Select Committee on Science and Technology Sixth Report


Primary Care Groups

9.21 Prior to the introduction of PCGs in April 1999, GP fund-holding practices could support the provision of CAM services through savings they had achieved on their budgets, and an estimated 12% of fund-holding practices were choosing to do this in 1995[55]. Once PCGs were introduced, all practice-based services, including CAM services, came under review. Many of our witnesses expressed concern that fund-holding practices which had decided to 'go it alone' in providing CAM services would not be able to convince their new partners in a PCG that CAM provision should continue.

9.22 The Department of Health commissioned a study in April 2000 on the way CAM services are "reconfigured in the NHS under PCGs"[56]. This study identified the need for a consensus across the PCG as one important factor likely to determine CAM provision (previous evidence shows that consensus on CAM was hard to reach even when it was only sought within the individual practices). The study also explained that any decision about CAM will have to take into account the two guiding principles for PCGs: these are the need to take into account the issue of adequate clinical governance, and to concentrate on the local population's primary care needs.

9.23 There does seem to be some justification for CAM practitioners' concern that the organisation of PCGs will impair the prospects of CAM services being commissioned within the NHS. We took evidence from the NHS Alliance, which was formed as a result of the introduction of PCGs in order to represent them and help them to become established (Q 1459). They told us that the extent of commissioning of CAM did seem to be falling, and with particular reference to osteopathy (one of the CAM services most commonly commissioned under fund-holding) they told us that "…surveys suggest that PCGs are not renewing the existing contracts held over from former fundholding arrangements. Our own research indicates that over 32.8 per cent have been discontinued. We believe this is due to the fact that PCGs have been given the role of balancing inequality of access from the old fund-holding system. This means they have to make a decision as to whether to extend a minority service or discontinue it completely. The problem we face, and it is a very important one, is that by discontinuing osteopathy PCGs are reversing the trend for innovation within primary care" (Q 427).

9.24 The NHS Alliance went on to elaborate on the problems CAM will face if PCGs continue with this trend: "If new approaches to treatment cannot be piloted in one or two GP practices before they are extended to all in a PCG then important opportunities for research in evidence-based practice will be lost. This reversal of the trend to using osteopathy in primary care will continue unless there is some incentive against it. Once this relationship is lost it is difficult to see how comparative studies will ever occur" (Q 427). They also suggested that one way of attempting to encourage PCGs to reverse this trend would be "…some exemption given to PCGs to allow the piloting of CAM projects within a single or a couple of GP units within each PCG. This would enable the evidence to be built up as to whether or not it is applicable to extend that service over the rest of the PCG. What we fear is that if that flexibility is not built into the system then complementary medicine will suffer" (Q 429).

9.25 The NHS Alliance did indicate that some of the problems discussed above may not be permanent: "… primary care groups and trusts are getting on to their feet. The primary care group is meant to be instilling new ideas, it is meant to be thinking the unthinkable, it is meant to be taking risks in many ways. There have not been great risks taken in that first year, largely, as I say, because of lack of funds. They will start, I think, taking greater risks in the conventional sense, I do not mean real risks of course. They will start doing that as they gain their confidence and their feet…as the public become more involved in what they are doing…It will take time for the professionals to become involved, it is going to take time for the patients to become involved, even more time for them to get properly briefed and be able to arm themselves with the same sorts of arguments and evidence that the professionals may be using against them. It is very doctor dominated at the moment, the scene, but I think that will change" (Q 1468).

9.26 However, some of the GPs interviewed in the Department of Health's commissioned report on the provision of complementary medicine under PCGs, referred to in paragraph 9.21, were less sure that the situation would change in the near future. That survey found that "most of the service providers who rated complementary medicine as a low priority within their PCG at the moment, felt that this situation was likely to continue in the medium to long term"[57].

