ACMAC Newsletter

Insights

I like the idea of a cooperative venture that aims to make acupuncture affordable to all – not just middle class people with plenty of disposable income. — Female patient, 50 yrs old, Dragon Acupuncture Project, Brighton, UK

Our USA friends

What does affordable acupuncture mean?

Affordable: [adj] that which can be afforded; believed to be within one’s financial means.

As you will be aware acupuncture in the West has historically been practiced in a one-to-one format. (This format

The Bright Room, Stoke Newington, UK

was not arrived at because of any clinical requirement; rather the physicians who brought acupuncture to the West were already psychotherapists, naturopaths, osteopaths, etc, who superimposed acupuncture on to their existing practice models.)

One-to-one practitioners charge an hourly fee appropriate for a highly-trained clinician. Some people can afford to pay such a fee whenever they choose; plenty of people can afford to pay it once in a while; but the vast majority of people will find it hard or impossible to pay this price regularly. This raises both class and elitist issues, to say nothing of the medical issues: it is vital that a patient can have treatment frequently enough and for long enough to get better and stay better. If a patient has to stop treatment prematurely, their condition may re-appear or worsen.

So, if one-to-one acupuncture is only affordable for some people, is there a way to provide acupuncture that is affordable for more people in our community? The answer is yes: “multibed” or “community” acupuncture clinics.

How long have multibed clinics been around?

In the East patients have always been treated together (well, ‘ordinary’ patients. We can assume that the Emperor and his family and high-ranking officials would have been treated privately). In China, a doctor is recognized for his or her ability to treat a high number of patients efficiently and effectively. A doctor would be laughed out of the hospital if he could only treat 8 patients a day! It is simply impossible to treat 100 – 200 patients a day staying with each patient in their own private room. So community-style clinics appeared early on out of necessity.

UK

A famous NHS clinic in the UK called the Gateway Clinic was founded in the late 1980s by John Tindall. It is extremely popular with both GPs and patients and offers the NHS very good value for money (see Library for research article into referral behaviour to the Gateway). Given that it is such a shining example of what an NHS-funded multibed acupuncture clinic can achieve, it is odd that its model has been so sparsely replicated in the UK.

The UK’s first non-NHS funded multibed clinic was founded in Brighton, in 2003. Called the Dragon Acupuncture Project, this clinic unwittingly started a revolution in acupuncture provision in the UK and beyond. The Dragon Project largely followed the Gateway’s model, with each practitioner treating 3 patients per hour on treatment couches. Other practitioners were inspired by the new type of clinic environment found at the Dragon Project and many new multibed clinics have opened in the UK in recent years, many of which more or less follow the Dragon model. Therefore we can see that the model for ‘Community Acupuncture’ in the UK has rested almost exclusively with practitioner-owned, non-state, non-charity funded, multibed clinics.

Australia

By contrast the definition of ‘Community Acupuncture’ in Australia has been much broader to include both privately run multibed clinics, but also acupuncture clinics in existing health-care settings; outreach programs; detox centres using auricular acupuncture; and projects that have come about in response to recent natural disasters. The first Australian clinic to join ACMAC did so in June 2011. For a detailed account of 3 seminars that brought together Community Acupuncture practitioners from all over the East Coast of Australia, in Autumn 2011, please CLICK HERE.

USA

At around the same time as the Dragon was founded in the UK, Lisa Rohleder and Skip van Meter founded Working Class Acupuncture in Portland, Oregon, USA. As in the UK, a network of similar clinics rapidly appeared, which was first united under the name Community Acupuncture Network (CAN). CAN has continued to evolved and their extended community of ‘comrades’ is now called the People’s Organisation of Community Acupuncture or POCA.

There is a small but relatively well-established Community Acupuncture movement in Ireland, with nascent movements appearing in Germany, Portugal and Switzerland.

ACMAC was founded in 2007, with 5 member clinics. It now has over 75 clinic members, in the UK, Ireland, Germany and Australia.

How do multibed acupuncture clinics work?

London Community Acupuncture Project, UK

By treating several people in a large room together (hence “multibed” clinic), rent overheads are vastly reduced. Acupuncture needles usually take between 20 minutes and 1 hour to do their work, which means that a practitioner can place needles in one patient, leave them to relax into their treatment, and then move on to another patient. By treating more than one patient each hour, a practitioner can reduce the price of each treatment, but still be able to earn a good hourly rate.

Acupuncturists, of all complementary therapists, are uniquely able to offer this service. You cannot massage three people at once, for example! We have a great opportunity to offer high quality treatment to people on average and lower incomes, begin to break the class barriers that are associated with complementary therapies, and still earn a living wage.

