If some complementary and alternative treatments have the potential to relieve symptoms and improve health, consideration should be given to integrating such treatments into the publicly-funded health system. Arguments in favour of integration include the low cost and high degree of consumer satisfaction associated with some CAM treatments. ["Potential to relieve symptoms and improve health" is a vague description and is not sufficient reason to offer a treatment in a publicly-funded facility. The correct standard of care is "proven safe and effective for its intended purpose." The recommendation also sidesteps the fact that (a) the majority of "CAM" treatments don't work; (b) methods that are effective tend to adopted; and (c) an appropriate suggestion should address what to do with methods that don't work.]
There are several issues to be considered when designing integrated health services. The House of Lords Select Committee on Science and Technology has identified a six-stage process for integrating CAM into mainstream general practice, and this process could be adapted and applied to integration in different health care settings (see Table 3).
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[This falsely assume that there are many methods that deserve integration.]
Integration of CAM and biomedicine occurs at different levels, from collaboration in the treatment of a particular patient (eg, referral from a GP) to full organisational integration (eg, the homoeopathic hospitals in the UK, see below). Integration can also take place in practitioner education, where the training courses available to CAM and biomedical practitioners might share some common elements, or at least seek to promote mutual understanding.
CAM is not currently formally integrated into the publicly-funded health system in New Zealand. There are, however, some CAM health services that receive public funding, including the following:
CAM services are also incorporated into some hospitals and health services, such as the following:
The Medical Council of New Zealand has published guidelines for doctors who wish to incorporate elements of complementary or alternative medicine into their mainstream practice (Medical Council of New Zealand 1999). These recommend that doctors focus on treatments that have been proven to be effective, whether these treatments be biomedical or CAM-based. [Do they also recommend that doctors advise patients when methods are not effective? Do the guidelines say which work and which don't?]
An Australasian Integrative Medicine Association has been established to promote the integration of CAM into mainstream medical practice in Australia and New Zealand. [The Web site is primarily a mechanism to make referrals. It contains almost no information about the methods.]
CAM is not formally integrated into the UK health system. However, there is limited provision through the National Health Service (NHS).
Currently most NHS CAM is delivered through primary care, with some cases of CAM being delivered through secondary care. An independent study commissioned by the UK Department of Health reported that 40% of GP partnerships in England provide some level of access to CAM for NHS patients (House of Lords Select Committee 2000).
Whether primary care patients have NHS-funded access to CAM is dependent on their particular Primary Care Group (PCG) or Primary Care Trust (PCT). In June 2000 the Department of Health published a Complementary Medicine Information Pack for Primary Care Groups. This is intended to help PCGs and PCTs make informed decisions on the provision of CAM. It contains information on the CAM treatments most commonly encountered in primary care and offers guidance on commissioning services. A companion publication specifically for primary care clinicians has also been produced (Department of Health [London] 2000a; 2001b).
The Foundation for Integrated Medicine has identified 80 examples of successful integration within both primary and hospital services, demonstrating that provision is increasingly becoming available through the NHS. However, access to these services remains patchy (House of Lords Select Committee 2000).
The following are two examples of integration of CAM into primary care in the UK (House of Lords Select Committee 2000).
Areas where CAM is integrated into secondary care are as follows (House of Lords Select Committee 2000):
The Foundation for Integrated Medicine has published a discussion document, Integrated Healthcare: A way forward for the next five years? (Foundation for Integrated Medicine 1997). It has also published a book on good practice in setting up and running integrated health services, which presents UK case studies from both primary and secondary care (Russo 2000). [Footnote: The Foundation was set up to promote the development and integrated delivery of safe, effective and efficient forms of health care to patients and their families, through encouraging greater collaboration between all forms of health care. The Foundation undertakes work in the areas of delivery, education, information, regulation and research and development.] [Why is there no mention of opposing the use of unsafe and ineffective methods?]
Complementary medicine is not formally integrated into the US health care system. However, the concept of integrated medicine is probably more familiar to biomedical practitioners in the US, where it is known as integrative medicine, than it is in the UK. This is partly because many US medical schools already offer elective classes and seminars on complementary medicine (Bhattacharya 2000). Other medical courses are being restructured to increase their coverage of complementary medicine. A Consortium of Academic Health Centers for Integrative Medicine has been established to expand this process. The Consortium aims to have programmes on integrative medicine included in 20% of the 125 medical schools in the US within the next few years (Rees and Weil 2001). [The majority of courses do not provide accurate information.]
