Feature

Beyond the fringe

There are a whole range of issues to face up to - quite apart from that of effectiveness - before complementary therapies could become integrated into the health service. Julie Stone reports

Within the last 10 to 15 years, alternative medicine has grown in popularity to such an extent that many therapies are now taken very seriously by the public and orthodox health professionals alike. This change is reflected in the nomenclature-the term ‘fringe medicine’, previously regarded as the province of a cranky few, has been replaced by ‘complementary medicine’, indicating an altogether more placatory approach to conventional medicine. The growth in use has been quite astonishing, with an estimated one in four of the population using some form of therapy or another.¹ But his growth has taken place almost entirely within the private sector. Often citing dissatisfaction with orthodox practitioners as a motivating force, those who can afford to pay have rejected the NHS and invested money in their own health and well-being.

In the last few years, a number of small, but significant projects have attempted to integrate complementary therapies within the NHS. Beyond these centres, various therapies are offered on a haphazard basis in many regions. A National Association of Health Authorities and Trusts survey estimated that £1m is spent on complementary therapies, a drop in the ocean in terms of overall NHS spending.² Given the apparent success certain complementary therapies seem to have, particularly in conditions where conventional treatment falls short, should complementary medicine be integrated into the NHS?

Attitude of orthodox professions

Given the level of support for complementary medicine amongst patients and practitioners, why are therapies not more readily available on the NHS? In the past, the answer might conceivably have been hostility from the orthodox profession. That argument no longer seems plausible. The tenor of the BMA’s 1993 report, Complementary medicine: new approaches to good practice, demonstrates just how far the medical profession has come in accepting alternative approaches. Recently, a survey by Sheffield University found that just under 40 per cent of GPs now either provide or support the use of complementary approaches.³ And growing numbers of nurses and other health professionals are incorporating alternative therapies into their practice.

The NHS reforms have provided greater scope for complementary therapies to be provided within the NHS, where the views of the medical profession still carry considerable weight, but are not wholly determinative.

More systematic integration would raise awkward questions about therapists’ accountability and professional autonomy. Although there is support for increasing access to complementary therapists, provided GPs act as gatekeepers, this arrangement may not suit therapists who have worked for many years in the private sector as independent contractors. And when many doctors do not even understand the rudiments of holistic medicine, can they realistically delegate treatment to complementary therapists? If, as will often be the case, the true relationship is that of referral, then complementary practitioners will be legally liable for their own mishaps. Doctors, however, could remain liable if they made a referral to someone who was not appropriately qualified. Fears about bogus qualifications, the absence of effective disciplinary mechanisms and the failure of some complementary practitioners to have professional indemnity mean that patients could be left without any form of redress, and with NHS doctors unwilling to refer.

Integration at a therapeutic level

The biggest barrier to widespread integration is the question of proving effectiveness. Central to the statutory regulation debate has been the ability, or at least preparedness, of therapies seeking formal statutory regulation to be able to demonstrate their efficacy in scientific terms. This is a critical obstacle, encapsulating the diametrically opposed reductionist, empirical approach of biomedicine and the intuitive, subjective approach of holistic medicine.

Proponents argue that proving the efficacy of holistic medicine is not possible with the randomised control trial, the gold standard of biomedical research. There is understandable hostility to the notion that complementary practitioners working within an entirely different paradigm should have to justify what they do in ‘scientific’ terms. This reluctance is compounded by the fact that few clients seem to care about objective evidence, choosing their therapist more on the basis of personal recommendation.

How would complementary therapy be provided within the NHS? Greater integration presupposes that a sufficient proportion of complementary therapists wish to work within the health service. For many therapists this is a deeply unappealing prospect. Whether private practitioners work from home or in dedicated practices, much attention is paid to a tranquil setting in which the patient can feel relaxed. Therapists emphasise giving clients time and space to explore physical, emotional and spiritual problems. Treatment sessions frequently run over time. Such an ambience would be hard to replicate within the NHS, where the cash-limited services that could be provided would be very different to existing private arrangements.

