Alternative Therapies Rule, OK. by Dr Michael Dixon Paradoxically the lack of evidence that shows complementary therapies work, may lead PCGs to adopt them widely. Complementary therapies have become increasingly popular with primary-care professionals in recent years. They have been responding partly to their own patients and partly to their own realisation that there are limits to what orthodox medicine can offer. In this way they have developed a different view of complementary medicine to their secondary-care counterparts. Thus, with the move to a 'primary-care-led NHS' it might seem logical that complimentary medicine would gain an ever high profile. However, whether or not it does will depend upon two factors. The first will be the force of demand (from GPs, primary-care professionals and patients) that led some fund-holders to offer complementary therapy within their surgeries. The argument runs as follows: if a patient wants a treatment, and feels that he or she is better after it, then it is only logical to offer it - especially if it saves medical time. Doctors who embrace complementary medicine in this way are regarded, rightly or wrongly, as progressive and there is likely to be a strong pressure, especially from patients to provide complementary medicine in primary-care groups. The contrary force is the onward march of evidence-based medicine. The problem with most complementary therapies is that hardly any of them, with the possible exception of manipulation for acute back pain, have been definitively proven to be effective. You could argue that this is so for a wide range of conventional medical interventions, but they had the advantage of getting into the NHS first. Decisions are easy when a medicine is proven to be effective, but when its ineffectiveness is not proven there will be interesting debates between the evidence heavy weights and those who will say that primary care groups should embrace promising treatments even if they are unproven. The debate will warm up when scarce resources are likely to mean that proven treatments will have to take first place to unproven ones. In practice it is unlikely to be 'either/or', pitching intuition to answer some of these questions. The public will be very much involved in this whole process as they will have to own the decision that might require one conventional treatment being dropped in favour of a complementary treatment. This will create interesting debates in localities where one group may be much in favour of complementary medicine (conventionally the upper socio-economic classes and rural communities) while another section of a locality may be much keener on putting money towards conventional medicine. It is quite possible that practice and primary-care-group research may support the future employment of complementary practitioners within the primary-care setting. These will probably need to be given back-up medical diagnostic support, and the effectiveness of referring particular patients to them will be maximised by guidelines between themselves and the primary-care professionals, which are owned by the whole primary-care group. It will provide primary care with a far wider range of therapeutic options and allow GPs to maximise their crucial role as diagnosticians while delegating work when quick-fix medicine is inappropriate and time-consuming therapies are indicated. Having such a facility will enable primary-care professionals to analyse why they feel pressured to give conventional therapies such as antibiotics or expensive anti-depressants at a lower threshold than is often justified. Having an 'alternative prescription' may lessen their dependence on expensive medicines and interventions, which is all they have to offer at present. It may also radically alter their perception of the job that they are doing - are doctors there to maximise length of life, minimise symptoms, improve quality of life or to alter the patient's perception of a body or a mind that is not functioning properly? The detail of how complementary medicine will impact upon primary care groups is also likely to vary from group to group. Some may form a 'special task group' - involving a wide range of members from primary-care professionals and pharmacists to complementary therapists themselves. Others may choose to include complementary medicines in their formulary for specific indications. Some may simply create links with private practitioners, which may guarantee quality standards locally and provide for better co-operative working though not actually offering complementary medicine on the NHS. Future research on complementary medicine is likely to be crucial in this respect. PCGs are going to radically alter the way in which treatment is given. They could offer complementary therapy a new lease of life, which will be quite different from the financial cynicism and scientific vagueness that private systems encourage. Change will be required so that both conventional health professionals and complementary professionals come to terms with their own vulnerabilities and insecurities to form a working partnership, which needs to exist whether or not complementary therapies are available on the NHS. A new dawn, if you like, for an NHS that will concentrate on fairness, equity, co-operation, accountability and the whole patient.
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