In identifying the characteristics of a 'NHS friendly' complementary therapy service, the service design features identified have been grouped into three areas, as detailed in the following diagram. Each will be discussed in turn in the results section (see Figure 1).
Specific therapies for specific conditions
During interviews, PCT managers and NHS clinicians appeared to be more favourably disposed towards a service model whereby specific treatments were provided for specific conditions (e.g. acupuncture for pain or chiropracty for low back pain). This 'specific condition' service model existed at the second case site, which was funded by the NHS, as three therapies (aromatherapy, reflexology and homeopathy) were provided for two types of female hormonal conditions. Once the NHS took over funding the complementary therapy service at the first case site, this type of model also was put in place with three therapies offered for musculo-skeletal conditions only. Thus, a service model in which any complaint would be treated (such as the service at case site one when it was funded by New Deal for Communities) appeared less popular. As a senior PCT manager said,
I think any introduction of complementary therapies has to be incredibly disciplined. And so we need very clear protocols that say this is the sort of case, this is the sort of need that we're going to meet through this service. Not a' come all ye'. (PCT manager BC site 1)
Another PCT manager gave an example of how a targeted complementary therapy service could work in practice.
Acupuncture, we know that in other agencies it's used in helping people over drug misuse and alcohol misuse. It's known to be, or it's been shown to be, quite effective. So if it was being targeted at those people, then we'd say well that is something we would want to support.... But we're not likely to develop an enhanced service for complementary therapy. It would be an enhanced service for a specific condition which may include complementary therapy as part of the service. (PCT manager CC site 1)
However, selection of the 'right' therapies and specific conditions is crucial. Our data suggest that one criterion for the selection of therapies and conditions in a 'NHS friendly' complementary therapy service is that NHS professionals believe little or nothing else is available.
I mean as a medic, it's sometimes quite hard to understand it [homeopathy] ....But I'm prepared to go with it and just, because I know I can't do much more from the normal medicine point of view. (Doctor Y site 2)
This has been coined as an 'effectiveness gap' [39, 40]. But such a gap is not sufficient in and of itself. According to the study participants interviewed, the 'gap' condition chosen should impact on a substantial numbers of patients. For example, a PCT manager partly attributed the success of the mainstreaming of counselling to the perception that counselling is appropriate for large patient volumes.
PCT managers and NHS clinicians in this study stated that another criterion for therapy and condition selection is 'good' evidence of clinical effectiveness. But interestingly, this appeared to be based more on perceptions of research evidence than actual knowledge. For example, only three of the nineteen NHS professionals interviewed had directly accessed the research literature on complementary therapies. Their opinions on which complementary therapies had good evidence appeared to be based on collective, unchallenged perceptions, rather than grounded in fact based knowledge.
For example, data from steering meeting minutes and interviews at case site one indicated that therapies should be chosen on the basis of robust evidence. Herbal medicine was rejected, because clinicians believed that there was not any research evidence, while other therapies such as reflexology and aromatherapy were adopted. Yet, the evidence base for herbal medicine has been identified as the strongest amongst complementary therapies [41], while the research evidence for reflexology and aromatherapy is less robust. Moreover, a doctor at the first site, who claimed during interview that her decisions were based on evidence and she believed that there was insufficient evidence for complementary therapies, was the third highest referrer of the 24 doctors to the complementary therapy service, according to the referral database.
We also found discrepancies in PCT managers' reported positions that research evidence was paramount in the decision process. For example, although PCT managers claimed that research evidence was an essential precursor to NHS funding of the complementary therapy service, the successful PCT funding bid for the revamped service in 2006 included no reference to evidence of therapeutic or cost effectiveness. An e-mail from the relevant commissioning manager confirmed that such evidence was not needed. Similarly, the funding bid for the service at the second case site in 1998 cited an audit study on homeopathy for one type of female hormonal condition [42] and a more general systematic review on homeopathy [43]. No specific randomised controlled trials on homeopathy for menopause or pre-mentrual syndrome or any research on aromatherapy or reflexology were referenced as research evidence in this bid. Thus, factors other than research literature appeared to be influencing both perceptions of 'good' evidence and referral and funding decisions for clinicians and PCT managers.
