COMPLEMENTARY & : SHOULD IT BE PROVIDED ON THE NHS? MEETING OF THE PARLIAMENTARY AND SCIENTIFIC COMMITTEE ON MONDAY 17TH OCTOBER 2005 Some 40 per cent of GPs recommend CAM therapies to their patients – indeed, 20 per cent offer them on their premises. Although many doctors accept that CAM has much to offer their patients, others are not so sympathetic. Nevertheless CAM is increasing in popularity with many patients who claim to have benefited. Is the evidence base for the efficacy of any of the twenty-five recognised CAM therapies good enough to justify the taxpayer paying for this treatment as part of the NHS? Complementary and Alternative Medicine – should it be provided on the NHS?

Lord Walton of Detchant

or ten years I served as a conventional medical practitioners. question as to whether it should be Member of the House of Lords We broadly accepted the definition provided by the NHS. FSelect Committee on Science provided by the Cochrane It soon became clear that the uptake and Technology, and chaired three Collaboration as “A broad domain of CAM in the UK had increased Sub-Committee Enquiries, of healing resources that steadily. More than 15% of people producing Reports which were encompasses all health systems, in the UK had consulted CAM accepted by the parent Committee modalities and practices and their practitioners and more than 30% and eventually debated in the accompanying theories and beliefs, had bought over-the-counter House. The last enquiry which I other than those intrinsic to the remedies used in CAM, with a total chaired was into Complementary politically dominant health systems annual expenditure approximating and Alternative Medicine (CAM). of a particular society or culture in a to £1.6 billion. In the USA To assist the enquiry, two specialist given historical period.” expenditure was estimated at some advisors were nominated, namely Having issued a public call for US$27 billion. Professor Stephen Holgate, who will evidence, we received 185 written Eventually, we classified the CAM speak later, and Professor Simon submissions, and held 21 oral Mills, Director of the Centre for professions and disciplines into hearings, interviewing 44 three groups. In the first group Complementary Health Studies at representatives of many the University of Exeter. were those known as “the big five”, organisations in the conventional namely osteopathy, chiropractic, Our first task was to try to achieve a medical field, in science and in , and definition of terms. We concluded CAM. Several individuals also gave . The professions of that alternative medicine normally oral evidence. One witness was Dr osteopathy and chiropractic are refers to a number of professions or Stephen Straus, Director of the individually regulated by Acts of disciplines which claim to offer Office of Complementary and Parlament. Herbal practitioners in systems of diagnosis, prognosis or Alternative Medicine in the USA, an the UK are also to some extent a management using approaches organisation funded by the National cohesive group, who have different from those employed in Institutes of Health in order to developed a powerful method of conventional Western medicine. undertake research in CAM. In our voluntary self-regulation and who Complementary medicine we enquiry we were not primarily subscribe to scientific principles. accepted as embracing a number of concerned with efficacy, but were Very many powerful drugs in other professions or disciplines required to consider evidence, common used in Western medicine which do not usually offer regulation, training and education, are of herbal origin. We also diagnostic information, but which research and development, learned that, through the British are more often used to complement information availability and the Acupuncture Registration Board, the treatment offered by delivery of CAM, including the practitioners using acupuncture,

