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Complementary therapy: issues for primary care

Julia Fearon
RGN RSCN BSC(Hons) Complementary Therapy MIFPA
Independent Complementary Practitioner
Proprietor Harborne
Complementary HealthClinic
Birmingham
Chair Complementary Therapies in Nursing Forum
Royal College of Nursing

The increase in the popularity of complementary therapies in the last decade is well documented.(1-3) The most common use of therapies in the UK is by those individuals suffering chronic conditions, especially where mainstream medicine has only limited success in offering sustained relief.(1,4) This should be of interest to primary healthcare professionals, who may be left to pick up the pieces when mainstream secondary and tertiary care has little further to offer their chronically ill patients. This may be partly why the continuing popularity of complementary treatments appears to be reflected in the increased access to therapies via primary care.(3,5-7) However, provision of therapies is often patchy, and many healthcare professionals have had no education or training about therapies.

What is complementary therapy?
Over the past decade, therapies have been commonly referred to as "complementary and alternative medicine" (CAM). In 2000, the House of Lords defined CAM as: "A diverse group of health-related therapies and disciplines, which are not considered to be part of mainstream medical care."(8)
However, as CAM is further incorporated into mainstream care, some disciplines, such as chiropractic and osteopathy, are increasingly considered part of mainstream care. Therefore there is now a move towards rebadging the field as complementary and integrated medicine (CIM).
This embodies the principle that any therapy for integration should be considered something to be used alongside, and not instead of, orthodox medicine.Complementary disciplines may be "whole system" therapies, such as traditional Chinese medicine, chiropractic, osteopathy and homeopathy. These therapies incorporate diagnosis and treatment and aim for significant improvement or cure (where possible).
Therapies such as aromatherapy and reflexology are different. Practitioners of such therapies are not taught to diagnose as part of their therapeutic intervention and are not attempting to affect a cure. They aim to provide supportive care and some symptom control, and to promote quality of life and wellbeing, often by helping reduce stress and increase relaxation.
 
Popular therapies
Chiropractic and osteopathy are among the most popular therapies utilised in the UK (see Box 1). Both are statutorily regulated. Other therapies are working towards regulation. Acupuncture and herbal medicine are most advanced along the pathway, and 12 others are moving towards voluntary self-regulation (VSR).

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The VSR programme is led by The Prince's Foundation for Integrated Health (FIH), part-funded by the government. The primary aim of VSR is to provide public protection and encourage the main professional organisations for each therapy to work closely together. The working groups for each therapy are developing:

  • A register of professional members.
  • A code of professional conduct (and definition of the measures to be taken in the event of a registrant breaching that code).
  • Standards for education, training, competence and continuing professional development.

VSR is an important way in which the therapies can demonstrate growth towards professionalisation. This is important for effective integration into care and not only increases public protection but will also help increase confidence in therapies by mainstream healthcare professionals.
A single register for each therapy will make it much easier for orthodox staff to be able to refer to therapy practitioners and/or recommend to patients how to find a therapist.

Benefits of complementary therapies in primary care
Box 2 lists the most common conditions for which complementary treatment is sought. There may be several reasons why a patient decides to try a therapy  (see Box 3).

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Sometimes the motivation is negative, such as poor outcomes from conventional treatment, but it may also be positive, such as the desire to maintain wellbeing.(2,9) The latter could be a hugely important factor in primary care from a health promotion perspective - a patient who actively seeks an intervention to promote good health. This offers the opportunity for health promotion to a client who is receptive and open to change. Examples of where research has demonstrated that therapies can help maintain and promote good health include: (9-11)

  • T'ai Chi for physical and psychological health and falls prevention in the elderly.
  • Moxibustion (a technique used by acupuncturists) to help turn babies in the breech position.
  • Yoga, aromatherapy/massage and hypnotherapy for stress relief and promoting relaxation.