There are many different Community Acupuncture models; different countries may develop particular styles over time. Some clinics are large, with several practitioners working together. Some practitioners prefer to work alone. Some clinics use treatment tables whereas others favour chairs or recliners. Clinics may or may not employ a receptionist, intern or helper. Some clinics use an appointments system, others run a drop-in service. Practitioners may either take the initial case history in the main treatment room, or use a private room. ACMAC does not promote a particular style or model because we believe that different communities and practitioners work better with different models. Instead ACMAC aims to provide lots of information about different practice models. We encourage each practitioner or group of practitioners to check out this information, talk to experienced practitioners, visit different clinics and decide what works best for you. ACMAC is here to support you.

How much do multibed clinics charge for acupuncture?

Again, worldwide and locally different clinics use different models. Most clinics use a sliding scale of charges, so those patients on low incomes can pay less than those on higher incomes, or they pay what they can afford each week. ACMAC supports this way of charging as we feel it substantially increases accessibility, and we strongly recommend a sliding scale of £15 – 35, or equivalent, for both initial and follow-up appointments. ACMAC does not recommend a higher charge for the initial appointment as this can reduce accessibility.

How will my patients benefit from being treated in a multibed clinic?

There are two major benefits to being treated in a multibed clinic: affordable treatment and the energetic field that occurs when several people are treated together.

Affordable treatment

Bondi Beach Affordable Acupuncture Clinic, Australia

Multibed clinics create more affordable acupuncture as described above. This is very important because patients are better able to access treatments frequently enough and for long enough to get better and stay better. For example, in China a course of treatment will often involve the patient being treated every day or every other day, for 10 treatments; another course of treatment will then be started if necessary. This is almost unheard of in the West.

As practitioners we know how important it is for our patients to have treatment at the correct frequency and for the correct duration. If a patient has a condition that necessitates treatment twice a week for the first two weeks, then weekly for the next month, for example, yet this patient can only access a one-to-one practitioner and can only afford to come fortnightly, it is unlikely that the treatment will be powerful enough to bring about meaningful change. We need to realize that this can essentially render our medicine useless in such a situation. That patient may then reasonably decide that acupuncture ‘doesn’t work’, which is bad for them and for our professional reputation. Similarly if a patient with a chronic condition needs ongoing treatment, but can only afford six sessions, they cannot expect to see the health improvements they need.

Practitioners in the West, working in one-to-one clinics, can feel pressured to adjust their prognoses or treatment plans as they may be aware that affordability is an issue for their patients. If we can only treat our patients at low-intensity, the conditions that we can heal are limited. (For an interesting challenge to the orthodoxy of weekly treatment, please read “Restructuring American Acupuncture Practices” by Subhuti Dharmananda, Ph.D, to be found in the Articles section of the Library.)

The ‘community’ aspect of multibed clinics

Philadelphia Community Acupuncture, Philadelphia, USA.

An amazing community spirit emerges in multibed acupuncture clinics. Patients consistently report that they like the sense of togetherness and humanity they find there.

For some isolated patients, visiting a multibed clinic has an enjoyable and important social aspect to it. This challenges the idea that illness is something that tends to isolate people. Furthermore, patients with similar conditions may start to ‘network’ and support each other. Patients may make friends.

Energetically, a qi field builds up when several people are treated together which can impact positively on the healing experience of the patients, just as when several people practice qi gong together it can feel easier to get into the ‘flow of the exercises. The benefits of this qi field can also be felt from the practitioner’s point of view, as if there is that little bit extra to draw from.

There is an interesting discussion of these aspects of multibed practice in John Tindall’s speech from our 2009 conference, the video of which can be accessed on our Library.

How will I benefit from running a multibed clinic?

The community aspect of multibed practice is not restricted to patients. If you are working in a team of practitioners, you can benefit from extra clinical knowledge on hand, emotional support in difficult times, help with marketing and general running of the clinic. Even in you prefer to work alone, having more than one patient in your clinic can increase the energy flow around you.

Counseling versus acupuncture

Berlinakupunktur, Germany

Different practitioners practice in different ways, and one of these differences is how much ‘counseling’ one likes to do with one’s patients. Some practitioners have acquired extra skills in this area and are very comfortable with counseling a patient for an hour or so during a private treatment. For an acupuncturist untrained in this skill, however, too much talking can become very draining. It can also be argued that acupuncturists need to maintain clear boundaries with their patients and stick to practicing the skills in which they have been trained, ie, acupuncture. If a patient needs to talk more than he needs needles, he should probably be referred for professional counseling.  In a multibed setting, you have to share you energy between your patients, and you have to elicit information from non-verbal sources such as pulse and tongue and ask just the most pertinent questions; reducing the time for talking isn’t necessarily a bad thing.

Finally, knowing that you are providing a high-quality service at a price that more of your patients can afford, feels good.

