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The UK National Health Services should Engage with Complementary and Alternative Medicine

by Richard Eaton(more info)

listed in complementary medicine, originally published in issue 248 - August 2018

The NHS England Consultation (updated on 1st December 2017) titled: Items which should not be routinely prescribed in primary care: A Consultation on Guidance for CCGs has confirmed that NHS England has taken action to reduce inappropriate prescribing of 18 medicines by which it aims to improve health and save millions of pounds a year. This includes recommending that herbal remedies and homeopathy be referred to the Department of Health to be “formally considered for the blacklist” and no longer provided in the NHS by General Practitioners (GPs) and Clinical Commissioning Groups (CCGs), because:

“… there is no clear or robust evidence to support its use…”

 

Eaton 248 b


The link to a news release about this important Consultation may be found at:

https://www.england.nhs.uk/2017/11/prescription-curbs-to-free-up-hundreds-of-millions-of-pounds-for-frontline-care/

It is a cause for concern that, although the “large proportion of those who responded” to the NHS England Board Paper (paragraphs 34 to 41 of the NHS England Board Paper, PB 30.11.2017/05 and paragraph 4.7 of Annex A) consultation was “self-identified patients” who supported the effectiveness and safety of homeopathy and herbal treatments, their views appeared to carry little weight. Also of concern, is the Board’s dismissal of the evidence of the cost-effectiveness of homeopathy as being simply “marginal cost issues.”

 

Eaton 248

 

In 2016, against a total spend of £9.2 billion on prescription medicines by the NHS, only £92,412.00 was spent on Homeopathic medicines and £100,009.00 on Herbal medicines [Data source: NHS Digital]. For further details, refer to the response (25.10.17) by the Alliance for Natural Health International titled UK NHS Clampdown on Natural Medicine in face of growing public demand.

To what extent do patients receiving homeopathy and herbal treatments relieve the burdens, financial and otherwise, on the NHS? This question should be explored and answered including by NHS Digital, about which please refer to my observations below. Is NHS England assessing the respective benefits to patients of CAM and conventional medicine, whether or not as part of an integrative treatment plan, in an unbiased and balanced way? Clearly, the answer is “No”.

In its 25th monitoring report How is the NHS performing? March 2018 quarterly monitoring report, published on 08.03.18, the King’s Fund analyses and comments upon the changes and challenges the health and care system is facing. Among other things, it reports as follows with regard to the results of its health care surveys:

“…78 per cent of CCG [Clinical Commissioning Group] respondents were considering extending the number of low-value treatments and prescriptions that will not be funded, and 56 per cent were considering extending waiting lists or reducing activity for certain elective specialties…”

This withdrawal of NHS services including, as mentioned above, in relation to Homeopathy and Herbal Medicine, may result in greater demand for Complementary and Alternative Medicine (CAM) but only for patients accessing such treatments and remedies outside the NHS and only for those who can afford to pay for them.

While this is a probable, but presumably unintended, consequence of the NHS CCGs policy, wouldn’t embracing CAM prove to be the most cost-effective way to save the NHS money overall? For instance, the use of CAM could contribute to a reduction in hospital bed blocking, alleviate pressure on GP surgery appointments and reduce prescription charges for conventional medicine. Has this been fully explored by NHS managers and those formulating NHS policy? I suspect not. 

It’s probably fair to say that when the trailblazing oncologist Professor Karol Sikora and 64 other signatories sent their letter to be published in the Sunday Times newspaper on 20th November 2016 under the caption We must think the unpalatable to stop death of the NHS, say doctors, they did not have in mind the potential of CAM.

The letter stated that the NHS was in crisis. It highlighted the early retirement and poor recruitment of doctors together with the lengthening of waiting times: for surgery, in emergency departments and in the diagnosis and treatment of cancer and further confirmed the problem of ‘bed-blocking’ in hospitals. It concluded that the fundamental reason for these failures, although complex, was down to lack of money and use of resources and called upon the Government to look at (by way of a Royal Commission):
“…all the options – even the most unpalatable – for raising spending on the NHS…[as]  without radical change the NHS will wither and die…” 

Similarly, I guess the potential of CAM was not an issue in the 2 press reports appearing on page 11 of the Times newspaper dated 18.01.18 under, respectively, the headlines: GPs see over 40 patients a day and One in ten nurses leaves as NHS crises deepens.

In the former, Mary McCarthy, vice-president of the European Union of General practitioners, is reported as saying the figures were “pretty dreadful” with British patients getting shorter appointments than elsewhere.

In the latter report, the Royal College of Nursing (RCN) is reported as warning that the trend of more nurses leaving the health service than joining it will: 

“‘...lead to a lost generation of nurses. It is estimated that one in nine posts is vacant…”

and further that according to Janet Davies, head of the RCN:

“…We are haemorrhaging nurses at precisely the time when demand has never been higher…”

And yet, a professionally qualified, regulated, insured, highly experienced, motivated and ‘untapped’ healthcare workforce consisting of CAM practitioners is ready, willing and able to assist. Many already work in the NHS, especially but not exclusively, in the primary care sector where they are not permitted to use CAM. Others, to a limited extent and particularly in oncology and palliative care, do practise in the NHS often on a voluntary basis. So what is the reason for this contradiction and why is the potential of CAM not being ‘tapped’?

On 4th January 2017, The Alliance for Natural Health International e-alert number 333 (bulletin) included the following observation by Executive & Scientific Director Dr Robert Verkerk PhD:

“…We need a community based healthcare system that can help guide as many people as possible, encouraging them to make the right choices to optimise their wellness. As it happens, this healthcare workforce is ready and waiting – it’s just dramatically under-utilised and marginalised by the mainstream healthcare system…In the UK, it’s estimated that around 9 million people use some kind of complementary or alternative medicine (CAM) and in the EU generally there are around 328,000 registered CAM providers made up of about 178,000 non-medical practitioners and 150,000 medical doctors.