NHS management priorities
In addition to developing a 'specific condition' model, a 'NHS friendly' complementary therapy service design should address NHS management priorities. One current NHS management priority is targeting high health need populations. A doctor at the second case site acknowledged during interview that the service had targeted a low NHS priority group (women with pre-menstrual syndrome and menopause symptoms).
Everyone in the NHS, they're looking much more at teenage pregnancies and all those figures that are figures, whereas the menopausal lady doesn't come high in the profile in the NHS.... She's not a target, she's not a number, she's not anything. She's very important to the family and everything else at home, but not in the NHS, so in the scheme of things we're very much out on a limb really. We're low priority is the [women's health] clinic, and so homeopathy is probably even lower in that it's just an extra to our clinic. (Doctor Y site 2)
This may have contributed to the decommissioning of the complementary therapy service at the second site, although we cannot be sure as these events took place after fieldwork terminated.
Another crucial NHS management priority identified in interviews is reducing costs.
Well, the PCT is in a very difficult financial position at the moment. We have what's called a local delivery planning group, which is the sort of first sound bite where bids for funding would go. And the criteria we use will be – how much money is this going to save? Basically, it has to pay for itself in terms of hospital admissions or even make savings over and above the cost of running the service. (PCT manager CC site 1)
So ideally, a 'NHS friendly' complementary therapy service should either pay for itself (cost neutral) or demonstrate that less money can be spent elsewhere in the NHS (ideally on hospital admissions), as a result of the complementary therapy service (cost saving). By demonstrating a cost saving such as reduced medication, GP consultation or hospital usage, complementary therapy services can help shift the allocation of financial resources into community services.
We can only invest if we find things we can disinvest in. Now that mainly is disinvesting in hospital interventions, whether it be outpatient clinics or diagnostics...And if we can reduce those because we're doing an earlier intervention in primary care, then we can for the first time probably take money out of the acute hospital system and bring it into the community. (PCT manager CB site 1)
But, according to PCT managers, to save costs, NHS complementary therapy services should only target patients who are already receiving NHS treatments rather than those currently outside the system.
If we had the respiratory nurse we'll probably find more people with wheezes and so being seen that wouldn't otherwise have been done because they wouldn't have been serious enough to get a hospital appointment.... Now that's an issue for us about whether we're expanding the boundaries of NHS capability and NHS priorities because we're making it more available. That's already an issue for us and I think there is a concern that complementary therapies would take that even further. (PCT manager BC site 1)
So, for example, a patient with low back pain having physiotherapy is a legitimate focus for a NHS complementary therapy service, as hospital costs for the out-patient physiotherapy service are incurred and a NHS complementary therapy service may be able to treat the same complaint as effectively and more cheaply. But an individual with the same condition who is 'self-managing' is not a candidate for a 'NHS friendly' complementary therapy service, as he or she does not currently make demands on hospital services or GP practices and thus incurs no costs. Ideally, complementary therapy services should treat the former (i.e. those requesting hospital and GP practice services), but avoid the latter (i.e. those who are self-managing).
Known as 'picking up unmet need', the widening of the NHS net is a major concern to PCT managers given its financial and resource constraints. Thus, PCT managers need reassurance that a 'NHS friendly' complementary therapy service will either be cost neutral or cost saving and reduce demand on existing services, rather than create a new pool of patients that incur additional costs. PCT managers received this reassurance with the service at case site two, as patients were either under the care of the specialist women doctors or received complementary therapy treatments. However, patients at the first site could access both conventional and complementary therapy services in tandem.
An additional NHS management concern is that demand for complementary therapy services will outstrip supply. Consequently, a 'NHS friendly' complementary therapy service will have mechanisms to regulate demand. These mechanisms were incorporated at the services in both case sites. Funding bids showed that patients could have up to eight treatments at the complementary therapy service at the first case site and patients could have up to six at the service at the second case site. Consultation length was also limited. Therapists at the service at the first case site offered appointments of 30–60 minutes for all consultations, while the homeopaths at the service at the second case site spent an hour with new clients and 15–20 minutes in follow ups. At the service at the second case site, an additional control mechanism was the utilisation of doctors as gatekeepers to the complementary therapy service.
