HO 09

 

 

Memorandum submitted by the Northern Ireland Association of Homeopaths (NIAH)

 

1. Our submission is based on findings from the Northern Ireland Integrated Medicine Pilot Programme 2007-2008[1]. The Pilot Programme was unique in that it was the first of its kind in the United Kingdom to be commissioned by a Minister for Health. It was not a clinical trial per se, but an evaluation of a service in which GPs were able to refer patients for a range of Complementary and Alternative Medical (CAM) treatments, including homeopathic medical treatment.

 

The nature of evidence

 

2. Evidence from observational studies is highly appropriate for homeopathic medicine as the treatments are individualised and therefore not fully amenable to analysis by, for example, randomised controlled trials. We welcome the acknowledgment by the Chair of the National Institute for Clinical Excellence, Sir Michael Rawlins that greater weight should be accorded to evidence from observational studies of this kind.

 

3. The findings and the recommendations in the evaluation report (executive summary appended) bear out the proposals made by the NIAH in the years prior to the announcement of the Pilot Programme. Since 1999 we briefed successive Ministers of Health and Department of Health officials that the provision of Complementary and Alternative Medical (CAM) therapies such as Homeopathy would produce benefits in:

 

· Reduction in drugs expenditure

· Alleviation of GP and hospital workload

· Savings accruing from reduced sick leave

· Increased creativity and productivity

· General well-being of society [2]

 

4. We also proposed that CAM therapies such as Homeopathy would make a significant contribution toward solving the intractable problems in Government healthcare priority areas such as:

 

· health inequalities

· deprived areas

· effectiveness gaps in conventional medical treatments[3]

 

5. The Report confirms that CAM treatments including homeopathic treatment delivered significant health gains and cost-efficiencies in all of the above circumstances. The evaluation includes analyses across a range of indicators, all of which bear out the case we presented in our briefings, as follows:

 

6. Comparison of NIAH briefing points and reported findings

 

NIAH Briefing	Reported findings
Reduction in drugs expenditure	- Half of GPs reported prescribing less medication and all reported that patients had indicated to them that they needed less - 62% of patients reported suffering from less pain - 55% reported using less painkillers following treatment - Patients using medication reduced from 75% before treatment to 61% after treatment - 44% of those taking medication before treatment had reduced their use afterwards
Alleviation of GP and hospital doctor workload	· 24% of patients who used health services prior to treatment (i.e. primary and secondary care, accident and emergency) reported using the services less after treatment · 65% of GPs reported seeing the patient less following the CAM referral · Half of GPs said the scheme had reduced their workload and 17% reported a financial saving for their practice · Half of GPs said their patients were using secondary care services less
Reduced sick leave ...increased productivity ...general wellbeing of society	· "Not only has this project documented significant health gains for patients, but it has also highlighted the potential economic savings likely to accrue from a reduction in patient use of primary and other health care services, a reduction in prescribing levels and reduced absenteeism from work due to ill health."

 

 

7. Health improvements by therapy

 

Using the MYMOP protocol - a validated audit tool for measuring

patient health gain in general practice:

 

· Patients receiving acupuncture treatment reported an average 33% improvement in their health and wellbeing.[4]

 

· Patients receiving chiropractic and osteopathy treatment reported an average 38% improvement in their health and wellbeing.[5]

 

· Patients receiving homeopathic treatment reported an average 54% improvement in their health and wellbeing.[6]

 

The clinical assessments of the referring doctors concurred with these figures.

 

 

8. Value for Money and Efficiency

 

We wish to draw the attention of the Committee to the amount of detail in the evaluation report in respect of wider social and economic context, which is more often than not omitted from such studies. We submit that this provides not only evidence of cost-effectiveness of healthcare investment, but extremely useful information relating to the problems and management of healthcare inequalities and the acknowledged effectiveness gaps in conventional medical treatment, especially of chronic conditions endemic in deprived areas.

