Who provides complementary therapies

Complementary medicine is provided by two groups of therapists. The first are those who have had a formal medical training as doctors, nurses or physiotherapists. The second have had no conventional medical training but have instead been trained in complementary alternative medicine (CAM) disciplines as, for example, osteopaths, chiropractors, pro­fessional acupuncturists, medical herbalists and non-medically qual­ified homeopaths.

It is difficult to say exactly how many complementary medical practitioners there are in the UK. Current estimates from the relevant societies suggest that in 1997 there were 40,000 practitioners with three disciplines representing over half of the registered individuals; healers accounted for 14,000 practitioners, and there were 7,000 aromatherapists and 5,000 reflexologists.

If we look at the therapies that most people seem to use, these include acupuncture, homeopathy, herbal medicine and manipulative medicine (osteopathy and chiropractic). Those practising full-time, such as chiropractors and osteopaths, may be fewer in number but, in comparison to a part-time reflexologist, may treat a far larger number of people. This makes a therapy like chiropractic a far more popular and available choice, even though there are only 1,000 registered chiropractors and 1,000 registered osteopaths in the UK.

Only two groups of CAM practitioners have achieved statutory regulation: osteopaths and chiropractors. Statutory regulation means that these professions have a legally constituted council similar to that for doctors and nurses and someone can call him- or herself an osteopath or a chiropractor only if he or she is trained and registered.

Medical herbalists, acupunctur­ists and non-medically qualified homeopaths are regulated by voluntary bodies, but are moving towards statutory regulation with the support of the Department of Health. Most of the other CAM professions are voluntarily or self-regulated and you should be very suspicious of a CAM practitioner who is not part of some self-regulatory organisation.

MEDICALLY QUALIFIED PRACTITIONERS

The main CAM therapies provided by doctors are homeopathy, hypnotherapy and acupuncture. The British Medical Acupuncture Society has roughly 2,000 mem­bers, most of whom are doctors, although a small number of vets and dentists are also members. Most medically qualified acu­puncturists provide an acupuncture service as part of their day-to-day NHS commitment in either hospital or general practice, although many medical acupuncturists also have a small private clinic. The greatest use of acupuncture in hospitals is focused on rheumatology and pain clinics, where acupuncture is used primarily with conventional medi­cine to treat persistent pain, sometimes with a Western acu­puncture approach and sometimes on a traditional Chinese medicine basis. In general practice, acu­puncture is also largely used to treat pain and headaches.

The Faculty of Homeopathy represents the medically registered homeopaths. In order to become a Member or Fellow of the Faculty, doctors must pass a very stringent specialist examination in homeo­pathy. As it is so difficult, and because there is such a limited career structure within medical homeopathy in the UK, there are only just over 200 medically qualified specialist homeopaths. However, this does not represent the extent of clinical practice within medical homeopathy. For example, one of the most popular medical postgraduate courses in Scotland is run by the Glasgow Homeopathic Hospital introducing the use of simple homeopathic techniques into primary care; 20 per cent of Scotland’s GPs have attended these basic courses.

The most common com­plementary therapy provided by physiotherapists is acupuncture. It is now a recognised part of physiotherapy practice and approximately 15 per cent of physiotherapists have an acu­puncture qualification. Some physio­therapists and doctors use Western acupuncture techniques, whereas others use techniques firmly grounded in traditional Chinese medicine. Some physiotherapists also use manipulative medicine, and in many cases are experienced in techniques that are very similar, if not the same, as those used by osteopaths and chiropractors.

It is difficult to estimate how many nurses practise CAM, but the CAM special interest group is the largest in the Royal College of Nursing. In general, nurses have focused their interest on massage and therapies such as therapeutic touch, aromatherapy and reflexology.

NON-MEDICALLY QUALIFIED PRACTITIONERS

These practitioners come from a complementary medical back­ground and have no conventional medical training. They include osteopaths, chiropractors, pro­fessional acupuncturists, medical herbalists and non-medically qualified homeopaths.

Many complementary prac­titioners have become increasingly interested in obtaining statutory regulation. Osteopaths and chiro­practors have the same kind of legally established regulatory body as all the other medical professions. At the moment, they are still thought of as complementary medical practitioners, but in reality they have become part of the medical establishment in the UK. Herbalists and acupuncturists, both of whom complete detailed full-time three- or four-year courses, may soon also begin the process of statutory regulation.

Almost all CAM has some form of organisation and self-regulation. This, as a minimum, includes basic training requirements to ensure that practitioners are safe and competent. They need to understand when the therapy should be applied, and also when it is not suitable and when patients should see another practitioner or their own GP.

Most therapy organisations have clear ethical guidelines, so that the patient’s confidentiality is pro­tected, and all practitioners who use patients’ personal details on computer should fulfil the requirements of the Data Protection Act. Research supported by the Department of Health and carried out by the University of Exeter has discovered that most com­plementary medical organisations are following these general guidelines.

It would certainly be wise for anyone thinking of having a CAM treatment to consider whether the therapist is competent, and whether the therapy itself can be provided in a proper and professional manner. Ideally, you should discuss this with your own GP and the complementary therapist you are thinking of consulting. If you are unsure or concerned about any of these issues, ask again and do not see a practitioner until you are happy that he or she is safe and competent.