Are there drawbacks to multibed clinics from a patient’s perspective?

The Acupuncture Clinic, Hove, UK

We can offer treatment at reduced cost by treating several patients together at the same time. This comes at the cost of some reduction in privacy. It is important to be sensitive to our patients’ needs for privacy as they come up. ACMAC would recommend that clinics have somewhere where a patient can talk about sensitive issues in privacy if necessary. We have found that if patients know that this facility is available, they are more likely to come to a multibed clinic for complaints at a mental/emotional level as well as at a physical level.

Similarly we recommend you make good use of screens, gowns, blankets, etc, to ensure patients’ dignity is protected during their treatments.

Informed consent it very important. Patients should be able to read through an information sheet that explains how a multibed clinic functions before they start their treatment. If they can anticipate the limits to privacy, and that it is OK and desirable for them to make requests if they feel uncomfortable, the whole experience is more likely to flow smoothly.

Are there drawbacks to multibed clinics from a practitioner’s perspective?

This will depend on the preferences of the practitioner. Obviously you need to see a higher number of patients if you are charging lower fees than in the one-to-one model, but it should be easier to attract these patients as you are offering more affordable treatment and therefore accessing a greater section of our community.

Is it easy to set up and run a multibed clinic?

Setting up a multibed practice requires the mostly same skills as setting up a single-bed practice, just with more couches. If you are working in a team you will benefit from good communication skills. Bear in mind that running your own business comes easily to some and is more of a challenge to others. If you are struggling, please post a request for help on our Forum, or look at the already existing posts. You are not alone!

ACMAC runs regular workshops where you can learn how to set up and run your own multibed clinic. Keep an eye on the News and Events page for more details.

Are there ethical or safe practice issues that come up in multibed practice?

The answer to this is ‘yes’. However, just by taking time to think things through, particularly from the point of view of your patients rather than yourself, you can mitigate any issues. Apart from doing good treatments, there is nothing more important in a multibed clinic than protecting the dignity and confidentiality of your patients. Patients take this very seriously.

Therefore, you must take seriously the following issues:

Informed consent. Don’t assume that a patient understands how a multibed clinic works. The onus is on you to explain to them how their treatment will be carried out, the limits to confidentiality and privacy in your particular clinic and how you mitigate these, how they can request more privacy if they aren’t comfortable and so on. It’s easy, as practitioners, to forget to do this, as we are in the space all the time and can forget how vulnerable patients can feel. ACMAC recommends that you give your prospective patient an information sheet to read before their first treatment, and make sure they sign something to say they have read and understood it.

Confidentiality. To a great extent, so long as you receive informed consent from your patient once you have clearly explained how much privacy/confidentiality they can expect, you are free to structure your clinic as you choose. Some clinics conduct the initial consultation in private; some clinics do all talking in private, with just the acupuncture taking place in the big room; other clinics conduct all talking and treatment in the big room as a matter of course. Even if you choose the latter, you must make your patients understand that private talking space is available at all times if needed, even if this is just a kitchen or quiet corridor. Adequate spacing between patients, talking in a whisper or low voice and using background music all help with maintaining a reasonable level of confidentiality.

Concealing notes. Make sure that your notes are always concealed, so that one patient isn’t able to glance at another’s notes. This would constitute a serious breach of confidentiality.

Discussing patients. Most multibed clinics have teams of 2 or more practitioners. You must formally receive informed consent (and make a record of this in your notes) if you want to discuss a patient’s case. Do not discuss your patients where another patient can hear, and especially do not discuss patients outside of clinic! If someone were to overhear this would constitute a very serious breach of confidentiality.

Named/responsible practitioner for each patient. Many GP practices have several doctors practicing, and a patient may be free to visit any doctor. However, one doctor will have ultimate responsibility for each patient. In the UK at least, to satisfy BAcC insurance requirements, this must also be the case in a multibed clinic. A patient may enjoy being treated by several members of the practitioner team, but the team must decide who carries ultimate responsibility for that patient. This should be made known to the patient, and should be marked on the patients’ notes.

Removal of clothes. This simply has to be handled with sensitivity. Never assume a patient is comfortable with revealing body parts. Use screens, gowns, blankets, whatever it takes to maintain dignity and have your patient feel comfortable and well cared-for. Also, remember that some patients may find it difficult to see other patient’s bodies, let alone reveal their own.

Some practitioners favour styles of acupuncture that utilise distal points only, for example the Balance Method as taught by Dr Richard Tan.

Safe practice. The rules here are the same as for one-to-one clinics. Additionally, you must make sure that there are sharps bins close to each couch so you do not have to walk any distance with needles in your hands. At the end of each day, check and wash pillow cases and blankets. If necessary, clean couches between patients, and definitely on a regular basis.