8 Science in Parliament Vol 63 No 1 Spring 2006 some of whom are doctors and including crystal therapy, radionics, which many of their patients may nurses but many of whom hold no dousing and kinesiology. consult. We also recommended other professional qualification, had While much evidence we received simple familiarisation courses for begun to develop a mechanism of stressed, very properly, the role of undergraduate medical students. self-regulation. There is good the therapist and of the placebo We also discussed the crucial physiological evidence to show that response, which has been shown, in importance of randomised acupuncture can induce an conventional medicine, to have controlled trials, sequential trials increased output of endorphins (the profound effects upon many bodily and many other research techniques body’s own analgesics) from the organs and especially upon the designed to collect evidence on the central nervous system. We also body’s immune system, we did validity and efficacy of the various included homeopathy, a long- receive evidence to indicate that CAM disciplines, with particular established method of diagnosis and several of the CAM disciplines, reference to being able to treatment used in the UK by many especially those in our group 1, do demonstrate which had effects medical practitioners, but also by have specific effects which could superior to placebo. We also non-medical homeopaths, in not be wholly accounted for by the recommended the establishment of Category 1. placebo response. We also noted Centres of Excellence in UK In our Category 2 we included that many alternative and universities, where CAM disciplines such as aromatherapy, complementary practitioners were practitioners could undertake massage, counselling, reflexology, able to offer much more time for research programmes in shiatsu, hypnotherapy, meditation consultations than can busy collaboration with scientists, and different varieties of healing. doctors. The Cochrane doctors and others already well We found that these disciplines Collaboration reviewed 154 trials, versed in research techniques. We were complementary in being used, 40% of which revealed some were pleased to note that the NHS generally, but not invariably, to benefit. The recent Smallwood R&D organisation has now complement conventional medical Report felt that CAM in the NHS supported several such research treatment. would be cost-effective, a point projects in the CAM field. We also Category 3 gave us the greatest disputed by Ernst and his considered mechanisms by which difficulty. In Category 3a we colleagues in a recent paper in the high quality information about included ancient Chinese medicine British Medical Journal. CAM could be made available, not and Ayurvedic medicine; we were Accepting that the practice of only to the public, but also to concerned by some principles osteopathy and chiropractic is healthcare professionals, and employed in Chinese acupuncture controlled by Acts of Parlament, we recommended that NHS Direct and Chinese herbal medicine, not recommended that herbal medicine might be a useful source of least because the large combinations and acupuncture should seek for information. We also recommended of herbs, widely used in both statutory regulation under the that health authorities should work ancient Chinese medicine and, to a Health Act 1999, alongside other with representatives of the well- lesser extent, in Ayurvedic healthcare professions; we took the regulated CAM professions to medicine, have sometimes included view that this might become produce information about well- harmful components such as possible for homeopathy, once qualified CAM practitioners in their aristolochia, which can cause differences of opinions and practice, respective areas and regions. serious renal damage, while some as between medically qualified Finally, in relation to the provision of preparations also contain homeopaths and those without CAM in the NHS, we recommended combinations of heavy metals which medical qualifications, are resolved. that primary care groups and trusts may be deleterious. We also feel We also recommended that the should be willing, in appropriate that many of the concepts upon many organisations representing the circumstances, to fund consultations which these disciplines rely (the disciplines in Category 2 should and treatment using well-established, elements, ying and yang and the seek to develop a system of rigorous well-regulated and well-founded five doshas, for example) which voluntary self-regulation for each , CAM methods, but that all such date from antiquity, are totally with a view perhaps ultimately to consultations paid for by public outdated. We therefore classified becoming registered by Statute. funds (ie through the NHS) should them in Category 3a, implying that, In relation to education and be by referral from doctors or other when practised according to training, we recommended that healthcare professionals, working in traditional concepts, they seemed to each profession should define a core primary, secondary or tertiary care. us to lack validity. Nevertheless, we curriculum including elements of Our Report was accepted without discovered later that some anatomy, physiology and clinical significant modification by the practitioners of ancient Chinese medicine, as well as statistics and parent Committee, and was debated medicine and many of Ayurvedic the accumulation and analysis of in the House of Lords early in 2001. Medicine take part in scientifically evidence. We felt it imporrtant that Our recommendations were valid research, exploring the value conventional medical practitioners, accepted, virtually entirely, by the of individual herbal preparations as nurses and others working in the Government. I and all those who distinct from massive combinations. healthcare field should develop served on the enquiry look forward In Category 3b we classified several some understanding of the CAM to seeing whether, how and when disciplines for which we could find disciplnies so as to be aware of the our recommendations will be no credible supportive evidence, principles underlying the systems implemented.

