Tuscany’s experience of integrating CAM into the healthcare system
As mentioned above, Tuscany has been gradually integrating complementary medicine into public healthcare since the late 1990s. Dr Elio Rossi summarized the development of CAM’s status within the Italian healthcare system in his presentation at the International Congress on Integrative Health and Medicine in 2016. (252). Below are two of his maps showing an overview of Tuscan clinics that CAM methods (Figures 25 and 26).
Figure 25 - Tuscany (Italy): the 97 clinics where CAM is provided in Tuscany (data from April 2014). The figures on the left show the number of visitors per year.
Source: ROSSI, Elio. Integrative medicine in Italy and the Tuscany experience [online].
Figure 26 - Tuscany (Italy) - examples of clinics where CAM is provided in Tuscany
Source: ROSSI, Elio. Integrative medicine in Italy and the Tuscany experience [online].
In 2007, a regional law was adopted in Tuscany which allowed selected fields of complementary medicine to be used within public health facilities. In Pitiglian, Tuscany, the first hospital of integrated medicine in Italy was established – a breakthrough in integrating conventional and alternative medicine. After two years of preparation, the Center for Integrated Medicine opened in 2011 making it the first hospital to provide hospitalized patients with CAM. Representatives of conventional medicine on the one hand, and homeopathy, acupuncture and traditional Chinese medicine specialists on the other hand, began to cooperate within a single medical team. Part of the project’s inspiration came from the experiences of the Royal London Hospital for Integrated Medicine - a representative of the RLHIM was even a member of the scientific team that developed the Pitiglian project.
More details about the project and its results can be found in the article Integration between orthodox medicine, homeopathy and acupuncture for inpatients: Three years experience in the first hospital for Integrated Medicine in Italy (253), from 2015. The abstract and some excerpts from this article are cited below:
The hospital in Pitigliano (Tuscany) is the first hospital in Italy to put into practice a model of Integrated Medicine. This clinical setting caters for the use of complementary medicine (homeopathy and acupuncture (針灸zhen jiǔ)) alongside orthodox therapies (conventional medicine). The therapeutic model implicates doctors who are experts in complementary and alternative medicine (CAM; 補充與替代醫學 bǔ chōng yǔ tì dài yī xué) and the rest of the hospital personnel working together as equals. This contribution explains the difficulties, critical aspects and potential of this innovative setting.
The clinical setting for Integrated Medicine was evaluated in part through observation and in part through the analysis of approval questionnaires. The writers of the questionnaires were the orthodox medical personnel and the hospital patients.
The project is still evolving today in spite of the initial partial contrariety of some doctors in the hospital and some external doctors in the area. However, it can already be considered a positive experience, as confirmed by the high approval gained from many health workers and most of the hospital patients. Moreover, the follow-up carried out through specific surgeries dedicated to CAM is extremely positive.
Up to now 532 inpatients suffering from acute illnesses, relapse of a chronic illness or neurological or orthopaedic rehabilitation following strokes, brain haemorrhage, neurological illness or limb prosthesis operations have been treated.
This work has tried to illustrate the innovative and positive experience for the Italian public health authorities so that it may also be useful to anyone who would like to promote similar initiatives within its public health Institution.” (254)
Figure 27 - Hospital in Pitigliano (Tuscany) - Integrated medicine model in practice: Evaluation of the results of 532 inpatients
Source: S. Bernardini, F. Cracolici, R. Ferreri, M. Rinaldi, R. Pulcri. Integration between orthodox medicine, homeopathy and acupuncture for inpatients: Three years experience in the first hospital for Integrated Medicine in Italy [online]
Complementary medicine is not officially recognised by orthodox medicine in most of the Western countries, Italy included. This is mainly due to cultural barriers, therefore it has not been possible to set out regulations nor to find credit within the Institutions. However, the opportunity given by the Italian Regional Government to apply operational measures within the region allowed the Centre for Integrated Medicine of Pitigliano (Tuscany) to implement an innovative healthcare approach (see Appendix 1).
The Centre for Integrated Medicine of Pitigliano was founded by the Health Government of the Tuscany Region in February 2011 in order to provide assistance to patients and to carry out scientific research projects. The Centre is the first public hospital in Italy which provides inpatients with homeopathy remedies, acupuncture (針灸 zhēn jiǔ) treatment as well as Traditional Chinese Medicine (中醫 zhong Yi, TCM). The cutting-edge project entails several objectives to be achieved within the Italian public healthcare system:
(i) to potentially establish a clinical setting between orthodox medicine and complementary and alternative medicine (CAM; 補充與替代醫學 bǔ chōng yǔ tì dài yī xué) practitioners, based on mutual agreement and close cooperation in terms of therapy and treatment;
(ii) to test the interdisciplinary approach among inpatients;
(iii) to verify the beneficial effects deriving from the approach regarding the improvement of the quality of life in patients suffering from chronic diseases as well as the decrease of side-effects triggered by conventional therapy;
(iv) to verify the potential advantages of integrated medicine in terms of cost management regarding the regional healthcare system.
