This is a clarion-call for healthcare organisations and medical research establishments to promote and to condone the effectiveness, efficacy and cost-effectiveness of Complementary and Alternative Medicine (CAM) as a contributor to integrative medicine and healthcare, including within the National Health Service (NHS), and for the publication of high-quality, unbiased and transparent evidence of this. Refer to the observations of Professor Debbie Sharp (Complementary medicine’s true potential cannot be unlocked without robust evidence for its use: 21.09.17) which are posted on the Complementary section of the College of Medicine website.
“A HEALTHCARE WORKFORCE IS READY AND WAITING…”
On 4th January 2017, The Alliance for Natural Health International e-alert number 333 (bulletin) included the following observation by Executive & Scientific Director Dr Robert Verkerk PhD:
‘…We need a community based healthcare system that can help guide as many people as possible, encouraging them to make the right choices to optimise their wellness. As it happens, this healthcare workforce is ready and waiting – it’s just dramatically under-utilised and marginalised by the mainstream healthcare system…In the UK, it’s estimated that around 9 million people use some kind of complementary or alternative medicine (CAM) and in the EU generally there are around 328,000 registered CAM providers made up of about 178,000 non-medical practitioners and 150,000 medical doctors.
There’s a real need for better integration of these forms of healthcare into mainstream offerings, something that is more common practice in Germany and France than it is in the UK…’
There is a strong case for further research into the cost-effectiveness of CAM (Is complementary and alternative medicine (CAM) cost-effective? A systematic Review) and for encouraging the increasing interest of medical students (Even medical students want conventional medicine to include alternative therapies and as reported here). Nevertheless, the research article titled Academic doctor’s views of complementary and alternative medicine (CAM) and its role within the NHS: an exploratory qualitative study (Nita Maha and Alison Shaw) concludes as follows:
‘…Despite the caution or scepticism towards CAM expressed by doctors in this study, more open doctor-patient communication about CAM may enable doctors’ potential concerns about CAM to be addressed, or at least enhance their knowledge of what treatments or therapies their patients are using. Offering CAM to patients may serve to enhance patients’ treatment choices and even increase doctors’ fulfilment in their practice. However, given the recurring concerns about lack of scientific evidence expressed by the doctors in this study, perceptions of the evidence base may remain a significant barrier to greater integration of CAM within the NHS…’
THE BERLIN AGREEMENT: THE ORGANISING COMMITTEE, WORLD CONGRESS ON INTEGRATIVE MEDICINE AND HEALTHCARE
The publication, earlier this year, in The Journal of Alternative and Complementary Medicine (Volume 23, Number 5, 2017, pp. 320-321), of The Berlin Agreement: Self-Responsibility and Social Action in Practising and Fostering Integrative Medicine and Health Globally includes a call to ‘commit to evidence-informed dialogue and practice’ to:
‘…end polarising dialogue and to stimulate collaboration in our collective ability to research, create, and operationalize optimal evidence-informed integrative care…’
Accordingly, all complementary and conventional health practitioners should work together in the best interests of their patients.
THE KINGS FUND: COMMITTED TO EXCELLENCE & INTEGRITY
The Kings Fund (KF) is an independent charity that works to improve health and care in England. It is committed to maintaining its independence, excellence and integrity and describes its vision as follows:
‘… that the best possible health and care is available to all…’
It provides work, commentary and analysis on some of the key health and social care topics in the English health care system including in relation to integrated care, NHS reform, Patient experience and Primary and community care.
As you would expect, the King’s Fund has published work relating to CAM. Below are extracts from some of its press releases and projects:
O4.03.02: Level of NHS-funded complementary and alternative medicines increasing, says The King’s Fund which refers to a survey commissioned by the KF and the Department of Health and includes this extract:
‘…Out of the 32 primary care organisations (primary care trusts and primary care groups) that responded to the survey, two thirds reported that complementary and alternative medicines services were available in their area. The most popular therapies available were acupuncture, osteopathy, homeopathy and therapeutic massage…’
24.10.02: Health research needs more direction to work in the public interest, says The King’s Fund book which declares:
‘…Public Interest, Private Decisions shows that the health research economy is dominated by pharmaceutical and biotechnology companies. This means that research into conventional medicines, with a view to obtaining new patents, is by far the biggest activity. Areas such as complementary therapies, health improvement and health service management, where profit-making opportunities are limited, receive fewer resources…’
06.10.05: Evidence for complementary therapies on the NHS should be considered by independent body, says The King’s Fund. This responds to the Christopher Smallwood and research consultancy FreshMinds’ report The Role of Complementary and Alternative Medicine in the NHS (see my February 2017 blog). The King’s Fund Chief Executive comments:
‘…The report makes a strong case for scrutiny of the existing evidence particularly in relation to the use of acupuncture for post-operative pain and chemotherapy-related nausea, manipulation therapies for acute lower back pain, and herbal medicines for the treatment of depression and as an alternative to conventional anti-inflammatory drugs…’
‘Case studies in the report demonstrate how complementary practice is already being integrated into NHS primary care services in some areas and is rated highly by patients. The authors are therefore right to suggest that NICE should consider how people are equally able to access services both geographically and in relation to individual therapies…’
21.11.05: The King’s Fund announces new integrated health funding and development programme for London. The aim of this programme was expressed as follows:
‘…this programme will focus on the five mainstream complementary therapies – acupuncture, homeopathy, chiropractic practice, osteopathy and herbal medicine – as well as traditional approaches that are often deeply rooted in people’s personal experiences and range from herbal medication through to the role of faith or spiritual leaders. The integrated health programme is not designed to fund the direct costs of providing complementary therapies.