 

9. We are confident that if the homeopathic treatments provided in the Pilot Programme were subjected to full Social Return on Investment analysis, they would produce a high index of return compared to many conventional treatments in the same circumstances. Government wishes to see more proof of value for money and return on future healthcare investment, as reported by the NHS Cross-Regional Social Value Commissioning Project:

 

10. Value for money is concerned not just with unit costs, but with what has been called the full value or public benefit that a provider brings to delivering a service. This recognises that every time the public sector spends money, it should do so in a way that achieves as many of its objectives as possible.

 

 

 

 

That is, it is concerned with the value a provider creates across a range of outcomes over the longer term with the resources it is given. The draft NHS Constitution states that PCTs 'will use (their) resources for the benefit of the whole community'. This is where social value concepts have a vital role to play.[7]

 

 

11. Conclusions and recommendations

 

We respectfully suggest that:

 

12. in respect of the evidence for homeopathy the Committee considers and accords appropriate weight to evaluations of observational studies such as the Northern Ireland Integrated Medicine Pilot Programme

 

13. in evaluation of the effectiveness of medical treatments the Committee takes into consideration the wider social and economic contexts for the treatments and outcomes, particularly in respect of social value and Social Return on Investment analysis.

 

 

14. Declaration of Interests

 

The Northern Ireland Association of Homeopaths is a non-profit group which represents professional homeopaths and homeopathic medicine, and has had representation in the Northern Ireland Department of Health CAM Advisory Group.

 

Appendix One

 

15. EXECUTIVE SUMMARY of the Independent Evaluation Report on the Northern Ireland Integrated Medicine Pilot Programme

 

16. This report presents the findings from an evaluation of a pilot project which

provided patients with access to a range of Complementary and Alternative Medicine (CAM) through their GP practice.

 

17. Overall 713 patients were referred to the project by their GP. Patients presenting to their health centre with musculo-skeletal and mental health conditions, were referred for a range of CAM therapies including acupuncture, chiropractic, osteopathy, homeopathy, reflexology, aromatherapy and massage.

 

18. The project was commissioned by the Department of Health, Social Services and Public Safety with a view to exploring the potential for CAM within existing primary care services in Northern Ireland. The project was implemented by Get Well UK in two primary care centres in Northern Ireland: Shantallow Health Centre in Londonderry and The Arches Centre in Belfast.

 

19. The evaluation, conducted independently by Social & Market Research (SMR), is based on an analysis of project monitoring data provided by Get Well UK; and focus groups and surveys of patients, CAM practitioners and GPs from the two participating health centres.

 

20. Key Findings: The Patient Experience

 

Using the various data sources, the evaluation has found a significant level of

health gain for the vast majority of patients who have received complementary and alternative medicine as part of the pilot project. This is evidenced by the following:

 

· Analysis of MYMOP (Measure Yourself Medical Outcome Profile) data, which was generated using a validated health instrument used for measuring patient health gain in general practice, found statistically significant improvements on each of the health outcome indicators measured i.e. the severity of patient symptoms; the level of patient activity associated with their symptoms; and, overall patient wellbeing (source, MYMOP);

 

· The proportion of patients reporting that the severity of their symptoms were 'as bad as it could be', fell from 31% prior to treatment to 5% following treatment (source, MYMOP);

 

· 80% of patients recorded an improvement in the severity of their main

symptom, with 73% recording an improvement in their level of activity

associated with their main symptom (source, MYMOP);

 

· 67% of patients recorded an improvement in their wellbeing (source,

MYMOP);

 

· 81% of patients said that their general health had improved, with a similarly high proportion of patients (82%) reporting to be less worried about their symptoms following treatment (source, MYMOP);

 

· 81% of patients reported an improvement in their physical health, with 79% reporting an improvement in their mental health (source, patient survey);

 

· 84% of patients directly linked the CAM treatments to an improvement in

their overall wellbeing (source, patient survey);

 

· 62% of patients were suffering less pain, with 60% having more control over pain (source, patient survey);

 

· There was a 14 percentage point reduction in the proportion of patients

using medication between the pre and post-treatment stages (i.e. down from 75% to 61%) (source, project monitoring data);

 

· 44% of patients who were taking medication prior to their treatment, had

reduced their use of medication (source, patient survey);

 

· Among patients using pain killers prior to treatment, 55% said that they use fewer pain killers following treatment (source, patient survey);

