Transcript: A Marriage Made in Heaven?
First broadcast on BBC Radio 4
Tuesday 26/10/04 2100-2130
Over the last five programmes we’ve explored various issues central to the debate surrounding the increased use of CAM - complementary and alternative medicine: its popularity, the debate about evidence behind it, the questions of safety and regulation. CAM, say some, is now poised to create a revolution that may be as fundamental a change to healthcare in this country as the creation of the NHS was over half a century ago.
Integration is the buzz word. The coming together of orthodox and complementary therapies to create a holistic system for the benefit of patients. It sounds wonderful but is it possible? Already pockets of integrated care exist around the country such as the four NHS homeopathic hospitals. But how well do these schemes integrate themselves into mainstream medicine and what does integration mean anyway?
PATIENT Well when I heard about the place I went to my own doctor and she says - Well homeopathic - some of us believe in it and some of us don’t - she says - it won’t do you any harm - she says - it might do you good.
FORD In Glasgow, the Homeopathic Hospital houses a 14-bed in-patient unit and a busy outpatient service. About 400 patients are admitted annually, most referred by specialists and GPs.
The hospital is run by Dr David Reilly.
It’s a place that cares for patients, it does it on the NHS and it has a model of care that’s I think that’s quite cutting edge. We have all orthodox trained people - so you’ve got doctors and nurses, physiotherapists, occupational therapists - who’ve gone on and developed other skills and studied other healing disciplines that would include both what would be seen as complementary medical approaches and mind body medicine and holistic orientations. And the remarkable thing is the extent to which we get such great results from that.
They work with conventional medicine, I mean you come in they don’t take you off of your drugs - that was my decision because of illnesses I’ve had previously and because of what drugs - the drugs have done. And with the help of the remedies and the staff, also the acupuncture, and they do what they call like your addiction points, which helps with withdrawals I suppose, I’ve managed to cut down over half of my medication, my conventional medication.
REILLY What happens is you start breaking the cycles of multiple specialists, multiple investigations and multiple referrals.
FORD Whilst the hospitals have been in existence for nearly 60 years, until recently providing CAM services within the NHS has often been down to the determination of individuals such as Sarah Budd. A midwife at the Derriford Hospital in Plymouth, Sarah started offering acupuncture for pain relief in pregnancy and labour 18 years ago.
BUDD I started using it on the labour ward with success and colleagues from the maternity community service were asking me if I could help them with some of their patients with problems like backache and sickness in pregnancy. I’d had a full traditional Chinese medicine training in London over three years part time and I’d also followed that up by a visit to China to do further training, so I felt well I’ve got the theory I’ll give it a go. And the results were very satisfactory and even I was very surprised at how good it was. We’ve treated over 5,000 women here now in Plymouth with antenatal problems - mostly morning sickness and backache - but we have a wide range of other conditions, such as constipation, varicose veins, headaches and migraines, pelvic pain needing admission to hospital.
If I’ve got a headache I’ll take a paracetamol - that kind of thing. Won’t avoid painkillers normally but obviously because of the pregnancy I really didn’t want to do that. I was told they wouldn’t hurt the baby but I didn’t want to take the risk, I didn’t want to take the risk with the pregnancy being quite early on and 15 weeks of taking painkillers wasn’t an option as far as I was concerned. But the acupuncture was fantastic, it was brilliant.
The first time didn’t - I got a little bit of a relief but it was for a short period but then after the second time, that was weekly at first, and it was brilliant, from week to week it - the relief was there.
Obviously acupuncture training costs quite a lot of money so once you have your midwife trained in acupuncture then you’re not particularly looking at any greater cost.
From my experience with the pelvic pain I would say that they tend to see it as a last resort, it should be offered as strongly as the painkillers are.
FORD The number of acupuncture services free at the point of delivery is increasing. But it’s not a given that all practitioners are happy about the prospect of working in the NHS. According to Mike O’Farrell of the British Acupuncture Council, many have concerns about how NHS bureaucracy might change the way they work.
O’FARRELL The statements like I don’t want to work in the NHS, well you don’t have to. Where I put the needle, who’s going to tell not to do that and I said that isn’t going to happen. There are those members and there are many of them and they’re concerned that regulation is going to mean audit and bureaucracy. There’s those things and of course there’s the overriding concern that anyone has in any profession which is one of reluctance to change. The only data I can offer is that we have out of our 2,400 members we’ve got about 150 currently working in the NHS, either in primary care trusts, in acute trusts, in mental health trusts, in maternity care and in palliative care. None of those to my certain knowledge have been told how to practise acupuncture. The only thing they’ve been asked to do is to ensure that - particularly if they’re working in a GP’s surgery, in a GP practice - that perhaps they restrict their treatment per patient to half an hour. Well that’s still significantly more than the patient gets from a GP.
