This article originally appeared in The Skeptic, Volume 19, Issue 3, from 2008.
The whole question of making complementary and alternative medicine (CAM) available on the NHS seems to be heating up. As someone whose health may at some stage depend on the quality of the NHS, I want that organisation to deliver the best health care possible. As a sceptic, I want it to concentrate on the things that work best. As a taxpayer, I want it to avoid wasting money.
Even with the most soundly evidence-backed treatments those three desires are sometimes going to come into conflict with each other. NHS doctors and trusts have to make tough decisions all the time. Should an 80- year-old alcoholic who smokes and is 50 pounds overweight get a liver transplant? Should a child with leukaemia and a terrible prognosis be given an extremely expensive brand-new experimental treatment because the family wants it and believes it could be successful? How much of a GP’s time should someone who seems to be a hypochondriac be allowed to consume?
These are the kinds of trade-offs that you might pick an economist like Christopher Smallwood to consider, probably along with medical experts. But that wasn’t the question Prince Charles set Smallwood. Instead, he asked him (and a team at FreshMinds, for whom I am, coincidentally, working on something else) to look into the benefits of deploying CAM within the NHS, considering both cost and medical benefits. Studies show that research tends to produce the results that the person paying for it wants, and so it proved in this case: Smallwood’s eventual report concluded that certain types of CAM could indeed both save the NHS money and help patients. It recommends further study (a slight Yes, Minister moment there: you can always safely recommend further study).
The report doesn’t, of course, suggest that all CAM was created equal, nor that the NHS should get rid of its orthodox medical treatments. What it does say is that the literature shows that acupuncture, herbalism, chiropractic, and homeopathy might be able to help plug “effectiveness gaps” in the NHS such as managing pain and nausea from chemotherapy and surgery, arthritis, asthma, lower back pain, and so on. And it makes some specific cost comparisons. For example, the average weekly cost of anti-depressants is £13.82 per prescription for a total cost to the NHS in 2004 of £400 million. By contrast, a weekly course of St. John’s Wort costs 82p. The report adds that non-steroidal anti-inflammatory drugs cost the NHS £247 million in 2004 (average £11.82 per prescription), while phytodolor costs 45p per week.
Whatever anyone thinks about it, CAM is growing. The report quotes surveys that suggest that the proportion of general practices in England offering some access to CAM has grown from around 40 percent ten years ago to around 50 percent by 2001 and is still growing.
Exactly which therapies are offered varies, of course: about 33 percent offered acupuncture (either directly or through referral), 21 percent homeopathy, 23 percent manipulation therapies. There is considerable geographic disparity in availability.
Given how much discussion CAM gets, it surprised me to read how small its research funds are. It commands 0.08 percent of the NHS research budget. In 2003, it got only 0.3 percent of the research budget from medical charities (a figure the report sources to Professor Edzard Ernst, at Exeter). The government itself provides no “ringfenced” funding for CAM research.
When I began reading the report, I thought it seemed entirely reasonable. It’s not arguable that there are large areas of misery in human physical life that the NHS doesn’t address well: anyone who has (or has relatives who have) a host of things, mostly not life-threatening –allergies or eczema, arthritis, Alzheimer’s, back pain, depression – has come up against those limits. People turn to CAM out of frustration and desperation, and sometimes it’s harmless and sometimes it helps, if only because the practitioner gives attention. It’s not as if the report, or the Prince, were proposing that homeopathy was a better treatment for cancer.
But on closer examination… you’d think that an economist might know to point out that one reason for these cost discrepancies is the cost structure and business model that prevail in the pharmaceutical industry. Many modern anti-depressants are still under patent, driving their prices up; herbal remedies are more like generic drugs, where multiple manufacturers in competition drive the prices down. It’s absurd to think that the pharmaceutical companies would fail to react to any threat that the NHS would begin to prescribe herbal competitors in such a way as to reduce the nation’s drug bill substantially: we spend £8 billion a year on prescription drugs.
The other reason, of course, is that CAM isn’t being held to the same “gold standard” (the report’s term) of research as orthodox medicine. Double-blind safety and efficacy testing aren’t a plot by those companies to block CAM. If there were anyone who wished the testing were less onerous and less expensive, it’s Big Pharma. There is no law of nature that says that CAM remedies have to be cheaper. The job an economist could usefully have done is telling us how much CAM would cost after it had been put through the mainstream mill.
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From the archives, Wendy Grossman assesses the 2005 Smallwood report, commissioned by then-prince Charles, on the role of CAM within the NHS.
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