§ 6.32 p.m.
§ Lord Walton of Detchant
rose to move, That this House takes note of the report of the Science and Technology Committee on Complementary and Alternative Medicine (6th Report, Session 1999–2000. HL Paper 123).
The noble Lord said: My Lords, I cannot but feel that those rumbles of thunder suggest that it is unusual that someone steeped in the practice and principles of conventional scientific medicine should be presenting a report on complementary and alternative medicine, but I am delighted to do so for a variety of reasons. To have chaired the sub-committee that produced the report was a challenging and, at times, daunting task. It was a long and detailed inquiry. I should like to pay a very special tribute to the members of my sub-. committee whose support and vigorous argument. throughout made this a most fascinating experience. They were at all times interested, dedicated and willing to put forward their individual points of view, often trenchantly. It was to their credit that, at the end of the day, we were able to publish a unanimous report on a difficult and controversial topic.
I should also like to pay a special tribute to our two specialist advisers, Professor Stephen Holgate, Professor of Immunopharmacology, University of Southampton, and Mr Simon Mills, Director of the Department for Complementary and Alternative Medicine, University of Exeter. I would be remiss if I did not also say that our Clerk, Chloe Mawson, throughout was a tower of strength. It was a difficult task as it was her first major commitment on becoming a Clerk in this House and she fulfilled it outstandingly. We received great support too from Andrew Makower and Adam Heathfield in the Select Committee Office.
The objectives of our inquiry were to examine what we felt could be reasonable definitions of complementary and alternative medicine, to look at the usage of those disciplines in the UK and abroad, and to examine matters relating to regulation, education, research, the production of information and NHS provision of the disciplines. We were riot primarily concerned with efficacy but, inevitably, in the course of our inquiry, we were drawn into making some value judgments about individual disciplines and about their respective evidence basis. We received in all 180 submissions from organisations and individuals 469 and we conducted 44 oral hearings. My committee and I were grateful to all of those who gave us written evidence and who came to give oral evidence to us.
The first issue we examined was the question of a definition. We found it impossible to produce an all-embracing definition. Perhaps the one that came closest to satisfying our wishes was that of the Cochrane Collaboration. It defined CAM—complementary and alternative medicine—as,a broad domain of healing resources that encompasses all health systems, modalities and practices and their accompanying theories and beliefs other than those intrinsic to the politically dominant health systems of a particular society or culture in a given historical period".While no firm distinction was possible, we regarded complementary disciplines as those which are usually, if not invariably, used to complement conventional medical treatment, while the alternative disciplines are those which purport to offer diagnostic and therapeutic alternatives to conventional medicine.
Since the report was published we have had much subsequent correspondence and even one or two informal meetings. Our broad divisions enabled us to look at four possible groupings. First, in group one we classified what are often called the big five in the CAM field. They are osteopathy, chiropractic, herbal medicine, acupuncture and homeopathy. Osteopathy and chiropractic are already regulated by law in that each of them has its individual Act of Parliament regulating its activities. There is a General Osteopathic Council and a General Chiropractic Council. The General Osteopathic Council has run into certain problems over registration of those calling themselves osteopaths. But I am sure that that matter is outside the terms of reference of our inquiry and that it will ultimately be resolved. The General Chiropractic Council pointed out to us a minor error in our report where we referred to its policy on retrospective recognition of qualifications. But the council is now functioning extremely well.
Our view was that herbal medicine and acupuncture as practised in the West have now become so well organised through their individual bodies—they are voluntary regulatory bodies—that the time is approaching when it is right that they should seek statutory regulation under the Health Act 1999. I am delighted that the Government's response to the report, published only yesterday, suggests that the time has come when discussions with the Department of Health on behalf of those professions should proceed with that end in view.
Homeopathy has been practised for a very long time by doctors in the NHS; not least in London and Glasgow, but also in other parts of the country. Those doctors are regulated by the General Medical Council. But the non-medical homeopaths have an active society. They are self-regulating but as yet they have not come to any kind of formal agreement with the medical homeopaths—the Faculty of Homeopathy—as to common standards of practice and principles which should guide their practice. We believe that such 470 discussions should be undertaken. We further believe that the time will not be far distant when non-medical homeopathy should also seek statutory regulation.
In group two we classified many disciplines. They are largely complementary in that they are generally used either privately or, in many instances, within the National Health Service to complement conventional medical treatment. They include disciplines such as aromatherapy, reflexology, healing, yoga, massage, shiatsu and many more. Those disciplines do not claim cure. They do not carry diagnostic capability. But, from the evidence we received from many quarters, there is no doubt that they give comfort and succour not only to the elderly but also to many patients suffering from terminal illness. For that purpose, they are commonly used and employed within hospices and in the hospitals of our National Health Service.
One problem with regard to this group is that many diverse organisations claim to represent them. However, one example of a group that has come together—I shall turn to regulation in a moment—is the Aromatherapy Organisations Council, which has brought together all but one of the bodies purporting to represent aromatherapists.
The most controversial group in our classification was Group 3. We divided that group into two sections; Group 3a included traditional, long-established systems of medicine which have been offered to the public in other parts of the world, sometimes for centuries. These included Ayurvedic and Ancient Chinese medicine. In a moment I shall turn to the problems relating to the disciplines, but because we were concerned about certain aspects of these particular disciplines we put them into a category in which we said that, at the moment, there was no convincing evidence—no convincing scientific evidence base—to support their diagnostic capability or to support all the forms of treatment that they provide.
Our Group 3b comprised a list of disciplines including, for example, dowsing, iridology and other methods such as radionics and crystal therapy, where we found no scientific evidence base to support their use and, indeed, no evidence was brought forward to suggest that they had a credible evidence base.
The evidence we have received has shown that in the United Kingdom, more than 40 per cent of the population has turned, at different times, to complementary and alternative medicine. The Royal Pharmaceutical Society told us that, in 1998, £93 million was spent on complementary remedies and that the figure was rising rapidly. If one takes into account the costs of consultation, it was thought that people in the UK probably spend £1.6 billion a year on complementary and alternative therapies. In the United States the figure is staggering: 27 billion dollars spent annually on complementary and alternative medicine, but much more statistical information is required.
Perhaps I may return to the somewhat controversial issues of Ayurvedic medicine and Ancient Chinese medicine. As I said at the beginning of my remarks, the 471 problem is that these traditional disciplines have been used for centuries. In Ayurveda, the difficulty we encountered was that, not only the philosophy that underlies the discipline, but also the concepts relating to the five elements and the doshas could not be sustained in modern medical parlance. Equally, we could not wholly accept the yin and yang concepts of ancient Chinese medicine. But what we did accept without any hesitation was that many of the herbal remedies used in Ayurveda and in Ancient Chinese medicine, when tested thoroughly, have been introduced into western herbal medicine to good effect.
After all. acupuncture was developed in China. However, western acupuncture, which now has a sound neurophysiological basis, is quite different from the acupuncture of the ancient Chinese practitioner, who believes that certain acupuncture points correspond to individual organs of the body and in the concept of meridians and changes in the pulse that may result from various techniques of acupuncture. We could find no solid evidence for these concepts.
However, quite recently we were shown a demonstration of certain remedies used in Ayurvedic medicine at the Indian High Commission. Effectively, very careful scientific study has demonstrated these to be beneficial in certain fields of medicine. However, what we were being shown was modern herbal medicine. For that reason, we wholly accept that some of the herbal remedies of Ayurveda and, indeed, of Ancient Chinese medicine properly can be included in Group 1; namely, they can be brought under the umbrella of herbal medicine as can some of the other methods used in the disciplines, including massage, counselling and so forth. I hope that that deals with those particular problems.
Throughout, we were looking for evidence and evidence base. It was our clear understanding that it was important to recognise that the efficacy of these remedies had to be demonstrated by careful study and by research using not only double blind control trials—we made comments on many other methods of research. Those trials had to prove the remedies to be better than the placebo effect, which we know from many medicinal trials to be extremely effective. Of course we were also conscious of the fact that complementary and alternative practitioners can offer long consultations which provide the tender loving care which has been a part of traditional conventional medicine, but which many doctors have found difficult to offer because of the sheer pressure of work and time constraints. We were satisfied that it was important to demonstrate a greater degree of efficacy than can be shown from the placebo effect.
On regulation, I have already said that in Group 1 we believe that regulation by statute is either appropriate in the near future or will soon become so. As regards the Group 2 disciplines, we have made it clear that the individual disciplines should all come together under a single, voluntary, self-regulating body with principles clearly laid down relating to training and practice. When and if they do that, the time may come when it would be appropriate for them, 472 too, to seek statutory regulation. But that must be the first principle. We made some trenchant comments and proposals on training courses for complementary practitioners, in particular for those in Groups 1 and 3 where it is important that they should gain a level of basic understanding of medical science in order to be able to offer diagnostic skills as well as therapeutic interventions. That is not so necessary in the Group 2 disciplines but, nevertheless, they need to lay down principles as regards their training.
We were quite satisfied that it is important that doctors, nurses and other healthcare professionals who wish to practise complementary medicine—many now do—should acquire a level of training comparable to the standards expected of non-medical practitioners. Equally, we have made firm recommendations to the effect that, in their training, medical students, nursing and other students in the healthcare field should be trained not to practise complementary medicine, but should attend courses of familiarisation in order to learn what kind of procedures and disciplines their patients are likely to seek.
We were very concerned about research. Most practitioners in this field practise in private and have little, if any, opportunity to embark on research. There are some islands of excellence: in Exeter, in Southampton, at the Marylebone Health Centre in London and elsewhere. These are centres where doctors and complementary health practitioners work together in order to carry out research which seeks to confirm or, if necessary and if possible, to refute the efficacy of the procedures. But we are in no doubt that much more is needed by way of research. We have made strong recommendations to the Government that, through the NHS research and development mechanism, funds should be made available for training fellowships to train complementary practitioners in research and to establish centres in relation to or in collaboration with conventional medical schools so that integrated medicine can be practised and research can be conducted in order to strengthen the evidence base of these various disciplines.
We are glad to see that the Government, in their response, accepted virtually all of the recommendations we made and further recommended that support should be given for training fellowships and for research through the NHS R&D procedure, along with the support of the Medical Research Council and charities. The only thing missing from the Government's response, as we anticipated, was a pound sign. The exact sum available is as yet uncertain, but at least they made a declaration of intent, which is most welcome. Furthermore, we believe that academic units in this field should be developed.
One perfect example—which I hope will inspire the Government—was the establishment some years ago of the National Center for Complementary and Alternative Medicine in the United States, chaired by a very distinguished biomedical scientist, Dr Stephen 473 Straus, who gave evidence to the Committee. That organisation is now receiving from the National Institutes of Health 73 million US dollars per year and is carrying out, and granting money for, a whole series of excellent reports and research projects in the field of complementary and alternative medicine. It is an example which—much more modestly, no doubt—we hope that the Government will be able to follow.
Let me make one or two final points. My first point relates to information. We have been impressed by work that has been carried out by the British Complementary Medicine Association, by the Research Council for Complementary Medicine, and by the databases that have already been established by them to identify not only research carried out in the field but, more particularly, facilities throughout the United Kingdom where complementary and alternative medicine are practised and where such facilities can be provided.
However, much more is needed. We are happy that the Government have accepted that through, for example, NHS Direct, the NHS Centre for Reviews and Dissemination at York and the Cochrane Centre, it is intended to clarify and produce a much more formal and comprehensive database so that patients in all parts of the country will know where to turn to find information about the best practice of complementary medicine in their locality.
It remains for me to mention the issue of NHS provision. There has been increasing NHS provision in this field. It increased markedly under the fund-holding system of general practice introduced by the previous government in that quite a number of general practices commissioned complementary practitioners and paid for their services. There is some evidence that under the NHS as now reformed, with primary care groups and trusts, that provision may have shown some decline, but we did not have firm statistical information upon this. We urge that more opportunity be made for such provision to be given under the National Health Service.
However, we were firm in our conclusion—a conclusion which was supported by organisations such as the Foundation for Integrated Medicine, a foundation which has fulfilled a seminal role in the field of bringing doctors and complementary practitioners together—that it would only be proper to provide complementary and alternative medicine from public funds once a firm evidence base has been established and once these professions and disciplines have become organised into either statutorily regulated organisations or have developed a single system of professional self-regulation for each of the mechanisms.
It is our firm belief that once that is achieved, it will be perfectly proper for doctors in primary care to refer patients to such practitioners, and for individuals in the other healthcaring professions—nurses, physiotherapists and so on—to have a similar facility, both in primary care and in secondary or tertiary care in the hospitals, wherever it seems to be appropriate. In other words, our recommendation is that the 474 general practitioners and the other healthcare professionals—who are becoming much better informed about the value of complementary and alternative medicine but who, nevertheless, need more information and, indeed, more education on this issue—should still be the gatekeepers through which complementary and alternative medicine are provided under the NHS. I beg to move.
Moved, That this House take note of the report of the Science and Technology Committee on Complementary and Alternative Medicine (6th Report. Session 1999–2000, HL Paper 123).—(Lord Walton of Detchant.)
§ 6.54 p.m.
§ Lord Winston
My Lords, perhaps my first job today is to thank the noble Lord, Lord Walton, for a piece of conventional rather than alternative medicine. In my absence yesterday I was given credit in the newspapers for a piece of medicine that in fact the noble Lord, Lord Walton, undertook; that is, the treatment that he gave to my noble friend Lady Castle. Certainly, we on this side of the House are deeply grateful to him for that. I am sorry that it seems that I have been given the credit for a piece of medicine I am not trained to deliver. Indeed, I understand that the noble Baroness was somewhat alarmed when she saw my name associated with the medicine that she was receiving. Your Lordships may draw the appropriate conclusion from that.
My second reason for thanking the noble Lord is for his outstanding chairmanship of the sub-committee, the parent committee of which I chair. His chairmanship follows the long tradition of chairmen of this wonderful committee, on which it has been a privilege to serve. He displayed great tact during what was, for many reasons, a quite difficult investigation; it is a vast, blurred field and there were very strong feelings on all sides. Any chairman who can lead my noble friend Lord Howie docilely to agree with him deserves very great credit. This was a very successful investigation indeed.
We are also grateful to the Government because essentially they have agreed, as far as I can see, looking at the response very quickly, with nearly all of the points raised during the course of our deliberations. It will be interesting to see what funding there may be for research, but at least there is a commitment. That in itself may stimulate more research in this area. Certainly, I know of certain ongoing research projects.