“There’s a real need for better integration of these forms of healthcare into mainstream offerings, something that is more common practice in Germany and France than it is in the UK…”

Research (Is complementary and alternative medicine (CAM) cost-effective? A systematic review: Patricia M Herman, Benjamin M Craig & Opher Caspi, BMC Complementary and Alternative Medicine – 02.06.2005) concludes as follows:

“…As health care costs continue to rise, decision makers must allocate their increasingly scarce resources toward therapies which offer the most benefit per unit of cost. Economic evaluations inform evidence-based clinical practice and health policy. To be considered by these decision makers, CAM therapies and their outcomes must be known and compared to conventional approaches. However, CAM practitioners must themselves decide whether the cost of performing these studies is worth the potential impacts to their profession of being considered in managed care. Nevertheless, these evaluations will be done and they will be better done with practitioner involvement. Whereas the number and quality of these studies has increased in recent years and more CAM therapies have been shown to be good value, there are still not enough studies to measure the cost effectiveness of the majority of CAM. If CAM providers wish to increase the provision of therapies to improve population health, they must report the potential outcomes of CAM therapies widely and well…” 

In addition to this research showing the “good value” of CAM, there is evidence that CAM is of increasing interest to medical students, as evidenced in the Medicine News article of 21.09.15 Even medical students want conventional medicine to include alternative therapies.[1]

Enthusiasm on the part of conventional medical practitioners for integrating CAM was also reflected in a Department of Health Policy Research Programme Project, The effectiveness and cost effectiveness of complementary and alternative medicine (CAM) for multimorbid patients with mental health and musculoskeletal problems in primary care in the UK: a scoping study (The University of Bristol), for which Professor Deborah Sharp and her colleagues published an Executive Summary[2] which included the following observation:

“…Complementary and alternative medicine’ was a difficult term for many NHS professionals and included a range of treatments which varied widely in their acceptability. All three groups (GPs, CAM practitioners and commissioners) felt that CAM has a role in primary care and MSD-MH multimorbidity (where there were limited conventional treatment options). Key barriers to integration were philosophical differences and having to ‘secularise’/reduce CAM to adapt to the NHS, NHS structural/organisational barriers, the challenges of adhering to evidence based medicine and finances (limited budgets, unpredictable funding and need for cost-effectiveness). A minority of GPs were concerned that integrating CAM into NHS primary care may not be feasible and would present challenges in terms of extra work in understanding the paradigm in which complementary practitioners work. A strong theme (from all three groups) was the need for improved education of GPs about what CAM is and what it can do…”

This summary concluded that:

“…We identified a number of services where CAM is integrated into NHS provision, using various models and with varying degrees of perceived success. Acupuncture and homeopathy were most commonly provided, followed by massage, osteopathy and mindfulness. Most was NHS-funded CAM, free to patients. GPs were often instrumental in service initiation and NHS staff enthusiasm facilitated integration. Perceived success, sustainability and acceptability may depend on: providing a wide range of CAM; full integration into an NHS service; dual NHS and CAM trained clinicians; and evidence. Barriers to integration were funding, anti-CAM attitudes, and negative NHS staff attitudes or lack of knowledge…”

Even at this early stage, the study indicates that NHS funded and integrated CAM (free to patients) could be viable and further that:

“…GPs were often instrumental in service initiation and NHS staff enthusiasm facilitated integration...”

These observations are also, as I opine below, relevant to the proposition that CAM practitioners, particularly those identified in the Executive Summary, should, where appropriate, be recognized as NHS Allied Health Professionals.

Caution and scepticism towards CAM could be addressed as suggested in the research article titled Academic doctor’s views of complementary and alternative medicine (CAM) and its role within the NHS: an exploratory qualitative study (Nita Maha and Alison Shaw),[3] which concludes:

“…Despite the caution or scepticism towards CAM expressed by doctors in this study, more open doctor-patient communication about CAM may enable doctors' potential concerns about CAM to be addressed, or at least enhance their knowledge of what treatments or therapies their patients are using. Offering CAM to patients may serve to enhance patients' treatment choices and even increase doctors' fulfilment in their practice. However, given the recurring concerns about lack of scientific evidence expressed by the doctors in this study, perceptions of the evidence base may remain a significant barrier to greater integration of CAM within the NHS…”

Refer, also, to the observations of Professor Deborah Sharp of the University of Bristol Centre for Academic Primary Care in her blog posted on the website of the College of Medicine, London, on 21.09.17: Complementary medicine’s true potential cannot be unlocked without robust evidence for its use.

Nevertheless, a research paper published in Cambridge Core (May 2015, Volume 16, Issue 3, pp. 246-253) titled General practitioners’ beliefs about the clinical utility of complementary and alternative medicine confirms that GPs see a role for CAM within clinical practice and that this is the case notwithstanding perceived limits in evidence-base.

To summarize, it seems that if the practice of CAM is to be given full, rather than, as now, only partial status and acceptance within the NHS and if the freedom of NHS patients to receive CAM treatments and remedies is to be secured, CAM professional organisations and regulators need to present, as many already do, an evidence-base in support of CAM while also seeking to persuade the, quite possibly smaller than anticipated, sceptical faction of NHS staff of its value.

I would argue that, for the reasons given below, it should not be requisite that such evidence-base be limited to Randomised Controlled Trials (RCT), in part because CAM researchers are so often unable to secure the considerable funding needed for a RCT research project. Also, it should be recognized that it is not appropriate to apply so-called “Gold-standard” methods of assessment, like the RCT, to some CAM modalities for which a more patient-lead, flexible approach should be taken. The BMC Medicine research article Six ‘biases’ against patients and carers in evidenced-based medicine, referred to below, while not expressly supportive of CAM, nevertheless advocates a less rigid approach to evidence-base medicine.

There is a continuing debate about the exclusivity of the RCT as a means of assessing evidence-base. Refer to the research articles Getting off the “Gold Standard”: Randomised Controlled Trials and Education Research: PMCID-PMC3179209 [4] and Fool’s gold, lost treasures, and the randomised controlled trial-PMID: 23587187.[5]

On 25th May 2017, The Alliance for Natural Health posted an article titled Our health predicament: How do we know what works and what doesn’t? that explored the question:

“…why many academics who are involved with trying to understand more about the best ways of managing our health are increasingly looking to means other than the RCT [Randomised Controlled Trial] – long upheld as the gold standard of evidence – to evaluate the effectiveness of different interventions and self-care regimes…”

Research resources presented by the CAM professions and regulators could include:

In October 2005 and further to its commission by HRH the Prince of Wales, Economist Christopher Smallwood led the publication of The Role of Complementary and Alternative Medicine in the NHS: An Investigation into the Potential Contribution of Mainstream Complementary Therapies to Healthcare in the UK. (193 pages) [http://magonia.com/files/smallwood-report.pdf], which concluded (page 8) as follows:

“…Our main conclusion is that there appears to be sufficient evidence to suggest that some complementary therapies, listed in the report, may be more effective than conventional approaches in treating certain chronic and psychosocial conditions, and that specific treatments offer the possibility of cost savings, particularly where they can be provided in place of, rather than in addition to orthodox treatments.

