Select Committee on Science and Technology Sixth Report


CHAPTER 1: INTRODUCTION

What is Complementary and Alternative Medicine?

1.1 Aspirin (acetylsalicylic acid) was the first synthetic chemical drug. It was manufactured by Bayer in Germany, patented and put on the market in 1899. Until then treatment in Western medicine, as in all other forms of medical practice, including Chinese and Ayurvedic medicine, was very largely based on the use of herbs supplemented by preparations of metals and occasionally animal preparations. The preparations in the Herbal of Dioscorides published in 55AD remained largely unchanged in Western pharmacopeias until the twentieth century. There was very considerable variation in the range of herbs available in Eastern countries and their pharmacopeias reflected this. But apart from such differences, the aims were the same, namely to use the herbs that were available for their effects in ameliorating the symptoms of disease.

1.2 In virtually all systems of medicine the claims made for the efficacy of such preparations in treating a wide range of diseases and symptoms usually lacked any clear supporting evidence or a sound foundation. This was reinforced by the tendency, still found in the Eastern systems of medicine today, to prescribe a mixture of many different herbs rather than a single remedy. Quinine (derived from cinchona bark) for malaria, digitalis (from the foxglove) for heart failure and opium (from the poppy) for pain relief were exceptions but even their efficacy was only established after many years of empirical use. Before the introduction of the National Health Service (NHS) in 1948, the provision of primary medical care in the United Kingdom was very uneven. Nevertheless, many doctors were able to find ample time to spend with their patients. They made many house visits and came to know much about the families for whom they cared, both medically and socially. Their principal method of caring for their patients, apart from using the range of herbal remedies available, was the provision of what has been referred to commonly as "tender loving care" (TLC) to aid natural recovery, namely to supplement the "vis medicatrix naturae"[1].

1.3 The rate of development in Western countries of new synthetic chemical drugs has increased steadily since the introduction of aspirin. Western medicine now has an armamentarium of remedies that provides the means of preventing or curing many specific diseases and also of mitigating the symptoms of many more. This has not happened to any major extent in any other systems of medicine, although new and effective herbal remedies are still being discovered and are becoming available to complement the enormous variety of effective synthetic drugs which are now being used in conventional Western medicine.

1.4 In parallel with the increased availability of synthetic drugs, there have been remarkable developments in surgery. These escalated following the development of effective anaesthesia, which made complex surgery possible for the first time. The range of feasible surgical interventions has increased dramatically and offers a new prospect of radical cures or mitigation of many maladies. There has also been a dramatic increase in knowledge of the biochemical or molecular origin of many diseases so that new diagnostic tests have emerged, many dependent upon measuring the concentration of various chemical entities in the blood stream, or upon the use of DNA recombinant technology.

1.5 There are however many common diseases, mostly chronic, for which new drugs and surgical interventions have so far failed to provide outcomes that are satisfactory for many patients. Among these are the various forms of arthritis, low back pain, asthma, some forms of cancer and many more.

1.6 Modern Western medicine is both complex and expensive. Increasing pressures on an under-doctored National Health Service (NHS) are now such that the average primary care physician has very little time to spend with each patient in consultation in order to offer the attention and 'tender loving care' which were important therapeutic weapons for his predecessors. When he or she diagnoses a serious or acute condition known to be amenable to modern treatment, the patient will usually be referred to an appropriate specialist, although some such problems can increasingly be handled effectively in primary care. When a chronic complaint is diagnosed it is often treated symptomatically with a prescription drug. Furthermore in a group practice patients may sometimes see different doctors on each occasion they attend, and thus lack a close therapeutic relationship with a single doctor. Added to this is the fact that many conventional medical and surgical interventions, as well as effective synthetic drugs, and even some of herbal origin, produce in some patients troublesome and distressing side-effects which may occasionally even have fatal consequences. Such adverse reactions are usually less common with complementary and alternative therapies. The benefit-risk ratio must be taken into account.

