This document provides an overview of access to complementary and alternative medicine (CAM) in the NHS Scotland chronic pain service. It notes that nearly 40% of GP partnerships in England provide CAM access to NHS patients, and that chronic musculoskeletal pain is the most common reason people use CAM. Several government reports and clinical guidelines since 1994 have recommended CAM therapies like manual therapy and acupuncture for chronic pain conditions. However, access to CAM through the NHS is currently unequal, as it depends on how affluent patients are. The document proposes developing a referral pathway for GPs to refer patients to nationally-regulated CAM practitioners, and increasing dissemination of chronic pain resources, as ways to help address this inequality.

1. PowerPoint®
presentation prepared by
Paulo Quadros
Patients’ access to
Complementary and
Alternative Medicine in
the NHS Scotland
chronic pain service:
an overview

2. Background
 Nearly 40% of GP partnerships in England provide
access to CAM for NHS patients*1
 one in ten of the population uses complementary
healthcare*2
 three-quarters of the population would choose
complementary healthcare if it were available on the
NHS*2
 Chronic musculoskeletal pain is the single most cited
reason for use of CAM*3
*1 Integrated Healthcare: A Way forward for the Next Five years? Published by the Foundation for Integrated
Health
*2 A Healthy Partnership – Integrating Complementary Healthcare into Primary Care; 2005 (published by the Prince
of Wales Foundation for Integrated Health
*3 The use of CAM and conventional treatments among primary care consulters with chronic musculoskeletal pain
(BMC Family Practice 2007)

3. Background
 The benefits of unconventional therapies (aka CAM
therapies) on chronic pain,
 their cost effectiveness
 the need for CAM regulation and
 the need for ongoing CAM research
have been recognised by health authorities in Scotland
and the rest of the UK since, at least, 1994
(‘Management of Patients with Chronic Pain’) all the way
to the SIGN guideline on chronic pain management
published in 2013.
This issue has been discussed for over 20 years

4. Background - Key documents recommending CAM
 1994: The Management of Patients with Chronic Pain (Scottish
Government)
 2000: The economic burden of back pain in the UK (‘Maniadakis Paper’)
 2000: Services for patients with pain - Report of the Clinical Standards
Advisory Group Committee
 2004: Chronic Pain Services in Scotland (‘McEwen Report’)
 2006: Management of Chronic Pain in Adults (QIS)
 2007: GRIPS report (Getting Relevant Information on Pain Services)
 2008: Department of Health Steering Group (‘Pitillo Report’)
 2009: NICE guideline (Early management of persistent non-specific low
back pain)
 2013: SIGN Guideline on Management of Chronic Pain(#136)

5. Background - GUIDELINES
1999
NICE - ‘Early management of persistent non-specific
low back pain’:
5.1.4 Offer one of the following treatment options - taking into
account patient preference - an exercise programme, a course
of manual therapy or a course of acupuncture.
(Manual therapies in these guidelines are spinal manipulation,
spinal mobilisation and massage) The guideline also
recommends ‘Alexander Technique’
Evidence included “high quality systematic review with a very
low risk of bias” and other “well conducted RCT with a low risk
of bias”

6. Background - GUIDELINES
2013
SIGN ‘Management of Chronic Pain’ (#136):
7.1.1 Manual therapy should be considered for short term
relief of pain for patients with chronic low back pain
7.1.2 Manual therapy, in combination with exercise, should
be considered for the treatment of patients with chronic neck
pain. (grade 1++ evidence with a 'B' classification).
8.1 Acupuncture should be considered for short term relief of
pain in patients with chronic low back pain or osteoarthritis.
‘A' classification
‘Guidelines’ are developed making use of the best evidence
available and GPs are encouraged to follow them.