“Our principal recommendation therefore is that Health Ministers should invite the National Institute for Health and Clinical Excellence (NICE) to carry out a full assessment of the cost-effectiveness of the therapies which we have identified and their potential role within the NHS, in particular in relation to the closing of “effectiveness gaps...”

The scope of the Report was restricted to the first of the three groups of therapies defined in chapter 2 of the House of Lords Science and Technology Committee’s Sixth Report. These include acupuncture (Report pages 35 to 36), homeopathy (Report pages 47 to 56), chiropractic and osteopathy (Report pages 57 to 68) and herbal medicine (Report pages 69 to 80). Christopher Smallwood’s Summary and Guide to the Report can be read on pages 8 to 18.

The Report defines its approach to the economic evaluation of healthcare (Cost-Benefit, pages 28 to 31) and provides Models of Integration and Methods of Delivery (pages 81 to 86) of CAM within the NHS (pages 122 to 130) together with a study of Effectiveness Gaps where the treatment of certain conditions are poorly addressed by conventional medicine (pages 131 to 146).

CAM practitioners may be forgiven for thinking that the NHS employment status Allied Health Professions must also include many of the CAM professions but, with a single exception, this is not the case. In an excellent Guest Blog by Joanne Fillingham[6] posted on the King’s Fund website on 20.07.17, an Allied Health Professional is defined as:

“…someone trained to perform services in the care of patients other than a physician or registered nurse…[including]: art therapists, drama therapists, music therapists, chiropodists/podiatrists, dietitians, occupational therapists, operating department practitioners, orthoptists, osteopaths, prosthetists and orthotists, paramedics, physiotherapists, diagnostic radiographers, theraputic radiographers, speech and language therapists…”

Further information about Allied Health Professionals may be found in the action paper of Allied Health Professions into Action[7] published by NHS England.

The “single exception” I refer to as being both an AHP and complementary medicine is the statutorily regulated profession of osteopathy which is defined as a Group 1 therapy in paragraph 2.1 of Chapter 2 [8] of the House of Lords Select Committee on Science and Technology Sixth Report dated 21st November 2000 [9] (see the press notice dated 28.11.2000.[10])

The Group 1 definition also includes chiropractic (which is also statutorily regulated), acupuncture, herbal medicine and homeopathy. Yet only osteopathy has been accepted as an AHP. Arguably, other CAM professions, including homeopathy and herbal medicine should be acceptable too.

There have been significant advances in relation to both the regulation and research of CAM in the 18 years since the House of Lords Report was published. Has the time come to reassess the contribution by CAM, perhaps by way of a new House of Lords call for evidence and subsequent Inquiry and Report? Might the resulting in depth analysis then lead to a reversal of the current “blacklisting” of homeopathy and herbal medicine by NHS England referred to above?

Here is brief summary presenting the case for homeopathy:

1. The “Australian Report”:

The National Health & Medical Research Council (Australia) Statement on Homeopathy (“The Australian Report”) is being challenged. 

Practitioners of Homeopathy will be interested to read the first item listed in the Letters to the Editor section of PH Online, Issue 238 (May 2017), titled World-Renowned Government Research Department Misled Scientists and the Public Over Homeopathy [http://www.positivehealth.com/article/letters-to-the-editor/letters-to-the-editor-issue-238] and to view the audio/video The Australian Report: the facts behind the Headlines [https://facultyofhomeopathy.org/australian-report-facts-behind-headlines/] posted by The Faculty of Homeopathy.

Information about the NHMRC Statement may be found here [11] and you can sign-up to a campaign launched in Australia [12].

2. Complementary Medicine (including Homeopathy) in Switzerland:

Complementary medicine in Switzerland is now a mandatory health insurance service: The Swiss Federal Government acknowledges that complementary medicine meets insurance regulations (Swiss Federal Health Insurance Act 1996) when it comes to effectiveness, guaranteeing high quality and safety.

On the 16th June 2017, The Swiss Umbrella Association for Complementary Medicine / The Union of Associations of Swiss Physicians for Complementary Medicine issued a press release  [13] announcing that specific medical services using complementary medicine are to be covered by mandatory health insurance (basic insurance) as of 1st August 2017. The following disciplines of complementary medicine will be fully covered: Classical Homeopathy, Anthroposophical Medicine, Traditional Chinese Medicine and Herbal Medicine, provided they are practised by conventional medical practitioners who have an additional qualification in one of the four disciplines as recognised by the Swiss Medical Association. This implements one of the key demands of the Swiss constitutional referendum held on 17th May 2009.

3. Homeopathic treatments and hospitals challenged:

Notwithstanding that it is an accepted health specialism in Switzerland and a treatment endorsed by the World Health Organisation [14] which is available in general practice in France [15] and in other European Union health sectors, it is surprising (some would say depressing) that the effectiveness and provision of Homeopathy prescriptions continue to be challenged within the NHS, in Australia [16] and in Scotland.[17]

In 2016, the Homeopathy Research Institute published an assessment titled Homeopathy within the National Health Service, UK  [18] setting out ‘some reliable facts on homeopathy and the NHS’.

In the summer of 2017 the Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups proposed the decommissioning of NHS homeopathic services at the Portland Centre for Integrative Medicine in Bristol) [19]. The Clinical Commissioning Groups official proposal document can be viewed here [20].

From 3rd April 2018, in line with the funding policy of Camden Clinical Commissioning Group, London, the local organization that plans and pays for healthcare services in its area, the Royal London Hospital for Integrated Medicine (RLHIM) ceased to provide NHS-funded homeopathic remedies for patients as part of their routine care, although remedies will continue to be available for purchase from the RLHIM pharmacy. The RLHIM, formerly the Royal London Homeopathic Hospital, provided homeopathic treatments and remedies since it was founded as the London Homoeopathic Hospital in 1849.

