An article in The Times proclaims a fifth of people in the UK will suffer from poor health before age 30, and by age 50 most people will suffer from at least one chronic condition. In the face of such damming odds many more than just ourselves at ANH are wondering how the NHS is planning to provide the service required of it without a significant change in its healthcare delivery.

We believe that our blueprint for a sustainable health system (due out September 2018) offers many such answers. But it’s refreshing to find that Richard Eaton, retired barrister and sustainable healthcare advocate, shares some of the same views. Below we offer you some of his considerations with regard to the role complementary and alternative (CAM) practitioners have to play in an integrated and sustainable healthcare system.

You can find Richard’s full article published in Issue 248, August 2018 of PositiveHealthOnline.

Over to Richard;

The UK National Health Services should engage with complementary and alternative medicine

The NHS England Consultation, Items which should not be routinely prescribed in primary care: A Consultation on Guidance for CCGs (clinical commissioning groups), confirmed NHS England’s action to reduce inappropriate prescribing of 18 medicines to save millions of pounds a year. This includes recommending herbal remedies and homeopathy be referred to be “formally considered for the blacklist” and no longer provided by General Practitioners (GPs) and CCGs, because:

“… there is no clear or robust evidence to support its use…”

It is a cause for concern that, although the large proportion of those who responded to the consultation were “self-identified patients”, who supported the effectiveness and safety of homeopathy and herbal treatments, their views appeared to carry little weight. Also of concern, is the Board’s dismissal of the evidence of the cost-effectiveness of homeopathy as being simply “marginal cost issues, despite a spend in 2016 of £9.2 billion on prescription medicines by the NHS, of which a mere £92,412 was spent on homeopathic medicines and £100,009 on herbal medicines. Further detail can be found in the response by the Alliance for Natural Health International titled UK NHS Clampdown on Natural Medicine in face of growing public demand.

To what extent do patients receiving homeopathy and herbal treatments relieve the burdens, financial and otherwise, on the NHS? This question should be explored and answered. Is NHS England assessing the respective benefits to patients of CAM and conventional medicine, whether or not as part of an integrative treatment plan, in an unbiased and balanced way? Clearly, the answer is “No”. In its 25th monitoring report, ‘How is the NHS performing’, the King’s Fund comments:

…78 per cent of CCG respondents were considering extending the number of low-value treatments and prescriptions that will not be funded, and 56 per cent were considering extending waiting lists or reducing activity for certain elective specialties…

Supply and Demand

This withdrawal of low cost NHS services including those mentioned above may result in greater demand for CAM but only for patients accessing such treatments and remedies outside the NHS and only for those who can afford to pay for them.

While this is a probable, but presumably unintended, consequence of the NHS CCGs policy, wouldn’t embracing CAM prove to be the most cost-effective way to save the NHS money overall? For instance, its use could contribute to a reduction in hospital bed blocking, alleviate pressure on GP surgery’s and reduce prescription charges for conventional medicine. Has this been fully explored by NHS managers and those formulating NHS policy? I suspect not. It’s probably fair to say that when the trailblazing oncologist Professor Karol Sikora and 64 other signatories sent their letter to be published in the Sunday Times newspaper on 20th November 2016 under the caption ‘We must think the unpalatable to stop death of the NHS, say doctors’, they did not have in mind the potential of CAM. And yet, a professionally qualified, regulated, insured, highly experienced, motivated and ‘untapped’ workforce of CAM practitioners is ready, willing and able to assist.

The Alliance for Natural Health International’s founder, Robert Verkerk PhD, observed:

…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…

In conjunction, earlier research concluded:

…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.”

“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…

Flipping the coin

With growing interest in CAM therapies, caution and scepticism towards CAM by GPs could be addressed as suggested in the following, well versed research paper:

…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…

If the freedom of NHS patients to receive CAM treatments and remedies is to be secured, CAM professional organisations and regulators need to convince NHS staff of its value. I would argue that it should not be requisite that such evidence-base be limited to Randomised Controlled Trials (RCT). Also, it should be recognised that it is not appropriate to apply so-called “Gold-standard” methods of assessment to some CAM modalities for which a more patient-led, flexible approach should be taken.

Further support comes from Economist Christopher Smallwood in the publication 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:

…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.”

CAM practitioners may be forgiven for thinking that the NHS employment status Allied Health Professions (AHP) must also include many of the CAM professions but, with a single exception, this is not the case. Despite harbouring a long list of beneficial alternative and complementary therapies as applicable, only the statutorily regulated profession of osteopathy is currently accepted as an AHP. Arguably, other CAM professions, including herbal medicine, should be acceptable too, having made significant advances in relation to both the regulation and research of CAM in the 18 years since the House of Lords report was published.

Despite being an accepted health specialism in Switzerland and a treatment endorsed by the World Health Organization (WHO) 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 CAM and homeopathy prescriptions continue to be challenged by health authorities.

The debate on CAM should not just be confined to cost and proof, but most importantly the response of the patient. Speaking in Westminster Hall, (10:58am) London, regarded governmental alternative therapy advocate 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...

It is likely a significant number of NHS patients will request one or more complementary therapies, for which they will want to make a ‘direct payment’. Logically, this should be a request that is difficult for the NHS 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. In the interests of patients and all health professionals, the NHS could implement a policy to record and analyse the use of (and requests for) complementary healthcare, especially within the integrated personal commissioning and personal health budgets schemes.

Changing the conversation

Returning to the nature of NHS and governmental scepticism regarding CAM therapy effectiveness, the BMC Medicine research article, Six ‘biases’ against patients and carers in evidence-based medicine, holds great significance – especially in the lack of embrace for patient involvement in research, systematic use of individual (‘personally significant’) evidence and unequal power dynamics in healthcare encounters:

…workable solutions have not arisen from within the EBM [evidence-based medicine] 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’…and consider whether it is time to extend and enrich EBM’s evidence base…

This article does not expressly refer to CAM. 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, questioning the “rigid gold standard” of the Randomised Controlled Trial, I suggest support the contention that CAM should be a treatment option available to NHS patients.

The sobering article General Practice is doomed unless we change direction, written by Dr Michael Dixon, Chair of the College of Medicine, opens with the following warning:

…If we continue as we are, general practice has no future. This is not a political statement blaming any politicians or organisations but a naked practical truth. Within five years, the family doctor providing personal and continuing care, will be gone – it’s happening already…

I believe it is in the interest of their patients and the pursuit of integrated medicine that CAM practitioners, regulators and professional organisations should heed Dr Dixon’s warning and combine to have their voice heard in support of GP practices; 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 reasonably evidence-based (i.e. relevant to the treatment modality and not exclusively by way of a Randomised Controlled Trial) CAM services from a professional practitioner of their choice.

To conclude, late in 2017, Angie Buxton-King, who was employed by University College London Hospital (UCLH) as a healer from 1999 to 2011, published her 2nd book titled The NHS Healer: Onwards and upwards.

The author commences this exceptional book with the following quotation attributed to the Greek philosopher Plato. I cannot think of a better way to end this article than by quoting it again here:

We can easily forgive a child who is afraid of the dark; the real tragedy of life is when men are afraid of the light”.

Read Richard’s entire article.

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