Visit to Mr Simon Mills' CAM Practice,
Department of Complementary Medicine, University of Exeter; and
the Centre for Complementary Health Studies, University of Exeter
On 22/23 March 2000
|Members present:||Earl Baldwin of Bewdley
|Lord Perry of Walton
|Lord Soulsby of Swaffham Prior
Wednesday 22 March
Simon Mills' Clinic
On arrival at Exeter the Committee visited the clinic where Simon
Mills practises. The purpose of this visit was to get a feel of
a working Complementary Medicine Clinic and to meet some practising
CAM therapists. The Committee were given a brief tour of the practice
which consisted of: a waiting room; a small herbal medicine pharmacy
where Simon Mills took questions; a treatment room where Chris
Bury the clinic's osteopath demonstrated; another treatment room
where Tricia Hemmingway the clinic's Alexander Technique teacher
and Roger Wells a GP/psychotherapist were based; and finally the
ESCOP secretariat and library.
Dinner at Crossmead Conference Centre
The Committee were welcomed by Sir Geoffrey Holland KCB, Vice
Chancellor of Exeter University. Other guests at the dinner were:
Dame Margaret Turner-Warwick - Past president
of the Royal College of Physicians
Professor Ruth Hawker - Chair of the local NHS trust
and member of Exeter University Council
Maurice Newbound - President of the British Complementary
Professor Edzard Ernst - Director of the Department
of Complementary Medicine and the holder of the only UK Chair
in Complementary Medicine
Professor Brian Kirby - Acting Head of the Post-graduate
Medical School at Exeter University
David Rogers - Head of Communications and External
Relations at Exeter University
Simon Mills - Director of the Centre for Complementary
Health Studies, University of Exeter
Sir Geoffrey Holland talked about Exeter University's
bid to develop a new undergraduate medical school in conjunction
with the University of Plymouth. The proposed curriculum for the
new undergraduate medical course would include aspects of CAM.
A course which promoted the awareness of other medical philosophies
would be a compulsory part of the curriculum, and optional courses
which explored different aspects of CAM would also be available.
Thursday 23 March
The Committee were welcomed to Senate House at the
University of Exeter by Professor Brian Kirby. Professor Kirby
discussed how the relationship between CAM and orthodox medicine
had grown closer since he graduated 40 years ago. He also discussed
how the two Exeter Departments look at both sides of complementary
therapies and he highlighted the growing popularity of CAM.
Presentations by the Department for Complementary
Medicine, University of Exeter
Professor Edzard Ernst
The aim of this presentation was to familiarise the
Committee with the Department's work. The Department use a specific
definition of CAM:
"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."
Ernst et al British General Practitioner 1995;
The Department of Complementary Medicine was established
in 1992 through a donation from the Laing Foundation, to the Centre
for Complementary Health Studies (CCHS). This donation has provided
a solid foundation of funding which helped establish a good infrastructure
for research. In 1993 Professor Ernst was appointed Professor
of Complementary Medicine and director of CCHS. In 1996 the Department
of Complementary Medicine was established within the School of
Postgraduate Medicine and the Directorship of CCHS was returned
to Simon Mills.
The Department chose to concentrate its research
on the CAM therapies that are most prevalent in the UK i.e. acupuncture,
healing, herbalism, homeopathy and spinal manipulation. It also
includes placebo studies. Their research aims to answer the questions:
is it effective? is it safe? does it save money? The main investigative
tools the Department uses are systematic reviews of published
RCTs, clinical trials, surveys and other experimental studies.
As well as research the Department participates in several other
activities; these include the publication of FACT, holding an
annual scientific meeting, occasional conferences, lectures, courses
Professor Ernst listed the strengths of the Department
as: relatively strong funding, a clear focus on research, having
no 'axe to grind', a staff of trained scientists, a multi-professional
team, staff with 'hands on' experience with CAM treatments and
numerous international collaborations, which included links with
universities in the USA, Austria, Switzerland, Turkey and Germany.
2. Research into homeopathy
This part of the talk summarised some of the research
that the Department has conducted into homeopathy. Several papers
were discussed. The first of these was a meta-analysis (by other
authors) that had looked at 89 trials of homeopathy and had concluded
that the clinical effects of homeopathy were not entirely due
to placebo effects. This paper had attracted a lot of attention
from various medical journals. However it had also been criticised,
primarily because it had examined a range of different homeopathic
treatments for a range of conditions and was therefore very non-specific.