Science in Parliament Vol 63 No 1 Spring 2006 9 COMPLEMENTARY & ALTERNATIVE MEDICINE: SHOULD IT BE PROVIDED ON THE NHS? Integrated Health Care; What can be learned from Complementary and Alternative Medicine

Professor Stephen Holgate, Medical Research Council Clinical Professor of Immunopharmacology, University of Southampton

he House of Lords report on complementary medicine deliver and sees the human as an integrated complementary and alternative their practice. Orthodox medicine is self-correcting whole. Thus it views Tmedicine (CAM) published in focused on specific disease causation, good health not simply as the 2002 has led to the wider recognition is divided into specialties and absence of illness, but as a self of complementary approaches for the delivers treatment specific to the regulating state that involves delivery of health care with diseased organ(s) (one disease, one interacting complex systems. improvements both in regulation and target, one cure). In contrast, CAM Professor Michael Hyland, a in research. However, the recent addresses distributed cause, is not psychologist from the University of Smallwood Report “The Role of divided into specialties and treats the Plymouth, views health as a complex Complementary and Alternative whole person with multiple therapies system in which parts form wholes, Medicine in the NHS” and recent that are not necessarily disease- with everything being interconnected articles in the premier medical dependant. and the whole behaviour not being journals have once again brought this predictable from the behaviour of the It is increasingly recognised that there individual parts2. As a consequence field of medicine to the forefront. It are some problems which currently is, therefore, worth exploring some of new properties of the component afflict conventional medical practice. parts and the whole system emerge. the issues that fuel this debate. These include the management of Features of Conventional He states that changing a part will chronic disease and pain and lead to a change in the whole and Medicine and CAM unexplained symptoms eg chronic that changing the whole will lead to Practitioners of CAM often say that fatigue syndrome; being able to take the part changing. Based on this they do things differently and have a full account of changing behaviour eg health concept represents the special connection with the patient housing, diet, stress and life style; behaviour of the whole system which (or client). The Parliamentary Select patients sense of fragmentation, has the capacity to self- organise and Committee on Science and disempowerment and adapt to constant change. Integrated Technology that reported on dehumanisation; concerns about health care is directed towards complementary and alternative drug side effects and the cost of supporting this adaptation. Hyland medicine in 2002 stated “any therapy adverse events and a lack of time for emphasises the important of that makes specific claims for being able communication between patients and networks with the brain at the centre to treat specific conditions should have health care professionals. Thus a of a self-regulating, self-organising evidence of being able to do this above legitimate question to be asked is pattern recognition system that is and beyond the placebo effect”. whether CAM represents a signpost intimately connected to immune and However, in a recent editorial in the for modern medicine’s missing endocrine systems functions. Two Lancet1, Vandenbroucke commenting elements. types of error in this complex system on continued controversy over the The Prince of Wales’ Foundation for may lead to human disease. The first use of homeopathy and the growth of Integrated Health defines integrated is an organic error leading to truth quoted William Osler in his healthcare as incorporating integrated abnormalities in sequential Harvean Oration of 1906 “Truth may medicine as its core component, but processing involving molecules, cells suffer all the hazards incident to is a broader concept that goes beyond and organs and against which generation and gestation….. all the treatment of illness to emphasise conventional treatments operate. The scientific truth is conditioned by the state the importance of improving health second is to an information error of knowledge at the time of its and wellbeing, views the living which is more closely linked with announcement”. There are clearly person as more than a collection of alterations in lifestyle and involves some fundamental differences in the molecules, cells and organs which network processing and an imbalance way that orthodox and may or may not be working properly against which CAM is directed.