The King’s Fund chief executive said:
‘This programme reflects the increasing interest in complementary health care and the often wide-use of traditional approaches within specific communities. We want to examine how health care practitioners can work together with patients to integrate complementary therapies and more conventional approaches to health…’
23.05.06: Some good evidence on complementary therapies but more research needed, says The King’s Fund. This responded to media reports on the effectiveness of complementary therapies. The King’s Fund Chief Executive opined:
‘…While more research is needed, some complementary therapies already do have a good evidence base – for example the use of acupuncture for post-operative pain and chemotherapy-related nausea, manipulation therapies for lower back pain and herbal medicines for the treatment of depression.
‘We have previously advocated that the National Institute of Clinical Excellence should consider key complementary therapies as well as conventional medicines as part of their work programme. This is especially important as patients rate these services highly and we need to ensure that as complementary medicines are integrated with conventional care, the system is well regulated to protect their interests…’
12.03.08: Regulating Complementary Medical Practitioners – An international review concluded:
‘…Complementary medical practitioners may be a distinct minority in places such as Europe, North America and Australia, but in other countries the number of practitioners and the people who use their services are in the majority.
Many practitioners practise without qualification or adequate training, and in response to this the World Health Organization has recommended that governments develop national policies that include regulation of practice, education, training and licensing. In this report the experiences of 16 countries in regards to this issue are reviewed…’
A download of the report is available here.
04.06.09: Partners for Health in London: integrated health sets two challenges to its partners. First, Integrating mainstream complementary and conventional approaches to health posed the question:
‘…does access to both complementary and conventional options encourage self-care?’
and, secondly, Integrating traditional and conventional approaches to health, that concluded:
‘…We believe that awareness of traditional approaches could inform NHS consultations (particularly in primary care) and be part of establishing a more integrated approach to health. We have funded projects that explore the impact that integrating traditional and conventional approaches might have on subsequent health care decisions at an individual and institutional level…’
More information about the King’s Fund’s Partners for Health in London may be found here.
10.08.09: Assessing complementary practice – Building consensus on appropriate research methods for which the King’s Fund set up an advisory group chaired by Dame Carol Black:
‘…to consider how to develop and apply a robust evidence base for complementary practice. The group drew on the experience of a wide range of academics, researchers, practitioners and funders, much of it shared in a two-day participative conference…’
in which:
‘…Researchers, funders and practitioners are urged to collaborate in finding a way forward to contribute to our understanding not only of complementary practice but of our ability to manage and sustain health and wellbeing…’
A Download of the Report is available here and more information may be found here
09.11.11: Are personal budgets really the best way to personalise health care? acknowledged that personal health budgets were ‘embraced enthusiastically by government ministers as a means of giving patients greater choice, flexibility and control’ and concluded, amongst other things, that:
‘…In some cases personal budgets were used to enable people to live more independently, for example, by employing carers, purchasing mobility aids, or providing travel to support groups or day centres. Others used their budgets to pay for treatments such as physiotherapy, speech therapy, podiatry or exercise classes. These uses of NHS funds are probably uncontroversial, but the fact that the budgets were also used to pay for services, such as reflexology, reiki, aromatherapy, electronic personal organisers and music lessons, will no doubt lead to some raised eyebrows…’
(See below for more on this topic);
17.04.12: Schwartz Center Rounds® staff stories in which staff at the Royal Free Hampstead NHS Trust talk about the benefits of holding such rounds at their hospital, including a story by the Complementary Therapy Co-Ordinator
16.05.13: 2013 GSK IMPACT Awards: FASA, which states:
‘…Northern Ireland has the highest suicide rate in the UK. For those in crises FASA’s ‘Safety Net’ programme is a lifeline…FASA provides a range of…complementary therapies…’
20.11.13: Case Studies of three volunteering services in the King’s Fund’s report on Volunteering in acute trusts in England included the following section on Complementary therapy:
‘…In the first 12 months, volunteers delivered complementary therapies such as reiki, massage, aromatherapy and reflexology to 400 patients and carers in the cancer centre and on wards. Patient feedback, collected in a book or on forms, has been very good. Feedback from staff was also positive and they reported that volunteers brought expertise and ideas to the team…’
14.05.15: 2015 GSK IMPACT Awards: WAVE Trauma Centre. This report includes the following:
‘…Wave offers care and support to those bereaved, injured or traumatised through the violence in Northern Ireland… [it] is a specialist trauma centre offering a range of services…including…complementary therapies…’
Notwithstanding its interest in CAM described above, it seems that the King’s Fund is not currently pursuing any projects investigating CAM.
However, it is undertaking a project titled The Public and the NHS which, I suggest, presents an opportunity for it to explore the proposition that patients should have the right to request CAM treatments that are safe, appropriate, evidence-based and cost-effective as part of an NHS integrated healthcare programme. In view of the evident demand for its services, predominantly provided for by the private health sector, it is reasonable to assume that a significant section of the public expects CAM services to be available in the public health (NHS) sector. In developing future policy the NHS could take account of this, particularly when exploring how to encourage patients to take greater personal responsibility for their health.
