SPEAKER_02 0:00

If you're listening to Confidence to Thrive, advocated for ambitious healthcare practitioners and entrepreneurs, brought to you by Alicity Advisors. Welcome to Confidence to Thrive, the podcast helping growing practitioners and healthcare entrepreneurs navigate the challenges and risks of regulation while building brands that matter. Every episode we tackle a different issue facing healthcare practitioners or entrepreneurs, or we interview a guest who's working on the leading edge of private healthcare, building something that matters in their sector or profession. My name is Jody Rainsford, and on today's episode, I'll be discussing with Christopher Cloak Brown and Roger Houston, directors at Our List D, the challenge of prescribing and the definitions surrounding the regulations on this. With functional medicine becoming more mainstream, supplements are becoming more and more specialized and targeted, moving away from simple food supplements as previously considered. We look at the challenges and risks around prescribing and how practices should protect themselves going forward. So let's get into this discussion. Roger and Christopher, what are the particular challenges that functional medicine practices face around the concept of prescribing?

SPEAKER_00 1:02

I'd almost move up a level, Jodie, and say it's really the complexities around the it's this shift from medicine two to medicine three. So medicine three functional medicine, which is integrative, personalized functional medicine world that looks at sort of biochemical systems and people as a whole, and holistic across across everything, multi-practitioner, and by multi-practitioner, that's not just medical practitioners, but you have nutritionists who are very biomedically focused. You can have dietitians who are a lot more clinical but very much experts in metabolic health, which is a big part of functional medicine. You can have psychologists, psychiatrists, you can have multiple doctors, but half the doctors have PhDs rather than medical degrees, so not a medical doctor. But all of the regulation around the diagnosis and management of disease is built on a clinical hierarchy. So if you're not part of that clinical hierarchy, no matter how good your knowledge and expertise is, you are not in the business of uh diagnosing, managing disease. And you're certainly not in the in the business of prescribing, because that is the domain of prescriber nurses, registered nurses, GMC registered doctors, GDC registered dentists, and so on. So I think one of one of the pitfalls we keep running into is if you take I am somebody who has been a GMC registered GP. I'm used to the sort of GP way of the world where I have six minutes to check off the symptoms that somebody's got, and if I some matches, if I get more than a two-thirds match, then they've got that, and I can look up in the national formulary which pill to give them and how much, and uh I write them a prescription and off they go and job done. So a lot of functional medicine is about rebalancing the body's own resources, and so that means its own resources which gets into food and then food supplements to adjust the levels of food you've got. So that's great. But for you and me, when we talk about food supplements, I always picture wandering past the window of Holland and Barrett, which seems to have about a million things and different buckets, but it all comes down to cod livel or oil and vitamin C, and when one of our colleagues was saying how wonderful Baroca is in the morning to go going and so on, and all that stuff. But then when you attend some of these functional medicine conferences, if we take gut microbiome, which is a huge thing and has massive implications and connections, and so on, when you get into the detail, I was at a conference last about a year ago now, where they were discussing a supplement which was not just gut microbiome, but it was two particular strains of gut microbiomes, and on top of that, they were looking for particular DNA characteristics within those strains. So that is still a food supplement, it's found in food, it's regulated as a food supplement, so you can go out and buy it yourself and do what you want with it. But if I am a doctor, and I would almost say whether or not I'm GMC registered or not, the way the world's going to look at that is if I recommend that somebody takes that, then as we've discussed before, the the GMC views that any recommendation by a doctor, and that's even go for a walk, it is a prescription. We were just discussing that you don't have to write it down, and certainly not on a yellow or green or piece of paper for it to be a prescription. Anything that you recommend is a prescription, and certainly the way the GMC is going to view a doctor recommending somebody take such a sophisticated substance is as a prescription. And Roger, I'd be interested in your view, but I would say any court in the land in terms of negligence is basically going to hold you to a medical standard there.

SPEAKER_01 5:05

Yeah, yeah, they will. The fact that you haven't written the script, there's neither here nor there.

SPEAKER_02 5:13

And the fact that it's a because it's classed as a a food supplement, it has traditionally this wide perception that a food supplement is a food supplement. And because things are becoming increasingly uh complex and uh at a biochemical level, which is the shift, then is the challenge around here who is making the recommendation, the diagnosis and then the prescription, rather than the the supplement itself.

