06/02/2006
Source: LOHAS Weekly Newsletter
Author: The Times
The Prince of Wales is well known for his interest in complementary medicine. Addressing the World Health Assembly in Geneva last Tuesday he issued a plea for patients to be offered both conventional and complementary treatments as part of an “integrated approach” to healthcare.
On the same day 13 medical professors issued a letter attacking what they see as a “campaign to promote complementary and alternative medicine as a component of healthcare provision” and appealed to National Health Service trusts only to fund treatments based on “solid evidence”. In their view, most complementary therapies do not fall into this category and the NHS should not touch them.
This is by no means a case of the prince against the doctors: medical opinion about the usefulness of many complementary therapies — osteopathy, chiropractic, acupuncture, herbal medicine, homeopathy — is not united behind the professors. University College hospital in London, for example, one of the country’s top hospitals, conducts joint antenatal and pain clinics with the Royal London Homeopathic hospital (RLHH), and more integrated clinics are planned.
Half the GP practices in the country choose to provide some complementary treatments, presumably because they believe the effects are beneficial. Yet the scientific end of the profession remains sceptical, citing the absence of systematic evidence of effectiveness.
It is a confusing scene, and two years ago Prince Charles asked me if I could come up with a “reasonable outsider’s” view of the likely effectiveness of different therapies and the possibilities for cost savings if they were adopted. As an economist who had filled senior positions in government, industry and banking, I was not a party to any of the warring factions.
I had no preconceptions about complementary medicine beyond some mild scepticism, ameliorated in my case by a successful experience at the British School of Osteopathy, which I had recently entered doubled up with back pain, leaving half an hour later fully straightened out.
My team and I decided we would focus on mainstream therapies — manipulation, acupuncture, herbal medicine and homeopathy — and adopted a threefold approach. We would scan the available literature in medical journals and databases; we would examine the experience of complementary health centres on the ground; and we would talk to as many people in the field as we could to try to establish whether there was a reasonable consensus about what worked and what didn’t, what was good value and what wasn’t.
The literature scan revealed that this is a hugely under-researched area. Many treatments are not adequately covered at all. Some high-quality studies appear to establish the efficacy of certain remedies, particularly in the area of herbal medicine, but many apparently well-conducted studies contradict each other. So the conclusions that can be drawn from the available literature are limited.
The treatments that seemed to us to come out best were: acupuncture for the relief of pain, particularly post-operative pain and pain associated with chronic conditions such as arthritis (notably arthritis of the knee); manipulation therapies for musculoskeletal complaints; and herbal remedies for a whole series of conditions, including musculoskeletal problems, osteoarthritis, depression, heart and circulatory problems and prostate conditions, although the effects are often mild.
On homeopathy, contrary to what is often claimed, we found the evidence inconclusive, concluding: “The most that can safely be said is that there are many conditions commonly treated by homeopaths for which they report good results.”
We then looked at three health centres, mainly because they had the best records and offered the range of treatments we were interested in: an experiment carried out by Newcastle Primary Care Trust in Newcastle upon Tyne, the Glastonbury Health Centre in Somerset and the Laurels Centre in Haringey, north London. Local GPs made referrals on the NHS and we found the majority related to back and neck pain, and psychosocial problems such as depression, anxiety and stress.
In all three the majority of those referred registered clinically significant improvements. In all three there were substantial savings in primary care costs, as consultations with GPs and the number of prescriptions issued fell. These were not sufficient to cover the costs of the complementary treatments in full, but when the Glastonbury doctors added in estimates of consequential savings in secondary (hospital) care as well, they found that the total savings generated were sufficient to do so.
Our conclusion is that the complementary therapies we studied have most to offer in relation to chronic musculoskeletal conditions such as arthritis and back pain, psychological complaints such as depression, anxiety and stress, chronic pain and the general management of pain.
Surveys show that doctors regard these areas as large “effectiveness gaps” in the NHS. In other words, complementary therapies may do best where conventional medicine is at its weakest. This is the case for an “integrated approach to healthcare.
Doctors do, however, need guidance in relation to complementary treatments and I recommend that the National Institute for Health and Clinical Excellence (Nice) becomes more active in this area. When considering new drugs, its advisory panels should also consider complementary alternatives.
After discussions with the Department of Health and Nice I am optimistic that this may happen. This work should be supported by a large increase in research into the cost effectiveness of complementary therapies: at present, spending in this area amounts to 0.03% of the NHS’s research budget so it’s not surprising we are under-informed.
Should complementary therapies be paid for by the NHS? My answer is certainly, if only in some communities. The chronic and psychological conditions highlighted in my report are particularly prevalent in deprived areas: precisely the places where people cannot afford to pay privately.
Should doctors be allowed to prescribe treatments whose effectiveness has not been scientifically proven in systematic trials? In the light of our work, I would say yes, if it seems to the doctor and patient that the treatment works and Nice decides there is a reasonable weight of evidence in their favour.
Take homeopathy: there is no conclusive scientific evidence in support of homeopathy. But Dr Peter Fisher of the RLHH recently told me about a patient who suffered for 10 years from unexplained vomiting before receiving homeopathic treatment, which he describes as “life-changing”, and a woman whose son suffered from severe asthma that “cleared up within days” after visiting the RLHH.
I heard one of the 13 professors who wrote last week’s sceptical letter say (though not about these cases): “It can’t be the homeopathy; they just got better.”
Really? After 10 years or 20 years of suffering, they suddenly just got better? Whether this is a placebo effect or not, it is evidence of healing that cannot reasonably be ignored.
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