In response to these criticisms a lot of further research including
new analysis by Department staff has been undertaken which has
looked at the effects of specific homeopathic remedies for specific
complaints. These more specific studies had found no direct effect
for any particular homeopathic remedy on a range of clinical problems.
Research in this area at the Department is continuing.
3. General CAM Research
This part of the presentation discussed several research
papers the Department has published on the perception of CAM in
the UK. Professor Ernst believes that non-specific (placebo) effects
are a fascinating and under-researched area which he thinks may
provide a link between CAM and orthodox medicine.
One study that he described had used a questionnaire
to examine levels of patient satisfaction with CAM and orthodox
medicine amongst arthritis suffers who had experienced treatments
by both types of practitioners. This research had found that CAM
therapists were perceived as much more friendly, as having much
more time to spend on the patient and the treatment, as giving
more information on the treatment and on the disease, and even
as giving slightly more efficacious treatments. Another study
that he discussed looked at cross-referral rates between CAM and
orthodox medicine and found that they were very low.
The third research area discussed was publication
bias. One survey the Department had conducted had shown that CAM
journals have a strong bias in favour of publishing papers which
had positive results for CAM as opposed to negative or neutral
results for CAM. However Professor Ernst also discussed other
research which had involved submitting almost identical papers
to CAM and orthodox medicine journals. The two papers both reported
fictional results of an RCT that showed positive results for either
a CAM therapy or an orthodox medicine therapy. They found that
the paper based on an orthodox medicine treatment was more likely
to be accepted for publication by an orthodox medicine journal
than the identical paper which provided the same results for a
Professor Ernst talked about research into the safety
of CAM. He noted that the CAM community have felt that safety
research is unnecessary as they feel CAM is inherently safe. He
said that he felt responsible as the only UK Professor of CAM
to look at safety. He discussed a survey of CAM users that had
found that users could remember side effects of homeopathy, herbalism,
spinal manipulation and acupuncture. However a similar survey
of GPs found they could only recall having seen side effects of
spinal manipulation. Later in his presentation Professor Ernst
was asked whether his Department's emphasis on safety gave it
a negative image in the CAM world. He answered by saying that
safety is the logical first line to examine and as much of the
Department's work has found in favour of the safety of CAM it
should be welcomed by the CAM world. He also responded to a comment
that CAM is relatively safe when compared to the levels of iatrogenic
disease caused by orthodox medicine by saying that one must always
keep in mind the risk/benefit balance.
The last part of this talk discussed CAM research
funding which Professor Ernst described as the biggest obstacle
to CAM research in the UK. A survey by the Department showed that
in 1996 only 0.08% of the NHS research budget and only 0.05% of
the medical charities' research budget was spent on CAM. Prof.
Ernst described the CAM research funding situation in the UK as
'dismal' and compared it to the situations in Germany, the USA
and Switzerland where public money is ring-fenced for CAM research.
He believes that if ring fencing is done well it does not necessarily
reduce the quality of research and he sees it as the only way
forward. Professor Ernst also discussed what he calls the 'Catch
22' situation whereby the MRC, Wellcome Trust etc. say they would
fund more CAM research if there were better research applications.
He suggested that his Department's experience of rejections of
grant applications has shown that the people on the research application
review panels often do not understand CAM.
4. Vision of Department's future.
The final part of this presentation described how
the Department would like to develop in the future. Professor
Ernst described a Department which had an overall head of operations
who was supported by a research unit, a publication unit, an education
unit, an information programme and a clinical programme. The education
programme would include undergraduate teaching and teaching of
CAM to orthodox medicine professionals to increase communication
between the two fields. The information programme would have links
with journals, the media and the public and would work to counteract
the misinformation present in newspapers; it would possibly be
linked to NHS Direct. The clinical service would ensure that those
in the unit were still seeing patients and therefore did not lose
contact with those that CAM is meant to benefit, thus developing
the 'ivory tower syndrome'.
Mr M. Pittler: Research into Herbal Medicinal
Mr Pittler started his presentation by making the
point that much of CAM research is in languages other than English.
He believes that one of the strengths of the Department is that
they are multi-lingual and so can examine of a lot of evidence
that would otherwise be inaccessible to them.
