On the 20th November last year the editor of the Sunday Times newspaper published a letter under the headline Royal Commission can cure NHS. The letter was submitted by 65 medical professional signatories, including the oncologist Professor Karol Sikora who is remembered for, amongst many other things, his trailblazing commitment to the renowned former Bristol Cancer Help Centre and for his recognition of the contribution made by Complementary Medicine. The letter stated that the NHS was in crisis. It highlighted the early retirement and poor recruitment of doctors together with the lengthening of waiting times: for surgery, in emergency departments and in the diagnosis and treatment of cancer and further confirmed the problem of ‘bed-blocking’ in hospitals. It concluded that the fundamental reason for these failures, although complex, was down to lack of money and use of resources and called upon the Government to look at (by way of a Royal Commission):
‘…all the options – even the most unpalatable – for raising spending on the NHS…[as] without radical change the NHS will wither and die…’
How might Complementary and Alternative Medicine (CAM) as a component of integrated medicine and healthcare help to alleviate such failures? Accepting that lack of money is a fundamental part of the problem, could it be argued that CAM, in addition to providing valuable treatments, is also “value for money”? As ever when presenting a conclusion with regard to a medical issue, “more research needs to be undertaken” when seeking the answer to this question. Nevertheless, research is available which indicates that CAM could make a substantial contribution to combating some of the matters identified by Professor Sikora and his professional colleagues. This is encouraging, because if CAM is to be accepted as part of integrated medicine and healthcare within the NHS, it must be demonstrated that not only is it value for money but, preferably, that it also saves money.
In October 2005 and further to its commission by the Prince of Wales, Economist Christopher Smallwood led the publication of The Role of Complementary and Alternative Medicine in the NHS: An Investigation into the Potential Contribution of Mainstream Complementary Therapies to Healthcare in the UK. (193 pages) which concluded (page 8) as follows:
‘…Our main conclusion is that there appears to be sufficient evidence to suggest that some complementary therapies, listed in the report, may be more effective than conventional approaches in treating certain chronic and psychosocial conditions, and that specific treatments offer the possibility of cost savings, particularly where they can be provided in place of, rather than in addition to orthodox treatments.
Our principal recommendation therefore is that Health Ministers should invite the National Institute for Health and Clinical Excellence (NICE) to carry out a full assessment of the cost-effectiveness of the therapies which we have identified and their potential role within the NHS, in particular in relation to the closing of “effectiveness gaps…’
The scope of the Report was restricted to the first of the three groups of therapies defined in chapter 2 of the House of Lords Science and Technology Committee’s Sixth Report). These include acupuncture (Report pages 35 to 36), homeopathy (Report pages 47 to 56), chiropractic and osteopathy (Report pages 57 to 68) and herbal medicine (Report pages 69 to 80). Christopher Smallwood’s Summary and Guide to the Report can be read on pages 8 to 18.
The Report defines its approach to the economic evaluation of healthcare (Cost-Benefit, pages 28 to 31) and provides Models of Integration and Methods of Delivery (pages 81 to 86) of CAM within the NHS (pages 122 to 130) together with a study of Effectiveness Gaps where the treatment of certain conditions are poorly addressed by conventional medicine (pages 131 to 146).
Other research (Is complementary and alternative medicine (CAM) cost-effective? A systematic review: Patricia M Herman, Benjamin M Craig & Opher Caspi, BMC Complementary and Alternative Medicine – 02.06.2005) concludes as follows:
“…As health care costs continue to rise, decision makers must allocate their increasingly scarce resources toward therapies which offer the most benefit per unit of cost. Economic evaluations inform evidence-based clinical practice and health policy. To be considered by these decision makers, CAM therapies and their outcomes must be known and compared to conventional approaches. However, CAM practitioners must themselves decide whether the cost of performing these studies is worth the potential impacts to their profession of being considered in managed care. Nevertheless, these evaluations will be done and they will be better done with practitioner involvement. Whereas the number and quality of these studies has increased in recent years and more CAM therapies have been shown to be good value, there are still not enough studies to measure the cost effectiveness of the majority of CAM. If CAM providers wish to increase the provision of therapies to improve population health, they must report the potential outcomes of CAM therapies widely and well…’
So the message to practitioners and to their professional organisations is: “…report the potential outcomes of CAM therapies widely and well…” Opportunities do present when practitioners can contribute to research projects, for instance to the Bristol University Centre for Academic Primary Care in relation to its research into the cost effectiveness of CAM for multimorbid patients with mental health and musculoskeletal problems in primary care.
Although, in the light of this research initiative, it is disheartening to read the NICE Guideline [NG59] published in November 2016 Low back pain and sciatica in over 16s: assessment and management which expressly excludes acupuncture (paragraph 1.2.8), a treatment that had been included in the previous Guideline. The manual therapy of Massage (paragraph 1.2.7), when used as a part of multi-treatment with exercise, is recommended but, sadly, Alexander Technique is not.