I think it works, I think it's essential. It's a screening process in that it does control who gets to the homeopathist [sic] and there's some feedback, so we've got a history and some idea of what's going on. (Doctor Y site 2)
Other service features
As well being a 'specific condition' service model and meeting NHS management priorities, a 'NHS friendly' complementary therapy service will have other notable characteristics.
For example at the services at both sites, evaluations had been conducted. Other research we have conducted found that the impact of complementary therapy service evaluations on funding decisions was limited [44]. Nonetheless, during interviews, study participants stated that they believed regular service evaluation was important.
I think [this] work has been appreciated only because we do the evaluation and [the therapist] continues to do the evaluation. And I think that's very, very powerful. (Doctor NP site 2)
In addition, doctors and nurses, in particular, stressed that a 'NHS friendly' complementary therapy service should be affordable. At the service at the first site, clinicians were "put off" referring (Doctor PS site 1) when patient contributions increased from £3 and £5 (unwaged and waged respectively) to £5 and £10–£15, as New Deals for Communities funding drew to a close.
Clinicians also stated in interviews that they were unlikely to refer if they did not know they could. With constant NHS staff turnover and a service based across two surgeries, ensuring a high profile for the service at the first site was challenging. Moreover, some potential referrers to the service at the first site indicated they needed personal contact as well as promotional literature to feel confident about referring patients.
Now it may be because of my part time role at [surgery], but I haven't met any of the [service] therapists and I like to meet people and then I think I'd feel much more comfortable about saying, "You know what I think? You should go and see [X] about this. Why don't we arrange a referral and this is how we can do it." (Doctor PS site 1)
This was more manageable at the second site partly because only six individuals were involved (three referring women's health specialist doctors and three therapists) unlike the service at the first site where there were 15 therapists and over 100 potential referrers. As one doctor from site one explained during interview,
You know we refer but part of the problem is that there are tons and tons of therapists many of which do few hours. It's hard for us to get to know any of them particularly well and build up a professional relationship. (Doctor DF site 1)
Meeting therapists might also go some way to address NHS professionals' concerns about safety. During interviews, concerns about safety were usually expressed in terms of 'safe therapists' rather than 'safe therapies'.
I would just like to know that hopefully they are not abusive relationships. And you can have an abusive relationship with a mainstream clinician, so I don't excuse general practitioners from that either. But I would hope that on the whole a lot of these people are very vulnerable and it worries me if they are going to see somebody who has had no training and no registration. (Doctor PS site 2)
To address the safety issue, data from minutes of meetings at site one and interview data from both sites indicated that only trained therapists registered with a recognised professional body would be employed at the services.
Concerns about safe therapists may also have been addressed at the second site by employing a doctor as a therapist. As one doctor at the second site stated during interview,
I'm a little bit more comfortable with [the medical homeopath] having a medical background as well as a homeopathy background. (Doctor Y site 1)
The induction process at the second site also helped to reduce fears around safety and cultivate inter-professional relationships, as all new doctors and nurses to the women's health service observed homeopathy consultations.
Whenever I first came along to do this [women's health] work, I actually spent time with [homeopath] and sat in with her, seeing her patients and I think it is really valuable that because it gives you an understanding of actually how the homeopath works, you know, how they really go through their decision making process. (Doctor WL Site 2)
Doctors and nurses at the service at the first site, where inter-professional relationships were less well developed, did not observe complementary therapy consultations. Nor, after nearly four years of complementary therapy service provision, did these NHS clinicians have much more understanding of complementary therapies.
I don't think I actually know any more about complementary therapies really. (Doctor BM Site 1)
So to sum up, a 'NHS friendly' complementary therapy should incorporate regular evaluation and be affordable and well-advertised. PCT managers and NHS clinicians need to know that the therapists working in a NHS complementary therapy service are 'safe'. This type of reassurance may come about through employing trained and insured therapists, as well as employing doctors as therapists, and through personal contact between therapists and potential referrers. Inter-professional relationships are more likely to flourish if the numbers of therapists offering treatments and the numbers of referrers are small and if there are opportunities for informal contact and formal interactions (e.g. observation of consultations).