 

· In the majority of patient cases, CAM practitioners reported an improvement in: patient quality of life; relief of presenting symptoms; relief of chronic conditions; increased mobility; increased emotional stability; and, a reduction in patient worry (source, project monitoring data);

 

· 24% of patients who used other health services prior to treatment (e.g. other primary care services, secondary care services and Accident and

Emergency), said they now use these services less often (source, patient

survey);

 

· 64% of patients in employment said that following treatment they now take

less time off work. Among patients not in employment, 16% said that having the CAM treatments had encouraged them to think about going back into employment (source, patient survey);

 

94% of patients would recommend CAM to other patients with similar health conditions (source, patient survey);

 

· 89% of patients expressed an interest in continuing with CAM, with just 30% saying they would be able to afford to continue with CAM treatments

(source, patient survey);

 

 

 

· Patients were supportive of CAM being integrated into primary health care,

with a call for increased public awareness of the potential of CAM for health gain (source, patient focus groups);

 

· Patients identified a need for CAM to be promoted among GPs in Northern

Ireland, and for initiatives to be taken to help reduce the level of scepticism

held by some GPs towards CAM (source, patient focus groups);

 

21. Key Findings: The GP Experience

 

· In 65% of patient cases, GPs documented a health improvement, with a high degree of correlation between GP and patient assessment of health

improvement (source, project monitoring data);

 

· In 65% of patient cases, GPs said they had seen the patient less often

following the patient's referral to CAM (source, project monitoring data);

 

· Improving patient health was found to be the main motivation for GPs getting involved in the pilot project (source, GP survey and focus groups);

 

· Most GPs said that their understanding and knowledge of CAM had

improved by participating in the pilot project, with most conceding that their

knowledge was limited at the initial stages. Some GPs had experienced

difficulty initially in matching their patients with appropriate therapies, with

most of the GPs supporting the need for further educational interventions

such as seminars, talks with practitioners and having more written

information on CAM (source, GP survey and focus groups);

 

· Half of GPs reported prescribing less medication for chronic or acute

patients (source, GP survey);

 

· Half of GPs reported that the option to refer their patients to CAM had

reduced their workload, with two GPs pointing to a financial saving for their

practice. All but one of the GPs had seen the project as a positive

development for their practice, with all agreeing that it provided them with

more referral options (source, GP survey);

 

· Most GPs reported that their patients were using Allied Health Professionals less often, with half saying that their patients were using secondary care services less often (source, GP survey);

 

· Ten out of the 12 GPs surveyed had a more positive view of the potential for CAM within primary care, with all wishing to continue with the option of

referring their patients to CAM (source, GP survey);

 

· In 99% of patient cases, the GP said that they would be willing to refer the

same patient, or another patient, to the Get Well UK service. Also in 98% of patient cases, the GP said they would be willing to recommend the service to another GP (source, project monitoring data);

 

22. Key Findings: The CAM Practitioner Experience

 

· CAM practitioners reported a health improvement in 77% of their patients on average, with health gains including: pain relief; improved quality of life;

improved mobility, stress relief and improved emotional wellbeing (source,

practitioner survey);

 

· CAM practitioners identified a need for a series of educational interventions targeted at GPs to improve their understanding of CAM and to better support them with matching health conditions with appropriate therapies (source, practitioner survey and focus groups);

 

· CAM practitioners called for GPs to supply more information on patient

medical condition as part of the referral process (source, practitioner survey and focus groups);

 

· CAM practitioners identified a tendency for GPs to refer patients with chronic medical conditions to the project, with practitioners concerned that the therapies may not be as responsive to this type of patient compared to, for example, patients with acute medical conditions (source, practitioner survey and focus groups);

 

· Affordability was identified as the main barrier for patients wishing to

continue with CAM (source, practitioner survey and focus groups);

 

· All CAM practitioners supported the integration of CAM within primary health care, with patient health gain cited as the key benefit (source, practitioner survey and focus groups);

 

· CAM practitioners reported a more positive attitude to CAM among GPs who had participated in the project, with ongoing contact and communication between GPs and CAM practitioners identified as a key requisite if CAM is to be rolled out more extensively across Northern Ireland (source, practitioner survey and focus groups);

 

23. Recommendations

 

(i) Given the evidence of health gain documented by patients, GPs and CAM practitioners, it is recommended that DHSSPS and the project partners explore the potential for making CAM more widely available to patients across Northern Ireland. Not only has this project documented significant health gains for patients, but it has also highlighted the potential economic savings likely to accrue from a reduction in patient use of primary and other health care services, a reduction in prescribing levels and reduced absenteeism from work due to ill health.

