Complementary and Alternative Medicine (CAM) raises a number of hugely important issues in terms of the NHS. If we are moving toward a more choice-based healthcare system, should funding of it be extended if patients choose it? Why do people often seem to prefer CAM to modern medicine? Should a publicly-funded healthcare system pay for treatments that don’t appear to be backed by high quality research when tested?
Let’s deal with these questions in turn.
The logic of NHS reform, in its present direction, has the stated goal of making healthcare systems more responsive to patient choices, arguing that, for too long, producer interests have dominated the NHS. What patients choose, in collaboration with their GPs, will be funded. The logic of this – let’s call it the consumerist logic, is that if patients want CAM, they should be allowed to choose it, and the NHS should pay for it because the individual patient choice is sovereign.
This sort of thing tends to get health economists who haven’t really got their mental ducks in a row rather vexed. On the one hand, all their instincts tell them that there ought to be free markets and extended choice, but on the other hand, funding treatments such as Reiki, which have next to no evidence base (in terms of published, peer-reviewed studies), makes them very cross. It’s almost as if people were deliberately making poor choices – something that economists get really confused about as we’re all supposed to be informed consumers for their models to work.
Let’s go to the second question – why do some people prefer CAM to modern medicine? I can think of four answers (I’m sure there are more). First, some people will have a predilection for treatments that are based on spiritual or alternative understandings of the world. They may regard CAM as being part of a lifestyle choice that is suspicious of modern medicine, and expect, especially if they are being told to behave like healthcare consumers, that their preferences should be paid for. So ironically, people who are often fervently anti-consumerist demand consumer rights to be anti-modern medicine.
Second, many people who use CAM report a specific condition that it has helped with where modern medicine fell short. I know of sensible people who (or perhaps more powerfully, whose children) have had a chronic condition such as eczema or asthma helped through CAM. According to the standard evidence base this shouldn’t have happened of course, but it does. Now I can’t explain this. It could be that the problem would have sorted itself out (my first daughter’s eczema seemed to disappear largely by itself after it has driven us nuts for nearly a year) or it could be that some other factor got rid of the problem (diet?), or it could be a placebo effect, or it could be the at the CAM worked.
The point here is that all the medical evidence in the world is unlikely to dissuade us from believing that CAM works where it seems to have worked for us, or for someone that we love. In those circumstances, all the criticism it receives may make us even firmer in our belief of its efficacy because we believe we know better. Personal knowledge will tend to trump scientific knowledge where experience appears to have shown us otherwise.
The fourth reason we might prefer CAM is that we are likely to have been given more time and attention that we often receive from our GP. Now that isn’t always the case (at least in terms of attention), but it does have a ring of truth. CAM therapists often do their best to have calming atmospherics and can often give more time to their patient than modern medicine practitioners, who are often pretty pushed. Given this, it’s no wonder that being with a CAM practitioner can make people feel listened to and valued – and that they, in turn, value CAM treatment as a result, regardless of whether what ails them disappears.
Then we come to the final question – should a publicly-funded healthcare system pay for treatment that, when subject to standard clinical tests of efficacy, fall down? Actually, I see no reason why not. The key thing here is that publicly-funded healthcare systems need to be democratically-accountable to taxpayers. If taxpayers want to pay for CAM, we should probably pay for CAM. I don’t really like this conclusion very much (I’m a signatory on any petition to get homeopathy removed from the NHS!), but the thing is this is about democracy, not about efficacy. It only becomes about efficacy if we agree, as a society, that is what we want from our healthcare, and that we won’t fund treatments that aren’t effective. As the public are often prepared to use their own money to pay for CAM, it seems to me there are probably a lot of people out there who would be prepared to sanction taxation-funded CAM.
What does all this add up to? A bit of an mess.
The consumerist logic suggests we should pay for CAM – it’s about patient choice. If the public (collectively) want taxation to pay for CAM, then the democratic argument also points that way. There seem to be lots of reasons why people prefer CAM, and so it shouldn’t be surprising that there is demand for it, especially when it is ‘on the NHS’. But this is the same kind of logic that assumes that people can make good use of choice in healthcare, and I can’t see how this is the case.
This points to an even bigger problem. When it comes to healthcare, most of us know very little. We simply aren’t in a position to judge whether treatments are effective or not. Without a great deal of time and effort, and without a long-term condition where patients may become extremely knowledgeable about their illness, we aren’t good judges of what is wrong with us, and what treatment we should choose to try and get better. Even if we do have a long-term condition, our judgement may be skewed by what we believe happened with particularly treatments rather than any kind of objective, assessable understanding.
As such, we need to assess the claims made by CAM specialists – and writers like Simon Singh have done us all huge favours on that front. But we also need to acknowledge that there are some areas where democracy alone struggles to help us in decision-making. Areas like medicine are complex and demand careful and difficult decisions to be made. Most of us probably wouldn’t make good choices about treatment if left to our own devices, and frankly we need saving from ourselves.
That, however, doesn’t excuse doctors who provide awful service, and who through their lack of caring drive people into the hands of unproven CAM. They need to do better, and to understand that their lack of caring can have terrible consequences – we have to learn from the positive lesson of CAM, that people will often want the most bizarre treatments if delivered in a kindly way.
But what we are left with in the NHS at present is a half-hearted attempt at health consumerism which can’t work because it assumes we are all super-empowered and knowledgeable about both our own health and the healthcare systems we have to navigate, but also a frivolous attitude toward clinical evidence, as we continue to fund homeopathy hospitals. Sometimes compromises can be sweet spots where the best possible outcomes are reached. Here patient choice policies are based on unrealistic assumptions that can’t possibly drive treatment improvements, and the funding of treatments that challenge the NHS more in terms of their service than their actual efficacy. We have to do better than this.