Furthermore, this proposition applies to proposals like the King’s Fund project “embedding enhanced healthcare in care homes” [https://www.kingsfund.org.uk/projects/enhanced-health-care-homes]. In future, when arranging events (like the recent conference on 31st October 2017 titled Community health services: shifting the focus to out-of-hospital care) the Kings Fund could include a speaker on the contribution of CAM.
Following the result of the Ipsos MORI survey [https://www.kingsfund.org.uk/publications/what-does-public-think-about-nhs] that it commissioned on the public’s attitude to the NHS, the King’s Fund concluded (among other things) with the following question:
‘…The public want to be involved in decisions about health services but to leave final decisions to health professionals. When and how should the public be consulted about changes to services? When, if ever, should their view outweigh that of experts?
This project (and others like it) present an opportunity to involve the public and to seek its views about making changes to services to enhance the availability of CAM services in health (NHS) and social care and if, as anticipated, such changes are sought, about how they may be implemented.
The continuing interest of the King’s Fund in CAM would be welcomed.
NHS ALLIED HEALTH PROFESSIONS (AHPs) SHOULD INCLUDE CAM PROFESSIONS?
In its e-newsletter dated 18.07.17, the King’s Fund advertised its event (06.09.17) titled Harnessing the value of allied health professionals (AHPs) [https://www.kingsfund.org.uk/events/harnessing-value-allied-health-professionals], informing its prospective attendees that:
‘…[it] will demonstrate how system leaders can best utilise AHPs to support integrated care and implement the triple aim set out in the NHS five year forward view; driving improvements in health and wellbeing, restoring and maintaining financial balance and delivering core quality standards…’
It also quoted from NHS England’s Allied Health Professions into Action Report [see link below], as follows:
‘Allied health professionals have the ability to take on new roles and to step outside of traditional boundaries. They are well placed to offer innovative solutions to develop and deliver what is required to radically transform care’
Information relating to the event informed prospective delegates that:
‘…You’ll find how other leaders of clinical commissioning groups, hospital trusts and local authorities are using the AHP workforce in their areas to support local integration; relieve pressure on primary care; prevent unnecessary hospital admissions; improve approaches to prevention and provide solutions to problems in urgent and emergency care…’
At this point, having read the above which accords so well with the aims and objectives of complementary/integrative medicine and healthcare, CAM practitioners may be forgiven for thinking that the term Allied Health Professions must also include many of the CAM professions. Sadly, this is not the case. In an excellent Guest Blog by Joanne Fillingham [https://www.kingsfund.org.uk/blog/2017/07/realising-potential-allied-health-professions] posted on the King’s Fund website on 20.07.17, an Allied Health Professional is defined as:
‘…someone trained to perform services in the care of patients other than a physician or registered nurse…[including]: art therapists, drama therapists, music therapists, chiropodists/podiatrists, dietitians, occupational therapists, operating department practitioners, orthoptists, osteopaths, prosthetists and orthotists, paramedics, physiotherapists, diagnostic radiographers, theraputic radiographers, speech and language therapists…’
Further information about Allied Health Professionals may be found in the action paper of Allied Health Professions into Action published by NHS England.
Interestingly, the AHPs listed above include the statutorily regulated profession of osteopathy. This is defined as a Group 1 therapy in paragraph 2.1 of Chapter 2 of the House of Lords Select Committee on Science and Technology Sixth Report dated 21st November 2000 (see press notice dated 28.11.2000). The Group 1 definition also includes chiropractic (which is statutorily regulated), acupuncture, herbal medicine and homeopathy yet only osteopathy has been accepted as an AHP. Might other CAM professions be acceptable too? There have been significant advances in relation to both the regulation and research of CAM in the 17 years since the House of Lords Report was published. Has the time come to reassess the contribution by CAM, perhaps by way of a new House of Lords call for evidence and subsequent Inquiry and Report?
It is a matter of record that many CAM practitioners work and practise, often on a voluntary basis, in the NHS and that there is an evidence-base for their safe and appropriate clinical contribution. The King’s Fund Guest Blog (July 2017: above) acknowledges that data from the National Audit of Intermediate Care 2014:
‘…demonstrates that the greater the number of professions in a care team – skill mix, not head count – the better the outcome for the person receiving care…’
In the interests of NHS patients and of CAM practitioners (whether or not also practising CAM), the question has to be asked:
Why is it that, in 2017, properly trained, regulated, insured and professionally accredited CAM practitioners are not acceptable as NHS Allied Health Professionals?
In answering this question and while it seems like stating the obvious, NHS Managers and policy-makers could apply the philosophy of Unipart Chief Executive, John Neill, and implement procedures to promote the provision of integrated (including CAM) health services within the NHS by seeking, listening to and acting upon the ideas of those NHS staff members who hold (or approve of) appropriate CAM qualifications. It is common sense to let people use their knowledge and experience, especially when this could lead to a more efficient NHS. There are reports that the “Unipart Way” is being applied in parts of the NHS.
SOCIAL PRESCRIBING: HEALTH CREATION AS A COMMUNITY SERVICE
CAM practitioners participate (often voluntarily) in the provision of Social Prescribing as an approach to (arguably cost-effective) health creation being developed by the Social Prescribing Network (co-chaired by Dr Michael Dixon, the National Clinical Social Prescribing Champion for NHS England and Chairman of The College of Medicine). Similarly, the NHS could benefit from the integrative CAM treatment services, commitment and expertise of these practitioners.
