Multi-bed Acupuncture clinics: a new model of practice

Multi‑bed acupuncture clinics ‑ a recent and successful phenomenon in the UK ‑ utilise a new business model for the provision of more affordable acupuncture treatments. Patients benefit from reduced cost of treatment in exchange for some loss of privacy, and they overwhelmingly report being treated in a communal setting as a positive experience. Practitioners benefit from a highly stimulating and supportive working environment, a significantly increased potential client base and the satisfaction of providing more accessible treatment.



Acupuncture treatment in the UK has predominantly been provided by a single practitioner treating one patient at a time in a private room, and usually staying with the patient throughout the whole treatment, which might be expected to last 45-60 minutes in total. This is in contrast to China, where cost- and patient- effective treatment models have evolved over the centuries to the current practice whereby patients usually receive acupuncture treatment in large rooms containing several beds. These effectively resemble the wards found in conventional hospitals, although in this case they are used for out-patients. Thus one or more doctors may treat several patients simultaneously. Of all Complementary and Alternative Medicines (CAM), acupuncture uniquely lends itself to this style of practice, as needles usually have to be left in the body for 10-30 minutes. During this time, as the patient rests, the doctor is free to treat another patient.

The first well-established clinic following a multi-bed model in the UK was the Gateway Clinic, London. Founded by John Tindall in 1990, the clinic is funded by the National Health Service's (NHS) Lambeth, Southwark and Lewisham Primary Care Trust (PCT), and lies in the grounds of Lambeth Hospital. In 2004-5 the clinic received £94,000 of funding and treated over 400 patients per week (Thomson, 2005), working out at a fee of £4.52 per patient per treatment. All patients must be referred by a general practitioner within the local catchment area and can receive a maximum of 12 free treatments per referral. Patients with HIV and Hepatitis C are given priority, can jump the waiting list which is often several months, and can receive unlimited treatments. Recently, due to constant high demand and an ever-expanding waiting list, the clinic has had to restrict referrals to those conditions clearly demonstrated by quality scientific trials to be successfully treated by acupuncture, i.e. musculo-skeletal conditions, headache, cancer treatment support, etc. In spite of this clinic’s perennial cost-effectiveness and popularity, its model has not been replicated elsewhere in the NHS.

One of the first multi-bed acupuncture clinics independent of the NHS was the Dragon Acupuncture Project in Brighton. It was founded in 2003 by Nik Tilling and Calum Thomson out of a pragmatic need to make a living in a town with a high number of established practitioners, many new acupuncture graduates, and a supportive but impecunious population. It was inspired by the Gateway model, and quickly became popular with the local community.

Other practitioners heard of the Dragon’s success, or were themselves inspired by the Gateway, or by clinics in the United States such as 'Working Class Acupuncture' in Portland, Oregon, founded by Lisa Rohleder, an eloquent and passionate advocate for the integration of multi-bed acupuncture practice into American healthcare (see www.workingclassacupuncture.org and www.communityacupuncturenetwork.org). Since 2004, 13 new independent multi-bed clinics have been established in the UK, with more expected this year.

What is a multi-bed acupuncture clinic?
I would like to propose a definition of multi-bed practice as one where a practitioner treats more than one patient per hour in the same room, with the aim of making acupuncture treatment more affordable. Beyond that, it is clear that multi-bed practice differs widely from country to country and clinic to clinic: "In the USA, an acupuncture treatment was more commonly offered using recliner seats and point prescriptions involving ’distal’ acupuncture points. Charges were also often made on a sliding scale basis, averaging $15-35 per individual treatment. In the UK a more traditional approach was taken to providing low-cost, multi-bed treatments, where full-body acupuncture is more commonly used but on multiple beds. Reduced rates are offered by treating more than one person at a time, but usually on a fixed rate averaging £15.” (Potter, 2008).

It is not exactly clear why the difference exists between the two countries. I suggest that a ‘tradition’ has rapidly emerged in each country, whereby the model of practice in the first successful clinic has largely been followed by subsequent clinics.

In the UK, multi-bed clinic models vary widely. The Gateway consists of a large room with nine beds, some separated by screens. Another large room serves as a waiting room, and a ‘drop-in’ ear-acupuncture clinic. There is a small room where patients can talk to their practitioner in private if necessary, although this is rarely used. The clinic employs several salaried practitioners and is popular for newly-qualified practitioners to intern. Each practitioner treats up to three patients per hour.

Some independent clinics follow this model quite closely, for example the Dragon Acupuncture Project in Brighton, which also has up to nine beds, some screened off. At the Dragon, as at many of the other independent clinics, an additional private room is seen as essential. It is always used to take the initial case history, and is also available for any patient to discuss issues that feel too personal to talk about within earshot of other patients. The Dragon treats around 130 patients each week, employing three or four practitioners, who treat up to three patients per hour. Other clinics are run by just one or two practitioners, who may treat between two and four patients each hour. Practitioners may choose to split their practice between multi-bed and one-to-one practice; others prefer just multi-bed practice. Most clinics use an appointment system, fewer operate a drop-in system. Some clinics have their own receptionist although this is expensive; others may make use of the receptionist provided by the clinic where they rent space, or use an ‘invisible receptionist’ system .

