The Charity Commission’s Consultation: The use and promotion of complementary and alternative medicine – Making decisions about charitable status, (13.03.17):
The deadline for responses to the Charity Commission’s Consultation about the charitable status of CAM expired on 19th May (see the May edition of this blog). Many responses were filed, including by The Complementary & Natural Healthcare Council (CNHC) and by The College of Medicine.
Confusingly, the Commission’s Consultation Document expressly provided (in the section What the Commission is not consulting on at page 5) that:
‘…This consultation is not about…whether or not CAM therapies in general, or any particular CAM therapies, are effective…’
Yet logic dictates that the effectiveness of CAM and, therefore, the reliability of the evidence for it, will clearly feature significantly in the Commission’s deliberations as it assesses the extent to which CAM is of benefit to the public for charitable purposes.
The submission by The College of Medicine included the following:
‘…the continuing appetite of the public for access to CAM both in the private sector and through NHS organisations, should offer the Commission at least some reassurance that CAM has overall, a beneficial impact for those who use it…’
and further that:
‘…Whilst an RCT can be regarded as the highest level evidence, this type of study is not always the most suitable for assessing the benefits (efficacy/effectiveness) of CAM. Other research designs such as observational studies, surveys and qualitative methods can provide high quality information. In addition, RCTs invariably require very large budgets to underpin their delivery and CAM has not on the whole been the recipient of sufficient grant funding to enable large RCTs to be performed…’
The outcome of this important Charity Commission Consultation is awaited. It will be of huge significance to charitable organisations using or promoting CAM and to CAM practitioners and patients.
The Exclusivity of the Randomised Controlled Trial – the debate:
There is a continuing debate about the exclusivity of the Randomised Controlled Trial (RCT). Research articles about the RCT may be found here [Getting off the “Gold Standard”: Randomised Controlled Trials and Education Research: PMCID-PMC3179209] and here [Fool’s gold, lost treasures, and the randomised controlled trial-PMID: 23587187].
The Human effect and its desirability:
Also relevant to the debate about the evidence-base for CAM is the desirability of the Human effect. The Smallwood Report (The Role of Complementary and Alternative Medicine in the NHS: 2005), at page 23, makes the following observation:
‘…While some critics have derided the use of CAM treatments, claiming the success of some therapies to be purely based on a placebo effect, CAM proponents see what Dr Michael Dixon calls the “human effect” as desirable in itself…’
(Dixon & Sweeny, 2000 and see the BMJ book review here)
National Institute for Health & Care Excellence: CAM Updates
Practitioners of complementary and alternative medicine (CAM) may recall my November 2016 blog which referred to confirmation by the National Institute for Health and Care Excellence (NICE) that it had decided to retain its guideline on improving supportive care for adults with cancer, thereby ensuring that, for the time being at least, selected CAM therapies will continue to be available within the NHS in England & Wales. This guideline has been given the new title of End of life care for adults in the last year of life: service delivery and is currently “in development” with a publication date of January 2018 when it is hoped that CAM therapies will continue to be retained.
In the meantime, Further NICE guidelines have been published covering the planning and management of end of life and palliative care for infants, children and young people (aged 0 – 17 years) with life-limiting conditions. These aim to involve children, young people and their families in decisions about their care, and improve the support that is available to them throughout their lives. Recommendations include (paragraph 1.3.25) consideration of non-pharmacological interventions for pain management including music and physical contact such as touch, holding or massage. These Guidelines will next be reviewed in December 2018.
As mentioned in my blogs posted in September 2016 and February 2017, NICE Guidelines regarding the assessment and management of low back pain and sciatica in people aged 16 or over (published in November 2016) have stopped recommending acupuncture. The removal of acupuncture from the guidelines conflicts with research published (in January 2017) by MacPherson H, Vickers A (and others) in The National Institute for Health Research Journals Library: Programme Grants for Applied Research, Volume 5, issue 3 (“Acupuncture for chronic pain and depression in primary care: a programme of research”), which concludes as follows:
‘…We have provided the most robust evidence from high-quality trials on acupuncture for chronic pain. The synthesis of high-quality IPD found that acupuncture was more effective than both usual care and sham acupuncture. Acupuncture is one of the more clinically effective physical therapies for osteoarthritis and is also cost-effective if only high-quality trials are analysed. When all trials are analysed, TENS is cost-effective. Promising clinical and economic evidence on acupuncture for depression needs to be extended to other contexts and settings. For the conditions we have investigated, the drawing together of evidence on acupuncture from this programme of research has substantially reduced levels of uncertainty. We have identified directions for further research. Our research also provides a valuable basis for considering the potential role of acupuncture as a referral option in health care and enabling providers and policy-makers to make decisions based on robust sources of evidence…’
These Guidelines will next be reviewed in November 2018 when, again it is hoped, acupuncture will be reinstated and that Alexander Technique together with other beneficial CAM therapies will be included.