9.27 The NHS Alliance told us that they did have a positive vision of how CAM may be provided by PCGs and PCTs in the future. Dr Michael Dixon told us: "I would see the future provision of complementary care being something that is decided at PCT level so that there is some standardisation and equity and that the actual service could be provided either from one of these centres or, where you have got large practices, there is no reason why the individual therapist should not be working in those practices. I think what that would offer would be a co-ordinated programme of complementary care within the Primary Care Trust and one which was flexible as to where the care was going to be provided…The new Primary Care Groups and Trusts are going to have to commission care, the long pathways of care, using these long-term service agreements. What I foresee is that the pathways of care, the long-term service agreements, will give relatively precise indications of at what point a patient might be offered a complementary option and, therefore, clear guidelines to all the primary care practitioners in that group as to when the work might be feasible or could be offered within the budget of that Primary Care Group. Therefore, again you would have that level of standardisation, whether the treatment was being offered from the resource centre centrally or whether it was being offered in an individual practice" (Q 1463).

9.28 The NHS Executive was commissioned by the Department of Health to produce a report on the key issues relating to CAM in Primary Care. The report was prepared by drawing together an information base on CAM in primary care through examining entries to the Guild of Health Writers' Integrated Healthcare Awards Competition, and through a questionnaire which was sent to all PCGs (and received a 60% response rate). The report identified some patterns of PCGs' commissioning of CAM therapies and important issues for PCGs to keep in mind. These were:

  • CAM occupied a greater or lesser profile within the PCG depending on local circumstances, e.g. the financial state of the PCG, need to review continuation of existing services and having to balance PCG priorities

  • Provision of CAM is usually based on the interest and enthusiasm of particular individuals rather than being part of an overall strategy of provision of services.

  • Where no such therapies were being provided, about one-fifth of PCGs had plans for provision within the next 2-3 years.

  • Factors to be taken into account in the provision of CAM were:

      a) information on effectiveness and cost effectiveness;
      b) knowledge of accreditation procedures and standards for practitioners;
      c) the wider resource implications of any decisions made.
  • Patients do not necessarily see the NHS as their provider of access to CAM, but do see NHS healthcare professionals as an information resource.

  • Given the significant number of people requesting and using CAM treatment it seems that doctors and healthcare professionals will not only need to be aware of what is available but also be able to give advice on existing evidence.

9.29 Within this research work[58] several areas for further work to aid PCGs in making informed decisions about CAM were identified. In response to these needs the Department of Health, the NHS Executive and the National Association of Primary Care collaborated to put together and publish a Complementary Medicine Information Pack for Primary Care Groups in June 2000. The aim of this pack is to "give primary care groups a basic reference on complementary and alternative therapies most commonly provided by PCGs." It includes information on current levels of provision, on individual therapies and the groups representing them on how to make referrals to CAM practitioners, and it outlines existing models of provision as well as identifying further sources of information. As these were all areas identified by PCGs as issues upon which they needed guidance it will, we hope, be a useful resource for PCGs in their practice reviews.

9.30 Another factor that is likely to impact on PCGs' commissioning patterns is the local Health Improvement Programme. The Department of Health told us that "Health Improvement Programmes (HImP) will be the local strategy for improving health and healthcare. They will cover the most important health needs of the local population, and how these are to be met by the NHS and its partner organisations...HImPs that engage all local interests and which will result in comprehensive LTSAs [Long-Term Service Arrangements - the replacement of annual contracts as the means of commissioning services] will take time to develop fully. As LTSAs develop, patients and their representative groups will be able to take an active role in influencing commissioning decisions. Those responsible for commissioning healthcare services will be required to involve users and carers in identifying local priorities…If local people and the relevant Primary Care Group, Health Authority and NHS Trust feel strongly that there is a priority need for CAM services, those responsible for commissioning services will need to consider whether these would represent a cost-effective means of meeting local health needs, consistent with the objectives of the local HImP" (P 117).

9.31 The newly published Complementary Medicine Information Pack for Primary Care Groups[59], previously mentioned, also discusses the role of HImPs in determining the use of CAM by PCGs. It advises that "Whilst CAM may not be specifically mentioned in the PCG Health Improvement Plan or Primary Care Investment Plan (PCIP), the PCG could still have an interest in how CAM may be integrated into services to improve the health of the local population. Across the PCG, there will probably be some variation in the extent to which the local population may be able to access CAM, usually related more to differences in local provision rather than patient need. In these circumstances the PCG will want to consider how the issue of equity of access for the local population should be addressed…A commissioning model for PCGs could involve care pathways for a given condition rather than individual services, providing an opportunity for CAM to be used and incorporated as an option, especially where there is evidence of efficacy to support its use."