Some clinics have found success by working alongside, and using rooms provided by, other organisations, such as Age Concern (Four Gates, Ealing, London). It would appear, in fact, that due to financial realities, no independent clinic at the time of writing enjoys full-time use of its own space, but instead rents spaces in other CAM clinics, yoga studios, etc. This is not the case in the USA, where rents are more reasonable.

Clinics may or may not provide auricular acupuncture, facial acupuncture, Chinese herbs or Chinese patent herbal remedies, tui na and moxibustion, alongside traditional full-body acupuncture.

What are the advantages of multi-bed practice from the point of view of patients?

Obviously one of the main advantages for patients is increased affordability of treatments: "With the national minimum hourly wage currently ay £5.52 (HMRC, 2008) and the national average hourly wage equating to approximately £9.50 (Office for National Statistics, 2007), a single acupuncture treatment [in one-to-one practice] can represent more than a day’s pay for many people. These figures suggest that acupuncture is likely to be inaccessible to large sections of the population." (Potter, 2008).

Research at the Dragon showed that 90% of patients were attracted to the clinic because of the cost of the treatments, with 90% also reporting that the main benefit of this was that they could afford to come as regularly as they needed and perhaps afford to utilise two therapies at the same time. In order to be effective for certain complaints, acupuncture is best performed intensively. However, in one-to-one practice in the UK, a tradition (following the homeopathy/psychotherapy treatment model and financial constraints) has emerged of weekly treatment being the norm. This is unrelated to practice in China and may damage the prognosis for some conditions. As Giovanni Maciocia points out, “You call weekly treatment proper treatment for here, but that’s created by social circumstances. We’re in private practice and people can’t afford to come more often. If they could they would come every other day” (Kaptchuk, 1985). 73% of patients at the Dragon Project reported that they were either receiving social security payments, or had chronic illness, and 59.6% of patients earned less than £1500 per month, meaning they would not be able to pay, or only pay infrequently, for the treatment they needed at full (one-to-one) cost (Stone, 2006).

Another significant advantage for patients at the Dragon was that the clinic filled their need for a sense of community. The research showed that initially patients were drawn because of the low cost, with only 7.6% either aware of or actively supporting the ethos of the clinic. However, after experiencing the feel of the clinic for at least two treatments, 9.6% of questionnaire respondents specifically mentioned that they like the sense of community, 5.7% said it reminded them they weren’t alone in having problems, and 44.2% said they enjoyed the atmosphere created when many patients were treated together. 11 out of 14 respondents who made extra comments concerning “unexpected positive aspects of being treated at the Dragon” mentioned ‘community’. One patient (Male, aged 33) noted, “I think it is positive to be seen in our conditions by others. It humanises illness and distress and unifies us.” Another found that, “It makes treatment less isolating, puts my own treatment into perspective. Makes me feel less precious and self-involved” (Male, 47). Some patients, particularly those with long-term illness, simply appreciated the social aspect of the project and enjoy the “friendliness of the clinic with people chatting and enjoying each others’ company” (Female, 70). We notice, at the Dragon Project, that patients are now as likely to recommend the clinic for its atmosphere as for its low cost. This is borne out by the fact that 17.5% of patients are on salaries of £24,000 - 36,000 per annum, with 5.2% on more than £36,000, and could therefore arguably afford more expensive treatments (Stone, 2006).

Practitioners in several clinics have noticed that patients seem to respond unusually well to treatment in multi-bed clinics. Tom Kennedy, of Four Gates, Ealing, says, “I feel as though the dynamic created by a shared healing environment definitely adds something to the process. It doesn't suit everyone, but most people seem quite happy in this setting. There is a 'buzz' at busy times which just isn't present in a private setting, and quite the opposite from being distracting, I believe this invigorates most patients.”

There is also political/ideological appreciation amongst patients of treatment being made available to a wider section of the community. One patient noted, “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, 50). Another said, “There’s a kind of collective feel about getting treatment in a room with other people. And it is that sense of … that it’s a clinic that’s dedicated to the welfare of a wider community, in the same way that a doctor’s surgery is, you kind of feel a part of something bigger." (Female, 39) (Stone, 2006).

40.3% of patients in the Dragon Project research reported that they liked to be left alone during treatment, rather than feeling obliged to chat with their practitioner. They appreciated that in a multi-bed clinic, they were able to relax in peace, but of course were not actually alone in the room and therefore felt safe. One patient had experienced an abuse of dignity when she was being treated in one-to-one practice in the past; she felt safer and more comfortable being treated in a room with several other people at all times, “because the chances of these kinds of abuses happening is so much reduced” (Stone, 2006).