Perhaps I may be rather specific today. I should declare an interest. In giving my maiden speech some five and a half years ago, I know that I upset a number of your Lordships. The noble Earl, Lord Baldwin, was somewhat concerned about my criticisms of alternative medicine. That was not entirely fair—I support alternative medicine—but I was incensed about the way in which it was being delivered in my specific area of medicine, and I made no bones about that at the time. I have reflected on how that has continued in the past five years.
475 Looking back at my own unit, I should declare an interest because we have been practising stress management for 15 years; we have been doing acupuncture for people with reproductive and pelvic disorders for certainly that amount of time, if not longer; and we have also promoted the use of a number of adjunctive therapies, such as aromatherapy, which undoubtedly have helped the well-being and welfare of a great number of our patients, particularly women attending for infertility treatment.
But there is a real problem which illustrates what is of concern about some aspects of alternative medicine. When I deliver treatment as a registered medical practitioner, I am subject to all kinds of careful statutory restrictions. I am required by the National Health Service to undergo appraisal. Indeed, your Lordships may be interested to hear that I underwent appraisal only last week and my appraiser was not at all certain that I was any longer competent to practice surgery because I was spending too much time in your Lordships' House.
Be that as it may, there is undoubtedly now vigorous and rigorous governance in the health service. I am required to audit my treatments and to make sure that they are genuinely effective. One of the problems is that this is not yet true in many areas of alternative medicine. That is why I believe that statutory regulation of some kind in certain areas is very much desired, and probably essential.
In particular, I wish to draw your Lordships' attention to the problem of reproductive medicine. About one in 10 couples, remarkably, have difficulties in conceiving. Infertility is extremely common. Very often when infertile people conceive, they lose the life within them; they miscarry. It is a tragic event which causes a deep emotional scar. Infertility starts off by people merely feeling rather anxious and a bit surprised that they are not conceiving; but it ends up with the most serious threat to their self-esteem, in a way that is difficult to imagine if you do not come into contact with these patients.
The threat to self-esteem often leads to quite severe depression; it leads to great anxiety, and to an attempt to clutch at straws. It also poses a real threat to people's sexuality—so much so that they often lose libido and find that there is no longer any point in taking part in the great pleasures of marital life. They often withdraw from young people around them. Loss of self-esteem affects their progress at work, because it affects every aspect of their being. It is quite common for women who are infertile and who have been trying to get pregnant for a long time not to be able to walk into a room where there are pregnant women.
Because of their desperation, such people are greatly open to being exploited. I regret to tell the House that this certainly happens in my field at present, through the offices of a certain type of alternative medicine. One organisation claims great efficacy in diagnosing the levels of trace elements in patients who are infertile. It recommends treatment with trace elements which it does not find to be in the right proportion. The organisation is particularly interested in a number of 476 substances: selenium, manganese, zinc, copper, molybdenum and iron. Some of these substances may have some relationship to reproductive processes, but it is by no means clear exactly how valuable they are and what a deficit in those substances really means. One organisation, Foresight, as I understand it, takes hair samples from patients, measures each hair sample and provides a print-out to the couples, saying that they are deficient in some of the trace elements.
It is well known from research in the United States that analysing hair samples in this way is not a reliable means of examining levels of any kind of substance in blood or tissue. It may reflect historically what was the case several months ago, but even then there is a large amount of evidence to suggest that hair samples do not correlate with what is actually happening in the bloodstream or in the body as a whole. It is, I believe, a fallacious test.
Once the patients have a print-out, they may be given an address where they may seek tablets to replace the substances that they are missing. Often, the tablets contain 10 to 100 times the amounts of each trace element that might be required to adjust their body balances. They may pay £50; they may pay £200 a month each if both partners are diagnosed.
The problem is that these poor patients are not subjected to any proper medical tests and no proper medical history is taken. They are prey to exaggerated claims; for example, it is common for them to hear that there is an 80 per cent chance of the woman becoming pregnant if they undergo this treatment. I believe that there has never been any peer review to demonstrate the truth of such claims.
Because I have been critical of this practice, I have been bombarded with letters from one particular organisation in the United Kingdom. I know that the letters are orchestrated, because they are all couched in similar language. Parliamentarians are familiar with that tactic. It gives the impression that there is much greater support in the community for a particular course of action, way of life or belief than is actually the case. It is signally clear that these organisations have failed to produce proper peer-reviewed evidence, properly carried out blind trials, to demonstrate that this medicine is efficacious.
Does it matter? No one dies from infertility. But as infertility is ineffectively treated, these patients age; as they become older, becoming pregnant is more and more difficult. The delay can be critical, particularly for a woman in her late 30s. That is a paradigm of what may happen to some extent in other areas where these sorts of medicines are not properly controlled.
It seems to me that there is a very real need to look at some proper regulation in regard to how patients are "prescribed". I say "prescribed" in inverted commas because, as I understand it, many of those who hand out these drugs, if I can call them that, are not registered pharmacists. The tablets are not obtained from a chemist's shop but usually through the organisation itself or through a friend of the organisation.
477 That said, let me emphasise that I am not in any way opposed to alternative medicine. I have seen the value of alternative medicine; it is undoubtedly of increasing importance in medical practice in this country. There is no doubt that one of the problems that people face, particularly in the National Health Service, is the hurried, stressed doctor who sometimes does not spend as much time as he should do communicating with his patients. For that reason, if for no other, the alternative practitioner offers a valuable service, because one of the most important aspects of medicine is listening to what a patient has to say about his or her predicament. That undoubtedly has a huge and beneficial effect, not excluding any other therapy.
However, there is no doubt that in this country we have accepted that medical practice needs to be audited. It needs to be demonstrated to have an evidence base. If the evidence-based approach is good enough for registered medical practitioners, it is essential that anything that is given to patients who are effectively not well, who have a problem with their physiology, should be given on the same basis as applies in regular medicine.
§ 7.6 p.m.
§ Lord Soulsby of Swaffham Prior
My Lords, I should like to echo the comments made by the noble Lord, Lord Winston, about the chairmanship of the noble Lord, Lord Walton of Detchant. He guided us through the examination of some 29 disciplines that are grouped together under the rubric "complementary and alternative medicines". They are a heterogeneous group based on hygienic, diagnostic and therapeutic philosophies and practices whose theoretical bases and techniques may diverge substantially from modern scientific medicine, veterinary medicine or dental medicine. Their heterogeneity is exemplified in the fact that some have roots in ancient, or indeed modern, philosophies or religious systems. Some are based on notions of anatomy, physiology or pharmacology which are not consistent with current scientific knowledge. Some are based on beliefs that contradict established scientific principles and there is little or no scientific evidence to support their efficacy, and especially their safety.
Among this array of disciplines, the committee discerned three major groups, the third of which was divided into two groups, 3a and 3b, based on the evidence that we could ascertain. In relation to groups 3a and 3b, our chairman in particular and some members of the committee came under a degree of criticism from bodies that were included in that grouping. We all admired the composure of our chairman in dealing with the dissent levelled against him and others. When we met at the Indian Consulate to discuss some of these, he was the soul of discretion and charmed his critics very well indeed.
The issue in relation to complementary and alternative medicine and its veracity is the provision of a critical mass of evidence to support claims for efficacy and safety which would lead to regulation. 478 Two therapies—acupuncture and herbal medicine—appear to be at the stage where it would be beneficial to strive for statutory regulation under the Health Act 1999. Osteopathy and chiropractice are already suitably regulated. Obviously, a major concern is the lack of the type of evidence that one would require for the registration of conventional, therapeutic molecules, which is accepted as being a very expensive and drawn-out process. The usual quotation of time is 10 years, and the usual quotation as regards finance is 100 million dollars. Very few, if any, of the complementary and alternative medicines could generate that sort of expenditure in order to become registered.
As the noble Lord, Lord Walton, mentioned, the evidence may well be there; it is a question of producing it by determined work. Indeed, we found at the Indian Consulate that they had produced the sort of evidence on four substances that would be accepted for registration. Hence, that changed our minds somewhat for the Ayurvedic medicine type of approach. However, it seems to me that there are several reasons for this lack of evidence. The first is the critical lack of a mass of research workers in any institution. In many of the institutions where CAM medicine is taught, the teaching is carried out by one person who may in fact be working part time. Hence it is very difficult, if not totally impossible, to mount a research programme under such circumstances.
Secondly, as has been mentioned, some of the teachers of CAM approaches are not research workers. They have never been trained in research and have never carried out such work. Therefore, they are unable to write the sort of research proposal that would generate support and interest from the major funding bodies. Nevertheless, we have been given to understand that funding would be forthcoming from some of the major medical charities, such as the Wellcome Foundation, were quality research proposals placed before them. That raises the question of ring-fencing research funding; in other words, whether special funding should be given to this area in order to kick-start research on the various complementary therapies.
While organisations like the Medical Research Council would reject ring-fencing, as the noble Lord, Lord Walton, pointed out, this is done in the United States by the national institutes of health. Indeed, between 80 million and 100 million dollars are made available for the purpose. With this large amount of grant funding available, we heard in committee that the major research groups went after such money and were willing to carry out the research. So the research followed the money, rather than the money following the research. We do not know whether that would happen in this country, but I suspect that the same thing would occur. If funding is made available in substantial sums, there is no doubt that research workers will follow it.
The way forward in the United Kingdom would seem to be to establish one or two critical centres of excellence where the necessary research can be undertaken and developed. Some of these centres 479 already exist; for example, in Exeter and Southampton. One would hope that there will be increased effort as regards research funding for such work.
A further area that is poorly attended to in this country is education in CAM. That applies both at the undergraduate level—not only in medical schools but also in veterinary schools and, I presume, also in dental schools—and also in CPD, or continuing professional development, to practitioners in medicine and veterinary medicine. It is no easy task to insert yet another instruction in an undergraduate course in medicine, in what is usually already a crowded curriculum. There is also the possibility that this might be dealt with on an elective basis. However, where that instruction is given, it is important that the provider should have a fairly broad view of the various disciplines; in other words, he should provide a broad-view outlook and not concentrate on his own specific area of interest.
The provision of further information on CAM via CPD is an important area of development. The committee recommended that as one of the ways forward in dealing with the education of doctors, vets and dentists in this area. In the delivery of CAM therapies, we strongly believe that a progressive integration between CAM and conventional medicine should be encouraged; for example, we recommend—and, interestingly, the Government agree—that patients wishing to try CAM therapy should be encouraged to discuss their conditions with a medical practitioner beforehand.
In my own profession of veterinary medicine, the delivery of CAM therapy is covered under the veterinary surgeons' Act. Under its provisions, only veterinary surgeons may practise acupuncture and other CAM therapies. However, it is now possible for the practice of those disciplines to be devolved to non-veterinarians, provided that they are carried out under the direction of a veterinary surgeon. This means that one can bring into these areas highly trained auxiliaries for the benefit of animals.
There is widespread use of the wide range of CAM therapies. There is a strong case for a greater understanding. of such therapies, both by the provision of more evidence of efficacy and safety and by the provision of self-regulation. Given these, a more useful integration of the conventional health delivery and CAM delivery would be possible.
I believe that the report looked in great detail at these therapies. I also believe that the recommendations contained within it are not only considered but also constructive. Attention to them will lead to a more beneficial appreciation and integration of the use of both complementary and conventional medicine. I believe that, together, the conventional and the alternative in medicine could work to the benefit of the patient. Indeed, that is what we aim for in the long run.
§ 7.18 p.m.
§ Lord Smith of Clifton
My Lords, I, too, should like to attest to the remarkable chairmanship skills of the noble Lord, Lord Walton of Detchant. He had to deal not only with a wide range of CAM therapies, but also with a wide range of disciplines represented by members of the committee. When I was co-opted to the committee, I saw this array of medical, veterinary, pharmacological and scientific expertise and felt it necessary to establish my own provenance. I remarked that I was bringing to the committee's deliberations the perspectives of a serious hypochondriac. I should declare an interest and say that in the royal fellowship of serious hypochondriacs I have been gratified to appoint myself its life president—but not for long, you understand!
In a more serious vein, I turn to the point made the noble Lord, Lord Soulsby of Swaffham Prior, and emphasise the importance of the role of research in the area of CAM. The noble Lord, Lord Walton, drew attention to that as well. It is gratifying to note that the Government have more or less accepted all our recommendations. I think that is common ground. We made a timely review given the enormous recourse to CAM by the public, which is likely to show no signs of abatement in the future. It is absolutely vital that, if the public and the relevant professionals are to be properly informed, an adequate research base is developed. I am slightly less optimistic than the other two noble Lords who have referred to this. I believe that it will be a major step to get that established.
I would like to add one other point which has not been made. I believe that it has to be done with a great deal of sensitivity and, in a non-patronising sense, hand-holding. This is almost virgin territory for many of the CAM therapists. For that reason, I believe that the sensibilities of the practitioners in CAM need to be a major concern.
It is therefore important that the Government have acknowledged their role there. When we were taking evidence I frequently remarked that while most people agreed that a greater research effort was needed to produce the sort of evidence base required, people were often waltzing around the subject. I am gratified to note that our recommendation that the Department of Health must really own this subject and be the main drive behind it will be taken on board. As I have said, I am not as optimistic as other noble Lords that we shall really get this matter moving. It will require money, which may be forthcoming in due course. It will require a major commitment on the part of the Department of Health in order to co-ordinate the various agencies which finance research in the medical area so that we can build up a fairly major critical mass at an early stage rather than letting it dribble along.
§ 7.22 p.m.
§ Lord Turnberg
My Lords, I would like to add my congratulations to those of other noble Lords to the noble Lord, Lord Walton, and the Select Committee on an excellent report. I bellieve that it is a balanced and important report which will serve as a bench-mark 481 in our understanding of complementary and alternative medicines and in helping us assess the value and place of what is a very widely disparate group of therapists.
I would like to focus on the section dealing with research in this field covered so admirably in Chapter 7. I believe that research is the key as to whether an independent observer—I suppose that there are such people in this rather controversial field—can conclude which, if any, of these treatments can be accepted as valid, that they work and they are safe. I note the remarks of the noble Lord, Lord Smith, about sensitivity in this field. Indeed, some of the CAM therapists have been able to demonstrate effectiveness by research because it is only through research that we can hope to collect the evidence on which we can base any confidence about others.
It is certainly the case that before any new conventional therapy is introduced and used, there has to be reasonable evidence that it is likely to be effective. After all, that is what the National Institute of Clinical Excellence (NICE) was set up to ensure and it is the basis of rational medical practice. So we should expect no less of complementary and alternative medicine.