Gatekeeper Role of GPs

9.32 The gatekeeper role of GPs is traditionally the route to most specialist care on the NHS; as Box 12 showed, all NHS CAM provision is currently accessed either through GP referral or the referral of another member of the primary or secondary healthcare team. As discussed earlier in this report, one of the main dangers of CAM is that patients could miss out on conventional medical diagnosis and treatment because they approached a CAM practitioner first who did not have the comprehensive medical training of a medical practitioner. One way of ensuring that this risk is minimised is to have GPs acting as gatekeepers so that CAM therapies can only be accessed (on the NHS) if the patient is referred by their GP or another member of the primary healthcare team.

9.33 The Royal College of General Practitioners (RCGP) supported the GP gatekeeper as the route for CAM access on the NHS. They told us: "The GP is the gatekeeper for many other services and, of course, if the patient has a particular condition, then in theory there is no reason why one should not consider CAM therapy as one of the points of referral...People also see the GP as somebody who can look at the effectiveness of what is likely to work for a particular condition. It may be a little bit difficult to work out the full benefits of a particular treatment without having a full assessment. It may just be the initial assessment but in some way co-ordinated" (QQ 1484 & 1490).

9.34 The BMA also envisaged the gatekeeper role as the best route for CAM access on the NHS: "We would anticipate that gatekeeper role within the NHS function. So if we are going to refer or delegate at the expense of the NHS we would expect it to be the route into that" (Q 378).

9.35 The gatekeeper role of the GP or other member of the primary healthcare team not only minimises the risk of failing to diagnose serious problems but also ensures that the GP is aware of the treatment their patient is getting, and that all treatment is recorded in patient records. It also encourages communication between healthcare professionals. Dr Simon Fradd of the BMA also saw advantages in the gatekeeper role for financial reasons: "The reason, I would say, for that gatekeeper role within the NHS is because we have finite resources and we have to balance that. This comes back to the whole evidence base again. In my own commissioning group in Nottingham we had to make a decision: would we buy CAM procedures or would we buy more hip replacements? In the lack of really clear evidence we bought the hip replacements. I have a function, not just in clinical gatekeeping but in financial gatekeeping, and that is why I see a need for a gatekeeper role within the NHS" (Q 379).

9.36 The gatekeeper role can only be effective in relation to NHS CAM provision. In the private sector it would be virtually impossible to have such a requirement to control CAM access. Even if it were possible, it is unlikely that it would be desirable. If people wish to access CAM practitioners without a GP referral, this is their right, as long as they are doing so privately. In fact, such visits probably aid the NHS, reducing the burden on an already over-burdened service. If all such patients were required to go through their GP it would add more pressure upon busy doctors. However, this does mean that if patients access CAM privately they may either: (i) not approach a GP first when they could be seriously ill and may benefit from conventional treatment; or (ii) they may see their GP but not tell him/her they are also having CAM treatment, which may interfere with the treatment which the doctors provide. Therefore it is very important that CAM practitioners encourage their patients to see their GP about health problems for which they have not sought a medical opinion beforehand. It is also important that GPs do not make patients feel embarrassed about accessing CAM treatments, but instead encourage openness so as to work with the CAM practitioner communicating about the patient's progress, etc. The BMA agreed with this approach, saying they would encourage "…best practice so that there is communication from the CAM practitioner to the patient's family doctor, and that would be the very least. However, I do not think we need to be proscriptive about it, but we do need the quality controls that we have spent quite a lot of time talking about today, to protect the public. Also, we need to make it clear to the public that the medical profession are behind this; that the public need not feel embarrassed about using an alternative practitioner" (Q 378).