Published on 3rd September 2012 (BMJ Open), “a systematic review of economic evaluations of complementary and integrative (CIM) medicine to establish the value of these therapies to health reform efforts” (Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations: Patricia M Herman, Beth L Poindexter, Claudia M Witt & David M Eisenberg) concluded:
‘…This comprehensive review identified many CIM economic evaluations missed by previous reviews and emerging evidence of cost-effectiveness and possible cost savings in at least a few clinical populations. Recommendations are made for future studies…’
The above conclusions generally accord with an initiative launched by Dr Sandra Goodman PhD, co-founder and editor of Positive Health PH Online and author of 4 books including Nutrition and Cancer: State-of-the-Art, in relation to CAM treatments and cancer care. Dr Goodman has published her research proposal Research Proposal: Cancer Patients’ Survival: Comparing Integrated Alternative Therapies and Chemotherapy/Radiotherapy Treatment – October 2014
which, amongst other things, states:
‘…Data comparing cancer survival in patients undergoing chemotherapy and radiotherapy with those who forgo these treatments has been difficult to uncover, due to legal constraints and overwhelming dominance of the conventional treatment establishment. It is proposed to research and compile data with a view to assessing and comparing outcomes for cancer patients being treated with Integrated Oncology – alternative and complementary treatments – who have and have not undergone chemotherapy and radiotherapy treatments. Data comparing patient survival with and without adjunctive therapy could be extracted from cancer registry databases. Data regarding survival with Integrated Alternative Therapies would require multi-factorial clinical database creation either from clinicians or patients once this treatment is no longer deemed illegal…’
Further observations by Dr Goodman may be found here.
I urge practitioners and their patients to take a pro-active interest in this proposal.
The above is a brief overview of some of the matters relevant to the proposal that CAM, whether or not as a part of integrated medicine and healthcare, has a significant and potentially cost-saving contribution to make to the public (NHS) and the private health sectors.
It is clear that any initiative will need the dedicated support of both CAM practitioners and of those practising orthodox medicine. It will also need funding. As regards the former, practitioners could lobby their professional organisations to advise upon and implement an appropriate policy agenda, including a recommended form of research methodology and evaluation. For this, advice is already provided by the Research Council for Complementary Medicine and I refer you to the further links to the research papers listed below. So far as funding is concerned, practitioners could begin by lobbying their Members of Parliament with the request that research funding is allocated by relevant government departments. Assistance might also by available from charitable organisations like The Health Foundation. Higher education medical and health faculties will be familiar with accessing sources of funding.
When presenting the case for the cost-effectiveness of CAM as a part of integrated medicine and healthcare, practitioners could also quote the following list of research papers:
Funding for CAM, (2007);
CAM research and development, (2000);
Study shows 99% of doctors have recommended natural remedies for children, (international study: camexpo blog on 04.08.16);
In a more general and commercial context, practitioners may find the principles set out in the Guide to Cost-Benefit Analysis of Investment Projects (European Commission, December 2014: including Chapter 7 at pages 269 to 295) of interest, with particular reference to the section Reduction of Health risks at page 291.
My earlier reference to Dr Sandra Goodman gives me the opportunity to acknowledge the outstanding contribution that she and her long-term partner, Mr Mike Howell, have made to the research and promotion of CAM through, initially, their founding and publication of the paper print version of Positive Health Magazine and, more recently, through its exclusively online successor Positive Health PH Online (although the internet site for this has been established since 1995). I’m sure that I reflect the sentiments of many practitioners when I use this blog to thank them both for their vision, commitment and stamina throughout the past 23 years.
Dr Goodman trained as a Molecular Biology scientist in Agricultural Biotechnology in Canada and the USA and was the lead author of the Consensus Document Nutritional and LifeStyle Guidelines for People with Cancer. In 1993, she compiled the Cancer and Nutritional Database for the (then) Bristol Cancer Help Centre. In 1994, Dr Goodman, together with its co-founder Mike Howell, launched Positive Health Magazine with a commitment to bridge the gap between alternative and conventional medicine and to enable a unified, integrated medicine.
Since its inception, the complete archive of all of Positive Health’s content has been transformed into a substantial, authoritative and independently owned online free-to-access body of publication concerning natural treatment approaches. This includes more than: 3000 articles across 150 subjects; 3000 research abstracts, book reviews and letters and 1.500 authors. The site receives 6,556 to 8,181 visits per day and 34,640 to 52,652 page reviews daily. In July 2016, there were 203,576 visits, 1,073,842 page reviews, 3,744,063 files and 3,915,967 hits. These statistics applied as at September 2016 so will have been added to since then.
On 7th December 2016, the Alliance for Natural Health (ANH) issued a press release following the meeting of the all-party parliamentary group on integrated healthcare (APPGIH) at Portcullis House, Westminster, London, held the previous evening. The meeting agreed a Brexit-inspired roadmap for healthcare reform, which the press release stated:
“…would also dramatically reduce the burden on an overwhelmed National Health Service…’
Consensus has been growing for this for many years. It is now down to the efforts of practitioners, both CAM and conventional, to make it reality. Interested parties need to contribute to research projects and proposals, especially where they relate to cost-benefit-analysis.
Finally, patients receiving complementary and alternative medicine now have an opportunity to contribute to a consultation on improving how they and the public can help develop National Institute for Health and Care Excellence (NICE) guidance and standards. Practitioners may want to let their patients know about this just in case they would like to take part in the consultation, for instance by proposing that NICE reviews its guidance and standards to take account of the provision and cost-effectiveness of integrated medicine and healthcare (including CAM) within the NHS. This is your patient’s chance to have their say but they will need to be quick as the closing date for the consultation is 5.00 pm on 28th February 2017. Details of the consultation can be found here. Practitioners could introduce their patients to the consultation by sending them a link to this blog.