What is it like working in the NHS as a Traditional Acupuncturist?

I practiced acupuncture in the NHS from 2001-2014 and I am often asked what was it like. People want to know if traditional acupuncture (as opposed to the trigger point acupuncture performed by physios to relieve musculoskeletal pain) can be applied within the confines of the NHS setting and still remain true to the objective of treating the underlying imbalance, rather than just symptoms. Some people even ask why I would even want to work under these circumstances. So this is my chance to offer my perspective of working in the NHS and hopefully answer some of the questions posed to me.

The Complementary Health Project was set up by the Marylebone Primary Care Group to offer complementary therapies to all NHS patients falling within its geographical area. In the autumn of 2001 the project was taken over by the Westminster Primary Care Trust and its catchment area expanded to include all Westminster residents and patients of Westminster. The project offered Osteopathy, Massage, stress management groups and Acupuncture.

Anyone registered with a GP in Westminster could be referred to the project, but the criteria for referral was specific to each therapy. In terms of Acupuncture patients could be referred by their GP if they had one of the following conditions:

• back pain
• peripheral joint pain
• insomnia
• migraine/headache
• menstrual pain

Patients could be referred for up to 6 sessions per year, each session lasted 30 mins.

Prior to the first consultation I was emailed the main complaint from the GP with a brief outline of their medical history, response to medication, physio already undertaken, surgery etc. All my case notes had to be kept on computer (my one finger typing is now a respectful 2-3 words a minute but only if I continuously stare at the keyboard; unfortunately my spelling has not caught up and my software does not have spell check).

For the first few years, session 1 and 6 ended with the patient completing a MYMOP (Measure Your Medical Outcome Profile) audit. Patients were offered a scale of 1-6 measuring outcomes of the treatment in terms of the reduction in physical symptoms, ability to function and emotional wellbeing.

These figures were collected and analysed as to the effectiveness of treatment. Despite seeing very complex cases with patients who had regularly been discharged from pain clinics and physio departments as they did not respond to treatment, I am happy to say at least 50% of my patients responded well to my treatment.

During these sessions I could potentially treat 18 patients a day, if they were all follow on treatments rather than new clients, but this was rare. Nevertheless my days were often very hectic, averaging 14 treatments a day.

I practice Japanese acupuncture based upon Dr Manaka’s Yin Yang balancing system. There is no tongue or pulse diagnosis in this system of acupuncture; instead there is abdominal palpation and palpation on what acupuncturists refer to as Front Mu points (points which become spontaneously tender when the organs in the torso are in distress). The diagnosis is based on the pattern of abdominal pain or tightness reported by the patient, combined with the case history.

Over time I learnt to be pragmatic and only concentrate on what I was able to treat within my allotted 6 treatments , which sadly meant sometimes discharging some patients early, so I could concentrate on the ones I felt more confident of helping. In my private practice I prescribe herbs, use moxa, massage and cup; due to a mixture of practicality and politics none of these modalities were open to me in the NHS. I learnt to adapt and use infrared lamps to tonify (strengthen), electro acupuncture to disperse and dietary advice instead of herbs (one of the first things my Kanpo herb teacher taught me was that the kitchen was the first pharmacy- get things right here and you will not need herbs. Unfortunately in my eagerness to prescribe I did not pay any attention to this until I found I did not have access to this modality).

It is unique to Japanese acupuncture that needles are very often inserted superficially or to a depth of 5mm. The sensation of Deqi (the achy sensation that often accompanies needling) is not necessary; needles are very often inserted on the Eight Extraordinary Vessels as opposed to the Primary channels that most acupuncturists use, and connected with an ion pumping cord (please read Yoshio Manaka’s book ‘Chasing the Dragon’s Tail’ if you want a full explanation of how this works). My feedback mechanism to ascertain whether the patient’s Qi has been regulated, is the patient reporting a reduction in pain or tightness. This can be as quick as only 2-3 minutes. The patient is then asked to turn onto their front and Back Shu points selected according to the pattern of abdominal symptoms and verified by palpation. The Back Shu points are then needled and warmed with an infrared lamp.

These first two steps are used to regulate Yin and Yang. This is known as the root treatment. As the patient is lying on their front, needles are often inserted in channels where there is stagnation of Qi which is very often around the points GB 20, 21, BL 10, 17-19, 23-24, 27-28, 41-44, SI 10-15 and thread needling along Huato Jaji points and medial border of the scapula. Points are located energetically rather than by strict anatomical location and constant verbal feedback from the patient during palpation is vital in Japanese acupuncture, and the needles are again only inserted relatively superficially.

Lastly, ear seeds (typically mustard seeds on a piece of adhesive tape to go over acupuncture points) are applied to auricular points to suppress symptoms; press tack needles (needles on tape) can be applied to points on the hand based upon Korean hand points and intradermal needles applied to ah shi painful points (sadly this technique is no longer available to BAcC members). Lastly I ask patients to demonstrate movements that were painful or restricted before the treatment to measure if there is a reduction in symptoms. The last two stages of the treatment are to treat the branch (symptoms) of the condition, not the root cause.