The Information pack for voluntary, community and social enterprise (VCSE) sector organisations: Health and Wellbeing Fund 2017-18 Social Prescribing may be viewed at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/640469/HWB_Fund_Application_Pack.pdf
INTEGRATED PERSONAL COMMISSIONING AND PERSONAL HEALTH BUDGETS: PROVIDING NHS PATIENTS WITH CAM?
As mentioned above, this initiative was examined by the King’s Fund as reported in its blog Are personal budgets the best way to personalise healthcare? , which included the observation (paragraph 6, lines 6/7):
‘…the fact that the budgets were also used to pay for services, such as reflexology, reiki, aromatherapy… will no doubt lead to some raised eyebrows…’
Why should this be so when these CAM services are, evidently, requested by patients exercising the autonomy they have been given to “improve their health and wellbeing through more choice and control over the services they choose?” Would they continue to request and to receive CAM if they did not find it benefitted their health?
The joint NHS England and Local Government Association Integrated Personal Commissioning: Personalised Commissioning and payment Summary Guide includes the following statement in its Introduction (page 3):
‘…Integrated Personal Commissioning (IPC) and personal health budgets are part of a wider drive to personalise health, social care and education. They promote a shift in power and decision-making, to enable a changed, more effective relationship between the NHS and the people it serves, aligning to the Five Year Forward View…The relevant guidance for the NHS and local authorities encourages a joined-up approach…A personalised approach to commissioning, contracting and payment enables people to access services that are more appropriate for their specific needs…’
and further (pages 4/5, paragraph 2.1.2) that:
‘…Personalised commissioning and payment supports people to improve their health and wellbeing through more choice and control over the services they choose. Such greater choice and control results in a better experience of care, improved outcomes and reduced costs, thereby representing a more effective use of health and care resources…This commissioning could be done by the clinical commissioning group (CCG) or local authority or by the person themselves using a direct payment…’
[Summary Guide: “Personalised Commissioning and payment: what needs to be in place?”]
Paragraph 2.2.2 (page 6), includes this recommendation:
‘…For people to receive high quality, personalised and effective care and support, local organisations need to work in a more joined-up way. Effective joint commissioning arrangements are characterised by…building local community capacity to enable solutions beyond traditional, formal services provided by the NHS and local authorities…’
More information may be found in the NHS England links: Personalised Health and Care Framework and Key features of personal health budgets and IPC.
Although there is no mention in the above Joint Summary Guide of Complementary Medicine or Integrated Health/Medicine (i.e. in the context of combining the best of complementary and conventional healthcare), it is virtually certain that a significant number of NHS patients will request one or more complementary therapies, in return for which they will want to make a ‘direct payment’. Logically, this should be a request that it is difficult to refuse not least because CAM is already available at many NHS hospitals, clinics and GP surgeries, for instance to help relieve the symptoms of cancer or the side-effects of NHS prescribed cancer treatment (when, incidentally, an Allied Health Professional who is also a qualified and accredited complementary medicine practitioner could, if permitted, provide CAM treatment alongside conventional treatment as part of an NHS approved integrative treatment plan).
The Royal Marsden NHS Foundation Trust, London, in its patient information publication Your guide to support, practical help and complementary therapies (page 7), refers to complementary therapies as contributing to integrated healthcare.
In the interests of patients and health professionals, the NHS could implement a policy to record and analyse the use of (and requests for) complementary healthcare within the integrated personal commissioning and personal health budgets schemes.
THE PROFSSIONALISM AND REGULATION OF CAM PRACTITIONERS
Information about the professionalism and regulation of CAM practitioners can be viewed on the websites of their respective professional organisations and regulators and, for example, by checking to see if they are registered with a CAM regulator such as the General Regulatory Council for Complementary Therapies, the CNHC or The Federation of Holistic Therapists. Such concerns are also addressed by Professional Standards Authority accreditation. The Professional Standards Authority (PSA) publication Rethinking Regulation (August 2015) states, at page 10:
‘…following the implementation of the Health and Social Care Act 2012, we began to accredit registers of those practitioners in health and occupations whose registration is voluntary – that is, where groups have self-organised to establish a register, identify standards for access, standards of conduct and competence for registrants, and complaints procedures. We have found accredited registers are an appropriate method to manage risk arising from those professions whose work results in less extreme risk of harm for patients and service users…’
Examples of PSA accredited complementary therapy organisations may be found on the PSA website. These include the British Acupuncture Council, The Society of Homeopaths, The Complementary and Natural Healthcare Council and The Federation of Holistic Therapists.
A preliminary review of some of the evidence-base for CAM (including regarding cost-effectiveness) may be found in my February 2017 blog.