Therapies such as baby massage can have multiple benefits (see Box 4). Another important benefit of therapies is the improved quality of life cited by patients with chronic illness who access complementary therapies. Patients consistently state that they feel less stressed, anxious and better able to cope with chronic disease when they use complementary treatments and also achieve improved symptom control.(6) Patient choice, empowerment and perceived greater control of their illness are other benefits identified.(6)

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Potential problems
However, there can be disadvantages and problems associated with the use of complementary therapies. Research evidence continues to show that over 50% of patients do not disclose use of therapies to conventional healthcare professionals.(12,13) This may be a particular issue if the patient is self-medicating with over-the-counter remedies. There are risks of adverse reactions and interactions with conventional drugs. A responsible complementary practitioner will advise the patient about possible reactions/interactions and to tell their conventional professionals what treatment they are using, whether it be an oral treatment or otherwise. However, enquiring as to complementary therapy use should still be part of the conventional health professional's initial patient assessment. Fear of a negative reaction from health staff is one of the reasons patients do not disclose therapy use.(13) Conventional healthcare staff should be able to encourage open, honest and nonjudgemental discussion about complementary therapy with their patients. This will help identify problems, such as potential drug interactions and where an unscrupulous practitioner was exploiting a vulnerable patient. This can happen and is compounded by the wealth of unregulated information available via the internet. Healthcare staff should be able to help patients identify appropriate questions to ask about a therapy and the therapy practitioner in order to identify reputable therapy professionals. 
Of course, often staff do not feel they have the education or training to equip them to discuss therapies with their patients.(13) Increased complementary education opportunities for primary healthcare practitioners are crucial. Patients continue to seek complementary treatments, and conventional staff need to be aware of the benefits and disadvantages of such treatments to be better equipped to discuss these with their patients.

Education dilemma
The education dilemma works both ways. Some therapy practitioners lack knowledge about working with sick individuals who may have altered anatomy, pathology and physiology. Better complementary integration into conventional healthcare is key to addressing this issue. Therapists can learn from health staff about altered pathophysiology in disease, and health staff can learn from therapists about complementary treatments. This will help to ensure that the patient gains the greatest possible benefit from the therapy.
The education problem is compounded by the perceived lack of research evidence relating to benefits of complementary therapy. In fact, there is plenty of research evidence around. The quality of the research is sometimes compromised by small study samples and the fact that most complementary treatments are not suitable to be researched using the randomised control trial (RCT) model, which is the cause of much current controversy. The RCT is an inappropriate methodology for most complementary treatments for several reasons. First, many complementary treatments, such as homeopathy, do not have a standardised "prescription" even for the individual patient. To be most effective, the treatment may be altered at every consultation. Similarly, there are many facets of a complementary treatment. For example, an aromatherapy treatment derives its effect from:

  • The client-practitioner therapeutic relationship.
  • The massage itself.
  • The use of essential oils, and often more than one essential oil is blended for a single treatment.
  • The oils' constituents are absorbed into the body, where they can exert their effect.
  • There is a psychological effect from the aroma.
  • The "time out" factor.

Investigating such a number of effects is not best served by the RCT methodology, and although alternative methodologies are being developed, large studies are extremely expensive and the research capacity in complementary medicine is still extremely limited in comparison with conventional treatments.

Complementary therapies in primary care
Despite all this, access to therapies is increasing all the time. Over 50% of GP practices and 43% of primary care trusts (PCTs) provide some kind of access to complementary healthcare, but still over 90% of people who use therapies do so outside of the NHS.(6) There are various models of provision and providers. For example, an enhanced service via the GP - usually funded by charity, PCTs and/or patient contributions. Provision may be by complementary practitioners, GPs or others, such as physiotherapists and a small number of practice nurses. It is thought that practice-based commissioning will further enhance access to therapies where a practitioner or group of practitioners will be commissioned via PCT medical services or alternative medical provider services.
This may be the favoured approach for many conventional healthcare professionals. Many already feel that there are not enough hours in the day to do their existing role, let alone incorporate a new skill such as therapy provision. However, there may be specific aspects of a therapy that can be legitimately incorporated as part of nursing/medical care: for example, needling techniques for pain control and to support those trying to overcome addiction to drugs, or alcohol and hypnotherapy techniques, such as guided visualisation for relaxation.
However the service is to be developed, funding is a major issue. Addressing commissioning priorities is likely to bolster but not guarantee chances of funding.(14) A service where the therapy provision is seen as a potential solution to an NHS problem is more likely to succeed, and robust policy development is a prerequisite for effective integration and the building of sustainable services.(15) Effective evaluation of existing and new services is also vital to promote further integration. A 2006 study looked at service evaluations to determine which evaluation strategies and outcomes were more likely to attract funding.(14) The study concluded that evaluation strategies should include patient satisfaction, alterations to patient healthcare status and cost-effectiveness. A multiprofessional approach is also a key factor in success. There are many examples of collaboration between conventional and complementary practitioners where multidisciplinary teams provide flexible, holistic packages of care.(6)
Potentially the future of therapy integration into primary care is very bright, despite competing for evermore thinly spread funding. There is increasing awareness that complementary therapy can provide solutions for patients where mainstream care is struggling. If primary healthcare professionals further engage with the complementary therapy agenda and therapy practitioners, there is the potential for significant patient benefit - and the easing of pressure on overstretched primary care providers.