The British Homeopathic Association (BHA) has launched a legal challenge against NHS England by way of Judicial Review proceedings, the background of which may be viewed here. The BHA describes its case as follows (excerpt):

“The British Homeopathic Association (BHA)- a charity that supports patients’ rights to homeopathic treatment on the NHS – is awaiting judgement on its legal challenge to NHS England’s 2017 consultation that ended with a recommendation that GPs should not prescribe homeopathic medicines… 

“The BHA commenced an application for judicial review in October 2017 on the basis that NHS England’s consultation was fundamentally flawed from the outset. It is the charity’s case that the proposal was not formulated with input from any homeopathy experts or practitioners; it was not a genuine attempt to engage the public; and did not provide the public with adequate information or access to provide a considered and informed response…The judge’s ruling is expected in the coming weeks…”

By the time this article is published, the judgement of the court should be available.

The House of Commons Science and Technology Committee 4th Report of Session [2009 – 2010], Evidence Check 2: Homeopathy, which can be reviewed here [21] concludes as follows:

“…[110 & 111 at pages 28 & 29] The Government’s position on homeopathy is confused. On the one hand, it accepts that homeopathy is a placebo treatment. This is an evidence-based view. On the other hand, it funds homeopathy on the NHS without taking a view on the ethics of providing placebo treatments. We argue that this undermines the relationship between NHS doctors and their patients, reduces real patient choice and puts patients’ health at risk. The Government should stop allowing the funding of homeopathy on the NHS… We conclude that placebos should not be routinely prescribed on the NHS. The funding of homeopathic hospitals—hospitals that specialise in the administration of placebos - should not continue, and NHS doctors should not refer patients to homeopaths…”

Contrast this with the approach adopted in Switzerland [22] and in The Homeopathy Research Institute’s [23] 3rd International Conference Report 2017, details and an Abstract of which may be viewed here [24] and here [25] and which concludes:

“…As always, the HRI conference was truly international, with 200 delegates from 25 countries coming together to hear presentations by researchers from 19 countries. The high calibre of the 36 oral presentations and 37 posters was evident throughout the intensive programme, reflecting the high scientific quality of abstract submissions and a competitive selection process.

The new findings presented captured the ‘cutting edge’ theme of the conference, from the emergence of ‘pragmatic clinical trials’ as a particularly appropriate methodology for capturing the full clinical effectiveness of ‘real world’ homeopathy, to the latest bioassays being developed for basic research…”

The Scientific Advisory Committee of the Homeopathy Research Institute (HRI) can be viewed here [26]

HRI observations on the Science and Technology 4th Report may be found here [27]. An independent critique written by Earl Baldwin of Bewdley concluded that the 4th report was “an unreliable source of evidence about homeopathy.”

Homeopathic practitioners and others may wish to view the film Just One Drop [https://www.justonedropfilm.com/] which was released “In Honour of World Homeopathy Awareness Week” (2017)

4. The Statement (03.11.17) by The Royal College of Veterinary Surgeons (RCVS):

I include reference to the RCVS statement in this article because I believe there are striking similarities between the policies adopted by the RCVS with regard to CAM in relation to veterinary practice and those being recommended for the NHS. 

The outcome of The Royal College of Veterinary Surgeons Standards Committee Review about the prescribing of homeopathy and CAM by its members was published on 03.11.17 and may be viewed here [28]. It includes this guidance to its members:

“Homeopathy exists without a recognised body of evidence for its use. Furthermore, it is not based on sound scientific principles. In order to protect animal welfare, we regard such treatments as being complementary rather than alternative to treatments for which there is a recognised evidence base or which are based in sound scientific principles. It is vital to protect the welfare of animals committed to the care of the veterinary profession and the public’s confidence in the profession that any treatments not underpinned by a recognised evidence base or sound scientific principles do not delay or replace those that do.”

The RCVS further clarifies the above Statement in its reply to the question:

“…Is the RCVS banning veterinary homeopathy and other complementary treatments and therapies?

Reply: “No. We have not banned veterinary homeopathy and neither does our position statement of 3 November 2017 suggest that we have.

“What we do state, is that we expect treatments like homeopathy, which are not underpinned by a recognised evidence base or sound scientific principles, to be offered alongside, or complementary to, those treatments that are…’

The response of the Faculty of Homeopathy to the RCVS statement may be read here [29]. The response by the campaign at http://www.vets4informedchoice.org may be viewed here.[30]

Links to research relating to Veterinary Homeopathy may be found on the website of The International Association for Veterinary Homeopathy.[31]

5. Homeopathy research sources:

Homeopathy research information is available from, among others:

The Homeopathy Research Institute;

International Association for Veterinary Homeopathy:

http://www.iavh.org/en/for-veterinarians/research/;

 The Faculty of Homeopathy:

https://facultyofhomeopathy.org/research/;

 http://www.homeopathyjournal.net/;

https://www.thieme-connect.com/products/ejournals/journal/10.1055/s-00034926;

The Society of Homeopaths:

https://homeopathy-soh.org/about-us/about-the-society/;

 The British Homeopathic Association:

https://www.britishhomeopathic.org/evidence/conditions-with-overall-positive-evidence-for-homeopathy/;

 The Carstens Foundation:

 https://www.carstens-stiftung.de/artikel/new-database-portal-for-complementary-medicine.html (Note: an English translation option is available on the website);

 The Alliance of Registered Homeopaths:

http://www.a-r-h.org/;

Homeopathy in Practice Journal: http://www.homeopathyinpractice.org/useful-links/:

 Teaching establishments like The School of Homeopathy: http://www.homeopathyawareness.com/.

Review the replies to FAQs:

https://www.hri-research.org/resources/homeopathy-faqs, provided by the Homeopathy Research Institute;

Listen to the personal message from Dr Russell Malcolm: https://facultyofhomeopathy.org/patient-access-homeopathic-medicine/, a medical doctor and homeopath, about patient access to homeopathic medicine.

6. The parliamentary debate continues:

During the debate about Homeopathy and the NHS held in Westminster Hall, London, on 29.03.17, Mr David Tredinnick MP observed:

“…On British practitioners, a survey recently showed that 72% of homeopathic patients rated their practitioners either very good or excellent. The 4Homeopathy group recent study showed that practitioners are treating all kinds of things, from irritable bowel syndrome - 30% - to depression - 20%. More than three quarters of teenagers and 41% of adults receive homeopathic treatments for skin disorders. About a third of adults and 40% of teenagers go to homeopaths for anxiety and stress. It is a service that delivers both in and out...”

