Positive Health Online

Dr Ava Lorenc (corresponding author), Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol

Professor Deborah Sharp, Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol

Professor Gene Feder, Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol

Professor Paul Little, Primary Medical Care, Faculty of Medicine, University of Southampton

Dr Sandra Hollinghurst, Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol

Professor Stewart Mercer, Department of Primary Care and General Practice, University of Glasgow

Professor Sian Griffiths, Institute of Global Health Innovation, Imperial College, London

Dr Hugh MacPherson, Department of Health Sciences, University of York

Introduction

This article reports on a study conducted by the University of Bristol and a team of researchers from across the UK.  We were funded by National Institute for Health Research -NIHR to provide up to date information about possible integrative medicine (IM) approaches for comorbid musculoskeletal and mental health conditions in primary care, that could be tested in a full trial. We wanted to find out which CAM would be the most likely to be effective, cost-effective and safe, as well as acceptable and feasible for provision in or via UK NHS primary care.

This project was a scoping study, an approach useful to identify gaps in the research and priorities for future research.[1,2] We used four phases:

1. A literature review
2. Focus groups with professionals
3. A review of existing IM provision in the NHS
4. A public survey of CAM use.

Each of these phases has been published as a peer-reviewed paper. The results from the four phases were combined to identify priority areas (conditions and CAM) for the future trial. We were looking for evidence of effectiveness, cost-effectiveness, safety, potential impact on comorbidity, acceptability to professionals and the public, and feasibility of provision in NHS primary care.

Why Musculoskeletal and Mental Health Comorbidity?

We chose to study people with both a musculoskeletal (MSK) problem and mental health (MH) condition (called comorbidity) because it is very difficult to treat, and has a major impact on patients, the NHS and society. We wanted to explore whether integrating CAM into NHS treatment could help GPs to treat patients experiencing this comorbidity. We included a wide range of conditions, such as back/neck/shoulder pain, osteoarthritis, anxiety, depression, and sleep disorders. 

1. Hoy D, et al. A systematic review of the global prevalence of low back pain. Arthritis and rheumatism 64(6):2028-37. 2012.
2. Office for National Statistics (ONS). Sickness Absence Report. 2016.
3. NHS Networks. Programme Budgeting 2012-13. 2016.
4. McManus S, et al. Mental health and wellbeing in England: Adult psychiatric morbidity survey 2014. Leeds: NHS Digital, 2016 http://digital.nhs.uk/catalogue/PUB21748
5. Knapp M, et al. The economic case for better mental health. In: Davies S, editor. Annual Report of the Chief Medical Officer 2013, Public Mental Health Priorities: Investing in the Evidence. London: Department of Health:  147-56. 2014.
6. Davies SC. Annual Report of the Chief Medical Officer 2013, Public Mental Health Priorities: Investing in the Evidence. London: Department of Health, 2014.

Musculoskeletal disorders (MSKs) are a large and increasing problem in the UK (see diagram above), with a major impact on health, disability, productivity and health care use. Mental health (MH) problems are also common and cause major burden for individuals and society. Comorbidity is increasingly prevalent in the ageing population.

What do we mean by CAM and Integrated Medicine?

In our study we only included CAM delivered by a practitioner, which is used by around 12-16% of the UK population in any one year.[3,7]  We used a very broad definition of CAM, including exercise-based approaches. By integrated medicine we meant CAM being provided alongside conventional NHS care. We focussed on primary care, where the patient accesses CAM via their GP, for example GP referral to a CAM provider, or accessing CAM as part of social prescribing,[4] or a GP who practises CAM themselves.

The Research Literature

Our first step was to review the literature to map the evidence for effectiveness and cost-effectiveness of CAM for MSK and MH, by reviewing systematic reviews from the past 10 years.  This work has been published in the BMJ Open.[5] Systematic reviews are the gold standard form of evidence, as they collate and analyse evidence from randomized controlled trials. We assessed the quality of the systematic reviews and only included those of good quality.  We found a large and increasing number of systematic reviews, covering 29 different CAM approaches. The MSKs with the best evidence were low back pain (yoga, acupuncture, spinal manipulation/mobilisation, osteopathy, spa/balneotherapy and tai chi), myofascial trigger point pain (acupuncture), osteoarthritis (acupuncture, tai chi), neck pain (manipulation/manual therapy), depression (meditation, tai chi, relaxation), anxiety (meditation/MBSR, moving meditation, yoga), sleep disorders (meditative/mind-body movement), and stress/distress (mindfulness).  Very few systematic reviews considered comorbid populations, however, acupuncture, yoga, tai chi and mindfulness approaches appeared to have evidence for both MSK and MH conditions.

Professionals’ Views

The second phase of our study was with healthcare professionals (GPs and CAM practitioners) and NHS commissioners. This work has been published in BMC CAM.[6] We used focus groups and interviews to explore their views on and experiences of providing CAM to primary care patients. ‘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 MSK-MH comorbidity (where there were limited conventional treatment options). Professionals identified the following key barriers to integration:

• Philosophical differences between CAM and conventional medicine, and having to ‘secularise’/reduce CAM to adapt to the NHS;
• NHS structural/organisational barriers;
• The challenges of having to practice evidence based medicine;
• Financial barriers, including 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.

Public Views

The third phase of our study was a national survey to obtain the views and experiences of the general population regarding consulting CAM practitioners, particularly via primary care. This has been published in BJGP.[7] We used the well-respected survey company Ipsos MORI, who added our questions to their Capibus survey which interviews a random sample representative of the English population.  The survey found that 16% of the adult population in England had seen a CAM practitioner in the last 12 months, mainly manual therapies and most commonly for musculoskeletal conditions. CAM use was associated with being female, having a higher socioeconomic status and income, being employed and living in southern England.  Strong negative views about CAM therapies or their effectiveness, safety, or lack of availability were uncommon reasons for not using CAM. Although the majority of CAM use was via self-referral, a small proportion of CAM use was from a GP referral / recommendation, mainly acupuncture, physiotherapist-delivered CAM, chiropractic and osteopathy. 

