During the last decade there has been a significant increase in the interest and use of Complementary and Alternative Medicine (CAM) therapies by the British public. This growing demand has led to CAM being offered in many National Health Service (NHS) establishments (Thomas et al 2004). With interest, has come much scepticism from the biomedical scientific community who feel there is a serious lack of evidence based CAM research. This assignment will critically examine the role of education and the impact it has on the lack of integration of complementary medicine into the NHS whilst exploring the implications for the consumer, CAM and orthodox practitioners and examine the provision of healthcare within recent NHS structural guidelines and legislature.
The House of Lords report (2000) recognised the unregulated heterogeneous and diverse nature of many therapies in CAM and called for tighter regulation to be implicated when using CAM therapies in the form of voluntary and statutory regulation, classifying therapies by their level of organisation, which is accompanied by beneficial evidence based effectiveness. The medical profession has expressed concern for patient safety by suggesting that there is a low level of research and regulatory standards available in CAM therapies, the perceived lack of regulation and research in CAM has resulted in uncertainty and scepticism from orthodox medicine resulting in the reluctance to support CAM integration into an NHS framework (Parkman 2004). Research compiled over a decade ago stated that CAM may be accepted more by the medical profession if it could establish its effectiveness and safety via more RCT studies(Angell, Kassirer 1998), since then Haselen et al (2004) has stated that more published evidence in CAM indicate that it is increasing at a steady rate. Verhoef et al (2005) states that using RCT’s in CAM research studies can compromise the nature of the CAM therapy being researched, however research has demonstrated that it is possible to use RCT’s as a research design in CAM and that using both qualitative and quantitative methods can prove to be beneficial to the study, Fonteyn, Bauer-Wu (2005) recognised the importance of using qualitative evidence in randomised control trials (RCT) CAM research studies, which proved to be invaluable, as it provided extensive information regarding the feasibility and practicability of a CAM therapy, which could not otherwise be detected quantitatively. A decade ago the HOL(2000) suggested that an understanding of research method, ethics and evaluation are limited in CAM practitioners and education. Within the report, the British Medical Association (BMA) and the Research Council for Complementary Medicine (RCCM), were in agreement that core curriculum for undergraduate therapists should include research, as this would improve the study quality and as a result implementations were made for this to happen in Higher Education Institutions (HEI). It was suggested by the HOL (2000) that whilst CAM therapists acquire the relevant level of research, via appropriate undergraduate courses, mainstream researchers could bridge this gap in research and bring their expertise of scientific knowledge to this underdeveloped area of CAM. However since the publication of this report, the undergraduate programmes for CAM in 2004 had been reduced to 46 programmes from 100 (Isbell 2004), which is currently offered at 24 establishments in the UK (UCAS 2010). The HOL committee (2000 chapter 6) reported that the educational requirements for CAM differ and recommend an agreed consensus on the length and depth of study, formal accreditation and the provision of continual professional development (CPD) amongst educational establishments. Shortly after the publication of this report these recommendations were implemented by the National Qualification Framework (NQF) who decides on the level of qualification for England, Northern Ireland and Wales, ensuring that the qualifications offered are within the framework of the NQF and are therefore of a high accepted academic standard (QAA 2001). They communicate with the framework for higher education (FHEQ) who are constructed by the higher education sector, and set the qualifications (FHEQ) framework for higher education, in 2008 they reported that the qualifications achieved in Higher Education (HE) must be appropriate, not misleading in its course content and consistently represented, they go on to say that HEI are responsible for the implementation and maintenance of the national expectations of attainment in HE (QAA 2008) and that once the HE course has been accredited by the FHEQ it can only then be recognised by the NQF (Gov 2010). In CAM the CNHC follow this framework, ensuring that its academic student’s qualifications represent national academic expectations.