FORD These genuine concerns have to be addressed but doubts over further integration don’t just come from CAM. Despite increased interest in the role of complementary therapies from the medical profession, some, like writer and doctor Ben Goldacre, point out that the boundaries of the NHS couldn’t envelope the luxuries of time and care that CAM offers in the private sector, however attractive that might be.
GOLDACRE There’s no way that alternative therapies will ever be accepted into the mainstream, not because of any kind of ideological objection that empiricists like me might have to alternative therapies but simply because you can’t do alternative therapy on the NHS. Alternative therapy is about people paying money to have somebody spend a lot of time listening to them talk about their problems and however much I might think that’s a great way to spend your time as a healer, however much I would love to do that in my own practice, it’s simply not possible on the NHS.
Research into complementary therapies is still a fledgling business that attracts furious debate. But more studies, placed within a scientific context, are showing that some therapies not only have clinical benefits over existing treatments but can be hugely more cost effective too. Scott Middleton is a chiropractor and spokesperson for the British Acupuncture Association.
The recent study published this year has shown including chiropractic in the medical system doesn’t increase costs, it decreases costs. It means there are fewer MRI scans done, fewer x-rays done, there are fewer patient visits to the doctor, fewer drugs used, fewer side effects of drugs therefore fewer cases of surgery. And if you look at the overall picture it’s not the cost saving to the health providers or the insurance companies, it’s also the cost saving to the economy because fewer people are off work, they’re back to work quicker, studies have shown that if a patient’s off work for six months only 50% ever go back to work, if they’re off work for one year 5% go back to work. In one study in Ontario they found that if they doubled the number of patients consulting a chiropractor in the first instance the saving for eight million people in Ontario would be $1.85 billion - the saving is massive.
The financial arguments are far from settled but with some CAMs at least, they look strong. But in an ideal world, money shouldn’t be the driving goal for integration. Take cancer care, where complementary therapies are increasingly seen by staff, as well as patients, as desirable not just to improve the quality of life of patients but as beneficial for staff. Kate MacKenzie is a nurse and massage therapist at the Bristol Cancer Help Centre.
For me it’s what nursing is all about. It’s about having the time to be with people and to truly understand what their experience is about. So I’m not just seeing somebody as Mrs B with a certain cancer. Cancer has so many ramifications in people’s lives so it’s going to have an impact on their employment, which may have an impact on the financial side of their life and so you know they’re no longer the accountant or the solicitor or the sales assistant they once were, so what am I? Who am I? Not being able to be the mother that you would like to be because you’re feeling tired and you can’t go and pick your children up from school. Lots of emotional issues, social issues. And here we can address all of those issues, it’s not just the medical side of things but also the whole mind, body, spirit and emotional aspects of what it’s like to go through a cancer experience. Traditionally nurses use much more care and touch and if you look back at Florence Nightingale and some of the texts that were around then there’s a lot of work around massage and touch and there’s a lot more of the word of love and care. And sadly I think a lot of that is lost, not because nurses don’t care but because they don’t have the time to do so.
It would be wrong to suggest that NHS nurses and doctors are not interested in the quality of life of their patients. But it is a struggle for them to provide this care under the present system.
I became a healer over a period of some time but I became interested in healing because my mother had ovarian cancer and she went to the Bristol Cancer Centre and received some healing there. And whilst I was in the room with mum I got very warm, I got very flushed and my hands started to tingle and after the session was over I sort of commented on this to the healer and that healer said everybody can potentially channel energy but the way that you’re feeling gives me the insight that you could channel energy very well.
Healers are, collectively, the largest body of CAM therapists in the United Kingdom - with around 15,000 practitioners. Producing objective scientific evidence that the powers of spiritual healing work is a difficult process, to say the least, and one that leaves many scientists deeply sceptical.
Nevertheless, thousands of patients turn to this form of supportive care. And they’re being helped by clinicians like those at University College Hospital who were the first to offer a healer on the NHS, she was Angie Buxton King. Who then sadly found that her skills were needed on her own son Sam, diagnosed with acute myeloid leukaemia - or AML.
Right from the start Sam of course responded by losing his hair but he didn’t respond by getting ill - he was having massive doses of chemo, which is common for AML, you have to be an in-patient the treatment is so toxic - and he was running around on the ward with a cheerful face, water pistol in his hand which was a 10 ml syringe and generally he was well and the other children were not. So I knew that there was something profound going on although at that point I was using so many other things I couldn’t really pinpoint it to healing. About a year after Sam died I felt very much that I wanted to try and offer other patients the help that Sam had had so I approached Great Ormond Street, which is where Sam had been treated, and they kindly gave me an hour of their time and I talked to the medics but they didn’t want to pick up on it. But I then went to University College London Hospital and said the same thing and for some reason the door swung open on a trial basis, I was given a month to prove a need and if the need was proved then they would think about paying me.
