PowerPoint® presentation prepared by Paulo Quadros

Patients’ access to Complementary and Alternative Medicine in the NHS Scotland chronic pain service: an overview

Background

Nearly 40% of GP partnerships in England provide access to CAM for NHS patients*1

one in ten of the population uses complementary healthcare*2

three-quarters of the population would choose complementary healthcare if it were available on the NHS*2

Chronic musculoskeletal pain is the single most cited reason for use of CAM*3

*1 Integrated Healthcare: A Way forward for the Next Five years? Published by the Foundation for Integrated Health*2 A Healthy Partnership – Integrating Complementary Healthcare into Primary Care; 2005 (published by the Prince of Wales Foundation for Integrated Health *3 The use of CAM and conventional treatments among primary care consulters with chronic musculoskeletal pain (BMC Family Practice 2007)

Background

The benefits of unconventional therapies (aka CAM therapies) on chronic pain,

their cost effectiveness the need for CAM regulation and the need for ongoing CAM research

have been recognised by health authorities in Scotland and the rest of the UK since, at least, 1994 (‘Management of Patients with Chronic Pain’) all the way to the SIGN guideline on chronic pain management published in 2013. This issue has been discussed for over 20 years

Background - Key documents recommending CAM

1994: The Management of Patients with Chronic Pain (Scottish Government)

2000: The economic burden of back pain in the UK (‘Maniadakis Paper’)

2000: Services for patients with pain - Report of the Clinical Standards Advisory Group Committee

2004: Chronic Pain Services in Scotland (‘McEwen Report’)

2006: Management of Chronic Pain in Adults (QIS) 2007: GRIPS report (Getting Relevant Information on Pain Services) 2008: Department of Health Steering Group (‘Pitillo Report’)

2009: NICE guideline (Early management of persistent non-specific low back pain)

2013: SIGN Guideline on Management of Chronic Pain(#136)

Background - GUIDELINES

1999 NICE - ‘Early management of persistent non-specific low back pain’: 5.1.4  Offer one of the following treatment options - taking into account patient preference - an exercise programme, a course of manual therapy or a course of acupuncture. (Manual therapies in these guidelines are spinal manipulation, spinal mobilisation and massage) The guideline also recommends ‘Alexander Technique’

Evidence included “high quality systematic review with a very low risk of bias” and other “well conducted RCT with a low risk of bias”

Background - GUIDELINES

2013 SIGN ‘Management of Chronic Pain’ (#136):

7.1.1 Manual therapy should be considered for short term relief of pain for patients with chronic low back pain 7.1.2 Manual therapy, in combination with exercise, should be considered for the treatment of patients with chronic neck pain. (grade 1++ evidence with a 'B' classification). 8.1 Acupuncture should be considered for short term relief of pain in patients with chronic low back pain or osteoarthritis. ‘A' classification

‘Guidelines’ are developed making use of the best evidence available and GPs are encouraged to follow them.

Current status of CAM referrals

Referrals to CAM therapist is supported by the

Government: “A GP or hospital clinician may refer a patient for alternative treatment” [circular HDL(2005) 37]

BMA: “The BMA is supportive of those forms of complementary therapy for which evidence of claims of efficacy can be demonstrated” GPs may delegate treatment to complementary therapists who are not registered with a statutory regulatory body.

Dr Blair Smith (Scottish Lead Clinician for Chronic Pain): “We also need to develop and review non-pharmacological treatments, including psychological approaches, exercise and activity, and complementary techniques such as acupuncture.” (The Scotsman – 28th March 2014)

Current status of CAM referrals

Government [circular HDL(2005) 37]

The GP or hospital clinician would require to 1. be satisfied of the value of the treatment and 2. the competence of the practitioner3. and would remain responsible for the patient's

medical care

But support for CAM comes with certain conditions

In effect, GPs need to:determine the evidence for the use of different forms of CAM for different conditions as well as determine qualifications, insurance status and safety/ethics of a therapist.

Current status of CAM referrals

GMCyou must be satisfied that systems are in place to assure the safety and quality of care provided – for example, the services have been commissioned through an NHS commissioning process or the practitioner is on a register accredited by the Professional Standards Authority.

BMAGPs may delegate treatment to complementary therapists who are not registered with a statutory regulatory body. In doing so, they remain responsible for the treatment given and would bear some liability should the patient come to any harm.

But support has certain conditions

Current status of CAM referrals

“In terms of referral pathways, a GP referring to a CAM would be considered as a TERTIARY REFERRAL under the extra-contractual referral process (ECR)” [NHS Lanarkshire]

A form is completed (for each patient) outlining • the basic clinical details, •the treatment (or sometimes investigation) proposed, •the duration and an estimate of cost

Such referrals are considered by the Divisional Medical Director

The new Scottish service model for chronic pain (launched in 2013) promotes the use of non-pharmacological treatments firstly within primary care then, for more complex cases, secondary care. Never tertiary.

Inequality of access

The Government say that it’s up to Health Boards to decide whether to provide unconventional therapies or not

Health Boards/GPs need regulation in order to comply with conditions for non-statutory referrals. Regulation is determined by the Government

NHS BOARDSCan provide but not regulate

GOVERNMENTCan regulate but not provide

Currently, access to CAM therapies recommended by guidelines is dictated by how affluent patients are.

Equality can only exist if therapies are provided by the NHS.

INEQUALITY OF ACCESS – POSSIBLE SOLUTION

REGULATIONGPs could refer their patients to therapists registered with a recognised national regulatory organisation, ideally accredited by the ‘Professional Standards Authority’

CNHC (Complementary and Natural Health Care)Originally funded by the Dept of Health in WhitehallCreated to regulate CAM in the whole of the UK

(much like the GMC regulate GPs)Accredited by the Professional Standards Authority Endorsed by the General Medical Council (GMC)*

INEQUALITY OF ACCESS – POSSIBLE SOLUTION

REFERRAL PATHWAY Creation of a direct REFERRAL PATHWAY similar to other existing mainstream services such as physiotherapy

WIDER DISSEMINATION OF INFORMATIONMaking GPs, practice managers and other health professionals (as well as patients) more aware of existing chronic pain resources such as guidelines, chronic pain website and the revised (2013) Scottish chronic pain service modelANY MORE?e.g.

• dedicated ‘drug-free’ chronic pain clinics?• dedicated Government funding?

Needed discussionsMatters related to the delivery of unconventional therapies through the NHS need to be discussed - such as:

• central regulation of unconventional therapies (rather than therapy-specific regulation)

• referral pathway• delivery model• cost effectiveness• risk/benefit analysis• possible integration within the MSK service• use of unconventional therapies in the context of the GRIPS

and McEwen reports• use of unconventional therapies in the context of human

rights and the ‘Patient Rights (Scotland) Bill’• the desirability of continuous evidence assessment through

trials and audits (before research)

RESOURCES

CAM in the NHS: www.bit.ly/CAMintheNHS

Revised chronic pain model: Chronic Pain Services in Scotland

SIGN guideline #136: http://bit.ly/CPGuideline

NICE guideline CG88: www.nice.org.uk/guidance/CG88

Chronic pain support website: www.chronicpainscotland.org

Service Improvement Groups (SIGs): http://bit.ly/SIGsScotland

For further information or enquiriespaulo@intlifepain.org