Medical Editor/Writer and Acupuncturist, London, UK
Received date: 10 April 2007; Accepted date: 16 April 2007
Complementary and alternative medicine (CAM) is widely used in addition to or instead of conventional medicines for positive or negative reasons. Negative reasons are a poor outcome from conventional treatment; unwanted effects from drugs; a negative experience of the general practitioner relationship; and health views not in line with the conventional medical model.Positive reasons are a good outcome from CAM treatment; being an active participant in health care; a positive experience of the CAM practitioner relationship; and health views in line with the CAM model.This paper discusses how complementary and alternative therapies may be used to address important gaps inNHSprovision not amenable to conventional therapy.
complementary and alternative medicines, patient-centred care, quality improvement, therapy
How this fits in with quality in primary care
What do we know?
Access to and use of complementary and alternative medicines (CAM) and therapies are important areas for quality improvement in primary care.
What does this paper add?
This paper describes positive and negative reasons for patients using CAM therapies and explains why these therapies may address important gaps in conventional medicine.
Complementary and alternative medicine (CAM) is more popular in the UK today than ever before, with an estimated 5 million adults seeing a CAM practitioner each year.1 Around 10% of these consultations take place within the NHS, at a cost of about £50 million in 2001.1 Among the most popular CAM therapies are acupuncture, aromatherapy, chiropractic, herbal medicine, homeopathy, hypnotherapy, osteopathy and reflexology, and up to one-third of people use complementary self-help techniques such asmeditation and relaxation, and over-the-counter remedies.2
What has created this apparent public and patient enthusiasm for CAM? The reasons for the increase in acceptability and use of such therapies reveal a great deal about social trends in the latter part of the 20th century, such as patient choice and involvement in decision making.Howeve r, there is much we do not know about why CAM has become so popular at this time.Even as recently as the 1960s, CAM was a fringe interest in the UK; before then there was not even a general name by which these therapies were known.In fact, it was not until the 1980s that interest in CAM really started growing, not only from patients and the general public but also from doctors and other healthcare professionals.Many theories have been put forward, such as disillusionment with certain aspects of conventional medicine or the claim that many people have benefited from CAM.Research suggests that most people tend to use CAM therapies alongside conventional medicine, rather than as an alternative to it, sometimes for different complaints, sometimes together for the same complaint.This article explores the growth of CAM use in the UK, and looks at why and how people are using CAM, particularly within the NHS.
What do we mean by CAM?
Broadly speaking, CAM includes those healthcare practices that are not currently an integral part of conventional medicine.What therapies are considered to be complementary or alternative is not fixed.New therapies are constantly being developed and, as a therapy is shown to be effective and safe, it can become accepted as a conventional healthcare practice (e.g. as is happening with acupuncture, chiropractic and osteopathy).
The Cochrane Collaboration defines CAM as including:
... all such practices and ideas which are outside the domain of conventional medicine in several countries and defined by its users as preventing or treating illness, or promoting health and well being.These practices complement mainstream medicine by 1) contributing to a common whole, 2) satisfying a demand notmet by conventional practices, and 3) diversifying the conceptual framework of medicine.3
The growth in CAM use
One study conducted in England in 1993 found that about 8.5% of the adult population had received at least one of the following main CAM therapies in the previous year: acupuncture, chiropractic, homeopathy, hypnotherapy, herbal medicine or osteopathy.4 Five years later, this had increased to 10.6% of respondents (n = 283) and, if reflexology and aromatherapy were included, it increased to 13.6% (n = 363).4 Applying the assumption that all non-respondents were nonusers reduced the estimate of use to 6.6%.4 In another UK survey in 1999, an estimated 20% (n = 245) of respondents had used some type of CAM therapy or bought an over-the-counter remedy in the previous 12 months.5 Also, 78% of respondents said that they were, or felt that other people were, using CAM therapies more than they were 5 years ago.5 In a survey conducted by the Consumers’ Association in 1995, nearly 9000 subscribers to the magazine responded, and almost one in three reported having used CAM at some time in their lives.2 Of thosewho had used it, one in five had done so during the preceding year.
Why the increase in popularity?