He went on to quote a written answer in the Scottish Parliament by the (then) Health Spokesperson, Nicola Sturgeon, in reply to a question about the effectiveness of homeopathy in relation to the Scottish Government’s approach to integrative patient care:

“In primary care, costs will relate to the cost of the remedy, which can be cheaper than the cost of orthodox drugs. Practitioners have also noted a reduction in side effects and dependency risks in some cases. In secondary care in Scotland, homoeopathy is only employed within a broader integrative care approach, with surveys showing both enhanced wellbeing and symptom reduction across a broad range of long term conditions, and a resultant reduction in NHS costs through reduced GP and hospital visits and repeat prescriptions.”

Turning now to evidence in support of CAM, generally, the following resources could be explored:

1. The new database portal for complementary medicine:

In 2017, the Carstens Foundation [https://www.carstens-stiftung.de/] announced this most welcome resource for practitioners, researchers and students of complementary medicine, naturopathy and homeopathy, as follows:

“…The Karl and Veronica Carstens Foundation is launching a free database portal for complementary medicine, naturopathy and homeopathy. A total of 96,000 records with recorded literature, including about 30,000 papers from clinical research and more than 9,000 publications from basic research, can now be searched free of charge - a unique and unrivalled research offer for scientists, doctors, therapists and students.

“If you are planning a research or doctoral thesis in the area of ​​complementary medicine or just want to get an overview of the current study situation, you have immediate access to the probably largest data collection in Europe.  After a one-time registration, the Carstens Foundation provides its entire catalogue, as well as all registered studies, experiments and case studies, for free online research. This makes possible a new, comprehensive database portal at https://www.carstens-stiftung.de/artikel/new-database-portal-for-complementary-medicine.html…”

(Note: English translation option is available).

2. The CAM NHS Evidence Collection:

In addition to the Carstens Foundation portal and links to research information provided by CAM professional organisations (as in the case of Homeopathy, above) there is the CAM specialist library (developed for the NHS Library for Health), the content of which has been incorporated into NHS Evidence [https://www.evidence.nhs.uk/] (note: insert the name of the CAM treatment specialism into the search box) which is available on the National Institute for Health and Care Excellence website. This resource is compiled by The Research Council for Complementary Medicine [32] in partnership with the Royal London Hospital for Integrated Medicine and the School of Life Sciences (now part of the Faculty of Science & Technology) at the University of Westminster.

3. The extensive research database of Positive Health Online: http://www.positivehealth.com/researches

What, surely, should not be in doubt is the value of offering NHS patients the best of CAM and conventional medicine. The publication, in The Journal of Alternative and Complementary Medicine (Volume 23, Number 5, 2017, pp. 320-321), of The Berlin Agreement: Self-Responsibility and Social Action in Practising and Fostering Integrative Medicine and Health Globally [33] includes a call to ‘commit to evidence-informed dialogue and practice’ to:

“…end polarising dialogue and to stimulate collaboration in our collective ability to research, create, and operationalize optimal evidence-informed integrative care…”

Pursuant to this Agreement, all CAM and conventional health practitioners should work together and collaborate within the NHS in the best interests of their patients.

 Many of those who formulate policy and manage NHS and public health organisations continue to ignore the effective contribution that CAM can make to the provision of health and social care. Why is this? Could one reason be because they lack adequate statistical information about its use and cost? Neither the Office for National Statistics nor NHS Digital [34] hold, produce or analyse statistical research dedicated exclusively to the provision and supply of CAM services and products in the UK.

Any initiative to compile such UK statistics could take note of the approach applied in the United States by The National Centre for Health Statistics  (NCHS) [35] in its Statistics Reports titled, respectively, Trends in the Use of Complementary Health Approaches among Adults: United States, 2002 – 2012 [36] and Costs of Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States, 2007 [37].

The aim of the NCHS reports is to:

“… provide annual data summaries, present analyses of health topics, or present new information on methods or measurement issues…”

Other Reports [38] published by the NCHS (U.S. Department of Health and Human Services) include:

  • Use of Complementary Health Approaches for Musculoskeletal Pain Disorders Among Adults: United States, 2012;
  • Expenditures on Complementary Health Approaches: United States, 2012;
  • Wellness-related Use of Common Complementary Health Approaches Among Adults: United States, 2012;
  • Use of Complementary Health Approaches Among Children Aged 4 – 17 Years in the United States: National Health Interview Survey, 2007 – 2012;
  • Complementary and Alternative Therapies in Hospice: The National Home and Hospice Care Survey: United States, 2007 and
  • Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007.

For further publications about complementary health statistics in the US, search: Publications Using NHIS Data [39] and Complementary and Alternative Medicine: What People Aged 50 and Older Discuss With Their Health Care Providers [40] 

NHS managers, UK patients and medical practitioners (Complementary and Conventional), researchers and those who formulate NHS policy should have access to similar summaries and statistical analysis of CAM services and products provided and supplied in the UK.

The NHS has already stated its support for personalised commissioning. The joint NHS England and Local Government Association Integrated Personal Commissioning: Personalised Commissioning and payment Summary Guide [41] states:

“…Integrated Personal Commissioning (IPC) and personal health budgets are part of a wider drive to personalise health, social care and education. They promote a shift in power and decision-making, to enable a changed, more effective relationship between the NHS and the people it serves, aligning to the Five Year Forward View [42]…The relevant guidance for the NHS and local authorities encourages a joined-up approach…A personalised approach to commissioning, contracting and payment enables people to access services that are more appropriate for their specific needs…”

The summary guide further states (pages 4/5, paragraph 2.1.2):

“…Personalised commissioning and payment supports people to improve their health and wellbeing through more choice and control over the services they choose. Such greater choice and control results in a better experience of care, improved outcomes and reduced costs, thereby representing a more effective use of health and care resources…This commissioning could be done by the clinical commissioning group (CCG) or local authority or by the person themselves using a direct payment…”

For the Summary Guide: “Personalised Commissioning and payment: what needs to be in place”, search the link at [43].