9.37 We recommend that all NHS provision of CAM should continue to be through GP referral (or by referral from doctors or other healthcare professionals working in primary, secondary or tertiary care).

Criteria for NHS Provision

9.38 One of the questions in our Call for Evidence asked what level of evidence was needed to justify NHS provision of CAM.

9.39 We heard much evidence about this matter. Many submissions suggested that 'only CAM therapies with an adequate evidence base in their favour should be considered for NHS integration.' As we discussed in Chapter 3, this is a difficult principle to apply as an adequate evidence base is hard to define. The Royal London Homoeopathic Hospital recognised this was a problem and told us: "As a general rule only therapies which have some evidence in their support should be introduced, but this should be interpreted flexibly: it may be necessary to introduce a therapy with a weak evidence base in NHS settings before it can be adequately evaluated. Conversely, existing evidence may not be generalisable to NHS contexts. It would be difficult to define minimum required standards of evidence in a hard and fast manner" (P 195).

9.40 In the NHS Executive's study on key issues for CAM in Primary Care[60] discussed in the previous section, one of the questions put to the PCGs in the survey was: "What factors are important in decision-making on the provision of complementary therapies throughout the PCG?" Respondents were asked to identify the five most important factors, and the results show that in considering CAM's role in NHS primary care the most important factors are evidence of effectiveness and cost-effectiveness, followed by accreditation procedures and standards (See Figure 1).

Figure 1:

9.41 These findings again stress the importance of doing more research and gathering more evidence about CAM's effectiveness, as has been discussed in previous chapters. But the Royal London Homoeopathic Hospital's point that it may be necessary to introduce into the NHS new therapies with weak evidence bases in order to facilitate such research was reiterated by other witnesses.

9.42 The NHS Confederation told us "Integration in itself will also assist in the process of developing an evidence base. It is also the most promising way to take forward the matter of public provision. The NHS Confederation believes there are several service reasons why CAM should be publicly funded. However it should be made clear that in the current financial climate, provision of CAM in the NHS would have to compete with other priorities. It is likely that these services not backed by good evidence will be given a low priority" (P 145).

9.43 The NHS Confederation believes that there are several steps to be taken in deciding the extent of future provision of CAM. These are:

  • "Systematically appraising the evidence and emerging evidence…alongside any other health technology assessments. NICE should take the lead in such appraisals.

  • "Where an appraisal is promising yet sufficient evidence is not available…supporting further research and development work" (P 145).

9.44 One of the prime reasons for integrating CAM into the NHS will be if it is found to be cost-effective and can save scarce medical resources. We have heard some evidence that preliminary studies show that integrated healthcare can be cheaper than conventional medicine alone but more work needs to be done in this area. FIM told us: "The amount of work which is done on cost-effectiveness within the NHS is very limited, similarly, there is very little which has been done in terms of the cost-effectiveness of CAM provision. There are some findings to show that it did result in savings to the NHS. Our view would be that cost-effectiveness is an area of additional research which should be given attention, for example, across some of the chronic conditions which could be alleviated by CAM approaches. We would suggest that certainly more research needs to be done in this area. It is a very important one" (Q 112).

9.45 There are also questions of what level of regulation a therapy, or a practitioner, should be subject to if they are to work on the NHS. This was discussed in Chapter 5 on Regulation

9.46 We recommend that only those CAM therapies which are statutorily regulated, or have a powerful mechanism of voluntary self-regulation, should be made available, by reference from doctors and other healthcare professionals working in primary, secondary or tertiary care, on the NHS.

Thomas, K. & Luff, D. (April 2000) The Provision of Complementary Medicine Under Primary Care Groups: Interim Report to the Department of Health. Medical Care Research Unit, University of Sheffield. Back

56   Thomas, K. & Luff, D. (2000) (Op.cit.). Back

57   Thomas, K. & Luff, D (2000) (Op.cit.). Back

58   Thomas, K. & Luff, D. (2000) (Op.cit.). Back

59   Thomas, K. & Luff, D. (2000) (Op.cit.). Back

60   Thomas, K. and Luff, D. (2000) (Op.cit.). Back