This contribution describes the hospital clinical setting of Integrated Medicine, the operational plan, the difficulties regarding its fulfilment, the crucial points, the opportunities and beneficial effects experienced by practitioners and patients three years after the beginning of the project. Among the tasks, CAM physicians (homeopathy, acupuncture and TCM) provide patients with Integrated Medicine, at five clinics (for outpatients) and in hospital wards, as well as at the neurological and orthopaedic Rehabilitation Centre (for inpatients) in Manciano (Tuscany). Patients at the Centre in Manciano have experienced cerebral vascular accidents or suffer from chronic neurological diseases (ALS, multiple sclerosis, Parkinson's syndromes and so on), or have undergone surgery for knee and hip implants. This represents a ground-breaking project for the Italian healthcare system whose preparatory plan lasted for two years (from 2008 to 2010) (see Appendix 1).” (255)
In the present contribution we have endeavoured to describe the characteristics of an innovative clinical setting of Integrated Medicine in Italy, the principle difficulties encountered and the solutions adopted to solve them. We hope that this article is useful to health professionals who wish to define a common strategy of integration, and at the same time that it may provide useful information to those who are aiming to adopt similar health initiatives. On our part, albeit with great difficulty on the part of orthodox physicians, we were able to demonstrate that:
(i) it is possible to realise a clinical setting of Integrated Medicine based on a close collaboration between orthodox and CAM (補充與替代醫學 bǔ chōng yǔ tì dài yī xué) physicians;
(ii) this model of health assistance is very much appreciated by the patients;
(iii) the perception of the well-being of the patients who receive integrated treatment in the hospital is enhanced.
We are convinced that a small hospital has simplified the realisation of such a health project through the establishment of a stronger collaboration between the individuals involved in the setting. The coexistence and collaboration among the physicians, both orthodox and complementary, are very much appreciated by the patients, who declare that they have more trust in the orthodox medicine offered in the hospital since the introduction of homeopathic and TCM (中醫 zhōng yī) therapies. Moreover, we consider the appreciation on the part of elderly and very elderly patients, who have little knowledge of CAM due to the local cultural background, an added value In our opinion, it would be important that this new health model be imported into larger sanitary structures in Italy, and for this reason we hope that our particular experience, which did not fail and is continually growing, may be an example for similar future initiatives.” (256)
The Tuscany Region has been providing Complementary Medicine services as components of its public healthcare system since 1996. Three regional centres for homeopathy, acupuncture (針灸 zhēn jiǔ), TCM (中醫 zhōng yī) and phytotherapy have been operating since 1999 in Tuscany. The patients can benefit from the service by paying a ticket which is similar to the one paid for other healthcare services provided by orthodox medicine. The Regional Law n° 9 approved in 2007 recognises four complementary medicines (manual medicine, acupuncture, homeopathy and phytotherapy) as “official” medicines of the regional healthcare service, which may be applied to the population within the public healthcare facilities of the Region. Currently there are more than one hundred outpatient clinics which provide complementary medicine services located around Tuscany.
Law No. 9 permitted the setting-up of the first hospital for Integrated Medicine in Italy, and it provides CAM (homeopathy and acupuncture and TMC) to inpatients too. The scientific Committee, appointed by the Tuscany Region, drafted and developed a research project from 2008 to 2010. The Committee is composed of delegates of the healthcare system governing bodies of Tuscany; physicians with great experience in homeopathy, phytotherapy, acupuncture and TCM; the Deans of the Faculties of Medicine of the Universities of Florence and Siena; an expert in legal medicine; the Administration of the local health Authority ASL 9 ; the Head Physician of internal medicine of the Hospital of Pitigliano and the Medical Director of the Royal London Hospital for Integrated Medicine; and it is coordinated by a Doctor specialised in Integrated Medicine nominated by the Tuscany Region. In 2010 the project was approved through appropriate norms adopted by the Tuscany Region that consented the opening of the hospital centre for Integrated Medicine in order to provide inpatients and outpatients with CAM assistance and to carry out scientific research.”(257)
(253) BERNARDINI, S., CRACOLICI, F., FERRERI, R. et al. Integration between orthodox medicine, homeopathy and acupuncture for inpatients: Three years experience in the first hospital for Integrated Medicine in Italy. Journal of Traditional and Complementary Medicine [online], Volume 5, Issue 4, October 2015, Pages 234-240 [cit. 2016-06-01]. Available from: http://www.sciencedirect.com/science/article/pii/S2225411015000450
(254) ibid., page 234.
(256) Ibid. page 239.
(257) BERNARDINI, S., CRACOLICI, F., FERRERI, R. et al. Integration between orthodox medicine, homeopathy and acupuncture for inpatients: Three years experience in the first hospital for Integrated Medicine in Italy. Journal of \traditional and Complementary Medicine [online], Volume 5, Issue 4, October 2015, Pages 234-240 [cit. 2016-06-01]. Available from: http://www.sciencedirect.com/science/article/pii/S2225411015000450