THE BMJ CLINICAL EVIDENCE EFFICACY CATEGORISATIONS
Practitioners, their patients and researchers will find it interesting to review the British medical Journal (BMJ) Clinical Evidence efficacy categorisations where the BMJ seeks to answer the question:
What conclusions has [sic] Clinical Evidence drawn about what works, [and] what doesn’t based on randomised controlled trial evidence?
and states its aim to include the following:
‘…We want to identify treatments that work and for which the benefits outweigh the harms, especially treatments that may be underused. We also wish to highlight treatments that do not work or for which harms outweigh benefits. For the research community, our intention is to highlight gaps in the evidence – where there are no good RCTs or no RCTs that look at groups of people or at important patient outcomes…’
while acknowledging the difficulty of categorising interventions which may have ‘Unknown effectiveness’ for one condition but be ‘Beneficial’ for another, as follows:
‘…‘Unknown effectiveness’ is perhaps a hard categorisation to explain. Included within it are many treatments that come under the description of complementary medicine (e.g., acupuncture for low back pain and echinacea for the common cold), but also many psychological, surgical, and medical interventions, such as CBT for depression in children, thermal balloon ablation for fibroids, and corticosteroids for wheezing in infants…’
The BMJ has added this reference to ‘complementary medicine’ to the original text of its review, apparently to label it as a contributory cause of ‘unknown effectiveness’, together with a brief mention of acupuncture and Echinacea. Is this a fair assessment of the patient outcomes achieved by CAM for the (at least) 1 in 10 of the UK population who, it is estimated, receive such treatments? Does it accurately acknowledge the available evidence-base (including Randomised Controlled Trials – RCT’s – about which please refer to my August 2107 blog) for the effectiveness of many CAM treatments? Should the BMJ be asked to clarify and substantiate its text?
PATIENTS AND CARERS INVOLVEMENT IN EVIDENCE-BASED MEDICINE
On the topic of evidenced-based medicine (EBM) and, I believe, relevant to the case for promoting unbiased acceptance of the patient-centred, holistic qualities of CAM within the NHS and recognising an NHS patient’s right to have a voice and to receive CAM as an integral part of their treatment plan, I refer to the BMC Medicine research article Six ‘biases’ against patients and carers in evidence-based medicine by Trisha Greenhalgh and others, which includes:
‘…We discuss six potential ‘biases’ in EBM that may inadvertently devalue the patient and carer agenda…To reduce these ‘biases’, EBM should embrace patient involvement in research, make more systematic use of individual (‘personally significant’) evidence, take a more interdisciplinary and humanistic view of consultations, address unequal power dynamics in healthcare encounters, support patient communities, and address the inverse care law…We hope that practitioners, teachers, and researchers of EBM will ask themselves when reading each of the biases… “Given that I personally seek to be unbiased in relation to patients and carers, how should I alter my use of evidence/teaching approach/research focus to help redress this bias?”
and observes in its summary:
‘…workable solutions have not arisen from within the EBM literature. In our view, this is because generating such solutions would require a fundamental change in perspective, an abandoning of certain deeply held principles and assumptions, and the introduction of new ideas and methodologies from disciplines beyond EBM. Given the policy push for greater patient and carer involvement in research, the time is surely ripe for those who adhere to the EBM paradigm to question its rigid ‘gold standard’ [107] and consider whether it is time to extend and enrich EBM’s evidence base…’
This article does not expressly refer to Complementary or Integrated Medicine or Healthcare. Nevertheless, it focuses on the value of patient choice, personally significant evidence and acknowledges the existence of power imbalances that suppress a patient’s voice. This, together with its arguments against bias and for a more flexible approach to EBM, I suggest support the contention that safe, appropriate and evidence-based CAM should not be excluded from treatment options available to a patient.
On 25th May last year, The Alliance for Natural Health posted an article Our health predicament: How do we know what works and what doesn’t? exploring:
‘…why many academics who are involved with trying to understand more about the best ways of managing our health are increasingly looking to means other than the RCT [Randomised Controlled Trial] – long upheld as the gold standard of evidence – to evaluate the effectiveness of different interventions and self-care regimes…’
Research papers and articles debating the exclusivity of RCT’s are referred to in my August 2017 blog.
PUBLICATION OF CLINICAL TRIAL RESULTS: CAUSE FOR CONCERN
Another consideration is the disturbing research article published in the BMJ (17.01.17) titled Financial ties of principal investigators and randomised controlled trial outcomes: cross sectional study which concludes:
‘…Financial ties of principal investigators were independently associated with positive clinical trial results. These findings may be suggestive of bias in the evidence base…’
and further that:
‘…Financial ties of principal investigators are prevalent and are independently associated with positive clinical trial results. Given the importance of industry and academic collaboration in advancing the development of new treatments, more thought needs to be given to the roles that investigators, policy makers, and journal editors can play in ensuring the credibility of the evidence base…’
See also research published by PLOS in 2005 and a research paper published in December 2016 by the American Medical Association Journal (JAMA) titled Failure in Investigational Drugs in Late-stage Clinical Development and Publication of Trial Results, which concludes that the majority of drug studies that fail are not published in peer-reviewed journals.
These articles and papers, together with the BMJ and Kings Fund initiatives, demonstrate the need for an in-depth, patient-centred, unbiased and transparent approach to the publication of evidence in support of integrated medicine, to include the combined practise and research of both CAM and conventional medicine.
CAM RESEARCH SCOPING STUDY APPROVED
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):
In my August 2017 blog, I was delighted to report about the following email that I had received 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…’
As I said then, this is great news. Many congratulations to Professor Deborah Sharp and to her colleagues. No doubt CAM practitioners and others welcomed the opportunity to provide feedback and to respond to the request for further input to this project.