There are probably many reasons why CAM therapies have increased in popularity.Up until the late 1960s, most people still had complete faith in conventional medicine; doctors were respected members of the post-war community, and they had the time to talk to and visit their patients.A substantial shift in attitudes has taken place since then.This has, in part, been due to a growing disillusionment with conventional medicine and a real or perceived negative harm: benefit ratio for some of its treatments, and may also be partly due to the desire for more equal relationships between patients and healthcare providers that is embodied in the new consumerism of the 20th century. 6 A person-centred, person-empowering approach to health and self-care is now also intricately linked to public health strategy.In their Choice Matters document, the Department of Health states: ‘Giving people more choice and control over their treatment and services is one of our key priorities in theNHS – because people want it’.7
One qualitative study, involving 49 semi-structured interviews in eight locations across England providing CAM therapy services within primary care, looked at satisfaction withCAMamong patients receiving treatment funded within the NHS.8 The researchers found that CAM therapies were experienced at ameliorating and curing conditions, including chronic problems, and that patients perceived CAM practitioners as being caring and valued the development of a therapeutic relationship within which they were encouraged to take an active part in looking after their health.The interviewees contrasted their positive experiences of CAM use with either a failure of conventional medicine or a dislike of the conventional treatments available to them.Very few negative aspects of CAM were reported, and patient satisfaction was consistent across settings and type of therapy received.Another qualitative study looked at complementary therapy use by patients and parents of children with asthma, and the implications for NHS care.9 Fifty semi-structured interviews of 22 adults and 29 children were carried out.The CAM therapies were usually used alongside conventional asthma treatment, and motivating factors included concerns about conventional NHS care and attractive aspects of CAM therapies, such as respondents’ empowerment to take greater personal control over their condition and enabling them to explore a broader range of possible causes of their asthma.A third qualitative study was carried out to help rheumatologists understand why patients with rheumatoid arthritis chose to use a CAM therapy.10 Five unstructured interviews were conducted.The incentives given as to why the patients used CAM included dissatisfaction with conventional treatment, often due to unwanted effects and drug ineffectiveness. Perceived benefits were either physical or psychological, and associated with aspects of choice and control.
Overall, patients and the public consistently report four negative and four positive reasons for using CAM.12 The negative reasons are: a poor outcome from conventional treatment; unwanted effects from drugs; a negative experience of the general practitioner (GP) relationship (possibly due to a decline in personal doctoring); and health views not in line with the conventional medical model.The positive reasons are: a good outcome fromCAMtreatment; being an active participant in health care; a positive experience of the CAM practitioner relationship; and health views in line with the CAM model.1
Patients’ beliefs and expectations of CAM
Research has shown that patients who use CAM assume it is inherently linked to a holistic approach and a therapeutic relationship founded on trust and support, understanding and empathy.6 They expect to be treated as individuals rather than as a collection of symptoms and have high expectations for cure, symptom relief, an improved quality of life, self-help advice and wide availability of such therapies on the NHS.6 A belief in the philosophical basis of the therapy chosen can also be important.Rese arch suggests that philosophical congruence is predictive ofCAMtherapy use, and that, rather than turning to CAM because of disillusionment with conventional medicine, people are most likely to be drawn to a CAMtherapy because it is seen as more compatible with their philosophies or beliefs about health and illness, their values and their worldview.2,11
There are certain concepts that are perceived as being beneficial and characteristic to CAM therapies, and which are often thought not to apply to conventional medicine.2 These concepts include holism, the mind–body link, ‘energy’, self-healing, patient involvement and empowerment, and wellness.The holistic approach to health involves taking the whole person into account – mind, body and spirit – and then tailoring treatment to the individual.Many, but not all, CAMtherapies purport to take this approach, and have a multifactorial view of ill-health and its treatment. The mind–body link is so important to most CAM therapists that they regard it as essential to take the time to explore any psychological factors that might have played a part in causing an illness.Many CAM therapies embrace the idea that the body, mind and spirit are all maintained by an underlying ‘energy’ or vital force, and associate its depletion or imbalance with ill-health and its restoration or balance with health.This ‘energy’ or ‘vitalism’ is referred to variously, as Qi in Traditional Chinese medicine, prana by Ayurvedic practitioners and yogis, subtle energy by healers, dynamis by homeopaths, vital force by herbalists and osteopaths, innate or universal intelligence by chiropractors, and vis medicatrix naturae by naturopaths, to name but a few.What this ‘energy’ is, whether it really exists or is used simply as a metaphor for, or model of, health and illness, is not known.CAM therapists often say that their aim is to allow or stimulate a person’s capacity for self-healing and they largely see their role as providing the right conditions for this to occur and to promote the body’s own self-regulating mechanisms.In many CAMtherapies, the patient is seen as an active participant rather than a passive recipient of treatment.Often CAM therapists include advice about lifestyle changes in their treatment, and an attraction can be this self-help aspect that encourages and helps people to take control of their health.