The government’s attitude

While the government hides behind a cloak of ‘benevolent neutrality’, the Labour party, in its paper Facilitation not prescription, has called for the introduction of GP referrals to five major therapies (osteopathy, chiropractic, acupuncture, homeopathy and herbalism) and the creation of an ‘office of alternative medicine’ with specific funds allocated for treatment and research.⁴

Inevitably, economic factors will have an important influence on integration. Complementary therapists argue that non-drug based, ‘natural’ therapies are cheaper to administer than their ‘hi-tech’ equivalents. While this may be true in the long term, in the short term there would be little prospect of therapies being offered in place of existing treatments. Rather, complementary therapies would be offered in addition to existing services, at least until there was sufficient evidence that the complementary approach was more effective. Substantial costs would be incurred training and employing therapists to provide services on a national level.

The need for effective regulation

The growth of complementary medicine has not been matched by appropriate regulatory controls. The standard of voluntary self-regulation varies from extremely efficient to virtually non-existent. Training standards vary hugely, and a multiplicity of professional bodies exists, with overlapping and rarely-invoked disciplinary mechanisms. Paradoxically, the Medical Act 1983 and the General Medical Council is the regulatory model to which many aspire. So osteopaths and chiropractors, who have been granted autonomous status, have based their regulatory structures on the GMC, at a time when even the GMC has publicly accepted its shortcomings.

Because the law effectively allows people to set themselves up in practice as ‘therapists’, it is very difficult at present for public and employers alike to know who is a good practitioner. Until core competencies and national standards are developed, NHS trusts will be hard pressed to know who to employ.

There is, in addition, an uncritical assumption that more formal regulation will promote better standards of practice. Therapists should be seeking an ethics-based, not a status-based, approach to practice. There is a real danger that by pursuing statutory regulation, and by making training more ‘academic’, complementary therapists may lose their humanistic skills and become indistinguishable from their ‘conventional’ counterparts.

Self-responsibility: ready or not?

Patient participation is an integral part of the success of complementary medicine. Health and well-being requires self-responsibility in areas such as diet, lifestyle and stress reduction. In choosing to consult a complementary therapist, patients are making positive choices about their own health. Greater integration means that the benefits of complementary medicine could be made more widely available, particularly for those unable to pay privately. But not all patients are ready or willing to embrace this fundamentally different approach to health, which is at odds with the high dependency, ‘pill for every ill’ approach that most people have come to accept as the norm. Until more people are prepared to exercise greater self-responsibility, a paternalistic form of healthcare provision will dominate.

The future

Currently, there is a great rush towards professionalisation among complementary therapists. In part, this is the result of concern that unless practitioners organise themselves, they will be marginalised by the government, which may follow other European countries in restricting the practice of complementary therapies to qualified healthcare practitioners. While it is extremely unlikely that the government would remove the common law freedom to practise, NHS employers, to the extent that they will consider employing complementary therapists at all, might be inclined to pass over lay therapists in favour of qualified staff who have developed complementary therapeutic skills.

While professional qualifications are important, the key question which must be addressed is efficacy, particularly for any therapy which carries a risk of harm to patients. Much current research into complementary therapies is being carried out by conventional medical researchers, further fuelling concerns that the more ‘medicalised’ therapies such as acupuncture will indeed be colonised by the medical profession.

Political and philosophical factors, and not merely practical issues, will determine the future direction of healthcare. At the heart of this debate is the profound question of what constitutes health. For holistic practitioners, health is defined not solely in terms of patients’ physical symptoms, but also their emotional and spiritual well-being, and their interaction with the environment, the air they breathe, and the food they eat. Until the full political consequences of this view are appreciated both by users and providers of healthcare, the introduction of complementary therapies into the NHS will be a purely cosmetic exercise.