Now the reasons why the necessary research is not done as much as it should be is said to be because there is not enough funding from grant-giving bodies. I shall speak about that in a moment or two. But it may also be said that there is a reluctance on the part of practitioners to engage in research because they know in their bones that what they do helps people. They are right to the extent that any sympathetic, kindly practitioner can produce remarkable improvements in patients' sense of well-being by what is effectively comfort and a mixture of psychotherapy and placebo effect. Most, if not all so-called conventional doctors know that and indeed practise it or try to do so.
But where complementary and alternative medicine practitioners go beyond that and suggest that what they do for patients has a specific effect over and above those non-specific results, and where those specific effects are the reasons they are in business—in many instances it is a business largely outside the NHS—then the public deserves to know what is the evidence for the effectiveness of the therapies that they are paying for. Therefore, I have little sympathy with the idea that research for evidence is not necessary.
Perhaps I may now turn to funding. Those who want to carry out research say that there is little or no funding available. But the Association of Medical Research Charities—here I should express an interest because I am the scientific adviser to the AMRC, which has over 100 medical charities as members—made a survey of its members asking what their position was on complementary and alternative medicines. It transpired that very few had ever received any application for CAM research. Those that had said most of these were unacceptable because they were so poorly formulated.
Some charities, most notably the Arthritis Research Council (ARC), have leaned over backwards to try to encourage high quality research proposals and have 482 had some limited success. But it is not as though there is no money available. One of the important recommendations of the report is that the manufacturers of the CAM remedies and preventatives sold over the counter and which are so profitable, should plough a small percentage of their profits into research. The rest of the pharmaceutical industry puts much more into R&D, so why not the others? Could it be that they fear that research will reveal that their products are not effective? Your Lordships may detect a note of provocation here. Perhaps I might provoke a positive response.
Most of the charities in the AMRC were set up by patients, parents or carers because they thought that not enough research was being done into arthritis, for example, or Alzheimer's disease, strokes or cancer and they did something about it. They began raising funds directly from the public. While they are open to receive requests from any researcher wanting to do any research which will improve the lot of the patients relevant to the charity, including requests from complementary and alternative medicine researchers, some charities have asked why it is that with the enormous public interest in CAM there has been no real concerted effort to raise funds directly from the public for research in this field. There is some, but why not more? Why go to other charities when funding from the public might be easier?
What I am trying to say is that many complementary and alternative medicines have an important role to play in easing the discomfort and symptoms of patients. But in order to go beyond that to having a specific effect in the cure or relief of disease, it is only by carefully controlled research that evidence of effectiveness can be obtained and only then can the public be reassured about what they are receiving.
§ 7.29 p.m.
§ Lord Colwyn
My Lords, in thanking the noble Lord, Lord Walton, for his excellent chairmanship of the committee, I should like also to thank the members of the committee, some who remained sceptics to the end, some who may perhaps have been influenced by some of the evidence and some who may even have changed their minds.
I collected my copy of the Government's response but have only had a short time in which to look through it. In his speech this evening the noble Lord, Lord Walton, has dealt with many of the queries that have arisen since publication, particularly the reactions from the long established and traditional systems of healthcare that felt they were being ignored in our Group 3 classification. I am sure that on reflection practitioners of these systems will realise that it would not have been possible to examine the detail and theory of those entities in a 14-month inquiry. It might have taken two or three years. Grouping them together showed the respect which they are due and, in reality, took them outside the scope of our inquiry.
I should like also to thank the various organisations which have written to the sub-committee and to me personally since the publication of the report. I hope 483 that our responses have offered sufficient explanation of the grouping arrangement. Perhaps I should declare an interest as president of the All-Party Parliamentary Group on Alternative and Complementary Medicine. I am president of the Natural Medicines Society and a practising dental surgeon who uses some of these techniques.
The modern, research-based scientific advances in medicine over the past 50 years have been spectacular and have brought relief, healing and sometimes health to countless numbers of patients. This growth of knowledge has been such that different specialties have developed, each competing for and making legitimate demands on the NHS budget, which has always, and will always, fall short of the personnel and materials needed to benefit all those patients who are perceived by conventional methods of diagnosis to be ill. It has been estimated that about one-third of all patients with chronic symptoms have no organic disease and another third have symptoms that are unrelated to their organic condition. The skill to understand and relieve the suffering of those patients is just not available within the accepted framework of conventional medicine.
Scientific advances in medicine have also affected the patient-doctor relationship and caused difficulty in communication. The committee heard that such misconceptions might be why help is sought from complementary practitioners, where patients can be assured of a listening ear. Very often the therapy involves the active participation of the patient. That has obvious appeal in an age when authority, including that of the medical profession, is being challenged and health is considered to lie in self-help.
In January, the all-party parliamentary group was addressed by Andrew Weil, the director of the Programme of Integrative Medicine of the Department of Medicine at the University of Arizona School of Medicine. He told us that American healthcare institutions have been engulfed by an economic crisis of unprecedented proportions that has alienated patients and eroded the job satisfaction of physicians. Simply, medicine has become too expensive. All over the world insurance systems are breaking down and hospitals are going bankrupt. He thought that in the not too distant future, when many smaller and community hospitals have disappeared, large areas will be left with only one central hospital— the only one that will be able to afford the hardware.
One of the great attractions of medicine as a profession was the promise of autonomy, an area where one could be one's own boss. We heard that few physicians today in the US can succeed in solo practice; most must work in corporate settings where someone tells them how many patients to see an hour, which treatments are authorised and which are not. The Minister will be aware of this already happening in my own profession of dentistry in this country. A very high proportion of new graduates cannot afford to set up on their own or buy into established practices. In a recent survey, 70 per cent of newly qualified 484 dentists said they would choose to go down the corporate route, where someone else makes the decisions and pays the bills.
The Minister will have seen the report in last Sunday's Times, where 80 per cent of doctors surveyed on the Medix website believed that the incentive payments for GPs to enter general practice would make no difference and that,medicine is losing its allure as a career".By eliminating much of the incidence of infectious disease—the major killer of the 20th century—modern scientific medicine has to assume the responsibility for this situation. We have been left to deal with chronic degenerative illness, a much more stubborn and costly problem. Medical expenses go up the more elderly people there are. The generation to which I belong—the generation that will soon constitute a gigantic demographic bulge of old people—has not yet reached the age where its medical costs will skyrocket. We have not seen anything yet!
Another reason for the expense of conventional medicine is its extreme dependence on technology. Medical technology is inherently costly and unless we change that dependence there is no hope of cutting costs. Consumers are very clear about their desires for natural, complementary and alternative therapies. It should be obvious by now that this is not a passing fad but rather a worldwide sociocultural trend with deep roots and great economic significance.
Much of the evidence we heard showed that patients want more involvement with medical interactions and want doctors who share their views about health and healing. They want physicians who have time to help them understand the nature of their problems and who will not just promote drugs and surgery as the only ways of doing things. They want physicians who are aware of nutritional influences on health and who can answer intelligently questions about the bewildering array of dietary supplements and natural interactions, who are willing to look at patients as mental/emotional beings, spiritual entities and community members as well as physical bodies. And they want physicians who will not laugh at them for inquiring about Chinese, Anthroposophic, Ayurvedic medicine or kinesiology. I mention kinesiology specifically because we relegated it to Group 3 in our list as having no evidence base. I use it every day of my life in my surgery as a diagnostic tool. It works brilliantly but I have no idea why.
The report recommends that there should be more consistent training offered to complementary therapists in all the different disciplines and that formal training should be offered to doctors, dentists, nurses and physiotherapists who wish to practise complementary disciplines. The setting up of a formal training structure should then produce practitioners and therapists who have a research-based background. It is our recommendation that the Government and the Medical Research Council pump prime the area of research by producing funds over a 10-year period in order to establish centres of excellence for those wishing to undertake research in 485 this field. It is important that we follow the example of the National Committee for Complementary and Alternative Medicine in the USA, which is funding research projects with a budget of 73 million dollars a year.
In their response the Government say that they recognise the need to develop research capacity and they will consider the best way to achieve that objective. The noble Lord, Lord Walton, mentioned the lack of a pound sign. The noble Lord, Lord Burlison, can make himself world famous. How about offering £5 million this evening?
The challenge is to create a new approach to medicine, one that is based on a model of health rather than disease, one that trains practitioners to take time to listen, to value nutritional and lifestyle influences on health and illness, to offer treatments in addition to drugs and surgery and to understand the innate potential of the organism for self-repair and healing. This approach operates from the premise that prevention is one of the primary responsibilities of practitioners and that, whenever possible, simple, safe, cost-effective treatments should be offered before invasive, expensive ones.
In conclusion, I hope that the Government's response is bold enough to take steps to endorse the integration of complementary and alternative therapists into routine NHS practice. The integration of the theories of complementary medicine at undergraduate and postgraduate level can go some of the way to meeting the demand for good quality care, to the provision of care that respects the dignity of patients.
Integrated medicine shifts the orientation of medicine to one of healing, engaging the mind, spirit and community as well as the body. This approach is based on a partnership of patients and practitioner within which conventional and complementary modalities are used to stimulate the body's healing potential. It is committed to the practice of good medicine, whether its origins are conventional or complementary and recognises that good medicine must always be based in good science that is inquiry driven and open to new paradigms.
The last page of the response is encouraging. It states:The Government agrees that there is scope for closer integration of CAM and conventional medicine. This is in the interests of all relevant disciplines and, above all, in the interests of their patients".I hope that the rest of the document is just as supportive.
§ 7.39 p.m.
§ Earl Baldwin of Bewdley
My Lords, I am glad of the chance to speak in this debate, just as I was grateful to be co-opted to Sub-Committee I together with the noble Lord, Lord Colwyn. He and I have helped to run the Parliamentary Group for Alternative and Complementary Medicine for a good number of years, and are patrons of a number of organisations within CAM.
486 It would not be sensible for me to go over the whole field covered by our recommendations, since this has been admirably dealt with by my noble friend Lord Walton of Detchant. From our conversations early in the proceedings he knows my views on the difficulty of a medical person chairing an inquiry into a domain which until very recently has been at loggerheads with the medical profession, and many of whose philosophies and assumptions will not have featured—shall we say?—in the medical curriculum. I can only pay tribute to his fairness, efficiency and skill in guiding us through a welter of paper, discussion and examination of witnesses which has resulted in this comprehensive and unanimous report.
That it has not pleased everyone is not surprising. It was almost inevitable that our attempt to categorise the various therapies at the beginning of Chapter 2 would upset some people. Like my noble friend, I have tried to explain to those who wrote in that it was not unreasonable to accept some of the therapeutic claims, for example for herbal medicines or acupuncture which feature in Group 1, while viewing the diagnostic criteria and the whole framework of Ayurveda or Traditional Chinese Medicine in a different light.
Speaking personally, I have little difficulty with the latter. If they are clinically useful, that is what chiefly matters. Colleagues may remember our visit to the Marylebone Health Centre, where the acupuncturist told us that her TCM approach often made more sense out of the symptoms of heart-sink patients than did the diagnostic tools of the GP, and consequently she was able to help them where others could not. There is more than one possible lens through which to view the human condition. I recently came across an attractive one I had not met before, when I read Plato's view that,medicine may be regarded … as the knowledge of the loves and desires of the body, and how to satisfy them or not: …he who knows how to eradicate and how to implant love, whichever is required, and can reconcile the most hostile elements in the constitution and make them loving friends, is a skilful practitioner".It is surely no insult to say that until the frameworks of ancient Greece, or in our case India and China—for which, as I say, I have the greatest respect—attain at least some form of scientific validation, it is logical, in a society dominated by western concepts of medical science, to place them in a category of their own. If we had called this "1b" instead of "3a", maybe we would have avoided much misunderstanding and, sadly, abuse. It is not as though we were recommending that they should be prevented from practising, or from doing good research, or from achieving a high standard of self-regulation.
I would highlight this evening just three recommendations in the report. In doing so, I would remark that it has been quite difficult to react to the Government's late response, which I have seen today for the first time. Other noble Lords, I think, have found the same. Some of what I say may be optimistic in the light of what at first sight appears to be a lukewarm response to one or two of our proposals, but I shall say it nevertheless, encouraged by my noble friend's review of the response, which is certainly more considered than my own.
487 Patients and doctors need full and reliable information about therapies and practitioners. There has been no thought of banning anyone: that would stifle innovation, as well as remove the patient's right to choose. But the corollary is that therapists should display their wares so that the public knows exactly what it is getting. I know from experience how hard it is to find one's way through the complementary medical maze. Much information will have to await good-quality research—other noble Lords have spoken about this— into efficacy and effectiveness in comparison with other treatments and in terms of cost. But there needs to be a central place, or places, where registers of practitioners are held, with details of their training and qualifications—what all those different initials mean, for a start—and assurances about regulation in all its aspects, and with enough unbiased information about such research findings as there are. Because the NHS already has structures that could handle this, and because patients turn to their GPs for information on most other aspects of healthcare, we thought that the NHS would be the best place to start.
A development close to my own heart has been the increasing acceptance by the medical profession of what CAM has to offer, or at least, where this is contentious, of the patient's right to follow the treatment of his or her choice. We met this in most, though not all, of our oral evidence sessions. We recommend that doctors. whether in training or long established, become familiar with CAM—not to the extent of practising, say, acupuncture or nutritional therapy, but of understanding enough of the principles and practices of the commonest therapies to be able to discuss treatment programmes and prospects with their patients. who in some cases at present know more about the CAM world than they do.
As a frequent CAM patient, and as the husband of someone with a serious illness to which conventional treatment has no adequate answer, I cannot stress too highly the importance of this. If you have to deal with a doctor who is all the time trying subtly to undermine what you are doing, it is dispiriting and it saps the energy you should he devoting to the disease. We have been fortunate in this; but at the same time the lack of anyone who can professionally oversee all aspects of the case, who will understand why an alternative approach may succeed where chemotherapy may not, who will give it due weight, understand its mechanisms and particular patterns of healing, be aware of any contraindications and of what to do when problems arise, has been a source of constant stress. If anyone tells you that patients recover in cases like this because of their commitment to their own healing, do not believe them. Managing a complex regime, and being responsible for life-and-death decisions because there is nobody else to help you take them, is no bed of roses. We need the multilingual physician, in the words of Dr George Lewith, one who understands the grammar and syntax of more than one system of healing, and when and how to use each.
