Why Gps Refer Patients to Complementary Medicine Via the NHS: a Qualitative Exploration

Primary Health Care Research & Development 2008; 9: 205–215 doi:10.1017/S1463423608000789 Why GPs refer patients to complementary medicine via the NHS: a qualitative exploration Sarah Brien, Emily Howells, Geraldine M. Leydon and George Lewith Department of Primary Medical Care, University of Southampton, Southampton, UK Background: The use of complementary and alternative medicine (CAM) is increasing. Access to CAM through primary care referral is common with some of these referrals occurring through existing NHS contracts. Yet currently little is understood about General Practitioners (GPs) referrals to CAM via an NHS contract. Aim: This exploratory qualitative study was designed to explore UK GPs experiences of referring patients to CAM under an NHS contract. Method: Semistructured interviews were conducted with 10 GPs in the UK, purposively sampled, who referred patients under an NHS contract to a private CAM clinic, staffed by medically qualified CAM practitioners. Qualitative methodology making use of the framework approach was used to undertake the interviews and analysis. Findings: The decision of GPs to refer a patient to CAM through an NHS contract is complex and based on negotiation between patient and GP but is ultimately determined by the patients’ openness and motivation towards CAM. Most GPs would consider referral when there are no other therapeutic options for their patients. Various factors, including clinical evidence, increase the likelihood of referral but two overarching influences are crucial: (a) the indi- vidual GPs positive attitude to, and experience of CAM, including a trusting relationship with the CAM practitioner; and (b) the patient’s attitude towards CAM. In-depth knowledge of CAM was not a vital factor for most GPs in the decision to refer. Conclusion: ACAM referral only took place if the patient readily agreed with this therapeutic approach, and in this respect it may differ from referrals by GPs to conventional medicinal practitioners. Such an approach, then, relies on patients having a positive view of CAM and as such could result in inequity in treatment access. Increasing knowledge about and evidence for CAM will assist GPs in making appropriate referrals in a timely manner. We propose a preliminary model that explains our findings about referrals considering patients need as well as the medical process. As data saturation may not have been achieved, further investigation is warranted to confirm or refute these suggestions. Key words: complementary and alternative medicine; primary health care; qualitative research; referral Received: October 2007; accepted: May 2008 Background ade (Giveon et al., 2003) and, although mainly accessed privately by patients, 10% of consultations Use of complementary and alternative medicine are accessed through NHS primary care (Ong et al., (CAM) in the UK has increased over the last dec- 2005). Forty per cent of patients would use CAM if recommended by a medical practitioner; there- fore, doctors’ views about CAM are important Correspondence to: Dr Sarah Brien, Department of Primary Medical Care, University of Southampton, Aldermoor Health to patients (Lewis et al., 2001; Lewith et al., 2001). Centre, Aldermoor Close, Southampton Hants S016 5ST, UK. However, General Practitioners (GPs) describe Email: [email protected] their knowledge of CAM as poor or very poor r 2008 Cambridge University Press Downloaded from https://www.cambridge.org/core. IP address: 170.106.202.58, on 23 Sep 2021 at 18:19:13, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423608000789 206 Sarah Brien et al. (Wharton and Lewith, 1986) and only a quarter on the existing literature, was used to ensure the report feeling confident talking about CAM with primary question was addressed systematically in patients (Perry and Dowrick, 2000). Many doctors each interview. Framework analysis was used to report that their ability to refer patients to CAM is identify key themes (Ritchie and Spencer, 1994). diminished by this lack of information and under- In order to be eligible, UK GPs needed to have standing (Thomas et al., 1995; White et al., 1996; referred patients to the private CAM clinic within Lewith et al., 2001; Schmidt et al., 2002). their NHS contract during the previous two years, Concerns about CAM that are commonly aired so their experiences were ‘current’. There were by doctors include patients stopping their con- no other criteria for inclusion. Invitation letters ventional treatment, treating CAM as a substitute from the CAM clinic were sent to 33 GPs who for conventional prescribed medicines, delayed or had referred their NHS patients for CAM within missed diagnosis, adverse effects of CAM, unqua- the existing NHS contract during the previous lified or overcharging practitioners, and lack of two years. An interview was arranged with those research evidence (Astin et al., 1998; Zollman and GPs who expressed an interest and were suitable Vickers, 1999; Cohen et al., 2005). Despite this, up to take part. to 40% of doctors view some CAM as having a The complementary practitioners (CPs) at the sound theoretical basis (Anderson and Anderson, CAM clinic study site are all medically qualified. 