1.7 It is not, therefore, surprising that the satisfaction expressed by many patients with conventional medicine is often not as good as it was in the past. It is probable that this is one of the principal reasons why there has been such a marked increase in the numbers of people who turn to other systems of medicine or to complementary or alternative medicine to replace or supplement their conventional medical advice. It is these complementary and alternative disciplines that we examine in this report.

1.8 Complementary and Alternative Medicine (CAM) is a title used to refer to a diverse group of health-related therapies and disciplines which are not considered to be a part of mainstream medical care. Other terms sometimes used to describe them include 'natural medicine', 'non-conventional medicine' and 'holistic medicine'. However, CAM is currently the term used most often, and hence we have adopted it on our Report. CAM embraces those therapies that may either be provided alongside conventional medicine (complementary) or which may, in the view of their practitioners, act as a substitute for it. Alternative disciplines purport to provide diagnostic information as well as offering therapy.

1.9 This Inquiry was mounted because there is a widespread perception that CAM use is increasing not only in the United Kingdom but across the developed world. This appeared to raise several important questions of substantial significance in relation to public health policy.

1.10 Before assessing how CAM use could, or should, influence public health policy, a more quantitative picture of use in this area would be desirable. However, quantitative survey data in this area are somewhat patchy and are beset by questions of definition which are hard to resolve.

1.11 Several professional bodies have attempted to define CAM. The British Medical Association (BMA) report Complementary Medicine: New Approaches to Good Practice suggests that although the term 'complementary therapies' is familiar to the public, a more accurate term might be 'non-conventional therapies'. The BMA defines these as: "those forms of treatment which are not widely used by the conventional healthcare professions, and the skills of which are not taught as part of the undergraduate curriculum of conventional medical and paramedical healthcare courses"[2]. This definition is now unsatisfactory as the use of some of the therapies traditionally considered to be non-conventional is growing amongst doctors (although practice varies widely). Some medical schools are now offering CAM familiarisation courses to undergraduate medical students while some also offer modules specifically on CAM.

1.12 Professor Edzard Ernst, who holds a Chair in CAM at Exeter University, provided the following definition: "Complementary medicine is diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine"[3]. This definition helps to elucidate the aims of complementary medicine, but it does not cover alternative therapies which do not seek to contribute to a common whole but which are offered by their practitioners as an alternative to conventional medicine. A more encompassing definition of CAM is provided by the Cochrane Collaboration as: "a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health systems of a particular society or culture in a given historical period".

1.13 The CAM community has been struggling for fifteen years to come up with a single definition of CAM agreed by all, but with no success. Therefore, when setting up this Inquiry we decided not to begin with a precise definition of CAM. Instead we began with a list of therapies which we thought were commonly considered to fall within the field of CAM and issued this list with our Call for Evidence (see Box 1). Additional disciplines have subsequently been added in the light of evidence received (identified by an asterisk in Box 1). In making the list of therapies we have provisionally grouped the ones we regard principally as complementary separately from the ones we regard principally as alternative. While no firm distinction is possible, we regard the complementary disciplines as those which usually, if not invariably, complement conventional medical treatment, while the alternative disciplines are those which purport to offer diagnostic and therapeutic alternatives to conventional medicine.

Growing Use of CAM in the United Kingdom

1.14 We have heard much evidence to the effect that we are now experiencing a rapid increase in the use of CAM across the Western World. There are limited data on the exact levels of use and much of the information that is available does not refer to the United Kingdom. However, some surveys have been conducted and are reviewed briefly below, in an attempt to achieve a snapshot of existing CAM use. This has helped to inform subsequent conclusions about the implications this evidence may have in relation to future healthcare policy.