 

 

(ii) This pilot project has clearly demonstrated that CAM fits well within a primary health care context, with patients valuing the support and judgment of their GPs in accessing treatments. It is recommended that DHSSPS and the project partners examine ways of integrating CAM within primary care, taking on board the need for a strategy to promote GP knowledge and understanding of CAM to ensure that health conditions are matched appropriately with CAM therapies. A strategy to promote awareness and understanding of CAM among GPs, as well as the positive health gains for patients, should also go some way to addressing issues around scepticism held by some GPs.

 

 

(iii) To further assist the process of integrating CAM with primary health care, it is recommended that consideration be given to exploring the potential for sharing medical records with CAM practitioners. Furthermore, consideration should be given to exploring the potential for CAM practitioners to be involved in clinical meetings and case conferences, which may provide patients, particularly those with chronic health problems, with more treatment options. This may also lead to significant cost savings for the health service.

 

(iv) The project has highlighted a number of areas where the operation of a CAM service can be further improved. In particular, it is recommended that DHSSPS and the project partners explore ways of ensuring that patients are provided with accurate and up to date information at all points of the referral process, as well as at the point of receiving treatments. In addition, the evaluation has found that patients may benefit from a 'triage' system to ensure appropriate matching of health conditions and CAM treatments;

 

(v) Given that the pilot project has raised expectations among patients,

DHSSPS and its partners should consider a mechanism for ensuring that patients who presented with long-term illnesses, and in particular those who experience pain, be offered booster or maintenance sessions beyond the life of the project.

 

(vi) Given the limited number of CAM practitioners in Northern Ireland, and the difficulties in identifying practitioners to participate in the pilot project, it is recommended that DHSSPS and the project partners consider ways of retaining this resource within a model for wider service delivery.

(vii) Given that the health outcomes for patients have been significant, it is

recommended that DHSSPS and the project partners consider the development of a public health information campaign aimed at promoting the potential benefits of CAM. Allied to this point, it is recommended that DHSSPS and its partners examine the role of CAM in supporting health prevention and health promotion strategies, given the evidence that patients are likely to adhere strongly to the advice provided by CAM practitioners.

 

 

 

 

 

(viii) The evaluation has documented the positive impact of CAM on patients who are economically active, particularly in the context of helping people back into work following illness. It is recommended that the outcomes from this project be shared with colleagues in other departments (e.g. Department for Employment and Learning), to allow them to examine the potential for CAM within their own operational areas.,

 

(ix) Given that the evaluation outcomes are based on the perception of the

various stakeholder groups (i.e. patients, CAM practitioners and GPs), it is recommended that DHSSPS and the project partners give consideration to integrating other approaches to measuring health impact (e.g. a formal case control study) on an ongoing basis.

 

 

November 2009

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[1] Evaluation of a CAM Pilot Project in Northern Ireland (2008) D McDade2008

[2] Homeopathy - A Briefing for Healthcare Policymakers in Northern Ireland, NIAH 2000, 2004

[3] Kenneth Mayne, NIAH. Presentation to DHSSPSNI Primary Care Conference, 2006

 

[4] Measure Yourself Medical Outcome Profile (MYMOP) aggregate score decreased from before treatment 4.76 to 3.18 after treatment

[5] Measure Yourself Medical Outcome Profile (MYMOP) aggregate score decreased from before treatment 4.28 to 2.66 after treatment

[6] Measure Yourself Medical Outcome Profile (MYMOP) aggregate score decreased from before treatment 4.42 to 2.05 after treatment

[7] NHS Cross-Regional SHA Social Value Commissioning Project

Bulletin No1 July 2009 p4