SPEAKER_00 5:46

Yeah, so I certainly think it's a challenge for the GMC doctor, as people I don't think the GMC nor the the sort of legal negligence process would differentiate between that and and any other prescription item in terms of uh the standard and the negligence. I think the issue also comes slightly the other way round. So where you have non-clinical people in these functional medicine practices, and I'm gonna pick out nutritionists because in our experience nutritionists possibly have the best biochemistry or best knowledge of the body's biochemistry. It's a major part of their degree. And interestingly, the bio the nutritionists have better bio medical biochemical knowledge than the dietitians. So dietitians are clinical people, they are HCPC registered, and they do have diagnosis rights of certain types of disease, mainly metabolic diseases, which is very much related to functional medicine. But they probably have probably almost certainly have less biochemistry knowledge, and that really comes down to uh so medicine and medical research is very much based on biochemistry, classic medicine isn't that based on biochemistry, it's still very much a sort of tick off the symptoms and match it, is how the training works. You end up with nutritionists who are consulted on their biochemical knowledge, and quite often because they've worked in an environment in a multidisciplinary environment where it's quite okay for them to say, Oh yeah, that looks like diabetes to me, that might be fine deep inside the NHS, where you're all part of a team and they all that view goes up to a clinician, a doctor to make the diagnosis and create the treatment plan. But if you step out of that big machine in that big environment into a much smaller environment and somebody just says, Oh, some results, what do you think of that? And you say, Oh, yeah, that's diabetes, then you are actually diagnosing diabetes, and diagnosis is the realm of an appropriately qualified clinical practitioner, which you're not. So you can trip over that yourself, and then even more interestingly, if you are a GMC doctor who runs a practice with those nutritionists in it, then ultimately you will be held responsible for or your team. The GMC will have something to say about the fact that your team is diagnosing it inappropriately and you're not controlling it. There's a big shift in the emphasis and value of expertise in functional medicine, and the regulation hasn't kept up with it. So oddly enough, the most qualified is the one who's not regulated to say it.

SPEAKER_02 8:38

And that's purely down to the speed at which functional medicine has been developing.

SPEAKER_00 8:42

And yeah, yeah, right.

SPEAKER_02 8:44

And how is this showing up in terms of cases then? Is this situations where people feel they have been misdiagnosed and then it's being traced back to the fact that a nutritionist is given this or someone that is not a GMC?

SPEAKER_00 8:55

You've had something pretty similar to that, Roger.

SPEAKER_01 8:58

Something you can yeah, it comes to both ways. There's that scenario, but there's also just the scenario is like pay for a doctor, why are you giving me any nutritionist?

SPEAKER_02 9:05

Oh, okay.

SPEAKER_01 9:06

So the other aspect of this, which is new to those coming out of the NHS into functional medicine, is you've got this whole commercial side, which manifests itself really in a number of ways. One is to let's start the patient journey, it's about explaining the relevance and need for testing and the fact that investigations cost money, and therefore you're going to spend several thousand in some cases to have those tests. And that isn't a cure in that sense. It's a federal for treatment. The treatment plan, which has to be utterly objective and brutally truthful. It can't be something that doesn't give confidence that there's a plan and a drive and results because the perception is that you're paying for something and you want to see results, so you have to deal with that. And then it's also the quality of the input. And quite a lot of functional medicine seeks to differentiate itself, A, within other functional medicine practices, but B functional medicine per se is that it's a holistic group type, multidisciplinary team type approach.

SPEAKER_00 10:17

I think that's quite interesting, Roger. And it was what if I'm I had a to be published podcast. I had a chat with Dr. Indra, who's one of the founding founding functional medicines, medicine practitioners. And I think where she's got to in her practice is this idea now that she has a health coach. So that is somebody really with a sort of coaching background and qualification, who their role is to they almost act like the GP in classical medicine. So their role is to sit next to the patient on this whole journey and say, I am your companion on your this journey, and they explain to the patient who each person is, what they do, why they do it, and so on, and then take them through that journey. And it was interesting because it is exactly that conundrum. Now, Dr. Indra herself is was a GP and clearly a very good GP, but she was saying actually the GP in this instant is not the best person to take people through that journey because they don't have enough of the overview of that particular journey. The GP has specialist skills which contribute into this, and they're bought in for their bit, as is the nutritionist, as is the psychologist, and so on. But it was really quite interesting that she's after developing her practice and trying things for many years, has come up with this sort of health coach to see you through the journey and explain all these things to the patient.

