Download Should CAM be funded by the NHS

MSc Medical Anthropology, Paper 1, Debate Group 2
(Speakers: Barbara, Leon, Sanjay, Non-speakers: Adrianna, Justin, Andrew)
4.12.2002
Debate Report: Should CAM be funded by the NHS?
Introduction
The recent discussions whether complementary and alternative medicine (CAM) should be
funded by the National Health Service (NHS) in the UK has brought up various issues. This
debate group argues that the NHS should not fund CAM, but instead focus on more urgent
health issues in the public health sector. Apart from the obvious financial constraints of the
NHS to cover an estimated budget of £2,700,000,000 a year for CAM therapies, there are
various other reasons that speak against the NHS funding CAM therapies, which are
summarised in this report.
Part I: Fashion in CAM and NHS Priorities
The current popularity of CAM is dictated by fashion. A survey of CAM users in the UK
found that a principle reason for use was for "relaxation"; some users even take CAM
therapies in the absence of any medical illness or documented deficiency (BBC, 1999;
Robertson, 2002). The 6th House of Lord Report maintained that many more surveys need to
be done to arrive at productive conclusions regarding the implications of CAM for the NHS.
(Select Committee on Science and Technology: 6th Report).
The main points that were brought forward in the first presentation of the debate are:
1. Lack of a single Definition of CAM: The CAM community itself has been struggling for
15 years to come up with a single definitions of CAM agreed by all, but with no success.
29 types of CAM are listed in the 6th Report and have been classified only according to
their ‘professional organisation‘ (Richardson 2001:794-5; and Select Committee on
Science and Technology: 6th Report).
2. Cost Ineffective: On average, the budget for CAM medical treatment in England would
be £2,700,000,000 per year (BBC, 1999). This figure is only for the cost of CAM
therapies in England, excluding the rest of the United Kingdom. It would clearly
marginalize essential activities of the NHS from general public health care.
3. Lack of well-researched studies on CAM: The lack of in-depth research on CAM
methods makes it difficult to evaluate the benefits of integrating CAM into NHS services
(Bodeker and Kronenberg 2002:1583).
4. Lack of rational data for the Public: If CAM is to have a strong effect on health policy
making, it is essential to provide the public with rational, non-commercial in-depth data
online, which is currently available mainly at MED-LINE and the British Library’s
AMED (Bodeker and Kronenberg 2002:1589).
5. Lack of standardisation: Most CAM educational facilities are monitored by internal
associations. Some of the CAM methods have as many as12 organisations (aromatherapy)
just in Britain. The principal purpose of regulation of any healthcare profession is to
protect the public from unqualified or inadequately trained practitioners (Committee on
Science and Technology: 6th Report: Chapter 6). The report shows how essential a
uniform system of regulating CAM would be to have any effect on NHS policy.
6. Lack of safety standards: Part two of the report demonstrates that there are not enough
scientific research studies published that would allow a safe distribution of CAM through
the NHS without potentially harming the public.
7. Lack of education on CAM, especially for GPs and nurses: If CAM is ever to be
introduced to NHS services, doctors and physicians will need to be trained in advising
their patients on CAM. A tremendous lack of education in the field would need to be
bridged to make this work effectively.
8. Time consuming: If CAM enters NHS services, time of consultation will be shortened at
a ration of 1:6 and waiting periods will increase even more. Existing data suggest that the
use of CAM by NHS general practitioners (GPs) takes so much more time than
conventional biomedical treatment that for each patient administered through CAM, the
GP has to sacrifice treating six patients through conventional biomedical therapy (Adams,
2001).
9. Building up dependencies and psychological addictions among the patients: Too
much of free attention to patients creates dependencies and psychological addictions
among patience which the NHS would have to pay for. Many CAM therapies are spread
out over several sessions and are observed to cause "dependence"-meaning that the same
patient will not only come once for CAM treatment (displacing six biomedically-treated
patients), but return several times for reasons related to the nature of the therapy, to poor
initial efficacy, or to the psychological addiction many CAM therapies seem to create in
users (Adams, 2001).
