Complementary Therapies Yrmg July 2008 For Handouts

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Complementary care

Complementary care

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  • 1. Complementary therapies: an overview Hugh MacPherson Senior Research Fellow Department of Health Sciences [email_address]
  • 2. 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.
  • 3.
    • 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**:
  • 4. Adult use of complementary therapies 1997/8
  • 5.
      • 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*
  • 6.
    • 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
  • 7.
    • 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
  • 8. 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
  • 9. 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
  • 10. Barriers to complementary therapies on the NHS
      • Inertia – resistance to change
      • Regulation
      • Financial concerns within NHS
      • Mixed evidence of effectiveness, and the placebo question
  • 11. 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?”
  • 12. 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?”
  • 13.
    • Osteopathy - statutory (1993)
    • Chiropractic - statutory (1994)
    • Acupuncture - statutory soon (2009-10?)
    • Herbal medicine - statutory soon (2009-10?)
    • Homeopathy - self-regulatory
    Current regulation of therapies
  • 14. 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
  • 15. 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……
  • 16. 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
  • 17. 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
  • 18. 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.