BMJ  2007;334:506 (10 March), doi:10.1136/bmj.39122.512211.BE

Feature

Head to head

Should NICE evaluate complementary and alternative medicine?

¹ University College London Institute of Child Health, London WC1N 1EH, ² King's Fund, London W1G 0AN, ³ NHS Alliance, Retford, Nottingham DN22 6JD

Demand for complementary and alternative medicine is high despite limited evidence. Linda Franck and colleagues believe that a thorough review by NICE would benefit the NHS and patients, but David Colquhoun argues that it cannot afford to re-examine evidence that has shown little benefit

The National Institute for Health and Clinical Excellence (NICE) guidance is built on the rigorous appraisal of scientific evidence and the evaluation of the cost effectiveness of diagnostics and treatments.¹² The Secretary of State for Health refers topics for development of guidance based on national priorities.³ NICE has received international recognition for its topic selection and appraisal processes and "commitment to using the best available evidence for decision making."⁴

Complementary and alternative medicine covers a heterogeneous group of therapies that share a focus on, or integration of, treatment of mind and spirit as well as body.⁵ The main goals of these treatments are often framed in terms of feeling better (that is, relief of symptoms) or prevention (promotion of general health and wellbeing) rather than cure.⁶⁷ They may therefore be particularly relevant for patients with long term disease, who account for 80% of general practice consultations and who, by definition, are unlikely to be cured. Furthermore, most people seek complementary therapies as an adjunct rather than substitute for conventional medicine.⁸

Complementary therapies are widely used by the public. Around half of general practitioners provide access to complementary medicine,⁹ and two thirds of Scottish general practitioners prescribe herbal or homoeopathic medicines.¹⁰ However, NICE has not been asked to develop guidance on these therapies.³ Given the high public interest in complementary medicine, we find this surprising.

Explanations

There are several possible explanations for the lack of investigation. The first is that complementary therapies are not relevant to NHS priorities of reducing health inequalities, promoting health and wellbeing, patient choice, and patient involvement. Yet as current usage statistics indicate, patients are choosing complementary therapies to promote health and wellbeing and there are inequalities in terms of access.

A second reason is that there are not always adequate methods for evaluating these therapies with the same rigour as applied to conventional medicine. Some therapies, such as herbal, nutritional, or homoeopathic remedies can be evaluated in standard double blind randomised placebo controlled trials.¹¹ For other therapies that are heavily dependent on the individual therapist, double blinding may be impossible. However, these research design problems are no different from those for conventional therapies such as surgery. Research methods used for comparative trials of behavioural interventions offer a way forward.¹²¹³¹⁴ In order for alternative therapies to be compared with conventional treatments, more work is needed to define the most important outcomes and to measure them appropriately.¹⁵

A third reason NICE may not have been commissioned to evaluate complementary therapies is that there is insufficient evidence with which to develop guidelines. However, there are numerous Cochrane reviews of complementary therapies.¹⁶ NICE has made some recommendations about benefits (or risks) of some complementary therapies within condition specific guidelines—for example, pregnancy, multiple sclerosis, Parkinson's disease, hypertension, and depression.¹⁷ The guidance and supporting documentation available on its website suggests that these "recommendations" of a few complementary therapies have not been subjected to the same rigour as those of traditional medical interventions. Furthermore, NICE has not addressed the important questions of comparative efficacy or additive value in relation to current treatments being offered in the NHS. Where there is insufficient evidence, NICE could draw attention to this in order to stimulate more research.

This leaves two final reasons for the absence of NICE guidance. There may be an attitudinal bias against complementary therapies or a lack of resources. Some people within conventional medicine remain deeply convinced that alternative medicine cannot have any possible benefit,⁵ but this is all the more reason that these therapies should be rigorously evaluated. The lack of resources for evaluation is equally difficult to defend, but perhaps understandable when there is great pressure to evaluate high cost drugs and technologies.