1987), and 70% believe in its safety (Schmidt et al., The NHS contract has been in existence for 12 2002). Indeed, there is some evidence that GPs years and covers referrals for irritable bowel syn- endorse CAM despite not necessarily under- drome, migraine, eczema, chronic fatigue syndrome, standing or believing in it (Perry and Dowrick, childhood behavioural disorders and non-specific 2000; Cohen et al., 2005). Estimates of GP referral allergy syndrome. Patients are treated for up to six rates vary depending upon the time period asses- sessions, which can be extended for a further six. sed, the therapy and the timing of the studies Therapies offered are homeopathy, acupuncture (Table 1), but studies show that between 59% and and herbal, environmental and nutritional medi- 72% of GPs have referred to CAM in the pre- cine. There is no specific upper limit for referral by ceding year (Wharton and Lewith, 1986; Anderson a single GP, although a provisional limit of 500 and Anderson, 1987). referrals per year is set by the PCT. No qualitative studies have specifically assessed Interviews took place in the GPs’ surgeries the reason or motivation for these referrals. Limited (EH). Informed written consent was obtained and non-systematic data from open sections in a prior to the interview. Open-ended questions small number of surveys have suggested some addressed GP perspectives about their referral reasons, for example patient request or a lack of practices and emergent issues relevant to the response to conventional treatment (Borkan et al., research question were added to the topic guide 1994; Boucher and Lenz, 1998; Kaczorowski et al., and explored at subsequent interviews. See 2002; van Haselen et al., 2004). However, these Appendix 1 for the initial guide, which also shows quantitative studies were focussed on the overall the two additional questions included in the final pattern of referral and not on understanding the guide. Interviews were audiotaped for transcription processes that shape referral behaviour. We have and the use of pseudonyms protected partici- addressed this research gap by exploring the key pants’ anonymity. This study was classed as a factors that shape GPs’ referring behaviour. This service evaluation by the relevant NHS autho- initial exploratory qualitative study formed part rities, so ethical approval was not required. The of a service evaluation within a UK Primary Care study met all of the standards that would be NHS contract and only relevant data from the required by the ethics process, including inde- study is presented. pendent peer review, data protection, informed written consent and researcher safety. Methods Data analysis Qualitative face-to-face semistructured inter- Analysis of the data used the framework views were used. An interview topic guide, based approach, a structured methodology following Primary Health Care Research & Development 2008; 9: 205–215 Downloaded from https://www.cambridge.org/core. IP address: 170.106.202.58, on 23 Sep 2021 at 18:19:13, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1463423608000789 Why GPs refer patients to complementary medicine via the NHS: a qualitative exploration 207 Table 1 Studies quantifying GP referrals to CAM Author Date GPs referrals to CAM Further information Referrals per year Wharton and Lewith 1986 76% to medical CPs in last 12 months Not all formal referrals 72% to non-medical CPs UK GPs (Avon) n 5 145 Anderson and 1987 59% in last year GPs with knowledge of CAM . GPs Anderson without knowledge UK (Oxfordshire) study n 5 222 Borkan et al. 1994 55–77% in last year Mean referrals per year 5 3.7, American and Israeli study Referrals per month Cohen et al. 2005 76% acupuncture, 72% massage, Australian study, shows GPs who refer at 8% aromatherapy, 5% reflexology least monthly to each therapy Referrals per week Thomas et al. 1995 44.8% endorse CAM use per week 10 800 referrals per week in 2001; 29 600 recommendations. UK study Perry and Dowrick 2000 31% GPs in last week Most to homeopathic hospital UK, Liverpool study Referrals ever Schmidt et al. 2002 79% ever refer to chiropractic UK portion of UK and German study 67% acupuncture, 66% osteopathy Giveon et al. 2003 25% never referred 91% have positive or neutral reaction to 69% referred occasionally being consulted about CAM, Israeli study Brems et al. 2006 79.15% refer regularly or often Not all formal referrals, American study 2.61% never refer Other Astin et al. 1998 43% acupuncture American study, review of 19 papers. No 40% chiropractic details about frequency of referrals 21% massage Lewith et al. 2001 41% hospital doctors refer regularly Study of UK physicians Hospital doctors refer , GPs Thomas et al.

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