Mr Pittler discussed the prevalence of CAM in the
UK. One telephone survey estimated that 20% of Britons had used
CAM in the last 12 months and herbal medicine was the most likely
CAM to have been used, with 34% of the share. He then discussed
the top selling herbs, referring to a US survey, the results of
which he suspected would be mirrored over here. This survey found
that the top selling herbs were: Ginkgo, St John's Wort, Ginseng,
Garlic, Echinacea, Saw Palmetto and Kava Kava (the use of which
is growing very rapidly).
Research into herbal medicine can examine particular
plant extracts as treatments for specific ailments so rigorous
research methods can be applied. Mr. Pittler reviewed a hierarchy
of evidence with systematic reviews of RCTs at the top, followed
by single RCTs, controlled clinical trials and lastly uncontrolled
data such as case reports which can be seen as useful in generating
hypotheses. He suggested that clinical replication is important
and thus he tries to concentrate on systematic reviews of RCTs
which minimise selection bias, minimise random bias and can look
at a range of studies and thus increase validity. However he acknowledged
that such systematic reviews also have potential weaknesses in
that they may include trials of poor methodological quality, they
may compare non-heterogeneous data and they may reflect any existing
The last part of this presentation reviewed specific
trials the Department has carried out for specific herbs and conditions.
The results of these trials showed that some herbs can be proven
to be effective for certain conditions; however other herbs have,
despite their popularity, produced results which are inconclusive.
Dr A. White: Research into Acupuncture
Dr White started his presentation by briefly reviewing
his own background. When working as a GP in the late seventies
he saw patients who were benefiting from acupuncture. At the same
time the discovery of endorphins made him think that the results
of acupuncture might have a rational explanation. These two events
led him to train as an acupuncturist himself and when he did so
he found that there was so little good quality research into acupuncture
that he became a research fellow. He discussed the fact that the
change from being a clinician who wanted to prove acupuncture
worked, to being a researcher who had to find out whether it works
or not, was a huge leap in attitude.
The rest of this presentation reviewed specific studies
into the efficacy of acupuncture. None of the papers that had
investigated acupuncture's efficacy had yielded conclusive or
particularly positive results. He is currently involved in a study
into the adverse effects of acupuncture that seems to be showing
that acupuncture is relatively safe. He has also been trying to
attract funding to do a study into the cost consequences of introducing
CAM into primary care but has been unable to attract funding as
it would be quite an expensive trial which would involve paying
Presentations by the Centre for Complementary
Roger Hill: Introduction
Roger Hill is the programme co-ordinator and co-founder
of CCHS. He provided an overview of the main features of the centre:
The purpose of CCHS is to
investigate and teach complementary health measures to practitioners.
The teaching is carried out by CAM therapists.
CCHS provides a taught MA course which covers a range
of disciplines, as well as research MPhil and PhD degrees. They
do not offer practical training.
All CCHS post graduate courses emphasise research
methodology which creates a tone of "mild scepticism"
in all their taught modules. These modules include the therapeutic
relationship, the cultural context of CAM and the holistic care
of terminally ill patients.
They welcome those who practise orthodox medicine
disciplines as well as CAM ones as they acknowledge there is much
to learn from orthodox medicine although they object to medical
CCHS has links with Bristol Cancer Help Centre and
the Thomas Jefferson University in the USA.
CCHS will soon become part of the Department of Lifelong
Learning at Exeter University.
Roger Hill aired some concern about the growth of
generic undergraduate courses in complementary health studies
which offer a smattering of knowledge about a range of disciplines.
He suggested these should not be seen to qualify graduates to
practise and that the organisations (often umbrella bodies) who
support such courses are of variable reliability.
Sarah Budd: Department of Health Scoping Study
In 1999 the Department of Health commissioned CCHS
to produce an information pack reviewing the process of regulation,
to pilot a standards validation mechanism and to update the 1997
study which surveyed all the CAM professional organisations in
the UK. Sarah Budd's presentation launched the updated version
of this study which is the main reference document describing
CAM organisations in the UK and includes contact details for all
the bodies surveyed. The 1997 report had recommended integrative
moves in all CAM fields; this second study inquired about the
progress organisations had made towards integration.
The main demographic findings of the new survey were:
There are approximately 50,000
CAM practitioners in the UK, some of whom are members of more
than one organisation.
There are approximately 10,000 statutory health professionals
who practise some form of CAM.
Up to 5 million patients have consulted a CAM practitioner
in the last year.