The Executive Summary, which may be found here, includes the following observation:
‘…Complementary and alternative medicine’ was a difficult term for many NHS professionals and included a range of treatments which varied widely in their acceptability. All three groups (GPs, CAM practitioners and commissioners) felt that CAM has a role in primary care and MSD-MH multimorbidity (where there were limited conventional treatment options). Key barriers to integration were philosophical differences and having to ‘secularise’/reduce CAM to adapt to the NHS, NHS structural/organisational barriers, the challenges of adhering to evidence based medicine and finances (limited budgets, unpredictable funding and need for cost-effectiveness). A minority of GPs were concerned that integrating CAM into NHS primary care may not be feasible and would present challenges in terms of extra work in understanding the paradigm in which complementary practitioners work. A strong theme (from all three groups) was the need for improved education of GPs about what CAM is and what it can do…’
and further concluded that:
‘…We identified a number of services where CAM is integrated into NHS provision, using various models and with varying degrees of perceived success. Acupuncture and homeopathy were most commonly provided, followed by massage, osteopathy and mindfulness. Most was NHS-funded CAM, free to patients. GPs were often instrumental in service initiation and NHS staff enthusiasm facilitated integration. Perceived success, sustainability and acceptability may depend on: providing a wide range of CAM; full integration into an NHS service; dual NHS and CAM trained clinicians; and evidence. Barriers to integration were funding, anti-CAM attitudes, and negative NHS staff attitudes or lack of knowledge…’
Even at this early stage, the study indicates that NHS funded and integrated CAM (free to patients) could be viable and further that:
‘…GPs were often instrumental in service initiation and NHS staff enthusiasm facilitated integration…’
It is also, I suggest, relevant to the proposition that CAM practitioners [particularly those identified in the Executive Summary] should, where appropriate, be recognised as NHS Allied Health Professionals.
NICE GUIDELINES REINSTATE ALEXANDER TECHNIQUE: PARKINSONS DISEASE
The National Institute for Health and Care Excellence (NICE) has published guidance covering the diagnosis and management of Parkinson’s disease in people aged 18 and over. The guidelines aim ‘… to improve care from the time of diagnosis, including monitoring and managing symptoms, providing information and support, and palliative care…’
Paragraph 1.7.4 of the section titled Non-pharmacological management of motor and non-motor symptoms (Physiotherapy and physical activity)
Provides:
‘…Consider the Alexander Technique for people with Parkinson’s disease who are experiencing balance or motor function problems. [2017]…’
These guidelines will be reviewed in July 2019.
Hopefully, NICE will also include Alexander Technique in its guidance relating to Low back pain and sciatica in over 16s: assessment and management when it is next reviewed in November 2018. Links to research into the use of Alexander Technique for treating back pain may be found here. For more information, please refer to my August 2017 blog.
IN DEFENCE OF HOMEOPATHY
- The “Australian Report”:
The National Health & Medical Research Council (Australia) Statement on Homeopathy (“The Australian Report”) is being challenged.
Practitioners of Homeopathy will be interested to read the first item listed in the Letters to the Editor section of PH Online Issue 238 (May 2017) titled World-Renowned Government Research Department Misled Scientists and the Public Over Homeopathy and to view the audio/video (The Australian Report: the facts behind the Headlines) posted by The Faculty of Homeopathy.
Information about the NHMRC Statement may be found here and you can sign-up to a campaign launched in Australia.
- Complementary Medicine (including Homeopathy) in Switzerland:
Complementary medicine in Switzerland is now a mandatory health insurance service: The Swiss Federal Government acknowledges that complementary medicine meets insurance regulations (Swiss Federal Health Insurance Act 1996) when it comes to effectiveness, guaranteeing high quality and safety.
On the 16th June this year, The Swiss Federal Government issued a press release announcing that specific medical services using complementary medicine are to be covered by mandatory health insurance (basic insurance) as of 1st August 2017. The following disciplines of complementary medicine will be fully covered: Classical Homeopathy, Anthroposophical Medicine, Traditional Chinese Medicine and Herbal Medicine, provided they are practised by conventional medical practitioners who have an additional qualification in one of the four disciplines as recognised by the Swiss Medical Association. This implements one of the key demands of the Swiss constitutional referendum held on 17th May 2009.
- Homeopathic treatments and hospitals challenged:
Notwithstanding that it is an accepted health specialism in Switzerland and a treatment endorsed by the World Health Organisation (page 36: see my November 2016 blog) which is available in general practice in France and in other European Union health sectors, it is surprising (some would say depressing) that the effectiveness and provision of Homeopathy prescriptions continue to be challenged within the NHS, in Australia and in Scotland.
In 2016, the Homeopathy Research Institute published an assessment titled Homeopathy within the National Health Service, UK setting out ‘some reliable facts on homeopathy and the NHS’.
The outcome of the joint consultation launched last summer by Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups (which proposes the decommissioning of NHS homeopathic services at the Portland Centre for Integrative Medicine in Bristol) is awaited. Like the recent Charity Commission Consultation (see my May 2017 & August 2017 blogs), the joint consultation provided a very limited ‘window’ for responses (18th July to 15th August). The Clinical Commissioning Group official proposal document can be viewed here.