Paragraph 2.2.2 (page 6), includes this recommendation:

“…For people to receive high quality, personalised and effective care and support, local organisations need to work in a more joined-up way. Effective joint commissioning arrangements are characterised by…building local community capacity to enable solutions beyond traditional, formal services provided by the NHS and local authorities…”

More information may be found in the NHS England links: Personalised Health and Care Framework [44] and Key features of personal health budgets and IPC.[45]

Although there is no mention in the above Joint Summary Guide of Complementary Medicine or Integrated Health/Medicine (i.e. in the context of combining the best of complementary and conventional healthcare), it is virtually certain that a significant number of NHS patients will request one or more complementary therapies, in return for which they will want to make a ‘direct payment’. Logically, this should be a request that it is difficult for the NHS to refuse not least because CAM is already available at many NHS hospitals, clinics and GP surgeries, for instance to help relieve the symptoms of cancer or the side-effects of NHS prescribed cancer treatment, when, incidentally, an Allied Health Professional who is also a qualified and accredited CAM practitioner could, if permitted, provide a CAM treatment alongside conventional treatment as part of an NHS approved integrative treatment plan.

An example of where CAM services are provided within the NHS is at The Royal Marsden NHS Foundation Trust [46], London. In its patient information publication Your guide to support, practical help and complementary therapies (page 7) [47], it refers to complementary therapies as contributing to integrated healthcare.

In the interests of patients and all health professionals, the NHS could implement a policy to record and analyse the use of (and requests for) complementary healthcare, especially within the integrated personal commissioning and personal health budgets schemes.

Relevant to the case for promoting unbiased acceptance of the patient-centred, holistic qualities of CAM within the NHS and recognising an NHS patient’s right to have a voice and to receive CAM as an integral part of their treatment plan, I refer to the BMC Medicine research article Six ‘biases’ against patients and carers in evidence-based medicine by Trisha Greenhalgh and others [48], which includes as follows:

“…We discuss six potential ‘biases’ in EBM that may inadvertently devalue the patient and carer agenda…To reduce these ‘biases’, EBM should embrace patient involvement in research, make more systematic use of individual (‘personally significant’) evidence, take a more interdisciplinary and humanistic view of consultations, address unequal power dynamics in healthcare encounters, support patient communities, and address the inverse care law…We hope that practitioners, teachers, and researchers of EBM will ask themselves when reading each of the biases… “Given that I personally seek to be unbiased in relation to patients and carers, how should I alter my use of evidence/teaching approach/research focus to help redress this bias?”

and observes in its summary:

“…workable solutions have not arisen from within the EBM literature. In our view, this is because generating such solutions would require a fundamental change in perspective, an abandoning of certain deeply held principles and assumptions, and the introduction of new ideas and methodologies from disciplines beyond EBM. Given the policy push for greater patient and carer involvement in research, the time is surely ripe for those who adhere to the EBM paradigm to question its rigid ‘gold standard’…and consider whether it is time to extend and enrich EBM’s evidence base…” 

This article does not expressly refer to CAM. Nevertheless, it focuses on the value of patient choice, personally significant evidence and acknowledges the existence of power imbalances that suppress a patient’s voice. This, together with its arguments against bias and for a more flexible approach to EBM, questioning the “rigid gold standard” of the Randomised Controlled Trial, I suggest support the contention that CAM should be a treatment option available to NHS patients.

Those professional organizations whose members are already employed in the NHS should provide guidance to those of their members who are qualified, ready, willing and able to practise CAM as part of an integrated medicine NHS treatment plan. One highly respected organisation is the Royal College of Nursing (RCN), which describes itself as follows:

“The Royal College of Nursing is the world’s largest nursing union and professional body. We represent more than 435,000 nurses, student nurses, midwives and health care assistants in the UK and internationally.”

In 2003, the RCN produced its publication titled Complementary therapies in nursing, midwifery and health visiting practice: RCN guidance on integrating complementary therapies into clinical care (Publication code 002 204: October 2003) which consisted of 13, A4 size pages and, among other things, observed (page 3: The need for integration strategies):

“…Complementary therapies are gaining in popularity (Ernst & White, 2000; Thomas et al, 2001) and finding a more substantial place in health care (Peters et al, 2002). Increasing interest amongst the public (Ong & Banks, 2003) and health care professionals seems to have created an assumption that complementary therapies are widely integrated into nursing and midwifery. Whether this is true is impossible to quantify, because there is no national strategy to collect data…”

and continued (page 4: Which therapies are appropriate?):

“…The therapies most frequently used by nurses and midwives, such as massage, aromatherapy and reflexology, come within the ‘comfort’ category. The most recent annual survey of RCN Complementary Therapy Nursing Forum Members (RCN, 2003a) shows that the use of Reiki healing by nurses has gained in popularity, and that acupuncture techniques are also used by a number of respondents in a variety of clinical settings. Members also showed a general interest in homeopathy. Issues have been raised about whether nurses can deliver the ‘whole’ therapy, and whether this is appropriate, or even possible, within clinical practice. For instance, nurses using essential oils are often not functioning as full aromatherapists – but they are using essential oils to enhance nursing care (Avis, 1999). Putting patients’ best interests first is the key that will help nurses to clarify the scope of intended practice…”

This 2003 RCN guidance concluded (page 11):

“…it is the responsibility of each clinical area within employing organisations to define the parameters of practice, and to develop a framework for integration so that services are offered under the principles of clinical governance and professional nursing practice. The overarching philosophy must be the enhancement of safe, effective and appropriate patient care…”

The guidance focused on care that is in the best interests of the patient and indicated that registered healthcare professionals believe this should include the provision of complementary therapies.

This guidance is now obsolete and currently there is no replacement publication available although, I believe, the RCN is currently revisiting this omission and having discussions about the “public and member facing information” [it] might need to develop. As I write, there is only a brief (one page) section headed Complementary Therapies posted on the RCN website which may be viewed at https://www.rcn.org.uk/clinical-topics/complementary-therapies.

For the benefit of its members and in the best interests of their patients, the publication of new, comprehensive and up-to-date RCN guidelines along the lines of those issued in 2003, which recognise the effective integration and use of CAM, cannot come too soon.

The sobering article General Practice is doomed unless we change direction written by Dr Michael Dixon, Chair of the College of Medicine, was published in Pulse Magazine on 07.12.17.

As argued above, CAM practitioners already contribute significantly to the NHS primary care sector, including in some GP practices, and could make an even greater contribution if NHS policy permitted.

Dr Dixon opens his article with the following warning:

“…If we continue as we are, general practice has no future. This is not a political statement blaming any politicians or organisations but a naked practical truth. Within five years, the family doctor providing personal and continuing care, will be gone – it’s happening already…”

and concludes:

“…If we want to save general practice then it is now or never - now time for patients and media, clinicians and managers, health leaders and politicians to become angry and difficult. Because if we fail general practice then we fail our patients. We fail our communities. We fail the NHS and the NHS itself will ultimately fail…” 

I believe that it is the interests of their patients and the pursuit of integrated medicine that CAM practitioners, regulators and professional organisations should heed Dr Dixon’s warning and combine to have their voice heard in support of GP practices.