Finally, there are the funding implications of the need, which most informed observers agree on, for more and better quality research. I hope the 488 Government will see our recommendation for pump-priming money for a few centres of excellence as an investment which offers a good chance, not only of cures in areas where few existed before, but of economies in a healthcare budget which—the noble Lord, Lord Colwyn, mentioned this—if continually linked to the latest developments in high-technology medicine, will spiral out of control. If government cannot rise to this challenge, at a time when so many patients are seeking and find help in the field of CAM, then there is comparatively little that small-time therapy bodies or manufacturers can achieve on their own. It needs, as so often, the initial impetus to set the ball rolling. I hope government will make an imaginative response to this as to other proposals in what I believe to be a sensible and forward-looking report. At present less than 0.1 per cent of the national research budget goes on complementary and alternative treatments. And here we are not asking for the moon.
Although there is as yet no definitive picture of why patients are flocking to CAM, and we have made no recommendations for further surveys, I believe there is evidence that Vickers and Zollman were correct when they wrote in the British Medical Journal of 25th September 1999 that people usually go for,long-standing conditions for which conventional medicine has not provided a satisfactory solution, either because it is insufficiently effective or because it causes adverse effects".The latter should not be underestimated. 1 t has resource implications as well.
We also know that patients report high satisfaction with their non-conventional treatments. Doctors like to ascribe this to the extra time available to CAM practitioners—a notion contradicted by the one chronic patient, at Southampton, to whom we put the question—and to the placebo effect. Neither of these entirely convinces me, though they are satisfying to some and may well play a part. But if complementary practitioners have learnt how to harness the placebo effect more effectively than their medical counterparts, then they deserve every encouragement.
Of course, this is not the last word on complementary medicine. To those therapy bodies who felt affronted by aspects of our report, I would say that they are quite at liberty to regard it as a product of a particular time and place. They could draw attention, if they like, to the fact that we were 11 white professional males with an average age of 71, and they could couple this with the view of Charles Darwin, who wrote in his autobiography,What a good thing it would be, if every scientific mail was to die, when sixty years old, as afterwards he would be sure to oppose all new doctrines".I hope, nevertheless, that CAM organisations will take to heart what we have said in our chapters on regulation and training, together with the need constantly to question and test what they do in an effort to improve their evidence base.
Despite criticisms, I do not believe we have done badly. I think this is recognised at what one might call the senior end of the CAM world. We have looked exhaustively, and sometimes exhaustingly, at the key 489 issues facing complementary and alternative medicine in this country, and have produced a set of sensible and practical recommendations. On the acid test of whether our recommendations, if implemented, will improve the lot of the patient, I think we have succeeded. And that is the most important thing.
§ 7.49 p.m.
§ Lord Rea
My Lords, it was a great privilege to be a member of the sub-committee that carried out the inquiry. Our chairman, our expert advisers and our excellent clerk mobilised the flood of evidence that came our way and steered us through it safely and competently. Our three external visits, to Exeter, Southampton and the Marylebone integrated practice, gave us a flavour of what it is like to be a CAM patient and showed us that high-quality research into CAM is possible. I shall use the abbreviation CAM throughout my speech because I shall be referring to it a lot and it will probably save me about 10 minutes.
Some of that research, particularly that being done in Professor Edzard Ernst's department at Exeter, showed that certain forms of CAM gave better results than the inert placebo treatment with which they were being compared, but others showed no benefit beyond that provided by placebo treatment. As a result, his department is not universally popular with the CAM fraternity. It is important to note that even when the placebo results were not greatly different from those of the treatment in question, both treatment and placebo usually had a beneficial effect. While we did not think that the placebo effect was the only reason for the benefits attributed to CAM, it always needs to be borne in mind when assessing the effects of different treatments.
I shall centre my remarks on the reasons why CAM is so popular today and look at some of the weaknesses of mainstream or scientifically based medicine that may lead patients to seek alternative remedies. Chapter 3 of the report gives the committee's thoughts after we received evidence on the factors underlying patient satisfaction with CAM treatment in general. In our view, the approach of the therapist to the patient and the power of the placebo effect of any treatment are crucial in understanding that satisfaction. CAM practitioners are usually more relaxed, friendly and welcoming and their premises are often more domestic in character and less formal and clinical—more like home. Although we do not know the exact mechanism of the placebo response, some of our witnesses gave clues as to which factors enhance it.
Paragraph 3.27 of the report says:Research on therapist variables has shown that those therapists who exhibit greater interest in their patients, greater confidence in their treatments and higher professional status, whatever their background of training, all appear to promote stronger placebo responses in their patients. … It is also possible that the almost 'magical' approach of some complicated and unusual therapies may have a similar effect to highly sophisticated technologies in inducing wonder in patients".As my noble friend Lord Turnberg pointed out clearly, the placebo response is present in mainstream medicine as well. Impressive technology sometimes 490 appears to enhance that effect. The effect is not merely psychological, but may result in an enhancement of the immune response that is measurable by laboratory methods. An effective placebo response should not be dismissed as valueless. A hurried consultation in mainstream medicine may not evoke as effective a therapeutic response as an encounter with a caring CAM practitioner.
In mainstream medicine there is a common impression among patients that the doctor's time is precious and must not be wasted. As the report says in paragraph 3.8:Constraints on time and other pressures on the NHS, and the reliance on drug prescribing in conventional medicine, have eroded the time patients spend with doctors and has tended to lead to a forced discussion of 'the problem' rather than also embracing the context in which the problem needs to be considered".Paragraph 3.12 says:conventional medicine as presently practised may lack something so that some patients are left feeling that not all their needs have been met".As a former National Health Service GP, I am only too aware of the truth of that, even though, like many other doctors, I was often fully aware of the social and psychological factors that lay behind the problems presented by patients. It is easy to blame a patient's dissatisfaction on the lack of time in an average GP consultation—seven and a half minutes—but that may not be the only problem. Even in a short consultation it is possible, although not always easy, to establish some understanding and mutual trust that can carry forward over subsequent meetings into a long-term therapeutic relationship. Many noble Lords who have a good relationship with their GPx2014;or their consultant, if they have had the misfortune to get that far—know that to be true. Unfortunately, that is not the rule in modern medicine. The sheer volume of technical knowledge that medical students have to encompass today can easily squeeze out the compassionate motivation of the young adult who entered medical school.
Academic medicine and the General Medical Council are much more aware than previously of the basic importance of good doctor-patient communication in diagnosis and treatment. However, the technically expert doctor is always in danger of losing touch with the caring person within. Final qualifying examinations overwhelmingly test technical knowledge and competence. That is understandable. In today's technological and health environment, turning out a safe and competent doctor must be high on the priority list of the General Medical Council or any medical school. It is often said that psychological skills and sensitivity in a doctor are either innate or learnt very early and that only a minority of those in the caring professions are so endowed. However, I contend that a great deal can be done during training to instil into even the most blinkered student an understanding of the need to listen to and empathise with patients, if only because it makes for much more effective consultations and saves time and National Health Service money in the long run.
491 We found repeatedly in our inquiries that the symptoms and conditions that were best helped by complementary medicine were complex and long-term and did riot respond adequately, if at all, to mainstream treatment with drugs. The noble Lord, Lord Colwyn, and the noble Earl, Lord Baldwin, both made that point. The conditions include migraine, asthma, irritable bowel syndrome, chronic joint or back pain, chronic fatigue syndrome, eczema or allergies. Most GPs find such conditions time-consuming and difficult to treat. They are often the "thick file" patients. The pain of cancer patients was also often helped and their wellbeing enhanced by complementary medicine.
The common factor in all those problems is that stress, due to psychological or social factors, often plays a part in their origin or continuation. Some studies have found that the "worried well"—those with higher than average anxiety levels—are frequent users of complementary medicine. They often find that it helps them better than mainstream care. That may well be because the psychological or social help that would help them to get to the bottom of their problem is either not available through mainstream medicine or, more probably, not acceptable to them because they—and sometimes their doctors—prefer to regard their symptoms as having a completely physical cause. The approach of CAM therapists is ideal for such people because, while concentrating on their physical symptoms and often laying hands on the affected part of the body, the therapist subtly plays the role of a psychotherapist by another name, because he or she allows the patients to talk holistically about their life problems as well as their symptoms. Many GPs have found that a CAM approach is very appropriate for a sizeable proportion of their patients who have chronic symptoms but few detectable signs of organic pathology. It is not surprising that 40 per cent of GPs now either practise some form of CAM or collaborate closely with one or more complementary therapists.
It may be demonstrated that such collaboration can save NHS resources by reducing the number of GP consultations, prescriptions and referrals to outpatient consultant clinics. More research into the cost-effectiveness of CAM and the extent to which it could save NHS resources should be commissioned in addition to the research that is already being carried out. We were shown the results of a few studies that demonstrated its cost-effectiveness but more, larger and more soundly planned studies are needed.
In fact, research into CAM, as nearly all noble Lords who have spoken have said, is woefully under-funded and the CAM professions lack the research expertise and training that underlies the development of mainstream medicine. In chapter 7 the report examines the whole problem of research and development in CAM. Other noble Lords have already discussed that more effectively than I was going to so I shall not discuss it further.
It was good to read in the Government's response on page 14 that they,recognise the need to develop the research capacity in this field".492 I was particularly pleased to note that they will include "the funding of fellowships", as was pointed out by the noble Lord, Lord Walton. However, their response was disappointing in that they did not feel able to respond positively to the report's recommendation that they should "pump prime" in order to create centres of excellence for CAM research. We have already heard about the way in which that has been done successfully in the United States.
In conclusion, it is fair to say that the report has for the first time put together a comprehensive description of CAM in Britain: its extent and varied nature and some of the reasons why it is so popular. The report also discussed some of the problems that are connected with complementary medicine, including its standards of training, its regulation and its lack of a good research basis. The report also points out some serious deficiencies in mainstream medicine as it is currently practised. I join the noble Lord, Lord Soulsby, in the hope that both complementary medicine and conventional, science-based medicine can learn something from the report.
§ 8.2 p.m.
§ Lord Hodgson of Astley Abbotts
My Lords, I begin by congratulating members of the committee and its chairman, the noble Lord, Lord Walton of Detchant, on producing a fascinating report. I was not a member of the committee so I apologise to its members, many of whom are in the Chamber this evening, for scrambling up the learning curve behind them.
I first became interested in CAM about 20 years ago for two simple reasons. The first arose because I was then a Member of another place representing Walsall, North, and I saw a constituent of mine at an advice surgery. She came to me in an extraordinarily stressed and tearful condition. She had a familiar tale—she was a single mother with three children and she lived in a high-rise block of flats. She had been prescribed some pills by her orthodox medical practitioner to deal with her stress; the practitioner did so entirely in good faith. A side effect of the pills was that they gave her vertigo, which is not good if one lives on the 15th floor. When she came to me she was at the end of her tether and it was extremely difficult to offer her advice. I knew another doctor in my constituency—a conventional medical practitioner—who undertook complementary medicine. He was for that reason regarded as something of a maverick. He saw her and prescribed a homeopathic remedy, which proved to be extremely effective.
When, 18 months later, there was a threat to close down the Royal Homeopathic Hospital, I met and was extremely impressed by several doctors there, many of whom were orthodox medical practitioners as well. From those two episodes came my interest in CAM.
The attitude of the medical profession then—20 years ago—was, to say the least, disdainful. We have, if the committee's report is any yardstick, come a long way since then. I congratulate the medical profession on that. It has had a lot of stick in recent months and years but this more positive approach is greatly to be 493 welcomed. The noble Lord, Lord Walton, has no doubt provided the leadership necessary to change those attitudes and I congratulate him on that. I say to him that in 1980 it would have been inconceivable for an orthodox medical practitioner, especially one of his eminence, to have agreed to lead an inquiry of this sort. That is evidence of how much attitudes have changed.
We have seen progress in the medical profession but now it is time to see it in the Department of Health. The Government's response to the report, at least in writing, seems to be encouraging although there are some uncertainties, especially about time-scales. The intentions seem to be good but what about the delivery? What concerns me—I hope that the Minister will forgive me if I sound churlish—was the Government's response to the Psychotherapy Bill, which was introduced by the noble Lord, Lord Alderdice. Mental illness is an omnipresent feature of our society. One in four Members will experience it at some time in their lives. Like CAM, it is bedevilled by uncertainty about clinical outcomes and general fear; lack of clear guidelines on quality standards for training and treatments; and some embarrassment among users. Such users may feel that mental health is for wimps and that having a cold is okay but that with mental health one should have a good brisk walk and a cold bath, after which one will feel better.
The noble Lord, Lord Alderdice, managed to stitch together the elements of the psychotherapy profession and put forward a proposal along the lines of the recognised professional bodies for chiropractors and osteopaths. I am afraid that the Minister's response on Second Reading was to push the proposal into the long grass. I was very disappointed by that. He said, in effect, "Yes, it is a good idea, but the time is not yet right". I hope that there is no long grass in the Government's response to the report.
There is a huge pent-up demand for CAM out there. I have three simple examples. Boots the Chemist, our largest high street chemist shop, is now changing several of its branches so that they provide alternative medical treatment. At its High Street Kensington branch, in an extremely valuable piece of retailing space—the whole of the second floor—electrical appliances, greetings cards, records and CDs have been got rid of in favour of a CAM centre.
On my second example I declare an interest as the director of a hospital company with 1,000 beds in 20 hospitals around the country. The company does acute and mostly elective surgery and all the time we see a demand for alternative therapies. As a company we cannot vet practitioners. We need a series of clear yardsticks. We have that in conventional medicine because admitting rights can be tied to consultants who have had, or who have, NHS contracts or who can be subject to the medical advisory committee, which is made up of doctors practising locally. For CAM we have no such yardstick. Our reputation, if we allow people to practice in our hospitals, is at stake. We need a regulatory framework for CAM on which we can rely.
494 Thirdly, finally and most critically for me, I had a brief personal journey to alternative medicine. A year ago I was diagnosed as having prostate cancer. I had a radical prostatectomy—that is, to speak plainly, removal of the prostate—and subsequently six weeks of radiotherapy. It was all handled with care and 100 per cent professional skill and diligence.
The noble Lord, Lord Winston, talked about the vulnerability of patients. Believe me, one is vulnerable when one has had one's prostate removed, when one is told that one's PSA is rising again, when the doctors are saying, "Once the radiology is finished, that's about it", and when only palliative not curative options are available. In doctors' speak, that means that one is going to die but die slowly. One is vulnerable. In that situation, one is going to cast around. One is no longer a statistic—it is you who is affected. That is when, for people like myself, a benchmark provided by a proper regulatory framework would be very helpful. Moreover, as the noble Lord said, patients in that condition get a bit depressed. That is a combination of the effects of the treatment and the options that lie ahead. It was then that I was introduced to a reflexologist who specialised in gynaecological and prostate bladder problems. It was that or more pills on the NHS—pills on the NHS which were paid for by the taxpayer or reflexology which I paid for myself. I have since then used, slightly cynically I have to say, reflexology in various 30-minute sessions and it has been remarkably successful. I have felt better; the NHS has saved money; and a conventional orthodox doctor's time, which I would have occupied in consultation, is available for others.