The variations of the courses are apparent in the diversity and academic standards ranging from Higher National Diplomas (HND’S) to degree standard, currently the institutions listed on UCAS (2010) offer both Bachelor of Arts (BA) and Bachelor of Science (BSc) in CAM which creates a discrepancy in the varying level of science vs. creativity academia for CAM. Fennel et al (2008), suggests that CAM is a variable concept which is based on culture and understanding will therefore be defined by the culture administering the CAM treatment. This may explain why the definition for CAM has been open to interpretation, creating confusion among the masses of western societies, which reflects on the UK academic institutions that offer CAM as a subject. Whilst conducting a course search via UCAS it emerged that the 46 available courses all specialised in CAM, however it appeared that the CAM abbreviation represented many different subjects, which were brought together by the umbrella term CAM, thus providing no clarity to what CAM is. The Complementary and Natural Healthcare Council (CNHC) are responsible for determining voluntary regulation and what a knowledge base is in CAM practitioners. Their main function is to enhance the protection of the public by raising the current standards for registration in Complementary Healthcare (CNHC 2010). Despite the numerous professional associations and bodies that currently represent CAM, the CNHC’s high level of standards and concern for quality and safety has led to them becoming the sole regulatory body of CAM that has official support of the government (DOH 2009) suggesting that the raised standards of the CNHC allow the consumer, medical practitioners and all commissioners of CAM to confidently make a choice regarding the most suitable practitioner for treatment. The professional associations that represent specific CAM therapies work alongside the CNHC in hopes of improving the standards of their members ensuring education is relevant and of a high standard (CNHC 2010). At this present time, all orthodox practitioners who wish to refer a patient to services within CAM, must ensure the CAM practitioner is CNHC registered, ensuring all involved that the CAM practitioner has at least been educated to National Occupational Standards(GCMT 2010).
Despite a long history and tradition of CAM use in other countries( Ernst et al 2005), the scientific community feel that CAM research methods should be subject to the same stringent rigor of assessment as in the UK and are therefore considered to be poor in quality (Bell 2002) and in an attempt to address the issue of lack of clinical research in CAM, the Smallwood report (2005) called for the National Institute of Clinical Evidence (NICE) to evaluate CAM therapies stating that CAM, offers the possibility of improving health in a manner that is cost effective to the NHS, in contrast to this, Calquhoun (2007) argues that the review would be a waste of money and if NICE were to apply its usual criteria to assessing the efficacy of treatments, CAM would be removed completely from the NHS due to lack of evidence. Calquhoun (2007) is possibly right, as the current state of UK CAM research is found to be of low quality, suggesting the need for more CAM researchers be educated in research to enable them to construct higher quality studies. Andreescu et al (2008) suggested that regardless of any positive results the study design of CAM reviews is poor and is further supported by, Ramos-Remus & Raut(2008), who conclude that higher quality studies are needed before CAM can be recommended to patients, highlighting the need for more education in CAM regarding reviewing and performing CAM research. Linde(2009) suggests searching beyond conventional databases and argues that systematic review questions relating to CAM are often broad and open to interpretation however, Linde(2009) acknowledges that finding good quality evidence within unconventional databases is doubtful. Sharples et al(2004) suggested that to train CAM students to become researchers so that they can produce evidence based research in CAM will take many years to deliver high quality research and cost effectiveness in CAM, suggesting that it will take time and finance for positive results such as clinical evidence to be to be produced from a relatively new way of looking at CAM. Sources of research funding are a major issue for UK CAM students, as they are notoriously difficult to acquire(Ernst 1999), suggesting that it creates a barrier for CAM students preventing them conducting the research needed to provide evidence of CAM treatments. Over a decade ago Ernst (1999) who suggested ring-fencing funds to CAM, was further supported by the HOL report the following year(2000) in which they suggested that ring fenced funding should come from the NHS Research and Development(R&D) directorate and the Medical Research Council(MRC), to initiate better opportunities for steering good research in CAM. The Pittilo report(2008) called for the Government to allocate more funding into educational establishments hoping to attract practitioners to conduct research in those areas and for practitioners of CAM to complete an honours degree in CAM, however as many CAM courses have been discontinued, this currently seems unlikely. If taken seriously by the UK scientific research community, the report could have attracted interest and funding from researchers and CAM therapists to conduct high quality research in CAM, and with positive results possibly attract its own funding to conduct research, supported by Ernst(2004) who states that the funds made available for CAM research in the USA has produced a larger proportion of research in CAM that is metholodically sound. In response to Pittilo(2008), Colquhoun(2008) believes that this is a waste of money and resources, and that it is impossible to award an honours degree without knowing if the treatments are effective and safe and that any university that offers a degree under these circumstances are discrediting themselves.
