Select Committee on Science and Technology Sixth Report


21 NOVEMBER 2000

By the Select Committee appointed to consider Science and Technology.




I.The use of complementary and alternative medicine (CAM) is widespread and increasing across the developed world. This raises significant issues of public health policy such as whether good structures of regulation to protect the public are in place; whether an evidence base has been accumulated and research is being carried out; whether there are adequate information sources on the subject; whether the practitioner's training is adequate and what the prospects are for NHS provision of these treatments. It was the need to consider these issues that prompted this Inquiry (Chapter 1).
II.CAM includes a large range of therapies. Some offer complete systems of assessment and treatment, others complement conventional treatment with various supportive techniques. Some have well-developed regulatory structures, others are fragmented professions with little interdisciplinary agreement about regulation. A few have begun to build an evidence base, most have not. The Committee have proposed three groups of CAM therapies. Group 1 includes the most organised professions; Group 2 contains those therapies that most clearly complement conventional medicine. While the question of efficacy was not included in our initial terms of reference, in the absence of a credible evidence base it is our opinion that the therapies listed in our Group 3 cannot be supported unless and until convincing research evidence of efficacy, based upon the results of well designed trials, can be produced. Such evidence must be capable of showing that the effects of any therapeutic discipline are superior to those of the placebo effect (see paras 3.19 - 3.34). It is our view that for those therapies in our Group 3, no such evidence base exists at present. For a full list of which therapies fall into which Group please see Box 1 (Chapter 2).
III.Therapies in Group 1 are likely to respond to research as to effectiveness; indeed, some of them have already done so to a substantial degree and NHS provision is increasing for these disciplines. For some therapies in Group 2, NHS provision (especially in the care of the terminally ill) is already a reality. However, more work needs to be done to develop their regulatory structures and, in some cases, to encourage more research into their specific effects. For therapies in Group 3, the prospect of attracting research funding or NHS provision is likely to be difficult or, more probably, impossible (Chapters 3 and 7).
IV.The interests of the public in their use of CAM will be best served by improved regulatory structures for many of the professions concerned. Although there is evidence of progress across many fronts, the Committee found considerable diversity of standards, with an unacceptable fragmentation in some therapies, especially in Groups 2 and 3. In the best interests of their patients such therapies must each strive to unite under a single voluntary regulatory body with the features we highlight (Chapter 5).
V.In a few cases regulation by statute may be appropriate. Our main criteria for preferring such a route are first, the possible risk to the public from poor practice; second, a pre-existing robust voluntary regulatory system; and third, the presence of a credible evidence base. We consider that acupuncture and herbal medicine comply with these criteria and we support their moves towards statutory regulation. In time, such regulation may become appropriate for homeopathy (Chapter 5).
VI.We have learnt that the regulation of herbal products presents significant challenges for public health. In particular it is difficult for the public to identify remedies of adequate quality, or to distinguish those with medicines licences from those sold as foods or those currently exempt from licensing. We recommend that the Medicines Control Agency (MCA) help the public identify regulated products more clearly. We also recommend that the law against illegal or misleading labelling be rigorously enforced. We further support the MCA and the Government in their advocacy of a new draft directive in the European Union that would more effectively regulate this complex sector (Chapter 5).
VII.There are currently no clear guidelines relating to the regulation and training in CAM practice amongst statutory regulated health professionals (such as doctors and nurses) who wish to incorporate a CAM therapy into their personal clinical repertoire. We recommend that the existing regulatory bodies in each of the healthcare professions should develop clear guidelines on competence and training in the CAM disciplines and on the position they take in relation to their members' activities in CAM (Chapter 5).
VIII.Many CAM therapies are based on theories about their modes of action that are not congruent with current scientific knowledge. That is not to say that new scientific knowledge may not emerge in the future. Nevertheless as a Select Committee on Science and Technology we must make it clear from the outset that while we accept that some CAM therapies, notably osteopathy, chiropractic and herbal medicine, have established efficacy in the treatment of a limited range of ailments, we remain sceptical about the modes of action of most of the others. We therefore emphasise that in recommending the regulation of training in CAM we specifically exclude training in the asserted modes of action of many CAM therapies. We do so because regulation could lead to a misleading public perception of improved status; such regulation is in fact an attempt to safeguard the public.
IX.CAM training courses vary unacceptably in content, depth and duration. Only a concerted partnership between higher educational institutions and properly regulated professions as validating bodies will adequately ensure that any CAM practitioner is well trained. Accredited training of CAM practitioners is vital in ensuring that the public are protected from incompetent practitioners. We hope that the recommendations in Chapter 6 will help guide the CAM professional bodies in developing and supporting consistently good quality training programmes (Chapter 6).