Given all that evidence, the Government need to move with urgency. There are always reasons for not acting urgently. When I was in the other place we worked on a report called, Prevention and healthcare: Everybody's Business. Two of our key recommendations were turned down. I read from the Government's response:In making some recommendations the Sub-Committee may have assumed certainty where none in fact exists. Examples are recommendations 42 and 45 which propose action by the Government to inform the public of risks arising from the consumption of certain foods including fats, and recommendation 53 which suggests the introduction of a national breast cancer screening service for women. Whilst the Government accepts that decisions must sometimes be taken in the face of uncertainty about consequences, its assessment, in the light of expert advice … leads it to conclusions which differ from those which the Sub-Committee reached. Clearly the Government cannot wait for absolute certainty before taking action; on the other hand, it would seem wrong to use resources or interfere with individual liberty if there is real doubt".Breast screening and fat in the diet: those of us who were not doctors who were on that committee could see the statistics that showed breast cancer rising year by year; we could see that overweight people died of heart attacks more often than thin people. Yet for some reason at that stage the Government could not give the urgency required to those two problems. I hope that will not be the Minister's reaction in his reply tonight.
495 I ask the Government, amid the many splendid reactions and proposals of this report, to adopt two priorities; first, to improve education and knowledge so as to close the gap between orthodox and alternative medicine. As the noble Lord, Lord Walton, said, it means that there is a need for medical students to be educated about CAM; for nurses, midwives and health visitors to become familiar with it; and for us to ensure that continuing professional education of all doctors and other health professionals takes place. After all, this is an area where knowledge, information and expertise is advancing all the time.
The Government must encourage the publication of research into alternative medicine. I felt that one of the most depressing sentences in the report was on page 121 where the committee received evidence from Exeter University that,the paper based on orthodox medicine treatment was more likely to be accepted for publication by an orthodox medicine journal than the identical paper which provided the same results for a CAM treatment".It is a shame if that is true because information is what we need.
Secondly, the Government must encourage the emergence of professional organisations which will lead to a regulatory and training framework. I am sure that that will need some pump priming. From my knowledge the professions are still too weak and fragmented. The efforts of the noble Lord, Lord Alderdice, were remarkable in pulling together the psychotherapy profession. They need to be duplicated elsewhere and where there is a will there is a way.
I conclude by saying that I am not starry-eyed about CAM. I would not trust my prostate cancer to a practitioner of, for example, crystal therapy. I wanted and received conventional invasive surgery and radiological follow-up. Equally, orthodox medicine does not provide all the answers. The trick must be for the various disciplines to work in harmony; to relieve the hard-pressed NHS; to spread the burden currently carried primarily by orthodox medical practitioners and thus, above all, to improve the health of the country.
§ 8.15 p.m.
§ Lord Haskel
My Lords, I too begin by congratulating the noble Lord, Lord Walton. As somebody who sometimes cannot remember what I had for breakfast, I congratulate him on his encyclopaedic knowledge of medicine and his instant recall of matters medical. It amazed me and many of our witnesses on many occasions. The noble Lord also set a tone of tolerance for this inquiry and that was well judged, because I soon found out what my noble friend Lord Winston knew already: CAM is something about which people have particularly strong feelings and not a few prejudices.
I know nothing about medicine—orthodox, contemporary or alternative; but I have my prejudices and they were generally pro-orthodox and anti-complementary. But during our work I learnt that that attitude is not universally shared. As our report states, 496 some 40 per cent of the UK population had used an alternative or complementary medicine or therapy, and Professor Strauss told us that the equivalent proportion in the United States is 42 per cent. In Asia, the number must be nearly 100 per cent. So CAM plays an important role in people's health.
That was brought home to me by the media response to our report. Almost all the broadcasters, magazines and newspapers reported our paper. So I should not have been surprised at the large number of individuals and organisations who responded to your Lordships' committee. As the noble Lord, Lord Walton, said, those responses were numerous and varied. Many welcomed our report, particularly our call for regulating accreditation and training and setting high standards. Others criticised it. A few angrily rejected it. One letter was quite the most acerbic I have read for many years.
The noble Lord, Lord Soulsby, referred to angry responses. The reason for that anger was that we had either omitted a therapy or did not accept that some treatments were effective, regulated and professional. Indeed, the practitioners of the Ayurvedic medicine were so outraged that, as the noble Lord, Lord Walton, told us, they arranged a seminar for us at the Indian High Commission and brought over several eminent practitioners and researchers to convince us. I found their evidence was convincing.
But that was after our report was published. Of course we explained that they should have done all that beforehand. We explained how the system works and that we are a committee of your Lordships' House. Of course all correspondents and organisations, pleased or angry, received a courteous reply from the noble Lord, Lord Walton, one of the members of the committee or from the committee's Clerk. But I wonder whether that is good enough. Perhaps we should do better.
Some correspondents accused us of arrogance. I do not agree. But perhaps that could be justified if we do not respond adequately. Members of Parliament respond because they are elected representatives. If voters do not like their response, they can vote them out of Parliament. People cannot do that with us and that is a reason why we should be more and not less responsive.
It seems to me that we should have a mechanism that allows people to discuss our reports, whether or not they agree with our recommendations—remember, we are creating yet more committees dealing with matters of great public concern such as animal testing and stem cells. After all, only five weeks ago, in this very Chamber, we were emphasising the importance of this kind of dialogue when we were debating science in society. We said how important dialogue is in building up public trust when dealing with scientific matters that affect people's everyday life. We spoke of how public dialogue assists decision-making and acceptance, especially where information is incomplete. It is also more democratic.
The point about democracy is important because many of the responses to our report on CAM came from minority ethnic and religious groups. They were 497 obviously unaware of how the call for evidence works and how the House of Lords committee system works. I would hate to think that, because of that, they feel excluded from debate and from the democratic process. It seems to me that those arguments point towards a structured dialogue to follow up our reports. Perhaps this is the structure within which we can revisit topics. Perhaps this is an initiative that can be taken up by POST or the Parliamentary and Scientific Committee on some kind of systematic basis. I hope that the House authorities and the committee will give that matter consideration.
How would I justify our report to those who have responded, especially to those who think that we have double standards: one for orthodox medicine and one for their particular therapy? I would start by saying that in science there is an uneasy balance between dispute and consensus. The evidence clearly showed that some CAM practices, such as Chinese herbal medicine, rely on consensus for justification that may go back a thousand years, but much of which has not been tested.
A number of those therapies, such as osteopathy, have proved to be safe and effective and have been assimilated into medical practice. They appear in the first group, as described by the noble Lord, Lord Walton. They have been accepted because people disputed the earlier consensus. That led to trials and research, which in turn led to a deeper understanding of the therapies and established the fact that they are safe and effective beyond the placebo effect.
Other therapies have yet to go through that process. It is essential that they should because our now deeper understanding of science may help to explain those therapies. Indeed, we are now beginning to learn that if the human body is reduced to its tiniest components, something is lost. A more holistic approach is perhaps more in keeping with the human condition. Our greater understanding of the immune system is beginning to explain how herbal treatments or acupuncture can boost our resistance. We are also learning how our immune system responds to stress and what meditation can do to reduce stress. That is why we are strongly in favour of research to determine those matters and of regulation to ensure that the treatments are properly administered.
The Government, in their response, rightly mention the need for regulation to be light so as not to stifle innovation and progress. Our purpose in seeking more regulation is to ensure safety and high standards. I welcome the Government's support in their response. My noble friend Lord Rea reminded us that some of the work to achieve those high standards is being carried out at Exeter and Southampton Universities. I compliment them on their work and the time and trouble they took to assist the committee.
I agree with my noble friend Lord Turnberg: research shows up the dangers and, once revealed, orthodox medicine is quick to react. That does not appear to be the case with CAM. It is often the case with CAM therapies that safety is based on tradition and philosophy, whereas in today's world we demand 498 scientific research as evidence. No longer can it be claimed that because people feel that a therapy is helping them, it cannot be harmful. During our work we learnt that St John's Wort was shown to be harmful when taken together with other drugs. I want all therapies, complementary or orthodox, to take their place in modern medicine, but all must justify their place by regulation and research.
That does not mean that orthodox medicine and CAM should be polarised. On the contrary, we need both. As the noble Lords, Lord Winston and Lord Hodgson, reminded us, CAM operates well in areas where orthodox medicine fails, in disorders such as allergies or chronic fatigue syndrome, and in quality of life therapies. We never have all the knowledge that we would like, so there is always risk.
In our Science and Society paper we discussed risk. We discussed the fact that if people are convinced of the benefits of a certain science, they will be more accepting of its risks. Surely CAM is the supreme example of that. The noble Earl, Lord Baldwin, told us of the high satisfaction of patients. Some people are so convinced of the benefits of a particular therapy that they are prepared to accept any risk. Indeed, that conviction has been the justification for some therapies by CAM practitioners over the years. But time has moved on. In this day and age we have to define those risks to enable people to make an informed choice. That is one of the main reasons for our recommendations.
I cannot close without thanking Stephen Holgate and Simon Mills, our specialist advisers. We had the unique experience of visiting Simon Mills's clinic where we saw herbal medicine being prepared for despatch around the world, and the therapists in action. We also had the opportunity to speak to some of his patients. All that provided me with an important insight for our work, as did the visit to the homeopathic hospital.
Our clerk, Chloe Mawson, coped with an extraordinary amount of evidence: 180 submissions. I extend my grateful thanks to her for making that manageable. I thank, too, my colleagues for their companionship. Some are eminent in the field of medicine, but not for one moment was I made to feel inferior. This was a fascinating study. I hope that it will change attitudes and, in that way, that it will help to improve the nation's health.
§ 8.20 p.m.
§ Lord Pearson of Rannoch
My Lords, I start by declaring an interest as patron of the Register of Chinese Herbal Medicine, which, with some 400 members, is the main body of Chinese herbal medicine practitioners in this country. It forms part of the European Herbal Practitioners Association, which represents professional herbalists throughout Europe and which gave evidence to your Lordships' committee. The RCHM also works closely with the Chinese Medicine Association of Suppliers, about which I shall say more shortly.
499 I am happy to add my congratulations to the noble Lord, Lord Walton of Detchant, and his committee on their landmark report. As he may be aware, the conclusions are not entirely satisfactory to our Chinese herbal medicine practitioners. Nevertheless, the fact that your Lordships' House has provided such a wide-ranging and penetrating report on complementary and alternative medicine is a great step forward. CAM is at last being taken seriously.
In common with many other noble Lords I was somewhat dismayed when the original membership of your Lordships' committee to consider this matter was first proposed in the autumn of 1999. Accordingly, I wrote to the noble Lord, Lord Walton, as did other noble Lords. The cause of our dismay was that the membership of the committee as proposed by your Lordships' Science and Technology Committee did not appear to include any noble Lord with specialised knowledge of CAM. Perhaps I may take this opportunity to thank the noble Lord, Lord Walton, publicly for his letter of 12th October 1999 in which he said that he and his committee would have in mind the possibility of co-options to its membership when the future membership of your Lordships' House was known. As your Lordships will recall, that was somewhat in doubt at that time.
I, and other noble Lords, am grateful that the noble Lord, Lord Walton, was as good as his word and that his committee subsequently co-opted the noble Earl, Lord Baldwin of Bewdley and my noble friend Lord Colwyn. I feel sure that their presence on the committee contributed to the wisdom and balance of the report that we now have before us.
As it is the practice in your Lordships' House to speak from personal experience when possible, perhaps I should reveal how I came to be such a firm supporter of Chinese herbal medicine and Chinese acupuncture. Some 15 years ago my former wife was unfortunate enough to grow a lump on her throat. It was diagnosed by Harley Street as being a nonmalignant thyroglossal cyst and was duly removed by surgery, leaving a rather nasty four-inch scar. The operation concerned is not a matter of simple skin surgery. It requires several days in hospital and involves quite deep surgery into the neck and throat.
After about three years another lump grew and Harley Street duly obliged with another operation and another scar. When a third lump appeared some time later, my wife heard of Chinese medicine and consulted one of our leading practitioners, Mr Ken Lloyd. By treating the constitutional cause of the cyst and not merely cutting out the symptom, or the lump itself, he was able to make the lump disappear. That was 10 years ago and no lump has since reappeared. From time to time it shows signs of doing so, but a short course of herbs sends it away immediately.
Then three years ago my 17-year old mentally handicapped daughter developed violent eczema on the back of her head, about which the conventional trichologist could do nothing. And so my daughter eventually ended up on cortisone ointment, which also failed. She was cured completely in three months by a course of Chinese herbs.
500 I could tell your Lordships several similar stories from among my friends, as word spread of the extraordinary efficacy of Chinese medicine when western medicine had failed. There was, for instance, the lively 12-year old daughter of the chief president of St John Ambulance, who is an entirely practical lady, I assure your Lordships, and not one to dabble in the "mumbo-jumbo of Chinese herbs", as she put it, unless sufficiently desperate.
Her daughter had picked up a kidney infection in an NHS hospital and after three years of treatment on antibiotics from an expensive Harley Street consultant, was getting rapidly weaker. She had to he taken out of school and was told that she would have to be on antibiotics for the rest of her life. We began I o fear that she was losing the battle.
In desperation, her mother took her off to Mr Lloyd, who first strengthened her immune system, which had been severely compromised by such a long period of ever stronger antibiotics, and then he killed the infection itself. Four months after starting on Chinese herbs, she was back in the netball team and eight years later remains entirely healthy.
I could go on. Your Lordships could have a word with no less a personage than the chairman of the 1922 Committee in the other place, one of whose daughters had a similar experience and who has also now been cured for several years of a very serious illness which conventional medicine failed to cure and for which she was told she would have to remain on western drugs for the rest of her life. So much for a little of my personal experience of Chinese herbal medicines and acupuncture.