The House of Commons Science and Technology Committee 4th Report of Session [2009 – 2010], Evidence Check 2: Homeopathy, which can be reviewed here, concludes as follows:
‘…[110 & 111 at pages 28 & 29] The Government’s position on homeopathy is confused. On the one hand, it accepts that homeopathy is a placebo treatment. This is an evidence-based view. On the other hand, it funds homeopathy on the NHS without taking a view on the ethics of providing placebo treatments. We argue that this undermines the relationship between NHS doctors and their patients, reduces real patient choice and puts patients’ health at risk. The Government should stop allowing the funding of homeopathy on the NHS… We conclude that placebos should not be routinely prescribed on the NHS. The funding of homeopathic hospitals—hospitals that specialise in the administration of placebos—should not continue, and NHS doctors should not refer patients to homeopaths…’
Contrast this with the approach adopted in Switzerland and in The Homeopathy Research Institute’s 3rd International Conference Report 2017, details and an Abstract of which may be viewed here and here and which concludes:
‘…As always, the HRI conference was truly international, with 200 delegates from 25 countries coming together to hear presentations by researchers from 19 countries. The high calibre of the 36 oral presentations and 37 posters was evident throughout the intensive programme, reflecting the high scientific quality of abstract submissions and a competitive selection process.
The new findings presented captured the ‘cutting edge’ theme of the conference, from the emergence of ‘pragmatic clinical trials’ as a particularly appropriate methodology for capturing the full clinical effectiveness of ‘real world’ homeopathy, to the latest bioassays being developed for basic research…’
The Scientific Advisory Committee of the Homeopathy Research Institute (HRI) can be viewed here.
HRI observations on the Science and Technology 4th Report may be found here. An independent critique written by Earl Baldwin of Bewdley concluded that the committee’s report was “an unreliable source of evidence about homeopathy.”
- The Statement (03.11.17) by The Royal College of Veterinary Surgeons:
The outcome of The Royal College of Veterinary Surgeons Standards Committee Review about the prescribing of homeopathy and CAM by its members (the initial Statement was referred to in my November 2016 blog) was published on 03.11.17 and may be viewed here. It includes the following guidance to its members:
“Homeopathy exists without a recognised body of evidence for its use. Furthermore, it is not based on sound scientific principles. In order to protect animal welfare, we regard such treatments as being complementary rather than alternative to treatments for which there is a recognised evidence base or which are based in sound scientific principles. It is vital to protect the welfare of animals committed to the care of the veterinary profession and the public’s confidence in the profession that any treatments not underpinned by a recognised evidence base or sound scientific principles do not delay or replace those that do.”
The RCVS further clarifies the above Statement in its reply to a question:
‘…Is the RCVS banning veterinary homeopathy and other complementary treatments and therapies?
No. We have not banned veterinary homeopathy and neither does our position statement of 3 November 2017 suggest that we have.
What we do state, is that we expect treatments like homeopathy, which are not underpinned by a recognised evidence base or sound scientific principles, to be offered alongside, or complementary to, those treatments that are…’
The response of the Faculty of Homeopathy may be read here. My August 2017 blog referred to the campaign by http://www.vets4informedchoice.org. Its response may be viewed here.
Links to research relating to Veterinary Homeopathy may be found on the website of The International Association for Veterinary Homeopathy.
- Homeopathy research sources:
Homeopathy research information is available from, among others, The Homeopathy Research Institute, The Faculty of Homeopathy (http://www.homeopathyjournal.net/), The Society of Homeopaths, The British Homeopathic Association, The Carstens Foundation [https://www.carstens-stiftung.de/artikel/new-database-portal-for-complementary-medicine.html] (Note: an English translation option is available on the website), The Alliance of Registered Homeopaths (Homeopathy in Practice Journal) and from teaching establishments like The School of Homeopathy.
Review the replies to FAQs provided by the Homeopathy Research Institute. Listen to the personal message from Dr Russell Malcolm, medical doctor and homeopath, about patient access to homeopathic medicine.
- The debate continues:
During the Parliamentary debate about Homeopathy and the NHS held in Westminster Hall, London, on 29.03.17, Mr David Tredinnick MP observed:
‘…On British practitioners, a survey recently showed that 72% of homeopathic patients rated their practitioners either very good or excellent. The 4Homeopathy group recent study showed that practitioners are treating all kinds of things, from irritable bowel syndrome—30%—to depression—20%. More than three quarters of teenagers and 41% of adults receive homeopathic treatments for skin disorders. About a third of adults and 40% of teenagers go to homeopaths for anxiety and stress. It is a service that delivers both in and out…’
He went on to quote a written answer in the Scottish Parliament by the (then) Health Spokesperson, Nicola Sturgeon, in reply to a question about the effectiveness of homeopathy in relation to the Scottish Government’s approach to integrative patient care:
“In primary care, costs will relate to the cost of the remedy, which can be cheaper than the cost of orthodox drugs. Practitioners have also noted a reduction in side effects and dependency risks in some cases. In secondary care in Scotland, homoeopathy is only employed within a broader integrative care approach, with surveys showing both enhanced wellbeing and symptom reduction across a broad range of long term conditions, and a resultant reduction in NHS costs through reduced GP and hospital visits and repeat prescriptions.”
Consider signing and sharing the UK Government & Parliament Petition before it closes on 13.03.18 and view the campaign links posted on 14.09.17 by the 4 Homeopathy Group.
Practitioners of Homeopathy should review the Advertising Standards for Homeopathy posted on 29.09.16 by the Advertising Standards Authority (ASA), which raise the question: Has the ASA become a Health Regulator? The powers of the ASA and the recent (2015 & 2016) parliamentary debates scrutinising its governance are referred to in my May 2017 blog.