In the ‘spirit’ of the personalised approach to healthcare, practitioners, their patients and other stakeholders could lobby Rt Hon Matt Hancock MP [49] (The Secretary of State for Health), Duncan Selbie (Chief Executive of Public Health England [50]), the Department of Health [51] and their own Member of Parliament [52] calling for the NHS and public health sectors to review and to recognise the use, cost-effectiveness and potential of CAM and its practitioners and also for the right of patients to receive safe, appropriate and reasonably evidence-based (i.e. relevant to the treatment modality and not exclusively by way of a Randomised Controlled Trial) CAM services from a professional practitioner of their choice.

Some recently published books that are relevant to the NHS may be of interest to practitioners and patients of what is generically called “energy healing”.

By clicking on the “Look Inside” facility of its amazon edition, inspect the Contents list of Healing in a Hospital: Scientific evidence that spiritual healing improves health by Sandy Edwards (Paperback: January 2017) [53] and scroll down to read the extensive Foreword by Dr Michael Dixon of the College of Medicine. Also, take a look at the article by Sandy Edwards Healing in a Hospital: Scientific Evidence that Spiritual Healing Improves Health [PH Online, issue 246 – May 2018], which concludes, among other things, that:

“…The findings of our research trial suggest that substantial cost savings could be made by the NHS, the Government and by businesses through adding healing to mainstream healthcare…”

Late in 2017, Angie Buxton-King, who was employed by University College London Hospital (UCLH) as a healer from 1999 to 2011, published her 2nd book titled The NHS Healer: Onwards and upwards (Amazon paperback: 26th October 2017 [54]; Vanguard Press ISBN 978 1 784653 11 8).

One of a number of endorsements listed at the beginning of the book is that by Stephen Rowley, Senior Divisional Nurse Clinical Haematology UCLH, from which I quote as follows:

“…Seeing doctors ask for a healer to help support a patient through a medical procedure was not unusual and at the time represented a quiet but important evolution in cancer care. Over the subsequent decade, the supportive and clinical benefits that healing provides has provided the evidence and assurance for healing to be delivered alongside conventional treatments on a wider scale. The further expansion of well governed healing into 13 other centres via the SBSHT is further tangible evidence of the role healing is playing in the integrated care of patients.”

[Note: ‘SBHT’ refers to http://www.cancertherapies.org.uk]

The author commences this exceptional book with the following quotation attributed to the Greek philosopher Plato (circa 428/427 BC to circa 348/347BC). I cannot think of a better way to end this article than by quoting it again here:

“We can easily forgive a child who is afraid of the dark; the real tragedy of life is when men are afraid of the light”.

Richard Eaton LL.B (Hons)

Richard writes a Complementary Medicine Roundup blog for The College of Medicine, London [https://collegeofmedicine.org.uk/complementary-medicine-blog/]. Some extracts from his blog have been adapted and included in this article. A similar, print version, of this article will also appear in Homeopathy in Practice Journal (Spring/Summer 2018) published by the Alliance of Registered Homeopaths.

Links referred to in the text of the article:

Note: Where the links in the text are not given below, access the relevant document or website by copying its title or address into your browser.

1. http://www.medicine.news/2015-09-21-even-medical-students-want-conventional-medicine-to-include-alternative-therapies.html

2. http://www.richardeaton.co.uk/wp-content/uploads/2017/07/BristolUniversitySCIM-Exec-Summary-FINAL.pdf

3. https://bmccomplementalternmed.biomedcentral.com/articles/10.1186/1472-6882-7-17

4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3179209/

5. https://www.ncbi.nlm.nih.gov/pubmed/23587187

6. https://www.kingsfund.org.uk/blog/2017/07/realising-potential-allied-health-professions

7. https://www.england.nhs.uk/ahp/

8. https://publications.parliament.uk/pa/ld199900/ldselect/ldsctech/123/12304.htm

9. https://publications.parliament.uk/pa/ld199900/ldselect/ldsctech/123/12302.htm

10. https://publications.parliament.uk/pa/ld200102/ldinfo/ldscpn02.htm

11. https://www.nhmrc.gov.au/guidelines-publications/cam02

12. https://www.yourhealthyourchoice.com.au/

13. https://facultyofhomeopathy.org/wp-content/uploads/2017/06/I-E_20170616_Communiqu%C3%A9_Fedmedcom-Union_int_E.pdf

14. http://apps.who.int/iris/bitstream/10665/92455/1/9789241506090_eng.pdf?ua=1

15. https://link.springer.com/article/10.1186/s13561-015-0055-5

16. https://facultyofhomeopathy.org/australian-report-facts-behind-headlines/

17. http://www.holyrood.com/articles/news/fresh-calls-scrap-homeopathy-referrals-scotland-after-nhs-england-calls-it-%E2%80%98-misuse

18. https://www.hri-research.org/wp-content/uploads/2016/02/NHS-homeopathy-in-the-spotlight-Feb2016.pdf

19. http://portlandcentrehealthcare.co.uk/

20. https://facultyofhomeopathy.org/wp-content/uploads/2017/08/bristol_nhs_proposals_07-2017.pdf

21. https://publications.parliament.uk/pa/cm200910/cmselect/cmsctech/45/45.pdf

22. https://facultyofhomeopathy.org/wp-content/uploads/2017/06/I-E_20170616_Communiqu%C3%A9_Fedmedcom-Union_int_E.pdf

23. https://www.hri-research.org/

24. http://www.hrimalta2017.org/

25. https://www.hri-research.org/wp-content/uploads/2017/08/HRI_RIF_34_MaltaConfReport.pdf

26. https://www.hri-research.org/about-hri/scientific-advisory-committee/

27. https://www.hri-research.org/resources/homeopathy-the-debate/uk-select-committee-report/

28. https://www.rcvs.org.uk/news-and-views/news/college-publishes-complementary-medicines-statement/

29. https://facultyofhomeopathy.org/wp-content/uploads/2017/11/FoH-statement-on-RCVS-CAM.pdf