1.15 Caution should be exercised when making comparisons. The results of the different surveys reveal a wide range in the extent of CAM use. This may partly be due to different definitions of CAM being used, different methods being used to implement the survey, the population surveyed and the range of therapies considered. We have therefore provided a brief summary of the specific CAM disciplines being considered by each survey at the beginning of each review. It must also be noted that these surveys take no account of the increasing use by the public of self-medication through the purchase of conventional over-the-counter remedies such as analgesics, cough medicines, antacids and vitamins. We have not attempted to compare in detail the extent of such self-medication with the extent of CAM self-medication. However, the Royal Pharmaceutical Society tell us that in 1999 £2318 million was spent on non-prescription medicine. They also told us that the non-prescription market has made increasing profits over the past four years for which they had figures.

British Surveys

1.16 In 1999 Mr Simon Mills[4] and Ms Sarah Budd at the Centre for Complementary Health Studies at Exeter University were commissioned by the Department of Health to conduct a study of the professional organisation of CAM bodies in the United Kingdom[5]. This was a follow-up to a study conducted on the same subject three years earlier[6]. It looked at how many people were working as CAM practitioners. Its results suggest that there are approximately 50,000 CAM practitioners in the United Kingdom, that there are approximately 10,000 statutory registered health professionals who practise some form of CAM in the United Kingdom and that up to 5 million patients have consulted a CAM practitioner in the last year. Hence there are two considerations to consider: the number of practitioners and the number of patients. Patients can access CAM either through professional CAM practitioners, through other health professionals (e.g. doctors, nurses and physiotherapists who offer CAM services) or through the purchase of over-the-counter preparations.

1.17 A telephone survey of 1204 randomly selected British adults was conducted for the BBC in 1999[7]. This survey did not specify which therapies it classed as CAM; instead respondents were asked if they had used 'alternative or complementary medicines or therapies' within the last year. This was followed by an open-ended question asking: 'What specifically do you or have you used or done?' Therefore the definition of CAM was left up to the respondent. This survey's results are summarised in Table 1.

Table 1: Use of CAM in the United Kingdom
  
1999 (%)
Use of any CAM in past 12 months
20
Of which: *
 
Herbal medicine
34
Aromatherapy
21
Homeopathy
17
Acupuncture / acupressure
14
Massage
6
Reflexology
6
Osteopathy
4
Chiropractic
3

Source: nationally representative random telephone survey of 1204 British adults, commissioned by the BBC.

* Percentages of those who had used CAM. It must be noted that some individuals use more than one therapy and thus the numbers above do not add up to 100.

1.18 However, this survey did not expand on whether the treatment was accessed through the purchase of over-the-counter remedies or through a professional consultation. This survey also found that the average amount of money each CAM user spent on CAM was approximately £14 per month with a large proportion of users (37%) spending less than five pounds per month. The authors extrapolated this information to the whole nation and estimated that the United Kingdom has an annual expenditure of £1.6 billion on CAM.

1.19 Another survey[8] of CAM use in England (not the United Kingdom) used a questionnaire sent out as a postal survey to 5010 randomly selected adults and received 2668 usable responses (a corrected response rate of 53%). This survey asked respondents whether they had visited a practitioner of one of eight named therapies in the last twelve months. The named therapies were acupuncture, chiropractic, homeopathy, medical herbalism, hypnotherapy, osteopathy, aromatherapy and reflexology. The survey also asked for information on whether respondents had purchased any over-the-counter, herbal, or homeopathic remedies. Results showed that 13.6% of respondents had visited a practitioner of one of the eight named therapies in the preceding 12 months, and overall 28.3% of respondents had either visited a CAM therapist or had purchased an over-the-counter remedy. The most commonly consulted CAM therapists were osteopaths (4.3% of respondents), chiropractors (3.6%), aromatherapists (3.5%), reflexologists (2.4%), and acupuncturists (1.6%). Of the respondents, 8.6% had bought an over-the-counter homeopathic remedy and 19.8% had bought an over-the-counter herbal remedy. The NHS paid for an estimated 10% of the visits to practitioners but the authors estimate that £450 million worth of out-of-pocket expenditure was used on six of the principal therapies (excluding aromatherapy and reflexology) during the preceding year.