10 Science in Parliament Vol 63 No 1 Spring 2006 The Role of Specific and some specific treatments eg in CAM is conducted in a way that Non-Specific Treatment Parkinson’s disease, pain relief, maximises the non-specific response Effects depression and the use of stimulants4. may help account for a substantial These findings greatly enrich the portion of the treatment effect It is stated by some that the placebo debate regarding the relative benefits beyond any specific action, and that or dummy treatment effect underlies of specific and non-specific treatment in conventional medicine insufficient much of the therapeutic benefit that responses. attention is given to this aspect of patients experience with medical health care in focusing only on intervention and that this non- It is now known that sustained pain results in the release of endogenous unitary solutions in the form of drugs specific (incidental or placebo) effect or surgery. differentiates CAM from orthodox opioides that stimulate opioide mu medicine. In conventional receptors in cortical and subcortical The challenge of integrated randomised placebo controlled trials regions of the brain, and that health care activation of these receptors reduces (RCT) designed to investigate a Recognising that the human organism sensory and affective ratings of the specific therapeutic intervention, the is a complex system, it is apparent pain experience5. By applying placebo effect is also often large and that each level of the system speaks a functional magnetic resonance not infrequently exceeds 50% of the “different language” and yet imaging (fMRI) of the brain, placebo total treatment response eg analgesia communicates continually, the levels analgesia decreases activation in the and depression. In RCTs the placebo being entangled and self organising2. pain sensitive regions – the thalamus, is subtracted to isolate the specific Integrated health care that interacts insula and anterior cingulate cortex. therapeutic response of the actual with this complex system entails The placebo also increases fMRI intervention (efficacy). Thus, the more than simply combining activity in the prefrontal cortex components of therapeutic response conventional with complementary during anticipation of pain. Of great comprise the sum of the specific approaches. It emphasises health interest was the finding that both effect (efficacy) and the non-specific promotion, self-care and patient placebo induced analgesia and altered effect (placebo). In the “real world” practitioner partnership. It aims to perception of pain were effectively the therapeutic response (or trigger, support or remove constraints blocked by naloxone an opioid effectiveness) of a treatment equals on the ability of the mind and body receptor antagonist. the sum of efficacy and placebo. to heal itself and it sees the With different forms of therapy the Implications for CAM humanisation of health care as a relative contributions of the specific The recent study investigating the central issue. There is already ample and non-specific responses will differ. effect of acupuncture on pain in evidence that when doctors use In seeking to characterise the osteoarthritis has revealed 12% communication skills effectively, their incidental or placebo effects in specific effect versus a more than patients and they benefit. Integrated complex interventions used in CAM 30% placebo effect. Based on health care means not using such as acupuncture Patterson and findings described above expectancy reductionist approaches alone, but Dieppe3 made the following four and belief could modulate the being aware and understanding the points: therapeutic response of pain relief by importance of body intelligence and 1. The RCT developed to test new acupuncture. In a trial of patients the impact of the lived experience, drugs is based on bio-medical with osteoarthritis, Pariente et al6 triggering adaptation and self healing assumptions alone. undertook PET scans of the brain processes, tailoring treatment to 2. In a drug trial talking and listening (that reflect local blood flow) before individual needs and circumstances, to patients are often defined as and after “real” acupuncture, optimising the human factor, incidental (placebo) factors Steitberger needle placebo and sham encouraging participation and separate from the drug effect. placebo (skin prick distant from the empowerment. Thus, such whole acupuncture point). They person care requires practitioners 3. In CAM interventions the demonstrated that the various who utilise both the science and the characteristic and incidental treatments each gave increased brain art of medicine. factors are intertwined. PET signals in the right prefrontal References: 4. Use of placebo or sham controlled cortex, anterior singular cortex and 1 Vandenbroucke JP. Homoeopathy and “the growth trial designs for complex of truth”. Lancet. 2005 Aug 27-Sep 2; thalamus the treatment order effect 366(9487):691-2 interventions may lead to false being real acupuncture > Steitberger 2 Hyland ME. A tale of two therapies: psychotherapy negative results. and complementary and alternative medicine placebo >> sham placebo. These (CAM) and the human effect. Clin Med 2005 Jul- This publication led to an extensive findings reinforce the view that real Aug; 5(4):361-7 acupuncture has both a specific effect 3 Patterson C, Dieppe P. Characteristics and debate in the British Medical Journal incidental (placebo) effects in complex correspondence column with a wide on the pain centres in the brain but interventions such as acupuncture. BMJ 2005 May range of views being expressed about also a non-specific effect also via the 21; 300(7501):1202-5. 4 Petrovic P, Dietrich T, Fransson P, Anderson J, the relative importance of non- brain’s reward system. Thus, at least Carlsson K, Ingvar M. Placebo in emotional specific responses with different types in the case of pain relief, active processing—induced expectations of anxiety relief activate a generalized modulatory network. of treatment. Possible factors that treatment and different types of Neuron. 2005 June 16; 46(6):957-69 make up the placebo effect include placebo may have effects on the brain 5 Petrovic P, Kalso E, Peterson KM, Ingvar M. Placebo and opioid analgesia – imaging a shared improved adherence to concomitant that may truly complement each neuronal network. Science. 2002 Mar 1; treatments, Pavlovian conditioning, other. This might indicate that every 295(5560):1737-40. Epub 2002. expectation and a physical (or effort should be made to enhance the 6 Pariente J, White P, Frackowiak RS, Lewith G. Expectancy and belief modulate the neuronal “organic”) response. Use of functional non-specific effects of a treatment eg substrates of pain treated by acupuncture. brain imaging such as PET, MRI and by practitioner interaction and the Neuroimage. 2005 May 1; 25(4):1161-7. SRI has now demonstrated that health care setting and, by doing so, Acknowledgments: The author wishes to acknowledge the contributions placebos can indeed mimic drugs in this can add to or enhance the effect of David Peters, Michael McIntyre, Michael Pittiol, activating the same brain areas as of a specific treatment. The fact that George Lewith and Michael Hyland to this paper.