True figures are difficult to ascertain as many practitioners
will not be members of any organisation, and some organisations
will not have responded to the survey.
Despite the desire for greater integration expressed
in the last report and generally encouraging movement since, there
was in fact some evidence of greater diversification. The report
contains a section on emerging and complex organisations and a
pilot study of the processes involved in improving co-ordination
within on therapy (reflexology).
Sarah Budd highlighted the fact that over the last
two years regulation has become one of the main concerns for CAM.
Mr M. Willoughby: Herbal Standards
CCHS has been working in collaboration with the British
Herbal Medical Association to produce quality standards for herbal
medicines. The CCHS received a large grant from the European Union
in 1994 to support various efforts. These include:
- Overcoming problems which arise because many
herbs, once processed, look the same. Different products can be
identified using thin layer chromatography and microscopy. Results
from this work have been collected together in the British Herbal
Pharmacopeia for manufacturers to use as reference material.
- Producing the Phytonet web-site for information
about herbal medicine. This web-site includes a reporting system
for any adverse effects.
- Producing ESCOP monographs on the medicinal uses
of plant drugs. These monographs use the 'core SPC' (Summary Product
Characteristics) format and are being considered by the European
Medicines Evaluation Agency for use in assessing licensing applications
Mr M. Bovey: Acupuncture Resource Research Centre
Mr Bovey began his presentation by describing his
work running the Acupuncture Resource Research Centre. The centre
was set up in 1994 by the British Acupuncture Council, and is
wholly funded by them; it promotes acupuncture generally and encourages
research mindedness. In order to do this the Centre:
Responds to requests
Provides direct support for practitioners
Interprets research by producing briefing papers
Supports other research groups by giving lectures,
hosting symposiums etc.
Supplies a purpose built data base and literature
searches for treating patients with unusual conditions.
Professor B. Goodwin: Academic Challenges
Professor Goodwin is a professor of biology and was
first external examiner for CCHS. He currently teaches a module
at the Centre which attempts to bring together alternative and
conventional theories of health. The part of the module he discussed
in this talk concerned complexity theory and health.
In order to give an idea of the diverse work of the
CCHS, several students gave brief presentations on the progress
of their studies at the Centre. These were:
Lizzie Baines an
MA candidate who also works as a specialist palliative care nurse.
She discussed her dissertation : 'An audit of Tibetan medical
practice in the UK.'
Helen Cooke an MA candidate who
also works as the therapy director for Bristol Cancer Help Centre
and is a registered nurse. She discussed her dissertation: 'An
evaluation of the role of the Bristol Cancer Help Centre in helping
patients and their supporters through its advice on complementary
therapies and self -help techniques.
Reg d'Souza a BPhil graduate who
works as a physiotherapist and an acupuncturist. He discussed
his dissertation: ' Trigger point acupuncture and ultrasonic therapy
in low back pain.'
Penny Franklin an MA candidate
who also works as a health visitor and a nurse. She discussed
her dissertation: 'Parental perceptions of the effects of lack
of sleep on the couple relationship of parents with children between
the ages of 12 and 30 months.'
Jessie Ng Fong Tiao an MA graduate
who works as a nurse, an acupuncturist and a Chinese herbalist.
She discussed her dissertation: 'A single blind, cross-over study
to measure the effect of acupuncture on low back pain.'
Ian Oliver an MPhil candidate who
also works as a homeopath. He discussed his dissertation: 'The
homeopathic treatment of benign breast tumours.'
Vicki Pitman an MPhil graduate
who works as a medical herbalist. She discussed her dissertation:
' The relationship between ancient Greek and Ayurvedic medicine.'
Bridget Simpson an MA graduate
who works as a dental surgeon. She discussed her dissertation:
'An investigation into 'dry socket': a pilot study of a new herbal
Frances Turner an MPhil candidate
who also works as an acupuncturist and Chinese herbalist. She
discussed her dissertation: ' An evaluation of whether some form
of standardisation of the English vocabulary of Chinese medicine
would raise the standards of understanding and practice of Chinese
medicine in the UK.'
Tina Wong an MA and PhD graduate
who also works as an acupuncturist, a nurse and a mid-wife. She
discussed her dissertation: 'The use of traditional medicine and
rituals in the prevention and treatment of post-natal depression
among the Kadazan/Dasan and Bajan/Malay communities of East Malaysia.'