try it out

Rune's picture

@Natalia Skoczylas, as of the hypothesis of 30% errors in my comment, I understand (and know) the 'try it out' stuff. I'ts ok I think. The problem is that as it is extremely valuable information gets lost. Consider two cases:

A: It worked            B: It did'nt work.

Was it due to chance or attributed to treatment?

If everybody reported the result systematically it would be easy to identify best treatment. Unfortunately this info gets lost and nobody learns. This leaves it to the bias of where money gets invested for clinical trials. Another reason for a  review system. 

 

 

Yes, you're right. Although

Natalia Skoczylas's picture

Yes, you're right. Although some of my dermatologists I've seen plenty of times over years - they just kept on trying things on me, instead of looking for some other reasons why their treatment didn't work (probably they didn't address the issue at its core). Anyhow, then I have learned an interesting thing about prescribing people tests. It turns out in Poland each doctor is given a number of tests he can prescribe to people: blood, sugar, more sophisticated ones. BUT, if the doesn't spend them all, he gets PAID for each test he didn't give out. Anyway, it's just one of the pathologies of the system I've discovered - as my family is full of doctors, every time I open the discussion I am more and more stunned by how badly it was designed. 

I am not enough of a sample I am afraid - I could only bring a couple of stories:)

yep

steelweaver's picture

Thanks, @Alberto. Couldn't agree more about the conveyer-belt paradigm of mainstream medicine. Acupuncturists who have tried to work in the NHS have been similarly frustrated to the doctors - more, in fact, as their treatment is so individualised.

But as the era of individualised medicine gathers steam, this is something that all forms of healthcare are going to have to grapple with.

2 months is an extremely long time (2 weeks would be more usual). I won't bore you with the details, but essentially, acupuncturists are licensed at the local level in the UK alongside tattooists and body piercers (which have far greater risks of injury, blood-borne contamination, etc, and are, clearly, not any kind of healthcare) - and are thus entirely at the mercy of whatever inappropriate regulations the district council chooses to impose.

As I said, the knock-on effects are common to any such grassroots community project - but I do think that there is a particular momentum that comes from the project delivering a treatment that directly makes people feel emotionally and physically better;

and, of course, the community clinic model is unique to acupuncture because you can't treat multiple patients at once with most other modalities!

Can you easily go unnnoticed then?

Noemi's picture
Hi @steelweaver, Just to thank you for the contribution and to say I'm intrigued by what it means that you're operating while waiting for a license, is it dangerous or do you risk anything? Or is it more a matter of time.. and you will get it anyway, be in the books etc? Ever since we heard about the volunteers led clinic in suburban Athens and the potentially many similar ones, it makes you wonder what it is about these grey areas in between formality and informality. Maybe involving people who are not health professionals in the system definition is a requisite for the kind of services you mention - precisely because the ones from the system are too trapped in it to get out alone.

Stepping outside the commercial model

steelweaver's picture

Hi @Noemi,

Well, working on a donation basis was my nod to being a non-commercial entity, which (as far as I know) means the clinic is not subject to licensing - similarly to people who volunteer in hospices, addiction recovery centres etc.

I am conflicted on this - on the one hand, I recognise that some degree of regulation of healthcare is probably desirable to avoid malpractice and protect patients (or at least it was desirable before networked reputation economies became a possibility - who knows what alternative models might be possible now?).

On the other hand, I was certainly struck by the degree to which stepping outside the commercial model of delivery freed me up to do things differently.

It's also made it far easier to get 'buy-in' from the community so that they think of it as something that belongs to them, that they can collaborate with. The terms of interaction defined by our habits of commercial consumption go deep, and having some way to differentiate yourself from it seems very important in encouraging people to thnk and act differently.

So some regulatory framework is needed..

Noemi's picture

While building trust in the service while ofering affordability and humane treatment is definitely a plus, the questions remains and it's for us to try to answer in the future looking at stories like yours (which is what OpenCare community essentially does): what happens when a number of such care services become available? We have great insights, yet risk running completely unprotected. The more they grow effective or meet a growing demand, the more attention they draw, the more concurential they become, the more they risk being antagonised by systems on more-or-less valid concerns. Uber being exhibit A.. 

@markomanka maybe has more interesting insights as to minium criteria which can make health services like these legit from system's perspective.

Good stuff for Can we afford to neglect this issue?

Rune's picture

Great discussion guys!

Alberto's picture

@steelweaver, @Noemi, I think you are zeroing in on something important. 