1.20 In their evidence to us the Royal Pharmaceutical Society discussed a report from 1999 on over-the-counter sale of CAM preparations prepared for industry by Mintel Marketing Intelligence (Q 1313). This report found that retail sales of complementary medicine (herbals, homeopathic preparations and aromatherapy essential oils) totalled £93m in 1998. A breakdown of this figure showed that £50m had come from sales of herbal medicines, £23m from homeopathic medicines and £20m from aromatherapy essential oils. The report also showed that these figures were increasing and that the total revenue was up 50% from £63m in 1994. Overall retail sales in 2000 were predicted to reach £109m and predictions for 2002 were £126m[9].

1.21 These rather limited data seem to support the idea that CAM use in the United Kingdom is high and is increasing. This conclusion is supported by anecdotal evidence received from many of our witnesses including the Foundation for Integrated Medicine (FIM),[10] the NHS Alliance and the Department of Health, confirming that the public are very interested in this area. A glance at any women's magazine will reveal pages of information dealing with dietary supplements and alternative medicine clinics. However, as mentioned earlier, a more authoritative picture is desirable. Apart from the data discussed above there is little other evidence available about usage of CAM in the United Kingdom and a comparison with the extent of usage of self-medication with conventional over-the-counter remedies would be useful. More detailed quantitative information is required on the levels of CAM use in the United Kingdom, in order to inform the public and healthcare policy-makers and we recommend that suitable national studies be commissioned to obtain this information. Information from other developed countries is also relevant.

United States Surveys

1.22 In the United States Eisenberg, David and Ettner[11] conducted two national telephone surveys of two randomly selected sets of adults, surveying levels of CAM usage in 1990 and 1997 respectively. They questioned respondents on their use of sixteen 'alternative therapies' and defined accessing alternative medicine as having used at least one of the sixteen therapies (either as an over-the-counter preparation or through a professional consultation) within the previous year. The sixteen therapies included several that we did not include in our Call for Evidence, e.g. mega-vitamins, self-help groups, imagery, and commercial and lifestyle diets. Their remit did not include osteopathy which was included in our Call for Evidence, and which is generally regarded as a mainstream medical speciality in the USA.

1.23 The results of this survey are shown in Table 2. In both the 1990 and the 1997 surveys, alternative therapies were used mainly for chronic conditions such as back pain, allergies, anxiety, depression and headaches. The authors of the survey found that extrapolation of their results to the entire population of the USA suggested a 47.3% total increase in visits to alternative practitioners, from 427 million to 629 million (which was more than the number of visits to all US primary care physicians). Out-of-pocket expenditure on alternative therapies was estimated at $27.0 billion in 1997.

Table 2: Use of CAM in the USA

  
1990 (%)
1997 (%)
Use of any CAM in past 12 months
33.8†
42.1†
of which‡
  
  
Relaxation techniques
13.1
16.3
Herbal medicine
2.5
12.1
Massage
6.9
11.1
Chiropractic
10.1
11.0
Spiritual healing
4.2
7.0
Homeopathy
0.7
3.4
Acupuncture
0.4
1.0

Source: two nationally representative random household telephone surveys.
Percentages of the total sample population (1539 for the 1990 data; 2055 in 1997).
Table shows selected figures relating to the top five therapies based on the 1997 survey, plus (for comparison with United Kingdom statistics) figures for homeopathy and acupuncture.

Reasons for Accessing CAM

Survey Data

1.24 A national postal survey of 1035 adults which was designed specifically to find out why patients use CAM was conducted in the USA in 1998[12]. The survey asked about respondents' need for control over their own health; their philosophical orientation towards religion, spirituality, mind and body; their belief in the efficacy of conventional medicine and their general health and demographic statistics. A multiple regression analysis was then used to identify predictors of alternative healthcare use. The most significant predictor was higher educational status, followed by overall health status. Chronic health problems such as anxiety, back problems, urinary tract problems and chronic pain were each also significant predictors of CAM use. Apart from health and social status the only other three significant predictors of CAM use were: being 'culturally creative'; having a holistic philosophical approach to life; and having had a 'transformational experience'. The author takes the view that dissatisfaction with conventional care was not the major factor leading to the use of CAM. He suggests that as well as being better educated and in poorer health, most users of CAM access these therapies because they find them to be 'more congruent with their own values, beliefs and philosophical orientations towards health and life'. However, it is worth noting that Astin never asked the critical question: " Has conventional medicine worked for you?" in his survey, even though he was assessing why people turned to CAM. The cost of conventional medical treatment in the USA may also have been another factor.

