Complementary therapies: an overview Hugh MacPherson Senior Research Fellow Department of Health Sciences [email_address]

What is CAM (Complementary and Alternative Medicine)? The Cochrane Collaboration defines CAM as: a broad domain of healing resources that encompasses all health systems, modalities, and practices, other than those intrinsic to the politically dominant health systems of a particular society or culture in a given historical period.

The Cochrane Collaboration defines CAM as:

a broad domain of healing resources that encompasses all health systems, modalities, and practices,

other than those intrinsic to the politically dominant health systems of a particular society or culture in a given historical period.

chiropractic 7.5 million osteopathy 7.3 million acupuncture 3.1 million herbal medicine 1.5 million homeopathy 1.3 million Total : 21 million *House of Lords Report 2000 ** Thomas et al 2001 Estimated number of “big five”* consultations per year in UK**:

chiropractic 7.5 million

osteopathy 7.3 million

acupuncture 3.1 million

herbal medicine 1.5 million

homeopathy 1.3 million

Total : 21 million

*House of Lords Report 2000 ** Thomas et al 2001

Adult use of complementary therapies 1997/8

Musculoskeletal 95% Depression 45% Eczema 36% Chronic pain 32% Irritable bowel 32% * Fisher et al 2004 Effectiveness gaps in primary care – according to GPs perceptions*

Musculoskeletal 95%

Depression 45%

Eczema 36%

Chronic pain 32%

Irritable bowel 32%

* Fisher et al 2004

Percentage of patients consulting CAM for musculo-skeletal problems*: osteopathy 54% acupuncture 38% chiropractic 31% herbal medicine 8% homeopathy 7% * Thomas 2003 Musculo-skeletal problems Patient defined problems for all five therapies*: 23% Back 19% Low back 13% Neck 9% Sciatica 7% Arthritis 7% Shoulder 4% Knee 3% Hip *Thomas et al 1991

Percentage of patients consulting CAM for musculo-skeletal problems*:

osteopathy 54%

acupuncture 38%

chiropractic 31%

herbal medicine 8%

homeopathy 7%

* Thomas 2003

Therapies acts as catalyst for change: Self-healing is triggered Each therapy has its own mechanism(s) Longer-term effects due to some sort of physiological relearning Underlying principles

Therapies acts as catalyst for change:

Self-healing is triggered

Each therapy has its own mechanism(s)

Longer-term effects due to some sort of physiological relearning

Patients of osteopaths appreciate: having their problem validated as real and deserving of care receiving an meaningful explanation on the nature and causes of their problem a treatment strategy that was directed towards the actual experience of low back pain a prognosis and strategy for improvement a preventative strategy. Ref: Kane 1993

having their problem validated as real and deserving of care

receiving an meaningful explanation on the nature and causes of their problem

a treatment strategy that was directed towards the actual experience of low back pain

a prognosis and strategy for improvement

a preventative strategy.

Ref: Kane 1993

Provision of CAM on the NHS 75% of population want CAM on NHS BUT Only 10% actually access CAM on the NHS (i.e. 90% pay for CAM out-of-pocket) Refs: Thomas 2003, FIH 2005

75% of population want CAM on NHS

BUT

Only 10% actually access CAM on the NHS

(i.e. 90% pay for CAM out-of-pocket)

Refs: Thomas 2003, FIH 2005

Barriers to complementary therapies on the NHS Inertia – resistance to change Regulation Financial concerns within NHS Mixed evidence of effectiveness, and the placebo question

Inertia – resistance to change

Regulation

Financial concerns within NHS

Mixed evidence of effectiveness, and the placebo question

And is it all placebo? “ Many clinicians are clear that they can see a role for homoeopathy, even if it does perform no better than placebo. I (would prioritise) randomised controlled (albeit unblinded) trials comparing “visiting a homoeopathy clinic” against “general practitioner's treatment as usual”, since this might be the clinical question of more interest to patients—ie, not “do the pills work better than placebo” but “will the experience of visiting a homoeopath help me to feel better?”

“ Many clinicians are clear that they can see a role for homoeopathy, even if it does perform no better than placebo. I (would prioritise) randomised controlled (albeit unblinded) trials comparing “visiting a homoeopathy clinic” against “general practitioner's treatment as usual”, since this might be the clinical question of more interest to patients—ie, not “do the pills work better than placebo” but “will the experience of visiting a homoeopath help me to feel better?”