Professional Standards Authority: Accredited Registers Programme
Practitioners will already be aware of the Accredited Registers Programme which is overseen by the Professional Standards Authority for Health and Social Care (PSAHSC). This programme aims to provide assurance to the public, care commissioners and patients who are seeking health practitioners (including complementary therapists) who are not regulated by statute. The President of the Federation of Holistic Therapists (FHT), Jennifer Wayte, has suggested that:
‘…By signposting the Accredited Registers programme in relevant Guidelines, NICE would help to ensure better safety and standards of care…’ (International Therapist Journal, Issue 117 at page 17: Summer 2016).
Commissioning cost-saving CAM: The future for Integrated Medicine
In March 2016, The Kings Fund published its report Bringing together physical and mental health: A new frontier for integrated health about which a discussion can be viewed here and a blog by the FHT may be read here. In the News & Analysis section of its Health and Wellbeing Board Bulletin (06.06.17), The Kings Fund also highlighted the article published in The Lancet on 23.05.17 titled Forecasted trends in disability and life expectancy in England & Wales up to 2025: a modelling study which concludes:
‘…The rising burden of age-related disability accompanying population ageing poses a substantial societal challenge and emphasises the urgent need for policy development that includes effective prevention interventions…’
In the light of this and having regard to research such as that relating to the worsening mental well-being of year 10 school children, practitioners and their patients could lobby relevant Government departments, NICE and the PSAHSC regarding the potential of CAM as a cost-saving contributor to preventative and integrated medicine. In his Economic Outlook published in The Sunday Times on 23.04.17 (Business Section, page 4), Economist David Smith predicted frightening health spending as doubling from (roughly) 7% of gross domestic product to over 12.5% over the next 40-50 years and that social care costs will also double to 2% of GDP. Health spending policy makers and Clinical Commissioning Groups would do well to keep these (long-term) numbers in mind when assessing the potential of CAM and integrated medicine.
Further information about integrated and complementary medicine may be found in the Elsevier publications Advances in Integrative Medicine and the European Journal of Integrative Medicine and by accessing British Medical Journal (BMJ) articles such as Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour (as amended), which concludes:
‘…The Complementary Therapies for Labour and Birth study protocol significantly reduced epidural use and caesarean section. This study provides evidence for integrative medicine as an effective adjunct to antenatal education, and contributes to the body of best practice evidence…’
For further research and debate about the cost-effective integration of CAM into the NHS, please refer to the February 2017 issue of this blog.
Adopting a business approach to practising CAM
Turning to a very different topic, my message to Practitioners and especially to those who are in the process of starting or establishing their CAM practice, is that adopting a business approach to practice management is crucial. By doing so and without compromising their professionalism, practitioners can help to defend their freedom to practice.
The past year has been challenging for practitioners. It looks like next few years will be even more so as those working in the health and social care sectors continue to assess the implications of ‘Brexit’ and how these may affect their freedom to practise and their patient’s right to receive a CAM treatment of their choice.
As ever, much of the popular press continues to present an unbalanced and misrepresentative view of CAM. For instance, I have yet to see popular print or broadcast journalism properly cover The World Health organisation Traditional Medicine Strategy 2014 to 2023: Strategy Document which states (at page 19; note: italics added by me):
‘…As the uptake of T&CM (Traditional and Complementary medicine) increases, there is a need for its closer integration into health systems…’
(refer to my November 2016 blog for more information).
Contrast this with the column in the Times Newspaper (by a Times leader writer and columnist) on Tuesday 13th December last year, captioned:
‘…Prince Charles’s homeopathy fad is joke medicine…’
I suggest there has never been greater need for practitioners to ‘fight their corner’, including by effectively organising the management of their practice and promoting the health benefits of their treatments.
To this end, I suggest that practitioners need to accept that running a CAM practice is, in essence, the same as trading in any (small) business. The knowledge, experience, professionalism and ethical standards of a qualified, insured and properly regulated CAM practitioner are acknowledged and to be congratulated. Nevertheless, now more than ever, practitioners need to embrace business processes.
The following are some straightforward business processes that could assist your business and thereby enhance the health and care of your patients.
Business planning will help you to prepare for most eventualities, including when, like most businesses, your practice encounters financial losses or failures. Don’t delay taking good business advice and realise that it is sometimes what you don’t want to hear that constitutes the most valuable advice.
Remember, “people buy from people” so you need to build good rapport with your patients. Listen to what they have to say about you and how you provide your practice specialism(s). If appropriate, adapt the structure and delivery of your business to their needs and requirements. Give them the opportunity to provide feedback [maybe use: surveymonkey]
While established practitioners may have the well-deserved and hard-earned luxury of relying on ‘word of mouth’ recommendations to find them new clients, this will rarely be an option for a new practitioner. So, whether you are practising alone or in association with other practitioners, for instance at a Health Centre, do not wait for patients to find you. You need to go out and find them. Recruit them by actively promoting yourself and your expertise.
Join local and national business support organisations such as the Federation of Small Businesses and the Chamber of Commerce. Always attend their meetings, networking events and, if appropriate, Trade Shows. As the contacts you make get to know and to trust you, they are likely to seek your professional help for themselves and their family and possibly for their colleagues and employees, too. Encourage this by offering to give a presentation [maybe use: presentme] about your practice to local businesses, to community groups and to the employees and students of local colleges and universities. Introduce them to your practice.