Here's what I'm reading.

  1. Like other people in the space we are calling open care (small letters: the concept, not the project), you, @steelweaver, are rewiring care services as community-driven. Your way to do so is the donation model. The Helliniko crowd's is the refuse to incorporate. What different ways have in common is this: they build trust and style these services as community-driven, and the communities as the owners. They also sidestep regulation, perceived as stifling. @teirdes and @markomanka are full of stories on why this perception is at least partially correct. @Lakomaa could probably offer additional insights.
  2. Such radical thinking frees up creativity and enable bottom-up emergence of more care in society.
  3. However, it also means you guys are very vulnerable. Noemi is right on the money: if an "Uber for health" were to emerge, it would be sued into a smoking hole at the first signs of scaling. Which makes me think that not scaling is a better solution for survivability of open care: sueing thousands of small initiatives is harder and more costly than going for the one Uber. Hmmm.
  4. But Noemi is proposing regulation as some kind of shelter for these initiatives. Would this work? To a first approximation, I am doubtful. Uber has access to legal advice, and they undoubtedly ran checks on their model before going live. But then they get sued. The sueing party claims that something in that model should be interpreted like something else already in the legal system. For example "an Uber driver is like the employee of a taxi company" or "if you rent out your spare room on Airbnb you become a hotel". If it wins the case (as it tends to do), then the sentence becomes a precedent. European version: lobbyists get the law change the way they want it. So, these innovative, disintermediating solutions start off as legal, but then they are made illegal as they begin scaling. 

All of which is pretty depressing, I must admit. Hope you guys can contradict me :-)

In my opinion te cases

Natalia Skoczylas's picture

In my opinion te cases against Uber and Airbnb are valid even if I love the ideas behind them. Uber is getting sued for not providing their drivers with essential support: health care, insurance, repair costs while being free to bring down the prices. And as Google is joining the race, prices will go down. Another problem with Uber is its hunger for monopolizing the markets around - which hopefully will be stopped as well, although this will happen most likely thanks to other giants. 

About Airbnb, you are entitled to rent a spare room where you live - the case is against fake sharing, de facto homes and apartments that were emptied so the owners would make money on short term rentals. This changes the landscape of the city and has huge, negative effects. 

probably the difference between scaling and monopolizing markets is one of the criteria here. These startups lost the reasonable idea of scale and infringed territories. Hotels and taxi corporation will protect their share and lobby against these companies, which doesn't need to be good in results. But these battles amplified processes in the urban spaces which could have been happening more quietly before, and that's good. And made people think about sharing and new ways of the economy. Built trust. 

I think the key here is not to let one giant to emerge, but to allow organic replicas to provide similar offers in their environments, without overarching the whole globe with a great huge fix. If the efforts remain decentralized, scattered, but also adapted to local needs and problems, I can't see a way in which this model would be bad (of course. pharmaceutical companies and other parties interested in ridiculing anything's that out of the system will try to fight it and there will be a need of great success stories that can be told to the people in order to change their attitudes towards alternative approaches to care. Maybe it's not even too late, herbal medicine didn't completely disappear...) or harmful. I believe there should be manuals and ways to ensure people providing help are capable of doing it, however, what kind of manuals and to what extent, I have yet no idea. 

Non-profit non-regulated health providers difft from Uber

Noemi's picture

@Alberto, we should keep your line in mind and mull over it: not scaling as a solution to survivability!

@Natalia Skoczylas my position is similar to yours: I cant argue in favor of "vulnerable" big companies as long as they do not give back to the community when they can afford to. Ok, they started by differentiation in their business model in that they are not a taxi company, they are a car sharing service. But de facto they operate in the same market except not playing by the same rules as everyone, and taking a route in which they dont make a claim on new and better rules. Or maybe I'm missing that claim. To me, the difference between future clinics such as @steelweaver 's or Helliniko-turned-big and services like UBER is that the former reshape markets to make it better for an overwhealming majority, while the latter just want to stay outside markets for a bigger margin. Yes, they made a contribution in their disruption - I see how bigger the service quality is on the local taxi market where I live and where UBER just arrived, but that's not enough when they can potentially take more from the community than what they give.