Disadvantages from the point of view of patients

One of the most significant concerns for NHS patients has been shown to be maintaining a reasonable level of privacy/confidentiality during treatment (Douglas and Douglas, 2003). Patients were shown to be more likely to withhold information when talking to clinical staff in curtained-off areas in hospital than in areas separated with solid walls (Barlas et al, 2001). This is obviously relevant to multi-bed acupuncture clinics; the research from the Dragon Project clearly shows that confidentiality is the single most common concern that caused patients to report a ‘negative experience’, with a smaller number of patients concerned about removing their clothes or seeing others’ unclothed bodies. Patients being treated for straightforward physical complaints reported no problems with confidentiality. As patients required more emotional support or had to reveal very personal information, the implications of being treated in close proximity to other patients became more evident (Stone, 2006). This shows that both patients and practitioners need to be realistic about the limitations of confidentiality in this type of clinic. How to deal with this – provision of private spaces and screens and gowns, for example – is up to each clinic. Anecdotally, patients at the Dragon report that they feel able to comfortably receive treatment for complex and emotional issues because they know they can talk in private whenever they feel the need. Patients should be made well aware of the set-up of the multi-bed clinic before they commence treatment, as this will constitute an aspect of informed consent. It must also be noted that staff sensitivity powerfully affects patients’ feelings around privacy, both in the NHS (Bailey, 2005) and in multi-bed clinics. And, as mentioned above, once comfortable in the multi-bed setting, the pay-off for less privacy seems to be a sense of communion with one’s fellow patients.

It is inevitable that there will be more noise in a multi-bed clinic than in a one-to-one clinic, and this can disturb patients. Patients are less tolerant of chatter that is not related to treatment, either from staff or other patients, for example when friends bump into each other or practitioners “talk shop” (Stone, 2006). Patients tend to learn to modify their behaviour, and again good boundaries and sensitivity on the part of practitioners are required to make the space effective.

Different clinics choose which treatment styles they will utilise within the tighter time constraints of multi-bed practice. This may result in patients missing out on very fine or time-consuming treatment styles such as tui na, moxa cones, etc. For example clinics in the USA generally prefer to use distal than full body points, while clinics in the UK are more likely to try to provide a very similar treatment to one that a patient might expect from a one-to-one treatment (Potter, 2008), but this may not always be possible.

While most patients appear to enjoy the atmosphere created in multi-bed clinics, there will be some vulnerable patients who are unable to feel safe or relaxed surrounded by other people. Acupuncture can bring up intense feeling states and practitioners need to be extra sensitive to the needs of vulnerable patients. Patients in the Dragon research reported feeling vulnerable when, for example, they unexpectedly bumped into a work colleague they may have struggled with or feared repercussions from; or when another patient may inappropriately have commented on personal issues they had overheard (Stone, 2006).

What are the advantages of multi-bed clinics from the point of view of practitioners?

The Dragon Project was set up to enable its practitioners to earn a living where they were struggling to do so before, and it has been successful in this by massively expanding its potential client base. Patients with less disposable income are now more able to access treatment. Also, patients are able to afford treatment frequently enough and for long enough to get better and stay better, and to use acupuncture for ‘maintenance medicine’ once they are better, meaning there is a high retention of long-term patients. It is also easier to publicise a clinic in the local press that is offering something new or unique, rather than being just another one-to-one practitioner in a busy marketplace.

Multi-bed practitioners will treat between two and four patients each hour in the UK, and up to six in the USA. High patient numbers allow for faster practitioner development, as it may take many years to build up to such numbers in a one-to-one practice. When one's patients are more relaxed about the financial demands on them, a more satisfying and clinically successful treatment experience may emerge for all. Nik Tilling, of the Dragon Project, explains, “It's important to recognise that acupuncture is not just an intellectual process, which is one of the pitfalls of the acupuncture courses currently available. In fact, the actual act of acupuncture (needle insertion and engaging with qi) isn't intellectual at all; it's all about developing sensitivity to what is occurring in the present moment. Speaking for myself, I wasn't improving in that aspect of my practice whilst I was struggling with limited numbers of patients working one-on-one. Multi-bed practice allows you to relax into the clinical experience. The pressure to give unrealistic prognoses due to the high cost of treatment is eliminated.”

Practitioners in multi-bed clinics enjoy the ethical and ideological aspect of offering acupuncture to a wider section of public. Stephen Potter, recent graduate from Westminster University, says he chose to research multi-bed clinics, “because I am committed to social and health provision for all, and could not work in a situation that perpetuated the myth that acupuncture is only wanted or needed by the upper middle classes. It is definitely an ideological standpoint for me rather than an economically convenient one; I am just so happy to feel part of a growing movement.” Multi-bed practice enables the provision of cheaper treatment for those practitioners who do not wish to work within the bureaucracy of the NHS.