SPEAKER_02 11:44

Doesn't this go to the heart of really what we're talking about in the podcast, in the sense that the traditional and conventional structures it won't always work for where the functional medicine is going, and so it's going to require a rethinking of how a practice works. Because I think what you said there, Roger, was that with however many years of the NHS we've had people expect a doctor, it's so heavily ingrained in our need that the doctor is at the pinnacle and uh other things, other people might be more qualified or whatever. Do you see that as more of a fundamental shift in that is going to require different models to work around the regulations and work around the patient expectations, or should the effort being put into campaigning for uh changing the regulation so that it does take into account the you know the position of nutritionist seems to be the one big big uh challenge in all of this?

SPEAKER_01 12:43

Speaking personally, I don't have enough life left to consider that the regulation framework will change. It is interesting that the way to deal with it is a long the doctor injury experience out for the practice to appoint the patient advocate. That's really quite interesting. And that shows the level of two things. One is the ingrained public perception of how medicine should be on the one hand, and two, the real scarf issue. And I would attest to this from my perspective of the client who have had real problems explaining quite what functional medicine is in a commercial setting to patients. And yeah, if it takes a patient after I know Dr. Injur from my perspective, then that's money well invested because the grain in emotion and executive time and all the rest of it for people misunderstanding and wanting to go from proof negligence is quite another thing. But yeah, so there you are. There's a good example that structurally the profession needs to change. Dr. Inge's clearly got a view about time frame relative to her practice, and her solution is to appoint a patient advocate, call it a health coach. Yeah. So I think we probably agree with that. I wouldn't be so gallant to suggest Dr. In is a similar age to me, but we're we're broadly similar. So she's clearly formed the view that Rick is not going to do it for her. I would agree with her.

SPEAKER_00 14:09

I think that's the thing, isn't it? Is the regulations are what they are. And so she has somebody whose job it is to see somebody through the journey and keep within the current regulations. And I think that's just wise commercial sense. What's very interesting about Dr. Ringer is she has really stuck at it. All credit to her, she stuck at her functional medicine practice because she thought it was the right way to deliver. And it was around somebody with diabetes, actually. It was very interesting. I think she was just struck, and again, it's maybe not perfect in in classical medicine. She was just struck that she had this one patient who turned up every year for his diabetes test, but had to just leave it, had no sort of concept of what it meant or what the results meant or anything. And I just turned up and got a number and went, okay. And she thought that maybe there was more to it than that, and maybe they should think a little bit harder about that, and took him down that journey and has really struck to it and struggled to create a profitable business. And I am enormously pleased to see her crack that nut now, and her business seems to thrive, but it wasn't an easy part. Uh, I think part of that part is having to think through and operate something that does what it needs to do whilst complying with the regulation as is, which doesn't fit what you're doing.

SPEAKER_01 15:23

It's created a regulation space to actually do some really quite exciting medicine for people. Yeah, like so many of these people got the privilege of being involved with, they could have just seen out their career playing playing the big farmer game, couldn't they?

SPEAKER_00 15:39

Yeah.

SPEAKER_01 15:40

Yeah, these are really motivated, passionate people that you've got to just take your hats off to, and they've really fought for it. And she's definitely one of those.

SPEAKER_00 15:49

Yeah, so I think possibly one of our takeaways from this is I mean, the whole space is almost in every direction. You have to separate the knowledge from the regulation from the registration to consent. So the person best placed to actually determine something might not be the person who can actually determine it.

SPEAKER_02 16:10

Yeah, so yeah, there's a whole good concurrency.

SPEAKER_00 16:14

So there's a whole sort of little bit of a dance going on as to so I think uh where we get to is we are very supportive of these multidisciplinary, and by that when we have functional medicine patients, we like to see everything dietitians, nutritionists, psychologists, psychiatrists, PhDs, non-PHDs, doctors, the whole lot, allied healthcare practitioners, everything, everybody has a a skill and knowledge, but then the the real skill of that is this idea to make sure that to get the choreography right. So that it all works.

SPEAKER_02 16:48

I imagine that like you said before, that most people don't find out that there's an issue until a claim or complaint is brought or that something is done. If someone fears, if someone running a practice fears that there may be a risk, what is the first step they can take would be to do some kind of audit? You said before that just because there is no written form of a prescription doesn't mean that prescribing isn't happening. So how would you suggest they go about assessing whether the the correct procedure is being done?