Priorities of the NHS
Looking at the NHS Reform Plan 2000 (www.nhs.uk/nationalplan/pressrelease.htm) it
becomes obvious that the NHS is a 1940s system operating in the 21st century and needs to be
reformed in terms of standard, de-centralisation and autonomy of local health services,
empowering patients, reducing waiting periods, especially in the emergency departments.
(www.nhs.uk/nationalplan/summary.htm).
The current budget will achieve by 2005 that GP appointment will be given within 48 hours,
cancer screening programmes and cancer drugs be made available, as well as free nursing care
in nursing homes. Another focus is diet improvement for children in schools (1 fruit a day),
and the establishment of mental health teams countrywide. Waiting periods for outpatients
will be reduced to three month and for inpatients to six months.
With such urgent priorities in conventional biomedical public health care any extra
expenditure on CAM would undermine the national health system considerably.
Part II: Safety and Efficacy Issues
The surge of interest in alternative treatment, that is methods of treatment that are not wellestablished within western biomedicine, demands a serious debate about scientific
documentation, efficacy and safety. It has been argued that there is no such thing as
alternative medicine. There is only scientifically proven, evidence-based medicine supported
by solid data.
What sets most alternative methods of treatment apart from biomedicine is that it has not been
tested scientifically and advocates for such treatments largely deny the need for such testing.
By testing is meant the marshalling of rigorous evidence of safety and efficacy, as demanded
by the approval boards in most western countries today before a new drug or treatment is
permitted, and is required by the best peer-reviewed journals in the field today. It is a point
that many treatments available in conventional medicine have not been subjected to rigorous
testing either, but the medical community generally acknowledges this lack of evidence and
seeks to mend it. On the other hand alternative practitioners often deny that rigorous scientific
methodology is appropriate to their remedies. With reference to key thinkers in the sociology
of knowledge, these practitioners claim that they operate within a completely different
paradigm and that their paradigm is incommensurable with biomedicine. These philosophies
are used as a shield by which these practitioners avoid scrutiny of their practices.
It is ironic that at this point in time when biomedicine has made such great advances, a real
disillusionment with school medicine has occurred and a shift towards these alternative
remedies has been going on for decades.
Efficacy
According to Angell and Kassirer (1998) the results of an American congressional inquiry
into the effects of alternative medicine have been disappointing. Of 30 research grants
awarded, to study the efficacy of CAM, 28 resulted in final reports, but only nine out of these
resulted in published papers. Five were published in journals not listed among the Conway
library of medicine’s collection of 3500 journals. Of the remaining studies, none was a
controlled clinical trial that would not allow any conclusion to be drawn about the efficacy of
the alternative treatment under study.
Issues of safety
The most widely used form of alternative therapeutics is herbal remedies, and fortunately
most of these are probably harmless. They seem to be used mostly by healthy people who
wish to remain that way, or people with relatively minor problems such as backache or
fatigue. In all probability, these people would seek out a conventional physician if they were
suffering from anything more serious than, e.g. serious chest pain or blood in the urine.
However, uncertainty about whether symptoms are serious could result in a harmful delay in
getting treatment that has been proven effective. Some people embrace alternative treatments
exclusively, putting themselves at grave risk. Baum (1991) reports the case of a cancer patient
who relied entirely on homeopathy while the disease progressed and her condition
deteriorated. The homeopathy itself did not harm the patient, but her complete reliance on it
led her to avoid getting more effective methods of treatment. Research has shown that
individuals who use CAM rarely turn completely away from conventional medicine, however
the exact number of people who do is unknown (Thomas et al. 1991).
There are risks associated with alternative treatments in addition to that of failing to receive
effective treatment. CAM is promoted as being natural and is generally perceived to be safe.
Nevertheless, over the past several years, there have been a number of high quality
studies on the adverse effects of particular CAM treatments such as acupuncture
(Rampes & James, 1995) and manipulation (Dantas, 1999; Dantas & Rampes,
1999). Ernst (1995) reported that acupuncture had caused hundreds of well-documented
adverse effects, including five fatalities. MacGregor et al. (1989) described four women who
sustained liver damage through the repeated use of herbal remedies for the treatment of stress.