The various reasons that CAM appeals to people may not always be helpful or valid.The view taken by some CAM therapists that we are all capable of achieving and maintaining good health, and that we are in a sense responsible for any illnesswe have, can be problematic as it can lead to feelings of poor selfworth, self-blame and guilt.2 Another problem with this approach is that it locates the illness and treatment within the individual rather than society, and could also redirect attention at a political level away from efforts to understand and improve the social and economic factors associated with ill-health.CAM therapists who have these beliefs might not address issues of inequality and poverty, and the consequent lack of satisfactory housing, inadequate hygiene and poor diet, which are some of the biggest causes of disease. CAMis popular partly because it is seen as natural and non-invasive.It is true that complementary remedies are usually made from naturally occurring plants and oils, which are generally regarded as safe when compared with the synthetic, laboratory-produced chemicals used in mainstream treatments.Howeve r, natural substances are not always inherently safe (e.g. ephedra) or non-invasive (e.g. acupuncture). The fact that many CAM therapies have their roots in ancient practices, leads to the claim that they have stood the test of time. ‘Old’, like ‘natural’, is often thought to mean ‘good’. Although some ancient treatments do have merit (for example, acupuncture relieves pain), others, such as bloodletting, are completely ineffective and can be dangerous.
Who uses CAM?
Women are more likely than men to use one of the more established CAMtherapies, and also to buy herbal and homeopathic remedies over the counter.2,4,5,12 The Which? survey found that an increasing proportion of young, fit people are turning to CAM,2 and another survey found that more people (9.2% of respondents, n = 195) in the ‘35–44 years’ age band used CAM services than in other age groups.12 One survey found that more people (30% of respondents, n = 112) living in London and the south-east use CAM than those living in the north/north-west/Yorkshire (21.7%, n = 68, P < 0.025).5 Research has also shown that, while people from all social classes use CAM, those from social classes AB and C1 are more likely to use it (25.7% and 31.4%, respectively) than those from social classes C2 and DE (20.8% and 22.45%, respectively). 5 This is probably a reflection of the cost of private CAM therapies and the variable and sparse availability of low-cost or NHS-based CAM.
What is CAM used for?
Several studies have found that people usually use CAM for long-standing (more than 1 year) illnesses, such as back pain, arthritis, gastrointestinal problems, problems due to injury, anxiety, depression, migraine and asthma.1 In theNHS,CAMis particularly used for musculoskeletal problems, and chronic back and neck pain.1 Most people have already tried conventional treatment for their condition.A survey of 499 patients visiting the outpatient department of the Royal London Homeopathic Hospital, designed to examine patients’ reasons for seeking CAM in the NHS, found that the most frequent reasons were that other treatment had not helped, and concerns about or experience of adverse treatment reactions.13 Sixty-three percent of patients had had their main problem for more than 5 years.Mus culoskeletal system problemswere the most frequent diagnostic group (32%).Satis faction with clinical care at the homeopathic hospital was high (90%), and 81% of patients indicated that their main problem had improved very much, moderately or slightly.Of the 262 patients who had been taking prescription medicines when they first attended, 29% had stopped and 32% had reduced their intake.
Who provides CAM?