As I fear that I shall be accused by those who adhere solely to conventional medicine of being anecdotal. or even giving in to delusions caused by the placebo effect, I suppose that I had better come to my main criticism of this report, which is so laudable in so many other ways. It is that although the report rightly places herbal medicine in Group 1 as a professionally organised alternative therapy, it manages to relegate Chinese herbal medicine to Group 3. Likewise, although it places acupuncture in Group 1, it demotes traditional Chinese medicine (TCM), (which, as I understand it, invented acupuncture some 5,000 years ago and has been at the forefront of the craft ever since), to Group 3. Relegation to Group 3 is a serious matter, given the committee's view expressed in the second paragraph of the report's summary, which I now quote:While the question of efficacy was not included in our initial terms of reference, in the absence of a credible evidence base it is our opinion that the therapies listed in our Group 3 cannot be supported unless and until convincing research evidence of efficacy, based upon the results of well designed trials, can be produced. Such evidence must be capable of showing that the effects of any therapeutic discipline are superior to those of the placebo effect. It is our view that for those therapies in our Group 3, no such evidence base exists at present".I can only assume that because the question of efficacy was nothing included in the committee's initial terms of reference, they did not exactly exert themselves in the quest for the colossal and credible evidence base which does indeed exist.
501 I understand that there is a growing body of research available in the English language to add to the many volumes in Chinese and Japanese, all of which demonstrate both the efficacy and the physiological mechanisms which lead to its positive outcome.
Indeed, if the definition of "useful research evidence" extends beyond randomised controlled trials—and that is one of the welcome approaches recommended in the report—I gather that the evidence base for Chinese herbal medicine would be supported by literally thousands of Chinese and Japanese research papers which use collected histories and outcome studies to demonstrate efficacy.
In these circumstances, I have to ask the noble Lord, Lord Walton, and his committee how many cases such as those I have quoted from personal experience, of which there are many thousands of examples in this country, would be necessary to convince them to withdraw their strictures. Perhaps the noble Lord would care to give me some form of answer when he comes to wind up.
However, the committee's conclusions are even more perplexing when one comes to a recent article written by Mr Michael McIntyre in the Journal of Alternative and Complementary Medicine in which he criticises your Lordships' report in the following way. Mr McIntyre is Chairman of the European Herbal Practitioners Association and I believe that his strictures must be taken seriously. He states that:their Lordships were incorrect in saying that no evidence of efficacy exists for Group Three therapies. Both written and oral evidence was presented to the Select Committee, mentioning trials involving Chinese herbal medicine. One trial that was specifically mentioned, published in 1998 in The Journal of the American Medical Association (Bensoussan et al., 1998) showed Chinese herbal treatment to be effective for treating irritable bowel syndrome. Another trial that was brought to the Committee's attention was one carried out by doctors from the Great Ormond Street, Royal Free and Middlesex Hospitals in London demonstrating the efficacy of Chinese herbal treatment in the treatment of atopic eczema (Sheehan et al., 1992). The dermatologists who wrote this paper commented that Chinese herbal treatment 'affords substantial clinical benefit in patients whose atopic dermatitis has been unresponsive to chemical therapy'.He goes on to state:Had it been clear that the Select Committee would consider questions of efficacy as part of its terms of reference and that this could lead to the demotion of traditional medicines systems of China, India, and the Middle East to Group Three, practitioners of these modalities would have been able to provide a wealth of scientific evidence in support of their effectiveness".He gives other examples but the evidence appears in the magazine. He continues:While there may be concerns about the quality and safety of some Asian medicines, there is surely no reason to question the efficacy of TCM and Ayurveda, which are used by approximately half of the world's population with published research on a worldwide basis. The fact that the Select Committee placed homoeopathy, the scientific rationale of which continues to be rejected by the scientific community, in Group One merely underlines the report's blatant Eurocentric bias in its evaluation of traditional medicine systems in the Near and Far East".502 That is strong stuff and I hope that your Lordships do not think me cowardly if I quote Mr McIntyre at such length. I do so because he speaks with greater authority than can I.
As Mr McIntyre also says, the report is not justified in relegating Chinese acupuncture and herbal medicine to Group 3 because of any self-regulatory shortcomings. The RCHM has a clearly defined code of ethics and good practice; a core curriculum, together with other herbal traditions, which is being implemented and properly accredited; a dynamic programme of continuing professional development; a research programme which publishes regular safety and efficacy data; and a democratically elected council supported by a busy central London office. The RCHM is a member of the European Herbal Practitioners Association and is actively participating in the rigorous process of applying to the Department of Health for statutory self-regulation.
I am aware that in the past there have been some problems with some supplies of Chinese herbs but the RCHM now works closely with the Chinese Medicine Association of Suppliers, which meets once a month. Together they submit to good manufacturing practices (GMP) as originally established for the manufacture of pharmaceutical drugs in the USA. Requirements to qualify for GMP status vary from country to country but it is generally recognised that the Australian Government's Therapeutic Goods Administration's standards are equivalent to the highest international GMP standards in the world; higher in fact than the United States FDA. It is to the Australian TGA standards that RCHM and CMA now submit and the best factories in China have made great efforts to upgrade their facilities in order to be internationally certified under this rigorous Australian GMP regime.
I heard the noble Lord's introduction to the debate, but I must still ask him whether he and his committee will think again about the placement of Chinese herbal medicine and acupuncture in Group 3. I feel sure that there may be other disciplines, such as Ayurvedic medicine, which would merit a similar review. I am sure that the noble Lord and his committee will be aware that there has been quite a bit of negative press comment, picking up on the lack of support in the report, and so it is important to resolve this matter as soon as possible.
Finally, there is in addition one other lacuna in the report which it might be helpful to put on the record. In paragraph 1.20 the committee reported that overall UK retail sales of herbal medicine in 1999 were around £100 million. It helpfully reported that those sales were rising fast, up from £63 million in 1994 and predicted to be £126 million in 2002, reflecting the growing use of herbal medicines. But I feel that it would have been helpful if the committee had given comparative figures for the total pharmaceutical market sales so that we could have some idea of the size of the conventional medicines industry compared with that of herbal medicine.
According to the Royal Pharmaceutical Society, which is the source of the figures for herbal medicines that I have just mentioned, total pharmaceutical 503 market sales, excluding hospital sales, amounted to £7,593.4 million. On that basis, the conventional medicines market is at least 75 times larger than the herbal medicines market. I mention these figures because they help to show the colossal size of the conventional medicines market. Of course, that is only one way to compare the size of the two sectors. Conventional medicine, through the drug companies and other institutions, also spends huge amounts of money on research which herbal medicine does not need to spend in quite the same way, because most of the research has been conducted over the ages and the ingredients do not need a laboratory for their manufacture.
In short, what we are looking at in conventional medicine is one of the planet's most powerful vested interests. Human nature being what it is, it must be very frustrating to those powerful vested interests to see their market undercut and undermined by a very much cheaper, and sometimes very much more efficacious, competitor.
It is against that background that I was very relieved to read in paragraph 14 of the Government's response to the report that they will recognise the diversity of practice and hold discussions with herbal interest groups to consider the way forward. I am sure that that we are all most grateful for that. I remember, too, that in 1994 the Department of Health was leaned on by the Foreign Office to be extra good "Europeans", and so fool's gold-plated an EU directive to propose a massive licence fee for each herbal medicine of, I believe, some £80,000. This total folly would simply have sent the whole herbal medicines practice underground, including Chinese herbal medicine which in this country uses about 400 herbs.
So, those of us who have benefited from herbal medicine and wish to see it grow and prosper will have to be on our guard, and we shall be. Of course we wish to see herbal medicines adequately regulated, but with as light a touch as possible consistent with the aims of this largely excellent report upon which, once again, I should like to commend the noble Lord, Lord Walton, and his committee. However, I should be most grateful if perhaps he could reassure me on the major point which I put to him when he comes to reply.
§ 8.43 p.m.
§ Lord Howie of Troon
My Lords, the noble Lord, Lord Pearson of Rannoch, made a very powerful and impressive case. It tailed off towards the end when Europe came up, but that did not surprise the House very much. However, the noble Lord might have been more conciliatory towards the noble Lord, Lord Walton of Detchant, who I believe offered an olive branch to the Chinese herbal business, as far as I understood his remarks at the beginning of the debate. The welcome given by the noble Lord, Lord Pearson, was rather more lukewarm than I thought appropriate.
I turn to more immediate and joyous matters. I enjoyed the committee very much, although my own background in technological matters lies in physics, 504 especially that branch described as "mechanics". I understand things like structures and was not at home with the kind of science with which the committee dealt. However, I listened with great care.
The spread of the committee was interesting. There were two true believers, two healthy sceptics, of whom I was one—I remain so—and in between was a rainbow coalition of people with a variety of views, some of which changed and some of which remained the same. The report was described as "unanimous". I thought that that was going a little too far. I would have agreed to "nem con" because of the guidance of the chairman, who was not only firm and fair but also extremely cunning. The noble Lord did not persuade me to support the report with the zeal and enthusiasm that he would have liked, but he made me give in. I thought that that was quite reasonable on my part.
As a sceptic, I ask what "medicine" means and what qualities a therapy requires to come within the meaning of that word as I understand it as a lay person. I would have thought that there are two or three characteristics. First, there must be a diagnostic element; otherwise to me it is not medicine. Secondly, it must have curative, not just "feel good", properties. Thirdly, there must be a scientific basis to understand how it works. We must also understand how it continues to work or, possibly, does not continue to work.
It is against the background of those three characteristics that I look at the classifications in the report. It is not enough to make a patient feel good, nor, as one witness put it, to promote spiritual and physical wellbeing. One can do that by a walk on the heath, but that is not really medicine, is it? If one turns to the classifications, the first group appears to be reasonably sound, with the qualification that has been made in respect of the Chinese objections. I have my doubts about homeopathy. I have diluted a little of what-you-like-does-you-good. I shall get on; otherwise, we shall be here all night.
The second group does not embrace diagnostic skills. That makes me feel uneasy, especially as it includes meditation and healing. I worry about that.
The third classification is divided into two parts. Some of them offer diagnosis but are indifferent to the scientific principles of orthodox medicine, and some are based on philosophies. During the committee hearings a number of philosophers outlined their philosophies. Some of them were very interesting, by which I mean weird or somewhat strange. Some of them were not weird. I believe that to base a medical therapy on a peculiar philosophy is unsound; or at any rate a Newtonian physicist would not like it. Others had no credible evidence base.
While there were critical comments relating to the classifications in the report, I believe that they were too general. I would have been much happier had we itemised each of the therapies—I cannot remember how many there were—and set against them our appreciation of their strengths and weaknesses, dealing with each one individually. I tried to persuade the committee to do that but apparently it had better ideas of its own.
505 I turn to one of the therapies. I refer to the therapy known as healing or spiritual healing, which is, as one of the witnesses told us, akin to prayer. People have been praying for good health for many years, and a great deal of good it has done them.
I should like to point to two questions in the oral evidence. They are Questions 1693 and 1694. Unless someone points it out, they were put to the healer by me. I asked about distant healing. It was alleged that one could cure by healing at some distance. It did not require the laying on of hands, although I am told that that sometimes happens. They had carried out some studies. The interesting reply was:Certainly in one of the studies that was carried out, the patients did not know that they were receiving distant healing in the form of prayer and also their doctors did not know that they were receiving distant healing in the form of prayer and yet the results were very very positive".There we are.
The healers also claimed to be able to carry out group distant healing. Therefore; if there is a group of people who are all ill they can be treated from a distance, presumably without them or their doctors knowing. I asked them to suppose that this group, however large—they mentioned a group of 1,000 in the United States in some test that they had done—suffered from a great variety of different illness, some of them diseases, some of them sore backs and a variety of things—eczema and so on—did that pose a problem for the spirit healer? The answer was no. Apparently one can heal people with a variety of diseases at a distance although they and the doctors do not know that one is doing it. We should have these people immediately in high places in the National Health Service. There is a good deal of talk about saving money. They would save a great deal of money.
I did not find that terribly convincing. The word "magic" came into my mind. Some of my friends described it as "mumbo-jumbo", but that is not the kind of language we should use in this House. The word "magic" is adequate. It reminded me of something that all noble Lords and their families will have experience of. That is of a child playing in the street who trips over his feet. It would always be a boy. He trips over his feet and grazes his knee. He immediately creates a hullabaloo and cries of pain emerge from him. His mother comes along. She cuddles him. She almost always says, "There, there now. It'll be all right in a wee while". Then she says, "I'll kiss it better", and she does.
Does anyone actually believe that the cuddle, the kissing better and the kindly words really heal the grazed knee? They make the child feel better. That is a good thing. That is the good thing in quite a number of these therapies about which we were informed. They make people feel better. They should be commended for that because making people feel better is clearly good. But it is not the feel-good factor which heals the grazed knee. In all probability the grazed knee, even if one puts Vaseline on it—or whatever one does—heals itself. That is a recurrent feature of the curative qualities of orthodox as well as unorthodox medicine.
506 That is almost all I have to say about the report, but I want say something about the manner in which we deal with committee reports in this House. We try to get a consensus or a unanimous report. The chairman feels that if the report shows clear indications of dissent, or even disagreement, as it were, that would diminish his report. I do not believe that. One result is that we are very reluctant, although it sometimes happens, to permit amendments to the report during consideration of the debate of the final version of it.
I do not think that that is sound. We should follow the practice of the other place which permits amendments. It votes upon them and the reports are not diminished in any way. I am supported in this matter by looking at the Companion to the Standing Orders. It is paragraph 9.32 of the recently revised version of the Standing Orders. It states:A report from a committee embodies the text agreed by the majority of the committee."—" Not unanimous, not even nem con but the majority of the committee.—Members of a committee may not make a minority report".We accept that.However, members who wish to express dissent may move amendments to the chairman's draft report or propose an alternative draft report. Amendments moved or alternative drafts proposed are recorded in the minutes of proceedings of the committee, together with a record of any vote. The minutes of proceedings are published with the report whenever a difference of opinion has been recorded in a division".That is a general remark about the general procedure in this House. It is not in any way a reflection of the procedures of the committee. I wish that to be made absolutely clear in case anyone is in any doubt.
I conclude by quoting the comment which cheered me up most in the evidence which we received. It came from Professor Lewis Wolpert. It is at paragraph 2.17 of the report. Professor Lewis Wolpert of the Academy of Medical Sciences told us that:Medicine aims to base itself upon science. I am sorry that any complementary or alternative medicine procedure for which one can see no reasonable scientific basis should be supported".I agree with that. That means that I am very sceptical about many of the CAM proposals which came before us. That raises a question which I must answer. Since I am sceptical, does that mean that I would wish to ban these therapies? The answer must be no. I am not a banner. We have tried twice this week to ban things in this House. On Monday we tried to ban fox hunting. I disapprove of that ban thoroughly. Yesterday, we set out to ban tobacco advertising. That is also preposterous and an interference with the liberty of subjects. In this case we are talking about the rights of people to treat their ailments in whatever manner they think and in whatever manner suits them best. Regardless of what I think, they should be permitted to do so. The report permits them to do so and I commend it.
§ 8.59 p.m.