7. Current status of CAM referrals
Referrals to CAM therapist is supported by the
 Government: “A GP or hospital clinician may refer a patient
for alternative treatment” [circular HDL(2005) 37]
 BMA: “The BMA is supportive of those forms of
complementary therapy for which evidence of claims of
efficacy can be demonstrated”
GPs may delegate treatment to complementary therapists
who are not registered with a statutory regulatory body.
 Dr Blair Smith (Scottish Lead Clinician for Chronic Pain):
“We also need to develop and review non-pharmacological
treatments, including psychological approaches, exercise
and activity, and complementary techniques such as
acupuncture.” (The Scotsman – 28th
March 2014)

8. Current status of CAM referrals
Government [circular HDL(2005) 37]
The GP or hospital clinician would require to
1. be satisfied of the value of the treatment and
2. the competence of the practitioner
3. and would remain responsible for the patient's
medical care
But support for CAM comes with certain conditions
In effect, GPs need to:
determine the evidence for the use of different forms of CAM for
different conditions as well as determine qualifications, insurance
status and safety/ethics of a therapist.

9. Current status of CAM referrals
GMC
you must be satisfied that systems are in place to assure
the safety and quality of care provided – for example, the
services have been commissioned through an NHS
commissioning process or the practitioner is on a
register accredited by the Professional Standards
Authority.
BMA
GPs may delegate treatment to complementary therapists who
are not registered with a statutory regulatory body. In doing so,
they remain responsible for the treatment given and would
bear some liability should the patient come to any harm.
But support has certain conditions

10. Current status of CAM referrals
“In terms of referral pathways, a GP referring to a CAM
would be considered as a TERTIARY REFERRAL under
the extra-contractual referral process (ECR)”
[NHS Lanarkshire]
A form is completed (for each patient) outlining
• the basic clinical details,
•the treatment (or sometimes investigation) proposed,
•the duration and an estimate of cost
Such referrals are considered by the Divisional Medical Director
The new Scottish service model for chronic pain (launched in 2013)
promotes the use of non-pharmacological treatments firstly within primary
care then, for more complex cases, secondary care. Never tertiary.

11. Inequality of access
The Government say that it’s up
to Health Boards to decide
whether to provide
unconventional therapies or not
Health Boards/GPs need regulation in order to comply with
conditions for non-statutory referrals.
Regulation is determined by the Government
NHS BOARDS
Can provide but
not regulate
GOVERNMENT
Can regulate
but not provide
Currently, access to CAM therapies recommended by
guidelines is dictated by how affluent patients are.
Equality can only exist if therapies are provided by the NHS.

12. INEQUALITY OF ACCESS – POSSIBLE SOLUTION
REGULATION
GPs could refer their patients to therapists registered with a
recognised national regulatory organisation, ideally
accredited by the ‘Professional Standards Authority’
 CNHC (Complementary and Natural Health Care)
Originally funded by the Dept of Health in Whitehall
Created to regulate CAM in the whole of the UK
(much like the GMC regulate GPs)
Accredited by the Professional Standards Authority
Endorsed by the General Medical Council (GMC)*

13. INEQUALITY OF ACCESS – POSSIBLE SOLUTION
REFERRAL PATHWAY
Creation of a direct REFERRAL PATHWAY similar to other
existing mainstream services such as physiotherapy
WIDER DISSEMINATION OF INFORMATION
Making GPs, practice managers and other health
professionals (as well as patients) more aware of existing
chronic pain resources such as guidelines, chronic pain
website and the revised (2013) Scottish chronic pain service
model
ANY MORE?
e.g.
• dedicated ‘drug-free’ chronic pain clinics?
• dedicated Government funding?

14. Needed discussions
Matters related to the delivery of unconventional therapies through
the NHS need to be discussed - such as:
• central regulation of unconventional therapies (rather than
therapy-specific regulation)
• referral pathway
• delivery model
• cost effectiveness
• risk/benefit analysis
• possible integration within the MSK service
• use of unconventional therapies in the context of the GRIPS
and McEwen reports
• use of unconventional therapies in the context of human
rights and the ‘Patient Rights (Scotland) Bill’
• the desirability of continuous evidence assessment through
trials and audits (before research)

15. RESOURCES
CAM in the NHS: www.bit.ly/CAMintheNHS
Revised chronic pain model: Chronic Pain Services in Scotland
SIGN guideline #136: http://bit.ly/CPGuideline
NICE guideline CG88: www.nice.org.uk/guidance/CG88
Chronic pain support website: www.chronicpainscotland.org
Service Improvement Groups (SIGs): http://bit.ly/SIGsScotland
For further information or enquiries
paulo@intlifepain.org