There are constant opportunities for learning when working in a team of practitioners. Every practitioner has their own specialities and one may notice at any moment a colleague using an unfamiliar point combination or technique. It is straightforward to ask for a second opinion, and one’s patient will know the other practitioner by sight. This also eradicates the need to entrust one’s patients to an unfamiliar locum, and we find at the Dragon for example, that we have a high retention of patients when one of our practitioners is away, whilst many of our ‘one-to-one’ colleagues complain of struggling with locum care.

Finally, just as patients are protected from abuses of dignity because of the constant presence of witnesses, so practitioners are protected from wild accusations of malpractice for the same reason.

Disadvantages from the point of view of practitioners.
The only real disadvantage of multi-bed practice is being on one’s feet more than in private practice and having to maintain the threads of several treatments at once. I imagine this sort of practice will suit some people more than others – it is more physically demanding, and I am uncertain a practitioner could sustain this five days a week. Practitioners at the Dragon work up to three days each week, seeing between 50 and 60 patients (which is enough to earn a living), and appreciate their rest days. However, the physical demands are offset by working in an emotionally supportive environment. Many practitioners complain of isolation and loneliness in one-to-one practice, with only their patients, who may be unwell, needy and draining, for company. In multi-bed clinics a practitioner talks less and needles more, and it is often becoming an unofficial talk therapist that seems to drain practitioners the most, whereas needling is generally considered energising. It is not only patients who feel the sense of ‘community’ that a multi-bed clinic provides, but the practitioners also form a close team bond. Even those practitioners who run their clinics alone report that treating several patients in the room together generally prevents any individual patient from draining their energy. To avoid burn-out on a daily basis, practitioners at the Dragon recommend a long midday break with a satisfying lunch and a siesta as essential.

Conclusion
There is and will remain a place, and a market, for one-to-one acupuncture practice in the UK. However, the various advantages of multi-bed clinics mean that patients are ever more likely to be treated in a community setting. The largest drawback for patients – lack of privacy – is countered by the destigmatising effect of receiving treatment in a community space. The largest drawback for practitioners – the demanding pace – is countered by the support of a team and the ability to earn a living by working three days a week in a busy clinic. The multi-bed business model has shown itself to be successful, and I believe that multi-bed practice will form a significant part of the future of acupuncture practice in the UK.

Bibliography

Bailey J, McVey L, Pevreal A. (2005) Surveying patients as a start to quality improvement in the surgical suites holding area. Journal of Nursing Care Quality; 20 (4): 319-26.

Barlas D, Sama AE, Ward MF, Lesser ML. (2001) Comparison of the auditory and visual privacy of emergency department treatment areas with curtains versus those with solid walls. Annals of Emergency Medicine. 2001; 38: 135– 139.

Douglas C, Douglas M. (2003) Patient-friendly hospital environments: exploring the patients’ perspective. Health Expectations, 2004; 7: 61–73.

Kaptchuk, T et al. (1985) Acupuncture in the West – A discussion between Ted Kaptchuk, Giovanni Maciocia, Felicity Moir and Peter Deadman. Journal of Chinese Medicine. Jan 1985: 17; 22-31

Potter, S. (2008). What is low-cost, multi-bed acupuncture? Available at http://www.affordableacupunctureuk.co.uk/links.html

Rohleder, L. (2006). The Remedy: Integrating Acupuncture into American Healthcare. May be purchased or downloaded from http://www.lulu.com/content/466287

Stone, C. (2006) Investigating patients’ experiences of receiving acupuncture treatment in a multi-bed clinic: A case study of the Dragon Acupuncture Project, Brighton. Available at http://www.affordableacupunctureuk.co.uk/links.html

Thomson, A. (2005) A healthy partnership: Integrating complementary healthcare into primary care. London. The Prince of Wales’s Foundation for Integrated Health London, England

Biography
Charlotte has been involved with the Dragon Acupuncture Project in Brighton, UK since 2004, initially as administrator, then as practitioner when she qualified in 2006. She has practiced NADA auricular acupuncture in a group setting since 2004 and is a certified instructor of qigong. She coordinates Affordable Acupuncture UK, an organisation which aims to promote and support multi-bed clinics in the UK.

Affordable Acupuncture
Affordable Acupuncture UK was founded in 2007 to inform the public and practitioners about multi-bed practice and to support and encourage the emergence of new multi-bed clinics. The Affordable Acupuncture UK website (www.affordableacupunctureuk.co.uk) listed three new clinics just in the month of July, 2008. If you would like further information on multi-bed practice in the UK, or are interested in setting up a clinic, please contact Charlotte on info@affordableacupunctureuk.co.uk.


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