So just tell me what you do for a typical patient.
Typical patient - most of our patients have their own rooms and so I’ll walk in, I’ll introduce myself and my therapy to them and I explain to them that it’s a hands on treatment which they simply have to lie in their beds to receive and that’s all I tell them. And then when the session is finished I rouse them and we discuss what they've felt or seen if anything.
My name’s Justine Smith and I’m from Stevenage in Hertfordshire. I first met Angie when I was in the UCH hospital receiving treatment. I was having extensive chemotherapy at the time and Angie came into my room and offered me healing.
What was your initial reaction?
I was - I didn’t know anything about healing at the time but I was really grateful that somebody came in to offer me something other than drugs. And I just laid on the bed and just relaxed and Angie obviously started healing and I just felt an enormous amount of calm in my body, my body just totally relaxed and various different places she put her hands I felt a lot of heat was being taken from various places and after Angie finished healing I actually felt like I had a little bit more energy.
How do you think you might have been if you hadn’t had any healing?
I think I would have taken longer to recover. It’s helped the healing process.
It’s well known that Prince Charles has long supported the use of complementary therapies - a view that’s got him into hot water with the medical profession. His Foundation for Integrated Health has been consistently working to get the two sides of the debate to come together over integration - by funding small research projects, organising conferences, publishing papers and lobbying parliament. Michael Fox is the Foundation’s Director.
Our efforts have been devoted to encouraging government to take more action in terms of research. We published a proposed national research strategy which said please can you government prime some research. And we were very pleased that they have taken some action, they’ve taken action about trying to encourage capacity - getting more universities to do research - and they’ve also launched an initiative on cancer research, which again we think is an extremely good idea.
Do you think the government’s doing enough?
I would love them to do more, we’d love to see more money being spent on research.
Compared to the millions which is spent on pharmaceutical research - it’s infinitesimal.
It is small. I think what was however important that in terms of legitimising research the action by government in funding research was a major step forward.
If CAM were integrated into the NHS could they afford it - could they afford all the treatments that people would want?
Not if the answer was in addition to what it’s doing. A different way of looking at it is the health service needs to change the shape of what it’s doing at the moment. And I think complementary medicine - the use of complementary healthcare - can help it do it. There are 17½ million people with chronic diseases in this country, potentially complementary healthcare has a major role to play with helping people live with their diseases and that might actually reduce the burden on the health service.
Now you said that your foundation is very much in favour of integration, do you hear very strong arguments from anybody against integration?
I sometimes hear an argument that says that the evidence base is only an emerging one so are we moving too fast? But I don’t - not sure that that’s going to stop us all from using complementary and conventional healthcare together - we’re doing that at the moment, so let’s be pragmatic and realistic about this and help with decent information about what’s going on.
A vociferous spokesman of those who believe that the move towards integration is ill-judged and too speedy is Professor Edzard Ernst of the Department of Complementary Studies at the Universities of Exeter and Plymouth.
I’m all in favour of using complementary therapies which demonstrably do more good than harm. I wouldn’t call this integrated medicine, in fact I have my problems with that term. I would call this evidence-based medicine, simply because that’s what it is. If you find any therapeutic modality to do more good than harm then you would use it in routine, you don’t need a whole new philosophy to do that because the philosophy exists. What slightly disturbs me with some proponents of integrated medicine is that they seem to think integration now and research tomorrow. And I believe if you integrate treatments into routine care which are perhaps of debatable value or perhaps even worthless then this could mean a serious step backwards in medicine.
If complementary medicine just becomes longer corridors of care there is a possibility of even greater fragmentation. There is a positive side to that that fall into one of the rooms of the complementary therapist and there is a possibility they’ll take a more holistic approach and a more mind, body approach and help you start to think in different ways but they might not, they might just try and balance your chakra or manipulate your back or prescribe you a herb. And no this will be the king’s new clothes because therapists like to treat people - how many times do you go to a complementary therapist and come out being told you don’t need anything at all? Right, it’s not happening.
The fundamental problem about bringing together or even attempting to integrate these two healthcare cultures is their very different ideologies - one celebrating the individual, the other providing a state-wide system of care. Paul Dieppe is Professor of Health Services Research at the University of Bristol.
There is a constant major tension in all healthcare provision between the societal view that says that we should do the best thing for the greatest numbers and the individual primacy view that says this single individual I’m faced with now has a problem now is the most important thing and to heck with the whole societal view. That tension is intrinsic in the whole of healthcare delivery. Now when it comes to CAM it seems to me that the essence of most CAM is that it takes a much better stab at the individual approach to what’s right for that individual than most current orthodox medicine, which is based on what’s the average number we get if we do this to a group of people. And of course the fact is that nobody’s average. But neither side has really managed to deal with the tension between the two perspectives.