§ Lord Clement-Jones
My Lords, tonight we have had a fascinating and expert debate. Before the very lively speech of the noble Lord, Lord Howie, I was 507 going to say that the committee speakers tonight had really demonstrated how well integrated their perspectives were, as they appeared to be in the report.
I join other noble Lords in congratulating the noble Lord, Lord Walton, on the report and on his chairmanship of the committee. I congratulate him on his stamina in so doing and also his stamina this week, because his prodigious speech-making efforts have resulted in his speaking in all three of the debates just mentioned by the noble Lord, Lord Howie.
The timing of the report was excellent. Shortly after the publication of the committee's report, a major conference in London organised by the Royal College of Physicians and the US Government's National Centre for Complementary and Alternative Medicine took place. They took great heart from the committee's report. In fact, the BMJ published a special edition on integrated medicine to coincide with that conference. That, itself, was significant. It is a far cry from its "Beyond Science" editorial of 20 years ago, which decried complementary medicine. We have come a very long way.
I have always been broadly sympathetic to complementary medicine because of my background. Research into enkephalins conducted by my late wife, Dr Vicky Clement-Jones, demonstrated the physiological basis of acupuncture. I am also connected with the British School of Osteopathy and have benefited from osteopathy myself. I am glad that the committee gave great encouragement to those in category 1 to seek registration, in particular, those engaged in acupuncture. I welcome the Government's encouragement to acupuncture practitioners in particular.
I am clearly not alone in being sympathetic to complementary medicine. We heard from the noble Lord, Lord 'Walton, how —1.6 billion a year is spent on complementary treatments. A recent NHS survey showed that 5 million patients consulted a CAM practitioner in 1999. We have heard the percentage of the population which now uses alternative and complementary medicine and how that percentage is higher both in the US and in Germany, where it has reached 65 per cent. The fact is, however, as the Chief Executive of the Foundation for Integrated Medicine recently said:Unfortunately those patients who would most benefit from integrated healthcare are those who can least afford to pay for it".A sign of the times, as the noble Lord, Lord Hodgson, pointed out, is that Boots the Chemists has opened two pilot stores in Kensington and Milton Keynes which have available professionals such as homoeopaths, physiotherapists, reflexologists, herbalists and osteopaths. That is an extremely interesting development. There is growing professional support for it too, as is charted in the report. At the NHS Alliance annual conference in October, 63 per cent approved expanding NHS provision of complementary medicine. As we have heard today, CAM is increasingly practised in a conventional medicine setting. The noble Lord, Lord Rea, was particularly interesting in that respect. General practitioners are now offering access to CAM 508 and 40 per cent of medical schools in the United Kingdom now offer courses in CAM. Primary care groups are establishing contracts with CAM practitioners.
The cause of a sensible evidence-based approach to complementary and alternative medicine has been much advanced by the committee's report on its superb examination of CAM, its therapies, practitioners, the state of research and the relationship with conventional practitioners. Its key conclusions have been rehearsed today and I shall not repeat them, especially now that the Government have come up with their response. I would say, however, that, caught as the Government now are between the hammer of the Prince of Wales and the anvil of the House of Lords Select Committee, I very much hope that they will be devoting adequate resources to research in this area. I rather share the views of those noble Lords who looked askance at the precise nature of the Government's commitment in this respect. The use of the words "research capacity" rather than "research resource" is rather significant. I hope that the noble Lord, Lord Burlison, can give an assurance in that respect.
The amount currently spent on CAM research is pitiful. As the Prince of Wales, the Foundation for Integrated Medicine and the committee in its report have pointed out, it is inadequate. Only 8p is spent for every £100 spent on orthodox research. The King's Fund, in its typically farsighted way, has started the ball rolling with a grant of £1 million and I hope that more private donations will be forthcoming as the profile of complementary medicine and research into it rises. The quality and quantity of research are clearly improving, as the BMJ recently pointed out, but research is inadequate even in disciplines such as acupuncture.
Sometimes, however, even where the research is adequate, there is poor communication about what research exists. A respectable broadsheet paper such as the Independent—1 notice it with my background—can still say as it recently did about acupuncture:The process by which it works remains a mystery but that it could have some effect is scientifically plausible".If the paper had done five minutes' research work, it would have found that there is considerable evidence in that respect. That is fairly ignorant even in the light of the existing research. How much worse is the situation in other areas of complementary medicine?
The report has had some criticism, principally from the noble Lord, Lord Pearson. I take some comfort from the fact that, while that may be criticism from one end of the spectrum, there was equal criticism from the other end. The late lamented John Diamond made considerable criticisms of the report from his perspective as a diehard anti-complementary medicine journalist, but the one key point that he did make was a powerful case for there to be no double standards as between complementary and orthodox medicine. I firmly agree with him on that. I thought that the committee struck the right balance in that respect.
509 It is extraordinary, however, to think that the research base of conventional medicine—randomised controlled trials—which we now regard as a scientific yardstick for evidence-based medicine is only a postwar development. Major pharmaceutical advances have been made from natural substances. After all, we know that Taxol is derived from yew and aspirin from willow bark. As a result, conventional practitioners should respect the benefits when the evidence is there that certain herbal remedies such as St John's Wort for depression—its pedigree goes back to Hippocrates—or gingko for dementia are effective. On the other hand, practitioners need to make it clear that they support an evidence-based approach. By the same token, we should all recognise danger when it is present, particularly when products are sold as food supplements.
However, I offer a few words of caution on the purely evidence-based approach. I was very taken by what was said by Dr Andrew Weil when he came over to speak to the committee, as regards not dismissing the placebo response. He has already been mentioned by the noble Lord, Lord Colwyn. Dr Weil is a well-known American practitioner of complementary medicine and is the director of a key programme on complementary therapies in Tucson. I hope that most doctors would agree that a positive mind-body response, if it cures, is in fact better than a course of drugs. I also entirely agree with him about the desire of patients to spend some time with their doctor, along with their desire to be treated holistically, as a spiritual entity as well as a physical body. Many noble Lords have touched on that aspect of complementary healing. I believe that conventional medicine has much to learn in this respect and that, as Dr Weil has suggested, the integrated medicine movement will become much stronger over the years.
I shall offer a further word of caution: the paradox here is that the public appears to prefer personal recommendations on CAM treatments to any kind of scientific evidence. Indeed, one of our key tasks is to restore trust in science and scientists. The noble Lord, Lord Haskel, quite rightly raised this point.
I do not normally sell House of Lords publications, but in this context, I always recommend another report from the Select Committee on Science and Technology, Science and Society, which was published in February and which we debated recently. The report tackles in depth the issue of public trust. I hope that we can sell the two reports in companion volumes. That would be the best way forward.
§ 9.10 p.m.
§ Lord McColl of Dulwich
My Lords, I, too, add my congratulations to the noble Lord, Lord Walton of Detchant, on what can only be described as an extremely important and thorough piece of work and altogether a brilliant job, especially when one considers the great variety of views and numerous conflicting interests in this field. No doubt he also had a little difficulty in controlling the noble Lord, Lord Howie of Troon.
510 Much of what I had planned to say has already been covered and emphasised by many noble Lords who have contributed to the debate. But I should like to stress that one of the strong points of our National Health Service is that the general practitioner acts as the gatekeeper. There are very good reasons for that. The patient is protected against too many eager beaver practitioners of whatever kind, and the GP keeps track of what medications the patient is receiving. I am sure that the Select Committee was absolutely right to recommend in paragraph 9.37 that,all NHS provision of CAM should continue to be through GP referral (or by referral from doctors or other healthcare professionals working in primary, secondary and tertiary care).Most of the speeches from noble Lords have rightly stressed the need for research into CAM, but it also has to be said that we need to continue to look critically at the efficacy of orthodox medicine. It is essential to keep an open mind in scientific research because so often it reveals surprises. Some while ago a carefully conducted trial was carried out to see what would be the best treatment for warts. Four methods were tested: cutting them out; burning them out; freezing them out; and charming them. The most successful treatment was charming them out. Several conclusions could be drawn from that, but there is no doubt that high morale does boost the immune system. Of course the reverse is also true: low morale diminishes the effectiveness of the immune system. If a man loses his wife, if she dies after they have been married for some years, he is then in danger of dying within a year of cancer or recurrent infections. That is especially the case if he does not grieve properly. Thus high morale is very important to ensure that the immune system functions well.
In the past, people have made the mistake of disregarding unlikely therapies. In Holland it was said for years that liquorice was good for healing duodenal ulcers, but that was pooh-poohed. Eventually it was proved to be the case and the active principal, carbonoxylone sodium, was isolated. Nearer to home, a dry-cleaner noticed that a fluid he was using in his business made him rather drowsy. He wondered whether it would be an effective anaesthetic agent. Because he believed in trying things out, he successfully anaesthetised his wife. When he approached one of the Royal Colleges with his discovery, at first he was received enthusiastically and taken in. But when he was asked which hospital he worked in, he said that he was only a dry-cleaner, so he was dismissed out of hand. We have to keep an open mind and seek evidence-based orthodox medicine and alternative medicine. Even more important than keeping an open mind is to retain a touch of humility.
It is often not only a shortage of resources which keeps people from doing effective research; it is also a shortage of good ideas and determination. As has already been said, acupuncture is widely integrated with mainstream medicine and is used in more than 80 per cent of chronic pain services. There is sound neurophysiological evidence to support its efficacy.
511 As the noble Lord, Lord Clement-Jones, said, some of the earliest work was performed by the late Vicky Clement-Jones, who demonstrated an increase in endorphin levels in the cerebral spinal fluid after acupuncture in patients with chronic pain. Research workers now believe that they have found the mechanism responsible for the sustained effect of acupuncture, which has been apparent to clinicians who are familiar with these techniques.
A high proportion of musculoskeletal pain arises in trigger points. One of the best recognised trigger points lies in the muscle that is responsible for the shrugging of the shoulders; on deep palpation it is tender in almost every subject. Anatomically, it equates to the site of the acupuncture point known as GB21. There are many more examples of this close correspondence between trigger points and acupuncture points.
As has been mentioned, the randomised control clinical trial is the gold standard in evidence-based medicine. It is, of course, vital to find whether a treatment is more effective than an apparently identical placebo treatment. When testing new drugs, this is quite straightforward; but in research into the relief of pain by acupuncture it is difficult to devise a valid control procedure for the subjects, and virtually impossible to have the therapist in the dark about what treatments he is giving. Placebo relief of pain appears to work by stimulating endogenous opioids, which is a mechanism shared at least in part by acupuncture. The problem is that if you have a placebo effect by sticking needles in elsewhere, they too will work.
To try to overcome this difficulty, an attempt was made to compare four groups of patients with pain in their neck. It was done in four different ways: first, standard needling; secondly, superficial needling; thirdly, a drug called diazepam; fourthly, a placebo diazepam. All the groups, apart from the placebo diazepam group, had significant improvement in their pain. There is now good scientific evidence for relief by acupuncture of pain, nausea, vomiting, dental pain and low back pain.
What should acupuncture practitioners be called? Doctors who use acupuncture would like to retain the term "acupuncturists". Perhaps they should be called "medical acupuncturists", as opposed to those who practice traditional forms, who could perhaps be called "traditional acupuncturists".
So far as concerns teaching, we shall have a major problem if there is any suggestion of doctors having to undergo several hundred hours of instruction in traditional acupuncture theory. This would require the suspension of belief in much of the conventional and neurophysiological bases.
In summary, the report of the committee of the noble Lord, Lord Walton, has made an enormous contribution to the subject. It will be a great move forward towards having a much better system, which I trust will be better for patients, practitioners and science.
§ 9.18 p.m.
§ Lord Burlison
My Lords, the Government have already welcomed the Select Committee report. In fact, our response shows that we have already begun to implement many of the recommendations in which we have a role to play. Although I know that noble Lords have had little time to consider the Government's response, I thank them for their general acceptance of the report and their kind comments during this excellent debate.
However, I should like to add my voice to the many notes of appreciation for the work of the sub-committee that have been expressed during the course of the debate. The fact that the report has been so well received in both Houses is testimony to the professionalism and objectivity with which the subcommittee approached its task and, if I may say so, to the quality of the chairman—a great man, of course, from my own county, Durham.
We are most fortunate to have so many medical experts in your Lordships' House. My noble friend Lady Castle was particularly grateful that the noble Lord, Lord Walton, was on hand yesterday to help her. I am pleased to say that she has now returned to her home. We look forward to her return to your Lordships' House.
The report published the results of what I believe to be the first comprehensive inquiry into complementary and alternative medicine in the UK by a parliamentary Select Committee. The committee received written evidence from many leading individual experts and professional organisations on both complementary and orthodox medicine.
This debate has touched on the main themes in the report: regulation, education and training, research and the evidence base, information and National Health Service use. It has also mentioned the way in which the report has introduced some structure to the CAM world by classifying CAM therapies into three groups.
I recognise the difficulty in making any generalisation about such a diverse range of therapies. But I think it important that we begin to introduce more structure into the very diverse world of complementary medicine. This might at least help patients and the general public to understand better what they are dealing with.
We do, of course, recognise the difficulty of classifying traditional health systems which, being rooted in cultures that are very different from ours, have not yet come to be fully understood by western science. We have therefore suggested a collaborative arrangement between organisations representing those systems and the professional bodies which regulate the leading components of these traditional systems; namely, acupuncture and herbal medicine.
The structure suggested in the report also provides a useful basis for improving the regulation of complementary therapies. Those practising the complementary therapies listed in Group 1 are already regulated on a statutory basis, or are recommended to give serious consideration to applying for regulation. 513 The acupuncture and herbal medicine professions were specifically recommended as early candidates for statutory regulation under the Health Act 1999.
In view of the potential public health risks posed by unskilled practitioners of acupuncture and herbal medicine, the Government accept that statutory regulation of these therapies is desirable and should be achieved as soon as practicable. Officials have held preliminary discussions with organisations representing both therapies.
Other groups need to progress to the point where each therapy has a single organisation to regulate it on a voluntary basis. In time, the Government would be prepared to consider extending statutory regulation to some therapies in Group 2. But a good case would have to be made for each candidate; most of its practitioners would have to support this move; and there should be a single organisation to regulate the whole profession concerned.
The noble Lord, Lord Hodgson, referred to the Bill introduced by the noble Lord, Lord Alderdice, on the regulation of psychotherapists. The Bill is currently going through Parliament. The noble Lord suggested that I had tended to kick it into the long grass. The Government would support the statutory regulation of psychotherapy, but they were not persuaded that the model that has been proposed is the best way of achieving that. I am sure that we shall continue those discussions with the noble Lord, Lord Alderdice. Whatever may develop from them, the ability and efforts of the noble Lord, Lord Alderdice, in pulling together the various groups of psychotherapists was an achievement which, I admit, was not within the ability of the National Health Service.