Science in Parliament Vol 63 No 1 Spring 2006 11 COMPLEMENTARY & ALTERNATIVE MEDICINE: SHOULD IT BE PROVIDED ON THE NHS?

Integrated Healthcare for better Health and Happiness

David Tredinnick MP

am honoured to address this every opportunity to question the that gave us a benchmark to work audience and follow on after Health Minister on around. There are some out there Itwo such illustrious speakers Complementary Medicine at every that say that some of the and with all the Doctors in the single Health Questions in order categories are wrong. I don’t see House of Commons present. I to get the matter up in lights. personally that you can claim that have been involved with According to Tony Benn, “first Chinese Medicine that has been Complementary Medicine for 30 they say you are mad, then they around for 2,000 years should be years. I fell off a horse in 1976 agree with you, then they want to divided into two different and then had to turn to own the idea.” This resulted in categories. With 60,000 hospitals Chiropractors and Osteopaths to me being dubbed “the Member in China delivering Chinese help straighten out my spine. for Holland and Barrett”. Medicine perhaps these methods Subsequently my wife had Ironically their headquarters are delivered over 2,000 years have allergies and headaches, resulting in my constituency. some credibility? On some of the in visits to Jean Munro in Hemel This talk focuses on the past, zanier treatments, ignoring Crystal Hempstead for treatment and she present and future for Therapy which we are not going has never had a headache since. Complementary Medicine. There to discuss further this evening, I Homeopathy has helped my has been an exponential growth in would say that 20 years ago, what family with treatment for asthma, demand for Complementary is now seen as mainstream colds, and I have had crippling Medicine to the extent that half of Complementary Medicine was pain that has been successfully the population have now had then seen as wacky and off-the- treated using acupuncture, that is some experience of it. People are wall. I put it to this distinguished the one component of Chinese not fools and tend to buy things Committee that they should bear Medicine listed in the first that work. The first major in mind that things do change category in the House of Lords attempt to improve CAM and that it is possible that some of report. Our group, the All-Party acceptance and regulation was in these treatments that have not Parliamentary Group for the 1987 Parliament. In the 1992 been given much credibility may Integrated and Complementary Parliament the two Private in the end turn out to be quite Healthcare has two objectives: Members Bills on Osteopaths and helpful. 1) to bring Complementary Chiropractors both became law, Where are we now in the political practitioners together and bringing them into mainstream world? There have been some medicine with the establishment very important developments; first 2) briefing Members of Parliament of regulatory bodies. The next of all the Government has brought on the benefits of Complementary stage was the House of Lords in practice-based permission for Medicine. report in 2002 with definable healthcare which means that When the Government changed categories. I would disagree with doctors now have almost got their from Conservative to Labour I some of the categories, but overall GP Fundholders status back that changed strategy and have taken it was a brilliant piece of work the Conservatives brought in. It