One place which has demonstrated that the tensions can be resolved and has been operating an integrated care system for 18 years is a doctor’s surgery in London - the Marylebone Health Centre.
ACTUALITY - MARYLEBONE HEALTH CENTRE
Come in and have a seat.
Susie has been a patient at the centre almost since it opened..
soaked and now the sun’s shining now everywhere.
Well you can take your coat off
When you have a check up, I have a check up with my GP because of my diabetes, Sue Morrison, my GP, was well I think you need this and I’m going to suggest you have some massage because you’re under a lot of stress or you’ve got some aches here you know you could do with some acupuncture. Remember that complementary medicine was there before modern medicine, it was always there and now we can use it with modern medicine, it’s brilliant, they shouldn’t be in battle with each other, they should be working together.
In Marylebone ,GP Sue Morrison works closely alongside CAM practitioner Arnold Desser, an acupuncturist.
In this context for me it means about an ongoing dialogue really between practitioners coming from a more traditional background and those currently working in complementary and alternative medicine. And the integration is the bringing together of our thinking and learning and working.
We all have a need to share our findings with people and you learn more about your own form of medicine, I think, by talking with people who don’t practise your form of medicine, in other words they can ask you questions - what do you mean, when you say this what do you mean by that? Well why did you prescribe that particular drug? I think it’s a learning experience here, you can’t just parachute in an acupuncturist or a homeopath into an NHS centre, it just doesn’t work that way. The advice would be don’t see it as an add on service, don’t see it as a pill and that’s often how it’s used.
When you talk about integrated medicine it sounds as if this is an understood thing, this is a body of knowledge or a skill or a total whole that we can move towards - tick these boxes to say these competencies have been achieved, then you’re an integrated practitioner, well I don’t think so because the whole point is about the process. So it’s about being able to think, doing the joined up thinking, it’s about keeping an open mind.
It sounds to me like an organic thing, which is reacting, constantly moving.
Yes. I can’t imagine working in another way, I don’t know how I would do it now.
So integration is not yet a clearly defined process which is an aggravation to its critics and a problem for its supporters. The many disparate examples of an integrated approach are just the seeds of a movement which seems to be gaining impetus.
There’s also evidence that politicians are beginning to view this patient-led process with interest. Peter Hain, Leader of the House and Secretary of State for Wales, was converted to the benefits of complementary medicine when his son suffering from eczema and asthma was greatly helped by homeopathy. I asked him how the government was going to respond to the growing popularity of CAM?
We are already making a great deal of progress, I mean the Prime Minister, himself, is personally enthusiastic about complementary medicine if properly assessed and in perspective, as I am and I know that John Reid has encouraged that dimension as well. And I think that we now - we’re almost seeing a popular movement in that direction, which is kind of swelling up underneath government and underneath the conventional medical establishment and saying - whether it’s taking dietary supplements or vitamin or mineral supplements or various other herbal type of remedies, on the one hand just in a sense self-treatment from an appropriate source or whether it’s using an osteopath, using reflexologists, using nutritionists, chiropractors, homeopathy - very widespread and very effective - I think more and more people are saying that we shouldn’t be at war here between conventional and complementary medicine, we should be working together.
On the point of integration shouldn’t we do all the rigorous research on complementary medicine before it’s integrated into the health service?
Well I’m in favour of rigorous research of course, I’m not in favour of just introducing it willy-nilly without proper regulation. But here are proven results over many decades and I think we would be failing in our responsibilities to just simply saying we want to keep on testing forever, when actually what I think behind that demand lies a certain scientific prejudice against complementary medicine from the traditionalists in the conventional medical camp. And I think they should be more open-minded as frankly more and more doctors and other medical practitioners and experts are and that is why they are prescribing more complementary medicines and good luck to them.
During the research for these programmes I met many people who said they were no longer interested in simply being treated for an illness. They were more concerned with staying healthy, looking after their immune system and searching for methods of treatment that looked at them as a whole. And many healthcare professionals would love to be able to work in that way.
But what sort of healthcare system could meet these needs whilst still providing effective and affordable care? Paul Dieppe expresses the view that in future we may have to abandon all the old divisions - of complementary, alternative or orthodox - and focus on providing a healthcare system that is simply interested in whether a medicine works or doesn’t, no matter what form it takes.
We have a lot of different beliefs, be they religious beliefs or health beliefs, we have a lot of different practices and behaviours in a very pluralist society. We need a pluralist health system to accommodate those different views and approaches of different individuals in our society. I would hope that the future will bring an understanding that the pluralist society should accept and accommodate pluralist approaches to healthcare.