A wide variety of biomedical practitioners and institutions in both the primary and secondary care sectors offer integrative medicine. One example is the Memorial Sloan- Kettering Cancer Center, a private institution based in New York. The Center uses those CAM modalities that have the strongest evidence base to complement, rather than replace, mainstream treatments. [The number of useful modalities is small. The best activity of the Center is its 300-item database on herbal and dietary supplement products, most of which, it notes, are unsubstantiated.]
The White House Commission on Complementary and Alternative Medicine Policy (WHCCAMP) recommends that an agency be established within the Department of Health and Human Services to facilitate the integration of those CAM products and practices that have been shown to be safe and effective. It also calls for greater emphasis on the use of CAM in the management of chronic disease, and for insurers, managed care organisations and health purchasers to expand their coverage of CAM (WHCCAMP 2002). [These recommendations which are preposterous, are based on the incorrect assumption that a substantial number of "CAM" methods warrant integration. The Department of Health and Human Services has not adopted any of the WHCCAMP's recommendations. In fact, top HHS officials though the report was so poorly reasoned that the agency did not publicize it in its usual ways.]
CAM is not formally integrated into the Canadian health care system. There are, however, some institutions that offer integrated health care. They include the following:
CAM is not formally integrated into the Australian health care system. However, many regulated biomedical practitioners offer CAM therapies alongside their mainstream practice.
Within primary care, a survey of GPs in Victoria found that over 80 percent of respondents had referred patients to CAM practitioners and 20 percent of respondents practise a complementary therapy themselves (Pirotta et al 2000). Acupuncture is the CAM most commonly adopted by GPs for inclusion within mainstream general practice (Australian Medical Association 2001). Around 15 percent of Australian GPs practise acupuncture. The Royal Australian College of General Practitioners now has special interest groups for members who practise acupuncture or nutritional medicine.
Interest in CAM has also grown within secondary care, particularly in obstetrics, gynaecology and rheumatology (Australian Medical Association 2002). Concerns have been raised about the lack of formal policies on patients who wish to continue using CAMs during their stay in hospital.
The Australian Medical Association has recently published a position statement on complementary medicine (2002). It acknowledges the growing popularity of CAM and recognises that 'evidence based aspects of complementary medicine are part of the repertoire of patient care and may have a role in mainstream medical practice'. [The Association recommended that "CAM" methods be properly studied and that appropriate information about them be given to providers as well as consumers. However, it said nothing about (a) the fact that many "CAM" methods are known not to work; (b) how to ensure that proper studies are carried out, and (c) how to ensure that appropriate information is disseminated.] An Australasian Integrative Medicine Association has been set up to promote the integration of CAM into mainstream medical practice in Australia and New Zealand.
There are currently no plans to integrate CAM into the mainstream health care system in Singapore.
Traditional Chinese Medicine (TCM) and biomedicine are fully integrated. The position of TCM is protected within China's constitution. The integration of TCM into the national health care system began in the late 1950s. This was overseen by health officials trained in biomedicine and the aim was to harmonise TCM with modern Western medicine. There has therefore been an emphasis on research and science-based education for TCM practitioners. It has been argued that biomedical control over the process of integration has led to important traditional aspects of TCM being lost or undervalued (Bodecker 2001), and some traditional practitioners feel that the form of TCM practised in places such as Taiwan and Hong Kong is more authentic than that found in mainland China. [Does this mean that scientific practitioners were able to cast out ineffective TCM practices?] The TCM sector is now managed by the State Administration of Traditional Chinese Medicine, which oversees all aspects of the TCM component of China's integrated health system. Today about 95 percent of general hospitals in China have traditional medicine departments. Each year they treat 200 million outpatients and almost three million inpatients (Bodecker 2001). Primary care is also integrated. Integration is more evident in primary and outpatient services than in inpatient care. [The key question is not popularity but whether or not this "integration" improves health outcomes.]