X.Many of the CAM therapies and especially, in our view, those in Group 1 and some in Group 2, share common concerns such as a need to improve research awareness amongst practitioners, a need to understand the ethical aspects of healthcare and the nature of the therapeutic relationship. If each such therapy develops one professional regulatory body responsible for supervising all training in that discipline, as we recommend that they should, this should result in core competencies covering these topics being defined for each therapy. The extent of training required will depend on how far a therapy claims to be independent of medical supervision and diagnosis (Chapter 6).
XI.Conventional healthcare practitioners should become familiar with CAM therapies, their potential uses, and their main weaknesses and dangers. We consider that the provision of CAM familiarisation in schools of medicine and nursing is currently too uneven. We make recommendations to the regulatory bodies concerned to rectify this position. We also highlight the importance of Continuing Professional Development in order that existing healthcare professionals are aware of this area and can advise their patients accordingly (Chapter 6).
XII.Very little high-quality CAM research exists; reasons for this may include: a lack of training in the principles and methods of research; inadequate research funding and a poor research infrastructure within the CAM sector. Another contributing factor may be methodological issues, with many CAM practitioners believing that conventional research methods are not suitable tools with which to investigate CAM. In the light of these problems we recommend that a central mechanism for co-ordinating and advising on CAM research and for making available research training opportunities be established, with resourcing from the Government and, possibly, the charitable sector. Such a body could implement various means of aiding CAM research. Training CAM practitioners in methods and principles of appropriate research disciplines will undoubtedly increase research activity in this area as will attracting mainstream investigators into CAM research. This will only happen if sufficient funds are available and an appropriate academic infrastructure is established (Chapter 7).
XIII.CAM faces problems in attracting research funds from industry and charity. Many of our witnesses suggested that without dedicated funds for CAM research, the research infrastructure for CAM will remain poor. We have recommended that the NHS R&D directorate and the MRC should pump-prime this area with dedicated research funding to develop a few centres of excellence for conducting CAM research on appropriate disciplines. These centres of excellence could be based on the model pioneered in this area by the very successful National Center for Complementary and Alternative Medicine in the USA (Chapter 7).
XIV.We recommend that CAM should attempt to build up an evidence base with the same rigour as is required of conventional medicine, using both randomised controlled trials (RCTs) and other research designs which we discuss (see paras 7.10 - 7.30). We believe that those therapies in Group 1 are likely to command the highest proportion of research resources. Other therapies will need to build up their respective evidence bases with small preliminary studies before large scale studies are justifiable (Chapter 7).
XV.There is a clear need for more effective guidance for the public as to what does or does not work and what is or is not safe in CAM. There is no central information provision for patients and healthcare practitioners; thus the media and other unregulated sources have an undue influence on opinion in the field. We are not convinced that many CAM professions themselves are yet in the position to provide balanced and consensual views on these issues of public interest. The obvious place to turn to for such advice is the NHS and we believe that this responsibility has not yet been adequately fulfilled. We recommend that central resources be directed either through the Government or in partnership with a neutral body to ensure that the public has access to balanced and fair advice on CAM (Chapter 8).
XVI.One of the main dangers of CAM is that patients could miss out on conventional medical diagnosis and treatment because they choose only to consult a CAM practitioner. We recommend that all NHS provision of CAM should continue to be through GP referral (or referral from other healthcare professionals working in the NHS in primary, secondary or tertiary care) (Chapter 9).
XVII.We recommend that the CAM disciplines define their respective areas of competence and confirm their willingness to refer patients to conventional medical care when appropriate (Chapter 6).
XVIII.Another actual or potential risk arising from CAM use is that patients may not tell their GPs that they are receiving other treatment, and may thus risk complications from drug interactions. In the past, the tendency for conventional practitioners to be sceptical or even sometimes hostile to CAM may have contributed to the likelihood of patients being secretive about their use of CAM. We urge CAM practitioners and GPs to keep an open mind about each other's ability to help their patients and to exchange information about treatment programmes and their perceptions of the healthcare needs of patients (Chapter 9).
XIX.NHS provision of CAM is currently very patchy and has been in some cases adversely affected by the recent NHS reforms in Primary Care. We heard much evidence about how to recommend which therapies should be made available on the NHS. In formulating our recommendations on the issue of the availability of such therapies on the NHS by GP referral, or by referral from healthcare professionals in secondary or tertiary care, we concluded that in view of the variable evidence bases which at present exist it might initially be unfair to restrict NHS provision only to those with firmly established efficacy. We recommend, however, that only those CAM therapies which are statutorily regulated or have robust mechanisms of voluntary self-regulation should be available through public funding (Chapter 9).

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