Benefits of review

However, failure to evaluate complementary therapies leads to health inequalities because of uneven access and missed opportunities. For example, as complementary therapies are often relatively cheap, if shown to be effective they could save money currently spent on costly drugs.

In summary, NICE already has a systematic review process that takes into account all available evidence, including observational studies.¹⁸ Recent publicity on the use of complementary medicine in the NHS suggests that it should receive greater priority in topic selection. Applying the same standards as we apply to conventional medicine, we simply need to ask is it safe, is it effective in relieving symptoms compared with no treatment, how effective is it (the number needed to treat), how much does it cost, and is it affordable (quality adjusted life years)? Complementary and alternative therapies deserve a full evaluation from NICE and, if the evaluation is favourable, they should be adopted either on their own or integrated with conventional medicine.

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Competing interests: None declared.

References

1. Pearson SD, Rawlins MD. Quality, innovation, and value for money: NICE and the British National Health Service. JAMA 2005;294:2618-22.[Abstract/Free Full Text]
2. Rawlins MD. 5 NICE years. Lancet 2005;365:904-8.[CrossRef][ISI][Medline]
3. NICE. NICE guidance and complementary therapies: briefing note. London: NICE, 2007.
4. Devlin N, Parkin D, Gold M. WHO evaluates NICE. BMJ 2003;327:1061-2.[Free Full Text]
5. Baum M, Ernst E, Lejeune S, Horneber M. Role of complementary and alternative medicine in the care of patients with breast cancer: Report of the European Society of Mastology (EUSOMA) workshop, Florence, Italy, December 2004. Eur J Cancer 2006;42:1702-10.[CrossRef][ISI][Medline]
6. Astin JA. Why patients use alternative medicine: results of a national study. JAMA 1998;279:1548-53.[Abstract/Free Full Text]
7. Cincotta DR, Crawford NW, Lim A, Cranswick NE, Skull S, South M, et al. Comparison of complementary and alternative medicine use: reasons and motivations between two tertiary children's hospitals. Arch Dis Child 2006;91:153-8.[Abstract/Free Full Text]
8. Zollman C, Vickers A. Users and practitioners of complementary medicine. BMJ 1999;319:836-8.[Free Full Text]
9. Thomas KJ, Coleman P, Nicholl JP. Trends in access to complementary or alternative medicines via primary care in England: 1995-2001 results from a follow-up national survey. Fam Pract 2003;20:575-7.[Abstract/Free Full Text]
10. Ross S, Simpson CR, McLay JS. Homoeopathic and herbal prescribing in general practice in Scotland. Br J Clin Pharmacol 2006;62:647-52.[CrossRef][ISI][Medline]
11. Manheimer E, Berman B, Dubnick H, Beckner W. Cochrane reviews of complementary and alternative therapies: evaluating the strength of the evidence. Cochrane Database Syst Rev 2004 (www.cochrane.org/colloquia/abstracts/ottawa/P-094.htm
12. Medical Research Council. A framework for development and evaluation of RCTs for complex interventions to improve health. London: MRC, 2000.
13. Marteau T, Dieppe P, Foy R, Kinmonth AL, Schneiderman N. Behavioural medicine: changing our behaviour. BMJ 2006;332:437-8.[Free Full Text]
14. Devereaux PJ, Bhandari M, Clarke M, Montori VM, Cook DJ, Yusuf S, et al. Need for expertise based randomised controlled trials. BMJ 2005;330:88.[Free Full Text]
15. Garratt A, Schmidt L, Mackintosh A, Fitzpatrick R. Quality of life measurement: bibliographic study of patient assessed health outcome measures. BMJ 2002;324:1417.[Abstract/Free Full Text]
16. Thompson T, Feder G. Complementary therapies and the NHS. BMJ 2005;331:857-8.[Free Full Text]
17. NICE. Published clinical guidelines. www.nice.org.uk/guidance/CG/published
18. Rawlins MD. NICE work—providing guidance to the British National Health Service. N Engl J Med 2004;351:1383-5.[Free Full Text]

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