WHERE IS CAM PROVIDED?

Most CAM practitioners work on their own, either in their homes or in their own practices. Increasingly, complementary medical centres are developing in the high streets, but in most cases these are simply environments in which various CAM practitioners work, usually by renting rooms. There is also no real integration, either between individual CAM practitioners or between the local medical services and the complementary medical centres. Although many CAM practitioners are particularly skilled within their own professions, this lack of integration is not always good for the patient, who may possibly benefit from a package of treatment (for example, dietary advice, nutritional supplements and manipulation for back pain).

HOW CAN I BE REFERRED TO A COMPLEMENTARY PRACTITIONER?

Many people are recommended to a practitioner by a friend or someone who has been successfully treated. They may think that their own doctors may be reluctant to refer them, but information about the behaviour of GPs shows that this belief is false. Referral from the GP is a common route to CAM treatment. In the mid-1980s, around 75 per cent of GPs in some areas of the UK were regularly suggesting that patients see CAM practitioners, based largely on their own personal experiences of the effectiveness of these therapies. They were particularly supportive of making referrals to osteopaths and chiropractors for back pain.

Over the last 15 years, the availability of CAM within the NHS has increased. A survey in the mid­1990s indicated that 40 per cent of general practices were offering some form of CAM therapy. Some was given by the doctors them­selves or practice nurses, some by employed CAM practitioners and some by CAM practitioners who rented rooms in the health centres for the convenience of patients.
It is often very difficult for a GP to know to whom to refer and for what. This is partly because most GPs have very little training, knowledge or experience of CAM. This is now changing as more medical schools run CAM familiarisation courses as part of their undergraduate curriculum. It is also because there is so little information as to how to use CAM effectively in any particular situation.

Referral to an acupuncturist for pain or to a manipulator for a bad back is simple and straightforward. Other referrals, say to a herbalist or a homeopath, may need some discussion between you and your doctor, along with some in­formation that you or the relevant therapy organisation may provide such as when it may be appropriate to seek their advice. It is impossible to lay down absolute guidelines for when such referrals should take place, but in general both you and your GP may wish to consider the following issues.
Has a clear diagnosis of your problem been made? If a diagnosis cannot be made, then have other common conditions been excluded so that both you and your GP know that you are not missing out on appropriate conventional medical treatment?
If you have a chronic condition that is relatively stable then it may be reasonable to try a comple­mentary medical approach, either to help your symptoms or to mini­mise the use of potentially damaging long-term conventional medicines. However, before you reduce your conventional medi­cations, this must be discussed with your GP.

Your GP may regularly refer patients to a competent com­plementary therapist. If this is the case, your GP will be confident that the individual concerned is com­petent and safe.

Your GP may wish to refer you to another doctor practising some form of complementary medicine. This kind of referral should be exactly the same as a referral to any medically qualified specialist, because the person to whom your GP is referring you will be a registered medical practitioner.
As we have so little information about where complementary medicine may work best, it is quite reasonable to try a treatment (providing it is safe) for a limited period of time. You should agree with both your GP and your complementary practitioner, at the outset, when you would expect to see some beneficial effects.

Finding the right practitioner with so little information about which treatment works best in which condition is a difficult process. People seeking CAM often take advice from satisfied patients but, although this may help them find a competent complementary therapist, it is not always reliable. Sometimes individual therapy organisations can provide useful guidelines, but in general both you and your GP need to be assured that seeking complementary medical help is both appropriate and safe.

In addition, both you and the practitioner need to develop a clear understanding of your objectives so that you get some improvement for a reasonable investment of time and money.

CAN I BE REFERRED ON THE NHS OR WILL I NEED TO PAY PRIVATELY?

There is some provision of CAM within the NHS. The homeopathic hospitals in London, Tunbridge Wells, Bristol and Glasgow have been part of the NHS since its inception in 1948. They offer a service that is largely homeopathic but also involves a comprehensive approach to a variety of CAM therapies, usually including acupuncture and manipulative medicine. Pain clinics and physiotherapy departments almost all offer acupuncture as part of their treatment regimens, and palliative care units dealing with patients who have terminal cancer often provide aromatherapy, reflexology and massage.

Complementary practitioners are increasingly forming part of the primary care team. In particular, during the whole process of GP fund-holding there were growing numbers of osteopaths, chiro­practors and acupuncturists who were employed by general practices to offer a service to their patients. A recent BMA survey suggested that around 50 per cent of GPs referred patients for acupuncture and 15 per cent actually practised acupuncture on their own patients as part of their NHS commitment.

However, most complementary medicine practised in this country is within the private sector. Our research group has estimated, based on a questionnaire study, that approximately £4 million was spent on CAM consultations outside the NHS, in Southampton (population approximately 200,000) in 1996. The provision of CAM in the UK does not follow the clearly organised structure that exists within the NHS.

If you wish to seek some form of complementary medical treatment, you will probably need to pay privately. However, it is worth discussing it with your GP, as there may be an NHS referral route that is not widely publicised. You can usually obtain more information from the individual therapy organisations – for example, the Faculty of Homeopathy gives clear guidance to GPs on how they may refer patients through the NHS for homeopathy.