1.25 The BBC survey of CAM use in the United Kingdom also asked respondents who had used CAM what their main reason was for accessing CAM medicines or therapies[13]. Results are shown in Table 3.

Table 3 : Reasons for Using CAM
Reason
Percentage of those who use CAM
Helps or relieves injury / condition
25
Just like it
21
Find it relaxing
19
Good health / well-being generally
14
Preventative measure
12
Do not believe conventional medicine works
11
Doctor's recommendations / referral
11
To find out about other ways of life / new things
11
Way of life / part of lifestyle
8
Cannot get treatment on NHS / under conventional medicine
7

Source: nationally representative random telephone survey of 1204 British adults, commissioned by the BBC.

Other Possible Explanations

1.26 Some evidence we have received has suggested reasons for CAM use that are neither to do with patient satisfaction with CAM, nor dissatisfaction with conventional medicine. Dr Thurstan Brewin (P 244) suggested that the current popularity of CAM is dictated by fashion, as is evidenced by the many articles and advertisements in the lay press. He also suggested that another reason for the rising trend in CAM utilisation relates to a cultural change with a renewed interest in the paranormal (e.g. astrology) which remains popular no matter how much evidence refutes it. He postulated that another factor in CAM's popularity is the increased anxiety about health across society, despite the longer and safer lives which people now lead. He therefore suggested that much of CAM's popularity lies with the 'worried well', a suggestion others have also made.

1.27 In their oral evidence to us the General Medical Council (GMC) put forward that one other reason for CAM's popularity may be the general attitude of society towards science (Q 1036). They suggested that in some areas of society there is a flight from science, fuelled by unbalanced and inaccurate articles in the media and by the unsubstantiated claims from some environmental groups. The subject of society's flight from science was tackled by this Committee last year and is discussed in our previous report Science and Society[14].

1.28 It would be useful to have more research on why the public are increasingly using CAM in their healthcare regimes. At the moment the reasons are unclear, but the answer to this question is important as it may have implications for the NHS, conventional healthcare practitioners and CAM practitioners, who wish to meet their patients' needs more comprehensively.

Approach of This Report

1.29 This report does not consider the clinical efficacy of particular products or therapies except insofar as evidence is available to inform policy. We shall return to our reasons for this later in the report.

1.30 Whatever the reasons behind the popularity of CAM it is clear that there is an increasing number of patients and practitioners who are each involved in this area of healthcare. It is this high level of public interest that has prompted our Inquiry, raising important public policy questions that we have been charged with considering:


(i)In an age where conventional medical research is advancing rapidly with major benefits for patient care and increasing life expectancy, why are people using CAM and for what are they using it?
  
(ii)Since most statutory controls pertain to conventional medical and other healthcare practitioners and their relevant organisations, are current regulations adequate to provide a safe service for patients using CAM?
  
(iii)Does current medical training prepare doctors, nurses and others to answer patients' questions about CAM? Do they have enough information? Should their training include familiarisation with CAM?
  
(iv)How well developed is the training of CAM practitioners? Are appropriate structures in place to support high-quality training? Are proper codes of practice being developed? Are appropriate accreditation processes in place to protect the patient? Are issues of Continued Professional Development being considered?
  
(v)Is the state of CAM research adequate? Is appropriate research being carried out to investigate efficacy and to ensure that patients are receiving safe, effective treatments? Are current research methods appropriate for CAM research? Is research funding available and is the research infrastructure there to support work in this area?
  