Tisserand and Balacs (1995) reported that some oils used in aromatherapy might be
carcinogenic.
Physicians have been advised to seek better integration of conventional and alternative
therapies because "it is what the patient wants." Even the WHO has recommended this (WHO
2002). To continue to have a laissez-faire attitude reinforces the public's notion that
alternative therapies are devoid of potential harm. Every physician has taken an oath to uphold
"the good of the sick to the utmost of my power, holding myself aloof from wrong." As a
medical community, they have a responsibility to educate the public not only about the great
benefits of evidence-based medicine but, in addition, about the risks of using therapies for
which any evidence of efficacy or safety is lacking.
Part III: Problems with the Integration of CAM into the NHS System
In addition to health and safety concerns, a number of basic institutional and structural
constraints pose significant obstacles to the effective integration of CAM treatment into the
NHS system. A close look at the NHS structure and the dynamics of CAM therapy use by
consumers demonstrates that the NHS and CAM treatments cannot be appropriately
integrated - they operate under different structural constraints, and if integrated, they will
undermine both the NHS service and the appropriate administration of CAM therapies.
Because of the demonstrated questionability of CAM therapies, GPs in group practices often
have differing viewpoints on the efficacy and safety of CAM therapies, and are often placed
at odds with each other within a single group practice (where, for example, one GP wishes to
use CAM while the others find themselves too constrained to take the additional caseload for
patients receiving biomedical treatment; Patel, 1987). Under such circumstances, some GPs
find themselves unable to provide proper attention to patients when their colleagues
administer complementary therapies and load their group practice colleagues with additional
caseload of patients in need of biomedical treatment (Gordon, 1995). GPs have resorted to
restricting the numbers of patients receiving both CAM and biomedical treatment,
undermining the distributive efficacy of both therapies (Adams, 2001).
This scenario gets to the heart of the problem posed by the integration of CAM therapies into
the NHS system: the NHS institutional structure simply cannot accommodate CAM because
of the fundamental nature of CAM therapies. A principle reason for the consumer use of
CAM, surveys reveal, is that CAM therapy provides more time for the individual patient than
does conventional biomedical care under current institutional frameworks (Douglas, 1994;
Ernst & Resch, 1997; Ernst & White, 2000; White, 2000). Yet when CAM is integrated into
the NHS system, we find that this key appeal of CAM is destroyed. Practitioners using CAM
in the NHS system have formed what are called "direct integrative practices" (DIPs), which
administer both conventional biomedical treatment and CAM therapy. Yet because of the
pressures of providing both biomedical and CAM treatments, the practitioners have cut-down
CAM therapies into a "quick-style" format to save time (Adams, 2001). This fundamentally
undermines one of the key motivations for consumers to appeal for alternative or
complementary therapy (Cant & Calnan, 1991; Peters, 2000).
In 1995, the New England Journal of Medicine published a study comparing the cost of lowback pain treatment by family physicians, orthopaedists, and chiropractors in North Carolina.
The median total charges were $545 by urban chiropractors, $383 by orthopaedists, $348 by
rural chiropractors, $214 for rural primary-care physicians, and $169 for urban primary-care
physicians. Although chiropractors charged less per visit, their treatment was costlier because
they saw their patients about five times as often (Carey, Garrett, Jackman, McLaughlin, Fryer
& Smucker., 1995). Dependence within the GP practice would displace patients from
biomedical therapy while simultaneously undermining the key advantage of the CAM
therapeutics (the desire for more time with the patient) as a result of the push towards "quick
style" use. The irony, then, is that CAM integration into the NHS would not only undermine
the NHS system, but would undermine the appeal of CAM itself.
Using only selected complementary therapies has limited efficacy, because they are removed
from their larger paradigm of philosophy and practice (Richardson, 2001). We are almost
assured that this would be the case if CAM were integrated into the NHS system, which is a
multiple-billion dollar structure entirely focused on the decentralised use of GP practices for
the delivery of care.