SPEAKER_00 17:18

So I think this is, and again, within our our sort of functional medicine clients, the principals, the sort of clinic owners, as Roger said, are enormously skilled and talented and driven people, and they have been very good and very meticulous in in setting policies and procedures. So when we see things like their prescribing procedure or even their assessment procedure, they are quite incredible, to be honest, and they are all the time working these things through and weaving this path. And I think that's again, you know, what the structure I described with Dr. Injury's, you know, that certainly wasn't, and when you listen to the podcast, that certainly wasn't the first thing she did. That was hard run experience to say, oh, actually, this is how we need to do it. And they're constantly developing the ideas and documenting them and getting them into procedures. And I guess that's part of the reason why, in many ways, having a doctor-led practice probably does make sense because that is one thing they are very much taught and trained on in their profession is having the procedures, making sure the procedures are there, visible, adhered to. It's almost like we say that doctors are great at medicine but don't really function in the real world. I think the other thing that they're they're great at is almost this sort of project management kind of thing that almost be uh is a a black belt or whatever it is, and uh in those project management black Jack Welsh of GE had his thing with black belts and all sorts of things and so on. And uh certainly the good clinical managers are generally medically trained doctors, surgeons, or whatever, and are very good at establishing and pushing through and enforcing those procedures and practices. And those clinics give us great comfort um because they are, I mean, uh spectral you know, Rogers on Roger's views on note-taking, on top of note-taking, where you have all the practices and procedures and can show you that they're there, they're embedded, they're adhered to, that just massively increases the defensibility.

SPEAKER_02 19:19

Yeah. When we talk about uh leading edge medical care businesses, it's not just in terms of the the advice, the functional medicine they provide, it's also in the fact that there has to be this contortion of the model in the best way possible to uh personally provide regulatory compliance, but also to make sure that you have those processes and policies in place for best practice, for defensibility, and then also to make it commercially viable so that you are able to grow, you're able to provide a good customer experience in the market. So there's these multiple things that have to come together that it's not just about the medicine, it's also about having to have just the navigation of that framework.

SPEAKER_00 20:04

Then again, we talk about the whole sort of confidence to thrive and the commercial side of the whole thing. And if you look at what people pay for functional medicine, it sounds really quite expensive, and it is really quite expensive, but when you actually lift up the hood and see what goes into the delivery of that care, it actually isn't expensive. These people are running on very thin margins. One of our sort of first sort of big medical clients is a lovely guy called Sean Summers, who's he was still one of the leading weight loss surgeons in the country. Not that there's so much weight loss surgery going on, but again, he was an expert in metabolic health back in the sort of mid-2000s, and he absolutely split opinion in the sort of medical community around him because he actually ran the view to say, if I am going to go into private practice, I'm not going to dabble. This is a commercial operation, I have to do it sensibly, I have to build it at scale, I have to make sure it's profitable, and it is interesting. He would literally, you know, and bariatric surgery is one of the most difficult and expensive to ensure. The bridge straw is just making surgeon would come to him for advice on on how do I go into private practice. And his view was even this would have been 15 years ago, if you're not going to make at least 30,000 a year out of it, don't bother because it will cost you more. And I think that's very sound advice. And I think we're seeing that in this sort of functional medicine space. It's not just the insurance, there's an awful lot that goes into this. So if you're going to do it, then you're going to have to imagine you're doing it in a business that's going to be making tens, if not hundreds, of thousands. And the people who are there and the people who are succeeding and the people who are pushing through, and they've got businesses that are making hundreds of thousands and heading towards the million mark. And I think you need that kind of scale to do it properly, especially in a slightly grey regulatory environment. If you're doing it at less scale and don't have the resource to deal with that kind of issue, you've got problems.

SPEAKER_02 22:05

Which is why you need advice at the end of a phone call when it comes to practices, policies, best practice, making sure that you are properly covered so that you're not always looking backwards and you can continue to grow.

SPEAKER_00 22:21

Yeah, no, I think that's the important thing. And you're not going to come out the gate making that much money. All businesses start at zero when they hang the shingle outside the door. So you've got to have that sort of mindset to say I'm starting at zero, and we're absolutely here to help and help people on their way. But I think you need to go into it with your eyes open as where you're going and what you're doing.

SPEAKER_02 22:45

Okay, amazing. I think that's a great place to round off that that discussion and compliment future episodes that we're going to be publishing on this as well. Thank you so much, Roger and Chris, and I will see you on the next episode. Thanks, Jodie. Thank you for listening to Confidence to Thrive. Before you go, please rate, review, and subscribe to Confidence to Thrive on your preferred podcast platform and help us spread our message to others while making a difference in private healthcare. This podcast was brought to you by Felicity Institute Advisors to support your business and visitors practitioners over healthcare practices communicating with