30. http://vets4informedchoice.org/mailshot-pdf.pdf

31. http://www.iavh.org/en/for-veterinarians/research/

32. http://www.rccm.org.uk/node/11

33. https://www.liebertpub.com/doi/pdfplus/10.1089/acm.2017.29024.jjw

34. http://content.digital.nhs.uk/home

35. https://www.cdc.gov/nchs/products/nhsr.htm

36. https://www.cdc.gov/nchs/data/nhsr/nhsr079.pdf

37. https://www.cdc.gov/nchs/data/nhsr/nhsr018.pdf

38. https://www.cdc.gov/nchs/products/nhsr.htm

39. https://nccih.nih.gov/research/statistics/NHIS/bibliography

40. https://nccih.nih.gov/research/statistics/2010

41. https://www.england.nhs.uk/wp-content/uploads/2017/06/516_Personalised-commissioning-and-payment_S8.pdf

42. https://www.england.nhs.uk/five-year-forward-view/

43. https://www.england.nhs.uk/wp-content/uploads/2017/06/516_Personalised-commissioning-and-payment_S8.pdf

44. https://www.england.nhs.uk/personalised-health-and-care-framework/

45. https://www.england.nhs.uk/personalised-health-and-care-framework/key-features-of-personal-health-budgets-and-ipc/

46. https://www.royalmarsden.nhs.uk/your-care/supportive-therapies

47. https://shared-d7-royalmarsden-public.s3.amazonaws.com/files_trust/s3fs-public/Your_guide_to_support_practical_help_and_complementary_therapies.pdf

48. https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-015-0437-x

49. https://www.parliament.uk/biographies/commons/matt-hancock/4070

50. https://www.gov.uk/government/organisations/public-health-england

51. https://www.gov.uk/government/organisations/department-of-health-and-social-care

52. http://www.parliament.uk/mps-lords-and-offices/mps/

53. https://www.amazon.co.uk/Healing-Hospital-Scientific-evidence-spiritual/dp/0957516908

54. https://www.amazon.co.uk/NHS-Healer-Onwards-Upwards/dp/178465311X/ref=pd_sim_14_3?_encoding=UTF8&psc=1&refRID=PNKGGWTFZ0XRYPXGBGN4

Further Information

Richard Eaton’s book Business Guide for Health Therapists: How to find what you need to Know  (2nd edition: October 2017) is available (price: £5.99):

As an e-book  (with hyperlinks) from a variety of digital stores at www.books2read.com/BG4HT

In print as a coil-bound paperback from Lulu: http://www.lulu.com/shop/richard-eaton/business-guide-for-health-therapists-how-to-find-what-you-need-to-know/paperback/product-23380869.html;

In print as a paperback and as a Kindle/e-book (with hyperlinks) from amazon: https://www.amazon.co.uk/Business-Guide-Health-Therapists-things-ebook/dp/B01LWTZSLA/

Comments:

  1. Richard Eaton said..

    Please note that the research paper: "The Role of Complementary and Alternative Medicine in the NHS: An Investigation into the Potential Contribution of Mainstream Complementary Therapies to Healthcare in the UK. (193 pages)", referred to in this article, is now available at the following link:

    http://www.richardeaton.co.uk/wp-content/uploads/2017/06/smallwood-report.pdf

    To search this link, please post it into your website browser. Thank you.


  2. Alan Henness said..

    You stated:

    "On the 16th June 2017, The Swiss Federal Government issued a press release [13] …"

    The document you linked to is a press release by Dachverband Komplementärmedizin, the Swiss Umbrella Association for Complementary Medicine, not the Swiss Federal Government.

    "The Swiss Federal Government acknowledges that complementary medicine meets insurance regulations (Swiss Federal Health Insurance Act 1996) when it comes to effectiveness, guaranteeing high quality and safety."

    The Swiss government stated:

    "The remuneration for the services is provisional and limited in time, because it is not necessary to prove that the services of the four complementary medical disciplines are effective, expedient and economic. It has now been shown that this proof for the disciplines is not possible."

    https://www.admin.ch/gov/de/start/dokumentation/medienmitteilungen.msg-id-61140.html (translation from German to English by Google)


  3. Richard Eaton said..

    Thank you, Alan, for the link to the Swiss Government portal media release dated 29.03.16. The paragraph you quote goes on to state:

    '...With the involvement of the parties concerned, a graduated procedure was therefore developed. In a new way, specializations in complementary medicine are to be equated with other medical disciplines compensated by the OKP. Thus, under certain conditions (application and research tradition, scientific evidence and medical experience, further education), they should be subject to the principle of trust and benefits should be reimbursed by the OKP. Analogous to the other medical disciplines...In addition to the four provisionally tempered areas, this equality should also include acupuncture, which is already being paid indefinitely by the OKP...'


  4. Alan Henness said..

    I see you've not yet corrected your article.

    As they say, the Swiss government had to ignore their own requirements (effective, expedient and economic) for inclusion in the reimbursement scheme so homeopathy, etc could be reimbursed.


  5. Richard Eaton said..

    Thank you for your patience, Alan. The text of the article has been amended to state the source of the press release.


  6. RICHARD EATON said..

    FURTHER UPDATE AMENDING MY FIRST COMMENT (ABOVE):

    Please note that the research paper: "The Role of Complementary and Alternative Medicine in the NHS: An Investigation into the Potential Contribution of Mainstream Complementary Therapies to Healthcare in the UK. (193 pages)", referred to in this article, is now available at the following link:

    https://magonia.com/wp-content/uploads/smallwood-report.pdf

    To search this link, please post it into your website browser. Thank you.


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About Richard Eaton

Richard Eaton LL.B (Hons) whose professional background is as a barrister (Bar Council - Academic Division) - now retired - and as a lecturer in law, believes that the future for practitioners of complementary and alternative medicine in private practice lies within well-managed Health Centres. He formerly owned and managed, together with his wife Marion Eaton LLB (Hons) Reiki Master Teacher, the Professional Centre for Holistic Health in Hastings, East Sussex. Richard Eaton’s book Business Guide for Health Therapists: How to find what you need to Know is available (price: £5.99): In print as a coil-bound paperback from www.lulu.com (Bookstore); In print as a paperback and as a Kindle/e-book from amazon; As an e-book from a variety of digital stores.  Richard writes a quarterly blog for The College of Medicine (“Complementary” section) and may be contacted via rmceaton@btinternet.com     http://uk.linkedin.com/in/richardmceaton

 

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