In my discussion with patients I always stress that I believe that good Traditional Oriental Medicine is based on a partnership, and just as it is my responsibility to do my best to reduce their suffering, they also have a shared responsibility to work with me. This may involve filling daily diet / exercise diaries, walking 10 minutes a day, abdominal breathing / visualisation exercise etc. For many patients familiar with conventional treatment, this way of being treated can be daunting. Some are reluctant to take responsibility for their own health because they are culturally used to playing a passive role, have no confidence in helping themselves and prefer to let a health practitioner take responsibility for their health. For others it can be liberating and empowering to know that by following some simple lifestyle advice they can increase the quality of their lives and manage their pain.

One of my responsibilities in the NHS was to write case studies for the project’s newsletters. I always steered clear of Oriental medical terminology as this would have made my case study user-unfriendly, and given the fact I was trying to communicate to the referring GP’s and health care professionals what I was doing, could have been detrimental. I would typically write using anatomical locations rather acupuncture points or channels, talking about over and under used muscles rather than the Xu and Shi terminology.

Here is an example of a case study I submitted to the newsletter.

Acupuncture Case Study

Patient: Mrs O. DOB 16.03.1928

Main Complaint

This patient suffered from Herpes Zoster in1991, which left her with a permanent dull ache on the lateral aspect of her left leg situated between the greater trochanter and the lateral aspect of the patella, plus lower back pain situated in the lumbar region and general weakness of the left leg.

The condition did not respond to drug therapy or physiotherapy. MRI and blood tests were inconclusive. Her symptoms were relieved on a short-term basis by stretching. She had good energy, no known allergies and regular bowel movements. She felt increasingly irritable due to her pain, which aggravated her condition and affected her sleep. She was very irritable for the first consultation and informed me that she thought acupuncture was “a load of rubbish”, but she attended as her GP thought it would be a good idea. She walked every day for up to one hour in an attempt to strengthen her leg but this did not have any effect on her condition.

In 1967 she gave birth via “C” section; in 1979 she underwent a full hysterectomy; in 1996 her gall bladder was removed.

Pressure pain (PP) was found in both subcostal areas, the superior aspect of the trapezius, and lumbar area in the region of L 3-5. No PP was found in the area the patient complained of suffering pain, but she found relief from pain when pressure was applied.

1st – 3rd treatment:

Needles were applied to distal points on arms and legs and retained until PP on the abdomen reduced or disappeared. Needles were applied to PP areas on the erector spinae in line with T 9/10 and L 2/3. All the needles on the erector spinae were warmed with an infra-red lamp. Needles were also applied to local points around the greater trochanter and trapezius. Ear seeds were used after treatment in an attempt to reduce irritability and pain.

Over the first three treatments the patient reported a steady reduction in pain and irritability, but the weakness in her leg remained the same.

4th – 6th treatment:

The same treatment protocol was adopted as in previous sessions. The pain completely disappeared but weakness remained. I wrote to the referring GP, to suggest a referral to physiotherapy, to gain guidance on how to rehabilitate the muscles in her left leg now that her treatment with me was complete.
Part of the procedure involved me writing a discharge report to all referring GPs. This had two purposes: firstly to inform the GP of any progress, and secondly to inform them as to what conditions the various therapies can treat. Over the years it had become standard practice for many GPs to refer patients for acupuncture and I was increasingly being informed by patients and GPs that consultant neurologists and rheumatologist were recommending referrals for acupuncture treatment.

Sadly in 2014 the project was disbanded due to financial cuts in the NHS, but I hope one day it may be revived.

So what did I think of working in the NHS? On the negative side I found it disheartening that some referrers sent their patients after they had exhausted every other avenue, which wasted valuable time for the patient and made my job just that bit more difficult. Also seeing so many patients in a day in only half hour slots could sometimes make me go into a pattern recognition mode. Failing to address each patient as an individual may have impacted on the therapeutic relationship.

However, on the whole I would say that the positives far outweighed the negatives. I had the opportunity to see conditions that clinically I would not see in private practice, and the sheer volume of patients made me re-evaluate my acupuncture techniques and hone them to enable me to gain better clinical results faster. My job allowed me to fly the flag for traditional acupuncture and demonstrate that we are clinically effective and can play a vital role in the public sector health care, which cannot be bad for the profession!

A the end of the day when I sit back reflecting on the various patients I had treated, my experiences left me in a state of awe and amazement as to what a truly incredible system of diagnosis and treating acupuncture is. Very often I take acupuncture for granted, as it is second nature for me to diagnose in terms of Yin and Yang and discuss with students and colleagues how to try to redress imbalances of Qi. I am in essence applying an ancient Chinese philosophical approach to health care in a 21st century setting. By inserting a few bits of wire into a patient I am able to ease someone’s suffering. The fact that I am able to do this when nothing else has worked is not really down to my abilities, but is a tribute to the practicality and effectiveness of traditional Oriental medicine and demonstrates it is as valid today as it was thousands of years ago.

Anand Marshall