What really matters is that, if complementary medicine practitioners are to be recognised as respected members of the caring professions, each of their professions must put in place a sound regulatory framework that will raise standards and protect patients. We have emphasised that in our response. We also emphatically agree with the report's recommendation that only those therapies which are fully regulated could be made available to National Health Service patients.
I should tell my noble friend Lord Winston and the noble Lord. Lord Soulsby, that it will take time to put strong regulation in place in all therapies. However, improved sources of information will educate the public as to the qualifications and regulation to look for in practitioners. At the same time, we have made available a guide on continuous professional development for practitioners, which should help them audit their practice with the guidance of their professional body.
Regulation of products is also important. Following extensive consultation with UK interest groups, we are now working with our partners in Europe on proposals for a directive on traditionally used medicines. The aim is to provide a framework for the effective regulation of traditionally used medicines, including herbal remedies, balancing public safety and consumer choice.
514 In fairness, I turn to the question for the need to recognise the Ayurvedic and traditional Chinese herbal medicines, as raised by the noble Lord, Lord Walton. In the European discussions on the draft traditional medicines directive, the UK is arguing that that measure should take account of the herbal traditions from outside the European Union. I hesitate to say this to the noble Lord, Lord Pearson of Rannoch, although I know that he will take it in the right spirit, but it is possible that Europe could come to his rescue on this particular issue.
An important function of professional regulation is that of setting standards for training and education. More work needs to be done in setting standards for the training of new complementary medicine practitioners, and of existing healthcare practitioners who want to practise complementary medicine. It is important for the professional bodies involved to agree clear standards, and to work closely together in the process.
The Government agree that all qualifications in complementary medicine should be assessed by the regulatory body that grants the licence to practise the therapy concerned. We should also welcome more standardisation of qualifications within each therapy. This would simplify the recognition of qualifications and make it easier for members of the public to judge the qualifications that practitioners claim to offer.
Healthwork UK, as the national training organisation for the health sector, has a key role to play in developing national occupational standards in complementary medicine. We have now commissioned that body to undertake further work in the area, which should help clarify the standards to which new practitioners should be trained before they begin practising.
Mention has also been made of the need for more research in complementary medicine. However, I believe it is understood that what complementary medicine needs is better, not just more, research. The most popular therapies need at least to be underpinned by more definitive, high-quality research evidence. That will take time to produce, but the opportunities are there for researchers to train in the techniques that they will require. The academic expertise is beginning to come together to help co-ordinate research efforts. However, we recognise the need to develop further research capacity in this field. We shall, therefore, be asking the National Health Service Research and Development Workforce Capacity Implementation Group to consider research capacity development needs in complementary medicine, and how these might be met. One option to explore is that of funding fellowships within the department's priority areas, including funding for pilot projects.
The noble Lord, Lord Colwyn, and other speakers, mentioned the issue of financing. Indeed, the noble Lord even suggested that it might be my way to fame, but I doubt that very much. I can tell the noble Lord that the exact amount of funding will depend on the outcome of the early discussions with those who can take forward such matters. As regards what the 515 Government are likely to do in this area, I can tell the noble Lord, Lord Smith of Clifton, that we have received written strategies for taking forward research in complementary medicine from three organisations. We find it very encouraging that people are now looking at research in a strategic way. Our response addresses many of the proposals in those strategies, but we shall now go on to discuss with those organisations how to develop and take forward a common strategy for research in complementary medicine.
In the meantime, the Department of Health welcomes applications to fund research projects which include complementary medicine provided that they offer a clear link to one of the NHS priority areas. For example, the NHS Cancer Plan identifies the need to review the evidence of complementary therapies in relation to supportive and palliative care and, as our response states, the department will be seeking high quality proposals for work in this area.
I fully accept that information on complementary medicine, such as it is, needs to be carefully synthesised and made available in a more user-friendly way both to the wider public and to health professionals. The provision of better information for patients is a key feature of the NHS Plan, and work is now in hand to include complementary medicine in the information that will be made widely available.
Our response makes it clear that we expect the National Electronic Library for Health and NHS Direct to be the main conduits through which information on complementary medicine will be made more widely available in the future.
NHS Direct Online already includes some basic information on complementary medicine, and is planning to run a specific feature in April this year. The possibility of including electronic links from NHS Direct Online to other reliable sources of information will also be considered.
To complement that, the Government have already commissioned the Foundation for Integrated Medicine to produce an information leaflet on complementary medicine for patients and the public and provide supporting electronic information.
Complementary medicine can, of course, play a part in treating NHS patients. But if complementary medicine is to be accepted alongside other forms of NHS treatment it must meet the same standards. It must be clear and realistic about the contributions that it can make. It should work in an integrated way with other forms of treatment. Effective regulation of practitioners is essential, as is an appropriate evidence base for the treatments that they offer.
The noble Lord, Lord Walton of Detchant, made a point about primary care groups. We are aware that some concerns have been raised about the impact that these groups are having on the amount of complementary medicine available via GP practices. We agree that the situation should be monitored and the medical care research unit at Sheffield University is already doing that on our behalf.
516 The Government have issued a basic information pack on complementary medicine for primary care groups. The pack focuses on those therapies which are most commonly encountered in NHS primary care and offer advice as to how they might be incorporated into local services. The feedback that we have received suggests that many found it helpful.
Towards the end of this year the National Institute for Clinical Excellence will publish evidence-based guidance to the NHS on supportive and palliative care for cancer patients. The guidance will aim to improve the quality of life for all those affected by cancer. One of the issues that NICE is considering is the potential benefit that cancer patients can derive from complementary therapies.
The Committee's report sets out an authoritative agenda for change. Some of the complementary medicine professions have begun making the improvements they need to secure a more lasting place in public affection. They must now drive forward these changes more decisively, and the professions which have still to put those changes in hand must do so more urgently.
I close by reiterating the Government's welcome for the report. We believe that its main recommendations will do much to protect the interests of patients and consumers. We have been as supportive as possible in our response to the report's recommendations and I hope that that will help to reinforce them. The report will undoubtedly be regarded as a benchmark for complementary and alternative medicine for some years to come.
§ 9.35 p.m.
§ Lord Walton of Detchant
My Lords, it is customary on these occasions when winding up to spend most of one's time responding to what the Government have said about one's report. One of the good reasons underlying that principle is that—I speak from experience in having presented several such reports in the past—on many, many occasions the Government have not found it possible to accept the recommendations set out by a Select Committee. It is rare, in fact unknown in my experience, to find that every single recommendation set out in a Select Committee report is approved and accepted by government. For that reason I can only express on behalf of the sub-committee, which I had the privilege of chairing, our gratitude for the fact that the report has been so greatly welcomed by government.
As the noble Lord, Lord Burlison, has said, it is crucially important that regulatory frameworks be devised for those professions in CAM which are not yet properly regulated in the interests not only of the professions but, above all, in order to protect patients.
I shall return to one or two points made by certain members of my sub-committee. I am deeply grateful for their support, as I said at the outset, and for their endorsement of the principles underlying our report. I offer to the noble Lord, Lord Winston, my thanks for his support and endorsement as chairman of the 517 parent Select Committee. Many of us are sad that his term of chairmanship of that Select Committee has come to an end.
I say to the noble Lord, Lord Soulsby, that it is important—as he rightly said—that safety is one of the paramount features of our report. The noble Lord stressed that. Reference was made to the crucial importance of regulating herbal medicine. That relates to a point made by the noble Lord, Lord Pearson of Rannoch. That was one of the cornerstones of our recommendations.
I shall return to the comments of the noble Lord, Lord Pearson, in a moment. I can only repeat that we recognise to the full that in Ayurvedic medicine, as practised for centuries in India and in ancient Chinese medicine as practised for centuries in China, many valuable herbal remedies have been identified and many of them have been introduced into western medicine with great success and great efficacy. Indeed, the seminar on Ayurveda that we attended at the Indian High Commission was not concerned with the principles set out in some of the documentation relating to the diagnostic capability of Ayurveda and the principles underlying the practice, but presented to us the scientific results of carefully designed trials of single herbal remedies which would certainly fall into our Group 1 of herbal medicine. That was stressed at the seminar. We would do exactly the same in relation to ancient Chinese herbal remedies. Our problem is that some of those consist of huge concoctions of herbal preparations where it is not easy to obtain consistency and where it is very difficult to determine the active principles involved. But as Ayurveda and Chinese medicine begin to develop the same kind of procedures as are practised now in western herbal medicine clearly those preparations will come into our Group I. There is no doubt of that at all.
As the noble Lord, Lord McColl, said, acupuncture has become an important part of western medical practice. But, on the other hand, as regards the ancient Chinese system of depending upon changes in the pulse resulting from acupuncture and of the identification of acupuncture points corresponding to organs of the body, there is no scientific or credible evidence to support that concept. We encountered difficulties on those issues and on the diagnostic capabilities of ancient Chinese medicine and Ayurveda which is why we classified them in Group 3.
The noble Lord, Lord Smith, spoke about a non-patronising attitude of the conventional medical profession. The report demonstrates that patronising attitudes are a thing of the past. Equally, as the noble Lord made clear, we were aware of the sensitivities involved in analysing the situation.
The noble Lord, Lord Turnberg, stressed the crucial importance of research. The Minister referred to that. We believe that the nature of these mechanisms and therapies are subject to examination by research. The noble Lord, Lord Pearson, and others will agree that there is not just the randomised double-blind control trial. That is still the gold standard in conventional medicine. There are other mechanisms of research. 518 One can do sequential trials, comparing one remedy with another in sequence; one can do cross-over trials, comparing remedies by crossing over from one to another; and one can carry out trials comparing the best known conventional treatment against a complementary or alternative treatment. Many techniques of research are available. One of the cornerstones of the government response is their wish to see funding devoted from the government R&D budget to research fellowships to train complementary practitioners in research methods and to help them to associate in an integrated way with schools of medicine and other centres of excellence. My committee will greatly welcome that desire.
The noble Lord, Lord Colwyn, referred to the partnership between the doctor and the patient. The relationship between the patient and healthcare professionals is crucial. As the noble Lord said, much of what we learned about complementary and alternative medicine has proved to be effective, in particular (although not entirely) in chronic, degenerative and progressive diseases. There are circumstances where some complementary remedies have been shown to be helpful in acute illness. But many have worked best largely in the chronic disorders.
I felt a little uncomfortable—I fastened my jacket—when the noble Earl, Lord Baldwin, talked about the bulge of the elderly. But as he said, we were an elderly committee. That is perfectly true. On the other hand, we were people of experience not only in conventional medicine but also complementary and alternative medicine. The outstanding support of noble Lords as co-opted members, and their enthusiastic but critical discussion of the evidence, were enormously valuable.
The noble Lords, Lord Rea, and Lord Turnberg, stressed the placebo effect. We know that the placebo was the cornerstone of medical practice before the Second World War because we had at that time so few effective remedies in conventional medicine. But, as the noble Lord, Lord Rea, said, in conventional medicine, we have concentrated on compassion, communication, understanding, release of stress and on the management of the worried well—a group of people in whom complementary and alternative practitioners often produce such effective results.
The personal testament of the noble Lord, Lord Hodgson, was moving. His help and support for integration between conventional medical treatment and complementary treatment were one of the cornerstones of the report.
I am grateful for the comments of the noble Lord, Lord Haskel, about my memory. I am grateful for the support of the report in general terms by the noble Lord, Lord Howie. I clearly remember our discussions about whether the noble Lord would wish to table an amendment. He may remember that we agonised over a specific section of the report; the noble Lord had an alternative to offer. Before lunch he indicated that he would wish to propose an amendment, the procedure for which is set out in the Companion to the Standing Orders. The committee agreed to return to the 519 discussion after lunch, by which time, I regret to say, the noble Lord was no longer present in the Committee.
§ Lord Walton of Detchant
In any event, my Lords, I am very grateful for the noble Lord's support and I appreciate the points that he made. He made a number of comments about spiritual healing, which was one of the disciplines about which we had some difficulties and anxieties. The same applied, to some extent, to homoeopathy, although it has been practised in the National Health Service for many years. Some of the scientists who gave us evidence said that they could not understand how a remedy that did not contain a single molecule of active substance could work, yet the noble Lord, Lord Soulsby, and his colleagues were able to produce some evidence that homoeopathic remedies worked in the animal kingdom, where it was difficult to see that the placebo effect could be active.
Those are some of the problems that we faced. Throughout, we were aware of the words of the Bard:There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy".Some of what we learned was not easily subject to scientific explanation, but nevertheless required further validation and investigation. We were concerned to find no fewer than 12 UK organisations purporting to support healing and spiritual healing. We had no concrete evidence, although we learned of certain trials that had failed to demonstrate any effect. We wished to give warm support to regulation and further investigation in that area.
We are grateful to the noble Lord, Lord Clement-Jones, for the welcome that he gave on behalf of his colleagues to the report. He is right that there has been a sea change in attitude on the part of the medical profession towards complementary and alternative medicine. The situation now is quite different from what the British Medical Journal published 20 years ago.
The noble Lord, Lord McColl, rightly told us that the evidence base of some conventional medicine—indeed, much of it—is still weak. He gave us a number of important examples. He stressed, as we did, the role of the GP gatekeeper as regards access to complementary and alternative medicine in the NHS. We were certain of the crucial importance of that. As a surgeon, the noble Lord knows that millions of dollars have sometimes been spent on research into various aspects of conventional medicine. He will remember that millions of dollars were spent on trying to discover whether, after a stroke, an intracranial-extracranial bypass made any difference. Many surgeons believed that it did, but after five years of investigation it was shown that that procedure, which is no longer performed, was ineffective. Those lessons from conventional medicine need to be taken on board as the whole field of complementary medicine is studied.
520 Finally, I am grateful to the noble Lord, Lord Burlison, for pointing out one important aspect of our report that I did not stress before. Herbal medicine needs closer regulation. We recommend that it should become regulated under the Health Act. The Government have confirmed that. The important point is that herbal remedies can never achieve the same standard of safety and regulation as is necessary in standard pharmacology, but under the European directive they require much closer and more effective regulation than exists at present. We are glad that the Government have confirmed that view.
I do not propose to speak any longer except to say that it has been a privilege to have chaired the inquiry and I am grateful for the warm response given by the House and for the kind things that my colleagues have said. We are particularly grateful to the Government for their positive response to our recommendations.
On Question, Motion agreed to.