NEW DATABASE PORTAL FOR COMPLEMENTARY MEDICINE
The Carstens Foundation [https://www.carstens-stiftung.de/] recently announced this most welcome resource for practitioners, researchers and students of complementary medicine, naturopathy and homeopathy, as follows:
‘…The Karl and Veronica Carstens Foundation is launching a free database portal for complementary medicine, naturopathy and homeopathy. A total of 96,000 records with recorded literature, including about 30,000 papers from clinical research and more than 9,000 publications from basic research, can now be searched free of charge – a unique and unrivalled research offer for scientists, doctors, therapists and students.
If you are planning a research or doctoral thesis in the area of complementary medicine or just want to get an overview of the current study situation, you have immediate access to the probably largest data collection in Europe. After a one-time registration, the Carstens Foundation provides its entire catalogue, as well as all registered studies, experiments and case studies, for free online research. This makes possible a new, comprehensive database portal at https://www.carstens-stiftung.de/artikel/new-database-portal-for-complementary-medicine.html…’
(Note: English translation option is available).
THE CAM NHS EVIDENCE COLLECTION: NHS EVIDENCE
In addition to the Carstens Foundation portal and links to research information provided by CAM professional organisations (as in the case of Homeopathy, above) there is the CAM Specialist Library (developed for the NHS Library for Health), the content of which has been incorporated into NHS Evidence (note: insert the name of the CAM treatment specialism into the research box) which is available on the National Institute for Health and Care Excellence website. This resource was compiled by The Research Council for Complementary Medicine in partnership with the Royal London Hospital for Integrated Medicine and the School of Life Sciences (now part of the Faculty of Science & Technology) at the University of Westminster.
THE NEED FOR STATISTICAL ANALYSIS OF THE USE OF CAM IN THE UK
Many of those who formulate policy and manage NHS and public health organisations continue to ignore the effective contribution that CAM can make to the provision of health and social care. Why is this? Could one reason be because they lack adequate statistical information about its use and cost? Neither the Office for National Statistics [https://www.ons.gov.uk/] nor NHS Digital hold, produce or analyse statistical research dedicated exclusively to the provision and supply of CAM services and products in the UK.
Any initiative to compile UK statistics could take note of the approach applied in the United States by The National Centre for Health Statistics (NCHS) in its Statistics Reports titled, respectively, Trends in the Use of Complementary Health Approaches among Adults: United States, 2002 – 2012 and Costs of Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States, 2007.
The NCHS Reports:
‘… provide annual data summaries, present analyses of health topics, or present new information on methods or measurement issues…’
Other Reports published by the NCHS (U.S. Department of Health and Human Services) include:
Expenditures on Complementary Health Approaches: United States, 2012;
Wellness-related Use of Common Complementary Health Approaches Among Adults: United States, 2012;
Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007.
For further publications about complementary health statistics in the US, search: Publications Using NHIS Data and Complementary and Alternative Medicine: What People Aged 50 and Older Discuss With Their Health Care Providers
UK patients, medical practitioners (Complementary and Conventional) and researchers should have access to similar summaries and statistical analysis of CAM services and products provided and supplied in the UK. Undeniably, those formulating and managing UK NHS and public health policies should make full and proper use of this information.
In the ‘spirit’ of the personalised approach to healthcare (see above), practitioners, their patients and other stakeholders could lobby Jeremy Hunt, the Secretary of State for Health, Duncan Selbie (Chief Executive of Public Health England) the Department of Health and their own Member of Parliament calling for the NHS and public health sectors to review and to recognise the use, cost-effectiveness and potential of CAM and its practitioners and also for the right of patients to receive safe, appropriate and evidence-based CAM services from a professional practitioner of their choice.
HOLISTIC HEALTH SHOW 2017: AN INTERVIEW
Aspiring publishers and authors of CAM and those interested in reading about the evolution of CAM, especially during the past 25 years, should take the opportunity to download or listen to Dr Carl Helvie’s interview of Dr Sandra Goodman PhD at the Holistic Health Show (17.06.17) in which he explores Dr Goodman’s journey from molecular biology scientist (working in agricultural biotechnology) to her launch and subsequent publishing of Positive Health Magazine and PH Online, including her compilation of a comprehensive, open-access and free online archive of natural medicine research and book reviews. More about Dr Goodman’s journey, published books and achievements may be found in my February 2017 blog.
THINKING OF BECOMING A CAM PRACTITIONER?
If you are thinking of becoming a CAM practitioner, you may find the following Report of interest: University of Birmingham Report: How can you make a career as a Complementary Therapist? [Citation: Gale, N K (2014) – How can you make a career as a complementary therapist? Dissemination Report, ‘Putting Embodied Knowledge Into Practice’ (ES/J002828/1). Birmingham: Health Services Management Centre, University of Birmingham].
The Report aimed to find the answer to the following question (page 8):
‘…How do osteopaths and homeopaths negotiate building a career that is personally and financially sustainable, and continue to develop their knowledge and skills?’
DR WARREN LEVIN, MD: A TRIBUTE BY DR JEFFREY BLAND, PHD
Finally, View the tribute by Dr Bland to the late Dr Levin, a pioneer of integrated and functional medicine, who died on 21st July this year.
A tribute to Dr Levin, together with details of a memorial fund to continue his work in integrative medicine, have been posted on the Alliance for Natural Health USA (ANH-USA) website and may be viewed here.
This website, together with (free subscription) The Pulse of Natural Health Newsletter (edited by Michael Sikora), include many natural health and health freedom topics that may be of interest to UK-based readers.
RICHARD EATON
1st December 2017