Resources

  1. Ernst E, White AL. The BBC Survey of complementary medicine use in the UK. Complement Ther Med 2000;8(1):32-6.
  2. Ong CK, Banks B. Complementary and alternative medicine: the consumer perspective. London: Prince of Wales's Foundation for Integrated Health; 2003.
  3. Thomas KJ, Coleman P, Nicholl J. Trends in access to complementary or alternative medicines via primary care in England: 1995-2001 results from a follow-up national survey. Fam Pract 2003;20:575-7.
  4. Baron S, Goodwin R, Nicolau N, Blackford S, Goulden V. Use of complementary medicine among outpatients with dermatologic conditions within Yorkshire and South Wales, United Kingdom. J Am Acad Dermatol 2005;52:589-94.
  5. Featherstone C, Godden D, Gault C, Emslie M, Took-Zozaya M. Prevalence study of concurrent use of CAM in patients attending primary care services in Scotland. Am J Public Health 2003;93:1080-2.
  6. Thomson A. A healthy partnership: integrating complementary healthcare into primary care. London: Prince of Wales's Foundation for Integrated Health (now The Prince's Foundation for Integrated Health); 2005.
  7. Van Haselen R, Reiber U, Nickel I, Jakob A, Fisher. Providing complementary and alternative medicine in primary care: the primary care worker's perspective. Complement Ther Med 2004;12(1):6-16.
  8. House of Lords. Complementary and alternative medicine. Select Committee Science and Technology. 6th Report. London: HMSO; 2000.
  9. Docker S. T'ai Chi and older people in the community: a preliminary study. Complement Ther Clin Prac 2000; 12(2):111-8.
  10. Tiran D. Breech presentation: increasing maternal choice. Complement Ther Nurs Midwifery 2004;10(4): 233-8.
  11. Pinder M. Complementary healthcare: a guide for patients. Prince's Foundation for Integrated Health: London; 2005.
  12. Thomas KJ, Coleman JP. Use of complementary or alternative medicine in a general population in Great Britain. Results from the National Omnibus survey. J Public Health 2004;2692:152-7.
  13. Robinson A, McGrail MR. Disclosure of CAM use to medical practitioners: a review of qualitative and quantitative studies. Complement Ther Med 2004;12(2-3):90-9.
  14. Wye L, Shaw A, Sharp D. Evaluating complementary and alternative therapy services in primary and community care settings: a review of 25 service evaluations. Complement Ther Med, 2006;14:220-30.
  15. Thomas KJ, Coleman P, Weatherley-Jones E, Luff D. Developing integrated CAM services in primary care organisations. Complement Ther Med 2003;11(4):261-7.


Resources

Association of Reflexologists
W: www.aor.org.uk

International Federation of Professional Aromatherapists
W: www.ifparoma.org.uk

National Electronic Library for Health including NeLCAM - the national electronic library for complementary and alternative medicine specialist library
W: www.nelh.nhs.uk

The Prince's Foundation for Integrated Health
W: www.fih.org.uk

Reflexology Forum
Working towards voluntary self-regulation for reflexology
W: www.reflexologyforum.org

Research Council for Complementary Medicine
W: www.rccm.org.uk

Royal College of Nursing
W: www.rcn.org.uk

Royal College of Nursing Complementary Therapies Forum Website (RCN members only, RCN membership number required)
W: www.rcn.org.uk/members/yourspecialty/newsletter-plus/forum/?f=complementary

Voluntary self-regulation register for aromatherapists
W: www.aromatherapycouncil.org.uk

Further reading
Complementary therapies in nursing, midwifery and health visiting practice: RCN guidance on integrating
complementary therapies into clinical care
Avis A. London: RCN (free to RCN members); 2003