And is it all placebo? Ben Goldacre The Lancet 2008; 371:985-986 “ Many clinicians are clear that they can see a role for homoeopathy, even if it does perform no better than placebo. I (would prioritise) randomised controlled (albeit unblinded) trials comparing “visiting a homoeopathy clinic” against “general practitioner's treatment as usual”, since this might be the clinical question of more interest to patients—ie, not “do the pills work better than placebo” but “will the experience of visiting a homoeopath help me to feel better?”

“ Many clinicians are clear that they can see a role for homoeopathy, even if it does perform no better than placebo. I (would prioritise) randomised controlled (albeit unblinded) trials comparing “visiting a homoeopathy clinic” against “general practitioner's treatment as usual”, since this might be the clinical question of more interest to patients—ie, not “do the pills work better than placebo” but “will the experience of visiting a homoeopath help me to feel better?”

Osteopathy - statutory (1993) Chiropractic - statutory (1994) Acupuncture - statutory soon (2009-10?) Herbal medicine - statutory soon (2009-10?) Homeopathy - self-regulatory Current regulation of therapies

Osteopathy - statutory (1993)

Chiropractic - statutory (1994)

Acupuncture - statutory soon (2009-10?)

Herbal medicine - statutory soon (2009-10?)

Homeopathy - self-regulatory

The fundholding experience CAM provision required GP champions – personal vision and commitment Some new services – extending choice to patients Based on belief in benefits of service to practice and patients Credible evidence needed to support funding requests Financial insecurity of NHS-funded services Sustaining Complementary Therapy Provision in Primary Care: Lessons from Existing Services. Thomas CTiM 2000

CAM provision required GP champions – personal vision and commitment

Some new services – extending choice to patients

Based on belief in benefits of service to practice and patients

Credible evidence needed to support funding requests

Financial insecurity of NHS-funded services

Since the end of fundholding … Dearth of policies on CAM provision Many PCTs levelling down provision Demand for/provision of CAM services seen as more relevant if designed to solve an existing NHS problem (e.g. waiting times for orthopaedic referrals) Opportunities with practice-based commissioning……

Dearth of policies on CAM provision

Many PCTs levelling down provision

Demand for/provision of CAM services seen as more relevant if designed to solve an existing NHS problem (e.g. waiting times for orthopaedic referrals)

Opportunities with practice-based commissioning……

Reasons to consider expanding provision with practice based commissioning Growing evidence for some therapies for specific conditions Patient choice, linked with appropriate referral Preventative healthcare agenda Potential cost-savings

Growing evidence for some therapies for specific conditions

Patient choice, linked with appropriate referral

Preventative healthcare agenda

Potential cost-savings

Specialist databases AMED (Alternative Medicine Database) British Library - access by license www.bl.uk / Complementary and Alternative Medicine Evidence On-Line (CAMEOL) http://www.rccm.org.uk/ Cochrane Library – 5000 RCTs and 60 systematic reviews: www.cochrane.org

AMED (Alternative Medicine Database)

British Library - access by license www.bl.uk /

Complementary and Alternative Medicine Evidence On-Line (CAMEOL) http://www.rccm.org.uk/

Cochrane Library – 5000 RCTs and 60 systematic reviews:

www.cochrane.org

Bibliography: Fisher, P., Van Haselen, R., Hardy, K., Berkovitz, S., & McCarney, R. 2004, "Effectiveness gaps: a new concept for evaluating health service and research needs applied to complementary and alternative medicine", J.Altern.Complement Med, vol. 10, no. 4, pp. 627-632. House of Lords 2000, Report of the Select Committee on Science and Technology: Complementary and Alternative Medicine, The Stationary Office, London. Kane M 1993, The patient's perspective: a qualitative study of low back pain and osteopathic treatment, Masters Thesis, University of Exeter. MacPherson H , Sinclair-Lian N, Thomas K. Profiles of acupuncture patients: a national survey. Complementary Therapies in Medicine, 2006; 14(1): 20-30. Thomas KJ, Nicholl JP, & Coleman P 2001, "Use and expenditure on complementary medicine in England: a population based survey. 9 :2-11.", Complementary Therapies in Medicine , vol. 9, pp. 2-11. Thomas, K. J., Carr, J., Westlake, L., & Williams, B. T. 1991, "Use of non-orthodox and conventional health care in Great Britain", BMJ , vol. 302, no. 6770, pp. 207-210.