Sign-up to (often free) supportive online business newsletters and memberships like enterprisenation.
Using, among other things, the feedback from your patients (see above), prepare a patient database and create a Marketing Plan and a Business Plan, including a cash-flow forecast. You will have a much better chance of achieving your business goals if you first write them down.
Ask yourself: when and why did my patients seek my services and how can I keep in touch with them? Distribute print or e-newsletters [maybe use constantcontact]. Write articles about your practice and its treatments for professional journals and general healthcare-focused magazines. Produce a well-designed, good quality brochure and publicity material, both in print [see, for instance, moo.com] and also online.
Make use of social media platforms. Although new practitioners are likely to be familiar with how this is done, it’s possible this may not be the case with established practitioners. Record a video about you and your business and post it on YouTube. Link this to your Twitter and Facebook accounts. Your “followers” might then “comment”, “like” or “re-tweet” to their “followers”, thereby promoting your professional status and practice. Create, or, if you already have one, keep updated a (free) LinkedIn business account profile.
A website that is well designed and informative is a vital marketing tool. It is a worldwide ‘shop window’ as it informs your patients (existing and prospective) about you, where you are located, what you do and when you do it. If, when starting your business, you cannot afford a professionally built site, then build you own (maybe try wordpress].
Keep your cyber security under constant review and seek advice and support from websites like cyberware and getsafeonline. Your business will be processing your patients personal and health information/patient records, so ensure that you comply with data protection legislation including the new General Data Protection Regulation.
There are other business processes that could assist your practice, especially if you decided to diversify into the manufacture and sale of CAM-based products (e.g. first-aid kits, aromatherapy oils/preparations, books/course material, meditation audio-packs, therapy tools and devices) or to associate your business with other health professionals (e.g. at a veterinary practice, NHS Practice or Hospital, as appropriate for your specialism).
I hope that you have found this focus on the business aspects of practising CAM useful and thought provoking. My further thoughts can be found as either a paperback or as an e-book (the latter including hyperlinks to business and CAM websites) and at the amazon.co.uk bookstore. Information about business guides for complementary medicine may be found online.
I anticipate that, in the coming years, the freedom to practise CAM (whether or not independently of the conventional medicine sector or as a contribution to the provision of integrated healthcare and medicine) will depend upon the adoption of a business-focused approach by practitioners.
Established practitioners might be prepared to mentor new members to help them to adopt this approach.
Veterinary CAM Practitioners: Review of guidance by the RCVS
The Royal College of Veterinary Surgeons has announced a review of its position statement and guidance regarding the prescribing of CAM by its members (see my November 2016 blog). A campaign by is underway by www.vets4informedchoice.org to:
‘…raise the awareness of the Evidence Base (or lack of) for many current Veterinary Practices, enabling animal owners and guardians to make considered responsible choices without pressure from the Veterinary Industry…concerns over frequent and unnecessary Vaccination, Corporatisation of Veterinary Clinics, Pressure Selling of products and services, etc, are widespread and growing…’
A facility is available on the campaign website to sign-up to join the campaign and to get regular updates.
Therapy Expo 2017 and RCCM Membership
Therapy Expo returns to Birmingham’s NEC on 22nd – 23rd November. Conference information and booking details can be found here. Have you thought of becoming a member of the Research Council for Complementary Medicine? CAMRN membership ‘is free and provides members with access to the CAMRN research network, which provides regular email messages about conferences, events, projects, funding, new research and dissemination of members queries and requests’.
Department of Health Policy Research Programme Project – The effectiveness and cost effectiveness of complementary and alternative medicine (CAM) for multimorbid patients with mental health and musculoskeletal problems in primary care in the UK: a scoping study (The University of Bristol):
On 13th July this year, I received a circulated email from the Senior Research Associate at The School of Social and Community Medicine (University of Bristol) advising as follows:
‘…We are pleased to be able to let you know that our project ‘SCIM’ – “The effectiveness and cost effectiveness of complementary and alternative medicine (CAM) for multimorbid patients with mental health and musculoskeletal problems in primary care in the UK: a scoping study” has now finally been approved by the funders and the final report is available on their website. I have also attached our Executive Summary. I hope you find it interesting and please do get in touch with any feedback…We may well be in touch again over the summer as we progress with this piece of work and look for collaborators and input from the wider CAM, primary care and research communities…’
(The Executive Summary may be found here).
This is great news. Many congratulations to Professor Deborah Sharp and to her colleagues. There will, of course, be more about this project in my next blog (November 2017). In the meantime, CAM practitioners and others will no doubt welcome the opportunity to provide feedback and to respond to a request for further input to this project.
Professor George Lewith
Finally and most importantly, I add my belated (following its inexcusable omission from my blog in May) expressions of sadness and shock to those of countless others at the untimely and sudden death of Professor George Lewith for whom numerous obituaries have been recorded, including by the College of Medicine, the University of Southampton and The Research Council for Complementary Medicine. All practitioners, patients, students and researchers of CAM and orthodox medicine owe him so much. Along with those of many, my thoughts are with his family.
1st August 2017