The Research Councils United Kingdom(2010) provide public bodies with public tax money to conduct science and research and state that in 1997, the Science Budget(SB) was at 1.3 billion and has since risen significantly to four billion for 2010/11(RCUK 2010). The Business Innovation and Skills(BIS) currently allocates the SB via seven research councils who provide funding to health researchers, they point out that the SB is ring fenced by request of the treasury and is only to be spent by the office of science and innovation(OSI) (BIS 2010). The Research Councils United Kingdom(RCUK) (2010), say that in supporting approximately 30 thousand researchers, over half are doctoral students, suggesting that a very small percentage of funding is available for CAM research. During 2006, the Department of Health (DOH) published the results of the patient choice survey, which was designed to provide consumers with variety, regarding the way in which healthcare needs are met. This opportunity allowed the multicultural British community, to play a role in ensuring their healthcare reflected their own priorities, needs and decisions. The Darzi report (2008) placed significant emphasis on promoting quality of care and the prevention of thriftlessness and waste within the NHS. Darzi’s (2008) definition of quality care includes safety and clinical effectiveness and hopes to address the many concerns made by all including the consumer, medical professional’s (MP’S) and CAM practitioners in establishing a more competent state funded NHS in the future. The Healthcare Commission (HC) were required to review the NHS trusts of England and report its findings to the government whilst recommending measures to improve quality of care. This is achieved in by measuring the performance of the trust (chosen by selective inspection) against the performance targets set out set out in the DOH 2004: Standards for better health document(Kings Fund 2008). The HC are accountable to Parliament; however they are appointed independent of government(BIS 2010). In line with the Health and Social Care Act(2008), three regulatory bodies including the HC were merged to form the Care Quality Commission(CQC). They require healthcare providers to register with the CQC prior to offering services and as of 2011, this will incorporate primary health care providers, due to the reported variations of the service quality in the NHS and the increase of primary care services which are now largely community based instead of hospital based(DOH 2008). As the lack of regulation and evidence based research of the majority of CAM is under much scrutiny and speculation, the probability and likelihood of integrating CAM services within the NHS seems to be currently low. In contrast to this, there is evidence to suggest that despite the majority of funding being allocated to medical students whose research proposals are of high quality, there is no guarantee their research will demonstrate clinical effectiveness within the NHS, this is supported by the clinical evidence(CE) team associated with the British Medical Journal(BMJ), who report to the NHS health technology assessment programme(HTA) providing information regarding the percentage of unknown and beneficial evidence in conventional medicine(CE 2010). In the CE review(2010), they stated that just 13% of 2,500 EBM treatments were shown to be beneficial and that 46-49% of common conventional treatments recommended for patients were found to have unknown effectiveness. The evidence(CE 2010) suggests that whilst there is an apparent gap of knowledge in CAM, this lack of EBM also exists in conventional treatments.
Many healthcare professionals comprehend that CAM does offer many people relief of symptoms and are happy to provide it in their practice, however most feel that CAM should be offered by healthcare professionals and would be willing to learn the techniques in an effort to improve safety and cut costs in the NHS. In view of the benefits of CAM described by NHS patients, the medical professions currently have the funding and the scientific research knowledge to be able to conduct high quality research studies, which could incorporate CAM practitioners, thus widening the safety and knowledge base of all concerned.
Evidence concludes that there are multiple problems faced with integrating CAM therapies into the NHS structure, although it does currently exist in some primary care units, there is currently an imbalance, regarding the prevalence of CAM in a primary care setting, however it is at the basic level of education where the issues arise. For CAM to be successfully integrated into the NHS, more high quality RCT studies, need to be produced to provide clinical based evidence of efficacy, safety and cost effectiveness of CAM. While there is currently a high usage of CAM therapies from the public and a perceived lack of medical knowledge from CAM practitioners, this imbalance needs to be supported by additionally structured access to research funds and more higher education courses, that teach research and critical appraisal skills so that they can test their theories in a similar way to conventional medicine (with clinical based evidence), however for this to happen more interest in the subject needs to be created to eventually produce new generations of CAM students who understand the importance of research in clinical based evidence, more importantly the closure of many teaching establishments of CAM courses during the past four years, proves to be counter-productive for the integration of CAM within the NHS and therefore enables the gap between them to widen.
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