12 Science in Parliament Vol 63 No 1 Spring 2006 is giving them more purchasing Now we have these clearly nationwide with useful research power and the ability to choose identified effectiveness gaps which studies, such as the Glastonbury where and what services they buy. is jargon for saying that there is Clinic the Get Well UK Clinic in I understand that 50 per cent of not enough treatment around for Camden that offers advice to GP practices are now using back pain, knees or stress and doctors by helping them to find Complementary Therapy to some nausea. What is now needed is suitable Complementary extent and that there will be a for these to be linked up with Practitioners. huge increase in demand through Complementary Therapies and these practices. the recommendation that the I would like to finish by emphasising that the risks of The second interesting National Institute for Clinical Excellence (NICE) performs Complementary Medicine are development will be the third overemphasised, especially since major change, namely Stephen further studies on this is welcomed. But what has not been there are many cases in Smallwood’s report which is very Mainstream Medicine where the helpful as it identifies the so- picked up from the Smallwood report is that it also stated that use of drugs such as aspirin can called effectiveness gap in the cause death, and even travelling health service where there is not Complementary Medicine is more effective than Mainstream around by London transport is enough treatment available. In not risk-free. the past the Complementary Medicine. Therapies were given the really So what about the future? Are There are 50,000 Complementary hopeless patients that doctors call Complementary Medicine and Therapists and huge gaps in our privately the “heart-sink patients”. Integrated Healthcare here to stay? National Health Service. Let us They are the ones that were The whole thrust is towards better have better regulation and farmed out to the Complementary regulation, awareness and interfaces with our doctors. This Therapists. Amazingly, about knowledge. is a hugely exciting time and if we 75% of heart-sink patients get Regulation of acupuncture and go down the route of Integrated relief in the Complementary herbal medicine is now almost Healthcare we will have a Medical sector. complete. There are many clinics healthier and happier population.

In discussion the following points were made: Variations in genotype affect the sensitivity and responses to both the placebo and to conventional and integrated medical therapies and the whole genome should be considered when treating chronic fatigue syndrome. Medical approaches to disorders of the prostate in the UK differs from those in the EU where herbal medicines are the treatment of choice and which have also been successfully used to extend longevity. The increase in conventional medical treatments has also grown enormously starting from a very restricted base in the early days. Intercomparisons between integrated and conventional medicine therefore should be continually updated. Integrated medicine emphasises the importance of the individual, in preference to the general application of a more conventional medical system. Delivery of the latter may be unduly constrained by a single, undifferentiated approach to population studies, based on systematic drug treatment hierarchies, with pressure on doctors to conform and subject to legal issues, with hospitals where pharmacists apply drug regimes based on external criteria, and doctors who don’t know their patients. For example, pooling the results of research on asthma studies on 3 year olds with those of young adults is anti-science and provides unusable data. An open mind is needed, based on direct observation, resulting in various differing explanations. The culture base for Chinese medicine is 2,000 years old which accounts for some of the differences from a more reductionist conventional medicine that tends to consider human health issues in isolation from one another. Nevertheless evidence is still needed for proper regulation of integrated medicine, to help inform sceptical doctors and to assess the science base for diagnostic procedures, using the pulse and tongue and therapies such as acupuncture for example. The human body needs to be put back together and considered holistically. Many modern treatments are based on ancient herbal remedies. For example, Indian scientists have recently provided scientific interpretations that support traditional Ayurvedic medicine that can also benefit from both placebo and and cultural effects. GPs can currently only afford 10 minutes per patient. How can this be extended to 45 minutes to match that of integrated therapists? The main benefits of medical research in the last 50 years have arisen from randomised, controlled trials and the production of high quality efficaceous medicines. In summary, don’t subtract the placebo effect as it may be one of the benefits of integrated medicine, for example, thought alone may provoke change. Whole person medicine giving help and comfort to the patient should be provided by the NHS.

Science in Parliament Vol 63 No 1 Spring 2006 13