Amen to that

Alberto's picture

Agree with most everything @Natalia Skoczylas and @Noemi are saying. The only difference is that I do appreciate that Uber/Airbnb create some value for local communities, by giving some extra freedom to people on the ground. For example, say you notice that there is a long queue for taxis at your local airport on Friday nights. You can then in principle step in as an Uber driver and make yourself availabe for that time slot, if you need the money more than the time. It is a market clearing mechanism, but a clearing market is, in itself, a good thing. What's bad is a market underpinned by asymmetric power relationships. But we have that anyway: taxi drivers telling people "you can't work here, this is our turf" is an act of violence. It is no coincidence that most Uber drivers in Brussels are Arabs: plenty of unemployed/underemployed young Arabs in town, and Uber lowers the threshold for them to enter the business. Without it, driving for money is off limits for them. But you have all heard this before, many times. 

Evidence based medicine

Rune's picture

@steelweaver, this is really interesting. Acupuncture has loong been considered alternative medicine. Lately it has become evidence based. Do you have objective evaluation of the effectiveness of your treatments?

acupuncture evidence

steelweaver's picture

Hi @Rune,

True, acupuncture is largely regarded as 'alternative' - at least in the West; it is integrated into mainstream healthcare in China and other East Asian countries, and increasingly in places like Israel and Australia. I would put it a bit differently - it has not been 'becoming' evidence-based in the sense of people changing how they practice. It is more a case of practitioners, who have ample experience of the effectiveness of the treatments in their own practices, looking to find ways to produce acceptable evidence to back this up so it will be more widely accepted by the mainstream.

As with all physical interventions, this is not easy! You can't really run a double-blind control study on a physical therapy where the patient can feel whether it's being done or not, and a lot of the resistance to accepting acupuncture involves either rejecting all the 'lesser' forms of evidence for its effectiveness, or designing 'sham' studies that don't really take into account how acupuncture works.

All that said, there is still a lot of evidence for its effectiveness for a variety of conditions. The Acupuncture Now Foundation have an accessible summary here: https://acupuncturenowfoundation.org/wp-content/uploads/2016/05/ANFwhitepaper2016.pdf

Or you can look at their research page - https://acupuncturenowfoundation.org/doctors/studies/ - or at the factsheets on the BAcC website: http://www.acupuncture.org.uk/category/a-to-z-of-conditions/a-to-z-of-conditions.html

I have Chinese colleagues who like to point out that this is just the tip of the iceberg - there are literally thousands of positive studies from China [and Japan, and Taiwan, and South Korea, if you're worried about the quality of communist science] that have never been translated into English...

I don't have any evidence of the effectiveness of my own treatments specifically, though! I can't afford to hire a medical research team, so I'm reliant on the already-existing body of evidence and theory. :)

EBM

Rune's picture

Dear @steelweaver, I do appreciate your references, but cochrane reviews are better in supporting the statements. Personally I have proposed some studies but apparently 'scientific approach' is disturbing the 'chi'. However we surrender to a universal law 'effectiveness is the measure of truth'  and we have a moral obligation to strive for the most effective treatment (leave the measure of effectiveness open for now) regardless of our personal beliefs, hopes and dreams. 

What I'm getting at here is that OpenCare should also consider establish a serious approach with double scope: avoiding infiltration of quackery and protect us from accusations of quackery. 

 What I'm asking the community for is to contribute with ideas of how to implement EBM in our approach, as in your clinic?

What I think we can offer each other within OpenCare is the solution to "can't afford to hire a medical research team", surely we have the skills in this comunity. 

So lets help each other. I've started a cook book over here

 

Insight?

Lakomaa's picture

I'm not familiar with the project and do not really immiedetly see what my contributon should be. References to previous insights on how private services are more customer oriented than public?

Stealth mode

Alberto's picture

No, other examples of care services that rewire themselves so as to (1) establish themselves as "owned" by the community and (2) bypass stifling regulation. 

traumatapping

ybe's picture

@steelweaver, as an acupuncturist, do you know this tapping technique: http://peacefulheart.se/trauma-tapping-technique and do you think it is effective?

tapping

steelweaver's picture

I haven't come across that exact technique - a quick google suggests it is a modified version of EFT suitable for people with more acute trauma.

What I have heard from colleagues [and here] is that these tapping techniques work, but mostly because the tapping helps to distract/reorient the system to allow the trauma to be released, rather than because it is a specifically effective sequence of acupuncture points.

That said, acupuncture points are areas that initiate particularly high physiological responses, so if you are going to be tapping yourself, arguably you might as well do it on acupuncture points to get an even better effect. And doing a sequence of points in all the areas of the body will ensure that no forgotten area retains the tension of the trauma.

In short - it's probably worth giving it a try!

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