(vi)Should CAM's popularity among the public result in an increase in NHS CAM provision? If so, how should CAM be delivered? Should it invariably be complementary, perhaps by reference to CAM practitioners by doctors in primary care, or is there any case for the provision of alternative medicine on the NHS? Will NHS reforms change how CAM is provided on the NHS?


CONDUCT OF THIS INQUIRY

1.31 This report was prepared by Sub-Committee I, whose members are listed in Appendix 7, with their declarations of interest. We received evidence from a wide range of individuals and organisations, to all of whom we are grateful; they are listed in Appendix 8. The written evidence received up until 1st February 2000 is printed in HL Paper 48. The oral evidence received at 21 public hearings, and the written evidence received after 1st February is published in HL Paper 118.

1.32 We record our gratitude to our specialist advisers: Professor Stephen Holgate, MRC Professor of Immunopharmacology, University of Southampton and a member of the Board of the Foundation for Integrated Medicine; and Mr Simon Mills, Director of the Centre for Complementary Health Studies, University of Exeter, and a member of the Council of the Foundation for Integrated Medicine. We also wish to express particular gratitude to those who met us at the University of Exeter, the University of Southampton, the Centre for Complementary Health Studies at Southampton, the Marylebone Health Centre, London, and the Glasgow Homeopathic Hospital.


1   The body's natural healing power. Back

2   British Medical Association Complementary Medicine: New Approaches to Good Practice (Oxford University Press, 1993). Back

3   Ernst, E. et al. 'Complementary Medicine - A Definition' [letter] in The British Journal of General Practice (1995; 5:506). Back

4   Simon Mills, Director of the Centre for Complementary Health Studies at Exeter University, was one of the specialist advisers to the Sub-Committee who prepared this report. Back

5   Mills, S. & Peacock, W. Professional Organisation of Complementary and Alternative Medicine in the UK 1997: A Report to the Department of Health (University of Exeter, 1997). Back

6   Budd, S. & Mills, S. Professional Organisation of Complementary and Alternative Medicine in the United Kingdom 2000: A Second Report to the Department of Health (University of Exeter, 2000). Back

7   Ernst, E. & White, A. 'The BBC Survey of Complementary Medicine Use in the UK' in Complementary Therapies in Medicine, 8 (2000), 32-36. Back

8   Thomas, K.J., Nicholl, J.P. & Coleman, P. 'Use of and Expenditure on Complementary Medicine in England - A Population-Based Survey'. Complementary Therapies in Medicine (In Press). Back

9   The fastest growing sales figures were for essential oils, which had almost doubled in sales volume in real terms since 1993. Sales of homeopathic products had grown at a steady rate of around 4% per annum and those of herbal medicines were growing at a steady rate of about 10% per annum. Back

10   The Foundation for Integrated Medicine was formed at the personal initiative of HRH The Prince of Wales, who is now its President. The aim of the Foundation for Integrated Medicine is to promote the development and integrated delivery of safe, effective and efficient forms of healthcare to patients and their families through encouraging greater collaboration between all forms of healthcare. The Foundation operates as a forum, actively promoting and supporting discussion, and as a centre to facilitate development and action. Its objective is to "enable individuals to promote, restore and maintain health and well-being through integrating the approaches of orthodox, complementary and alternative therapies". Back

11   Eisenberg, D.M., Davis, R.B., Ettner, S.L. et al. 'Trends in Alternative Medicine Use in the United States, 1990-1997: Results of a Follow-up National Survey' in The Journal of the American Medical Association, 280 (1998) 1569-1575. Back

12   Astin, J.A. 'Why Patients use Alternative Medicine. Results of a National Survey'. The Journal of the American Medical Association, 279 (1998) 1548-1553. Back

13   Ernst, E. & White, A. (2000) (Op.cit.). Back

14   See our Report: Science & Society, 3rd Report 1999-2000, HL Paper 38. Back


 
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