Existing NHS Integrated Services

The final phase was a review of NHS services that provide CAM in an integrated service accessible from primary care, to treat MSK and/or MH patients. This has been published in EuJIM.[8] We visited services and collected data by meeting with staff, reviewing documents and asking services to complete a questionnaire. We identified a number of integrated services, using various models and with varying degrees of perceived success – see the map below and for more detail click here. 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.

Map of the UK showing selected sites providing integrated CAM (accessed via primary care)

What Next?

Our study highlighted the need for further research in the area of CAM for MSK, MH and comorbidity, particularly high quality, large, long-term trials of effectiveness and cost-effectiveness. Many GPs, commissioners, service providers, and particularly CAM practitioners, supported our proposal for a research trial. We have now submitted a funding application for a trial of mindfulness based stress reduction and yoga for comorbid MSK and MH, which includes development and feasibility phases.

What does this Work Mean for Health Policy and Practice?

Our results suggest that integrative medicine has the potential to offer the NHS an effective and cost effective way of managing MSK-MH comorbidity, and appears to have support from the public and some NHS professionals, particularly for areas where conventional medicine offers limited options.[9] IM may offer one way to deliver some of the recent NHS initiatives promoting self-care and holism.[10,11]

Integrating CAM into NHS primary care appears feasible and appropriate, particularly given GPs’ increasing role in addressing patients’ overall mental and physical wellbeing, and the expanding interest in initiatives such as social prescribing.[12]  Questions remain around the way to fund IM, with co-payment and integrated personal commissioning as possible options.

IM requires GPs and CAM practitioners to improve their communication and to understand and respect each other’s philosophical and professional approach. Attention needs to be paid to medical education, which currently rarely includes complementary approaches,[13] and to GPs’ awareness of CAM regulation - something which the Professional Standards Authority is currently attempting to address through their initiative ‘Let’s Work Together’, developed with the RCGP.[14]

References

1.  Arksey, H. & O'Malley, l. 2005. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology, 8, 19-32.

2.  Mays, N., Roberts, E. & Popay, E. 2001. Chapter 12: Synthesising research evidence In: Methods for studying the delivery and organisation of health services. London : Routledge, 188-220.

3.  Hunt KJ, et al. Complementary and alternative medicine use in England: results from a national survey. International journal of clinical practice

4.  Kimberlee, R. (2015). "What is social prescribing?" Advances in Social Sciences Research Journal 2(1): doi:http://dx.doi.org/10.14738/assrj.14721.14808.

5.  Lorenc A, Feder G, MacPherson H, Little P, Mercer SW, Sharp D (2018) A Scoping Review of Systematic Reviews of Complementary Medicine for Musculoskeletal and Mental Health Conditions. BMJ Open 8:e020222. doi: 10.1136/bmjopen-2017-020222

6.  Sharp D, Lorenc A, Feder G, Little P, Hollinghurst S, Mercer S, MacPherson H (2018) 'Trying to put a square peg into a round hole': a qualitative study of healthcare professionals' views of integrating complementary medicine into primary care for musculoskeletal and mental health comorbidity. BMC Complementary and Alternative Medicine 18:290 https://doi.org/10.1186/s12906-018-2349-8

7.  Lorenc A, Sharp D, Morris R, Feder G, LIttle P, Hollinghurst S, Mercer S, MacPherson H (2018) Complementary medicine use, views and experiences - a national survey in England. BJGP Open 13 November 2018; bjgpopen18X101614.

8.  Sharp D, Lorenc A, Little P, Mercer SW, Hollinghurst S, Feder G, MacPherson H (2018) Complementary medicine and the NHS: experiences of integration into UK primary care. European Journal of Integrative Medicine 24:8-16. https://doi.org/10.1016/j.eujim.2018.10.009

9.  Fisher, P., Van Haselen, R., Hardy, K., Berkovitz, S. & McCarney, R. 2004. Effectiveness gaps: a new concept for evaluating health service and research needs applied to complementary and alternative medicine. J Altern Complement Med, 10, 627-32.

10.  NHS ENGLAND. 2016. Delivering the Forward View: NHS planning guidance 2016/17 – 2020/21 [Online]. Available: https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf  [accessed 25/10/18]

11.  NHS ENGLAND. 2016. General Practice Forward View [Online]. Available: https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf  [Accessed 25/10/18]

12.  Matthews-King, A. (2017). Providers invited to bid for £4m worth of funding for social prescribing schemes. Pulse. http://www.pulsetoday.co.uk/clinical/clinical-specialties/prescribing/providers-invited-to-bid-for-4m-worth-of-funding-for-social-prescribing-schemes/20035430.article

13.  Niemtzow, R. C., Burns, S. M., Piazza, T. R., Pock, A. R., Walter, J., Petri, R., Hofmann, L., Wilson, C., Drake, D., Calabria, K., Biery, J., Baxter, J. S., Gallagher, R. M. & Jonas, W. B. 2016. Integrative Medicine in the Department of Defense and the Department of Veterans Affairs: Cautious Steps Forward. The Journal of Alternative and Complementary Medicine, 22, 171-173

14.  Professional Standards Authority. 2016. Let's Work Together [Online]. Available: https://www.professionalstandards.org.uk/what-we-do/accredited-registers/lets-work-together   [Accessed 25/10/18]