The figure of £2,700,000,000 (BBC, 1999) is only for the cost of CAM therapies in England,
excluding the rest of the United Kingdom. Such an astonishing and exorbitant cost is simply
impossible for the NHS system to absorb; the NHS would be spending more money on
acupuncture than it currently spends on cancer treatment (and Britain has the worst survival
rate of cancer in the developed world; British Council, 2000). The same quantity of money
would also go toward the provision of treatments whose efficacies are often highly
questionable (two most used CAM treatments in the UK, for example, are aromatherapy and
homeopathy), as opposed to being spent on therapies that have undergone years of rigorous
testing and use (BBC, 1999; Tonelli & Callahan, 2001).
The NHS is fundamentally a welfare-state-based social security system-a public insurance
scheme designed for the collection of funds and their distribution so that those who could not
otherwise afford to pay for therapies could obtain necessary treatment rather than being left to
die because of the inability to pay. Yet the use of CAM is fundamentally contradictory to this
welfare-state scheme, and would even produce redistribution in the wrong direction: from
poor to rich. Across the vast majority of published surveys taken of CAM use to date, the
wealthiest classes are those using CAM therapies (MacLennan, Wilson & Taylor, 2002;
Rafferty, McGee, Miller & Reyes, 2002; Ong, Petersen, Bodeker & Stewart-Brown, 2002).
Many users of CAM are also under the false impression that the medicines have been
extensively tested and are subject to the same standards are prescribed medicines
(MacLennan, Wilson & Taylor, 2002).
Conclusion
We are left, then, to conclude that the proposal to integrate CAM into the NHS would
undermine the basic redistributive structure of social security. Rather than doing so, we might
ask why CAM therapies are so popular among consumers. In survey after survey, we find that
CAM therapies are used by those disenfranchised by the biomedical system (Douglas, 1994;
Ernst & Resch, 1997; Ernst & White, 2000; White, 2000). Persons who have not given
enough attention by their GPs are principle among users of CAM, but GPs show that their
budgets are too constrained to afford needed time to their patients (Adams, 2001). Rather than
further undercutting the national healthcare budget to distract ourselves from this central
problem and fund therapies of questionable efficacy (while undermining the national health
security system), shouldn't we instead place our emphasis on keeping the funding base within
the current NHS framework, so that patients receive the attention they need and are not
distraught by the increasingly impersonal nature of biomedical practitioners who are so costconstrained that they have little time for patients?
Rather than fund CAM therapies, the NHS should focus on integrating its practices to
decrease waiting times-which are at one-hundred and seventy-two days for open heart surgery
in some parts of the UK-and to better aid in the distribution of medicines to the poor, who are
consistently those suffering most in the Britain according to the NHS's own admission (NHS,
2002).
As Richardson (2001) writes, the debate over whether to integrate CAM into the NHS offers
the critique that nursing and medicine are becoming increasingly "removed from the genuine
therapeutic relationship and we try to fill the gap by learning new techniques" like CAM
therapies. If the real issues at play "are neglected there is a real danger, that in the rush to
incorporate different 'techniques' into our conventional practice, we may miss an opportunity
to explore the therapeutic relationship." The integration of CAM into the NHS system would
draw funds away from efforts to redistribute healthcare and improve patient service, and so it
must be avoided in order to prevent the breaching of our most fundamental social contracts.
Despite lack of evidence for the efficacy of alternative therapeutics it cannot be ignored that a
substantial amount of people in the western world utilise the alternative approaches. Whether
there is a true effect or not, this is a reason in itself why the scientific community ought to
scrutinize these methods more thoroughly.
It must be pointed out that unless substantiated by research, the therapeutic use and
acceptance of alternative remedies cannot be extended in the future with confidence. It is
unethical to promise cure and recovery when the methods used lacks evidence of an effect.
We have to stop giving alternative treatments a free ride. There can’t be two kinds of
medicine –conventional and alternative. There is only medicine that has been adequately
tested and medicine that has not, medicine which works and medicine that may or may not
work. Once a treatment has been tested rigorously, it no longer matters whether it was
considered alternative at the outset. If it is found to be reasonably safe and effective, it will be
accepted. However, assertions, speculation and testimonials do not substitute for evidence.
There are few well designed papers on the effectiveness of methods of treatment that are not
generally established in Western medicine, and thus at present the adoption and use of these
treatments by the NHS cannot be recommended.
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