The growth in public popularity of CAM in the UK is reflected in the recent increase in registered CAM therapists.2 From 1981 to 1997, the number of nonmedically qualified registered practitioners trebled from around 13 500 to about 50 000.The re are also several thousand conventional healthcare professionals who practise some formor other of CAM therapy and who are registered with their own organisation, such as the British Medical Acupuncture Society or the Faculty of Homeopathy.A survey in 2003–2004 found that 54% of the practitioners providing CAM on the NHSwere non-medical complementary practitioners, 18% were GPs, 2% were practice nurses and 26% were other conventional practitioners.14
Integrating CAM within the NHS
CAM therapies are mainly provided via the private sector, either paid for ‘out-of-pocket’ or through private health insurance.Ho wever, over the past 20 years there has been a significant increase in the amount ofCAMbeing accessed via the NHS, and nowtheNHS provides about 10% of CAM services in the UK.4,15
The Smallwood report (often described as controversial), commissioned by the Prince of Wales to look at the contribution that CAM can potentially make to the delivery of health care in the UK, comprised a literature review, a series of interviews with stakeholders in the field, and case studies.15 It concluded that evidence from the literature review and from the case studies indicates that many of the most effective CAM therapies correspond to recognised ‘effectiveness gaps’ in NHS treatment (e.g. pain relief of osteoarthritis in older patients, in whom the standard treatment of NSAIDs is often contraindicated due to side effects), which suggests that they may have the potential to make an important contribution to the delivery of health care in the UK.It recommended that Health Ministers should invite the National Institute for Health and Clinical Excellence (NICE) to carry out a full assessment of the cost-effectiveness of the main CAM therapies and their potential role within the NHS, to make more funds available for research into the cost-effectiveness of CAM treatments, and to maintain GPs’ role as ‘gatekeepers’ as far as NHS provision of CAM therapies is concerned.It has been suggested that a more sensible recommendation to NICE would be that, in developing the scope of new guidelines on chronic conditions, the institute pays greater attention to reviewing complementary therapies.16
CAM in primary care
According to a survey carried out by the University of Sheffield for the Department of Health in 1995, around four in ten GPs in England then provided access to some form of CAM therapy for their NHS patients.17 The study found that, in one week, 45% of GPs recommended or endorsed the use of CAM therapies in their consultations, 21% referred patients to a CAM therapist, both privately and under the NHS, 6% employed an ‘independent’ CAM therapist, and one in ten GPs treated patients with a CAM therapy themselves.
However, according to a report by the former Foundation of Integrated Medicine, which analysed primary care group (PCG) plans for CAM from 1999 to 2000, the abolition of GP fundholding and the advent of PCGs had a dramatic effect on the provision of CAM on the NHS.17 It found that many therapies previously paid for out of GP fundholders’ budgets were cut completely.The reasons for this included lack of evidence to support their use, or lack of equal access because the therapies provided were not available across the whole PCG.Neve rtheless, a survey carried out by the University of Westminster in 2003–2004 of primary care trusts (PCTs) in England found that around two-thirds offered CAM services, with the most popular therapies being acupuncture osteopathy, homeopathy and therapeutic massage.14 With the advent of practise-based commissioning of services, it is possible that more money will be spent on CAM again because practices will have greater autonomy in terms of deciding what sort of services they offer their patients and will hold a budget that will allow them to offer patients a choice of CAM therapies.
At least one survey of the general public showed that there is a belief in the principle that the NHS should pay for CAM therapies, but disinvestment from existing services was not supported by the majority.18 Some patients will suggest or request that their GP refers them for a CAMtherapy.The response will vary depending on where they live.The Department of Health acknowledges that there are numerous CAM therapies available in the UK and that they are clearly attractive to a number of patients.19 It has stated that, in principle,CAMtherapies could feature in a range of services that local NHS organisations provide, if they agree that it would be a clinically and cost-effective use of resources and be in line with locally agreed health priorities.19 PCTs often have specific polices on the extent to which their patients can be given access to CAM.19 Within those policies, it is open to GPs to give access to specific therapies where they consider it is in the interest of the individual patient.19
CAM in hospitals
Although not many hospitals explicitly offer CAM, many nurses routinely incorporate it into their nursing practices; in particular, massage, aromatherapy and reflexology are increasingly being offered as part of palliative care to patients with cancer.Other CAM provision within secondary care includes: acupuncture in pain clinics (given by anaesthetists, physiotherapists or palliative care physicians); yoga and acupuncture in obstetrics departments (by midwives or physiotherapists); and acupuncture and manipulative therapy in rheumatology and physiotherapy departments (by chiropractors, osteopaths, physiotherapists or orthopaedic physicians).
Patients want to know whether they can play a part in managing their illness and what they can do in practical terms to reduce the impact of the illness and of its treatment on their lives.20 Attention to the patient’s own possibilities for action and self-care can provide a balance in treatment away from dependency towards enhancing the patient’s own sense of personal power.The aim should be to help the patient to take responsibility for his/her health, but not to take the blame for the illness.Research has found that people who use CAM therapies are more likely to express a sense of greater control over their lives as a result of being given guidance on how to help themselves, and described great satisfaction in this new selfreliance. 21
The increasing emphasis on patient choice and the new drive to decentralise responsibility for funding and service provision within the NHS could result in an increased provision of CAM within primary care. The demand frompatients is certainly there.Howeve r, the emphasis on evidence-based medicine within the NHS, coupled with the lack of funding for research into CAM, is an important hurdle to get over before CAM becomes more widely available and integrated into NHS practice.
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