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NATIONAL SURVEY OF ACCESS TO COMPLEMENTARY HEALTH CARE VIA GENERAL PRACTICE
Final Report to Department of Health
August 1995
Kate Thomas Margaret Fall Gareth Parry Jon Nicholl
Medical Care Research Unit SCHARR
Regent Court 30 Regent Street Sheffield S1 4DA
KJT /MCRU / 1995
CONTENTS Page List of tables and figures Abstract 1 Background 3 Study aims 4 Methods 4 Sample size and character 4
Pilot study 5
Data collection 5
Results 6 Response rate 6
Representativeness of the sample 12
Available data sets 19
Availability of complementary therapies via general practice 20
• Access to different complementary therapies 22
• Provision within the practice: estimates and characteristics 25
• NHS referrals for complementary therapies 31
GP behaviour in consultations in past week 33
• GP behaviour in relation to different therapies 33
• Differentials in behaviour by characteristics of GPs 36
• Estimates of GP activities in an average week 38
Discussion 43 Acknowledgements 48 References 49
Index of Tables and Figures Page Table 1 Response rate: by mailings
7
Table 2 Comparison of response rates: all national studies, involving postal questionnaires to GPs, published in 1992-1994 in the British Journal of General Practice
7
Table 3 Comparison of response rate: all local studies involving postal questionnaires to GPs, published in 1994 in the British Journal of General Practice
8
Table 4 Representativeness of data: analysis of partnership size
10
Table 5 Representativeness of data: analysis of fund-holding status
11
Table 6 Spearman Rank correlation co-efficients for relationship between response rates for each FHSA and for known characteristics of FHSAs
14
Table 7 Access to complementary therapies: estimates based on unweighted data compared with estimates based on data weighted to take variation in FHSA response rates into account
14
Table 8 Unweighted data: proportion of practices indicating access to complementary therapies by number of mailings received
15
Table 9 Representativeness of data: analysis by GP age group
15
Table 10
Representativeness of data: analysis by sex of GPs
16
Table 11 Unweighted data: proportion of GPs indicating use of complementary therapies by number of mailings received
17
Table 12 Weighted and unweighted data by partnership size of GP
17
Table 13 Proportion of partnerships providing access to complementary therapies via treatment within the practice or NHS referrals. Estimates of provision weighted by type of response
21
Table 14 Characteristics of practices offering access to complementary therapies via primary health care team, independent therapist or NHS referral
21
Table 15 Complementary therapy provided by type of provision
23
Table 16 Complementary therapy via general practice by FHSA of responding practice and response rate
24
Table 17 Provision within the practice by type of practitioner and therapy offered
26
Table 18 Mode of provision within practice by therapy
27
Table 19 Who pays for complementary therapies provided within general practice by therapy
28
Table 20 If NHS provision, source of funding for complementary therapies
in general practice by type of practitioner
30
Page
Table 21 NHS Referrals outside the practice for complementary therapies
by place of reference
32
Table 22 NHS referrals outside the practice for complementary therapies by source of funding
32
Table 23 Complementary therapies in consultations in one week: a) The number of GPs treating patients with complementary therapies, referring for such therapies, or recommending/endorsing treatments; b) the number of occasions each action was performed; and c) the average weekly interventions per GP reporting the action, d) the average weekly intervention per GP in England by therapy (weighted data)
34
Table 24 Complementary therapies in consultations in one week: a) The number of GPs giving a neutral response to a patient enquiry about complementary therapies or advising against their use; b) the number of occasions each action was performed; and c) the average weekly interventions per GP reporting the action, d) average weekly intervention per GP in England by therapy (weighted data)
35
Table 25 Complementary therapies in consultations in the last week: estimated proportion of GPs treating, referring or endorsing treatment by age group, sex and status of GP (weighted data)
37
Table 26 Complementary therapies in consultations in the past week: estimated proportion of GPs treating, referring or endorsing treatment by location of practice (weighted data)
37
Table 27 Estimated proportion of GPs treating, referring or endorsing complementary therapies by therapy (weighted data)
39
Table 28 Estimated proportion of GPs giving neutral or negative response to enquiries about complementary therapies by therapy (weighted data)
39
Table 29 Complementary therapies in consultations in the last week: GPs who gave a neutral response or advised against, by GPs giving treatment, referring, recommending or endorsing treatment (weighted data)
41
Table 30 National estimates of treatment, referral and recommendation/endorsement of complementary therapies in GP consultations in an average week
42
Figure 1 Groups of patients or conditions mentioned by GPs treated by complementary therapies within the practice
30
ABSTRACT
Study aims: To describe the scale and scope of access to complementary therapies
obtained via general practice with particular reference to acupuncture, chiropractic,
homoeopathy, hypnotherapy, medical herbalism and osteopathy.
Design: A postal questionnaire relating to provision of complementary therapies in
the practice as a whole, and to consultations in the past week, was sent to 1226
individual GPs in a random cluster sample of GP partnerships in England, taken from
24 FHSA lists. GPs received up to two reminders. A follow-up survey of all non-
responders was undertaken, requesting answers to three key questions.
Subjects: GPs from a random sample of 1226 (one in eight) GP partnerships in
England.
Main outcomes: Description of the scale and scope of access to complementary
therapists via general practice, including provision within the practice and NHS
referrals outside the practice. Estimates of the proportion of GPs treating, referring
and endorsing the use of complementary therapies in consultations in a one week
period.
Results: Seven hundred and sixty GPs returned the completed questionnaire, a
response rate of 62%. In addition to this, 204 (16.6%) non-responders replied giving
basic information. Responders appear to be representative of GP practices in
England with respect to known characteristics, and to the provision of complementary
therapists when compared with non-responders.
Analysis by practice showed that an estimated 39.5% (95% CI 35%-43%) of GP
partnerships in England now provide access to some form of complementary therapy
for their NHS patients. An estimated 21.4% (95% CI 19%-24%) are offering access
via the provision of treatment by a member of the primary health care team, 6.1%
(95% CI 2%-10%) employ an ‘independent’ complementary therapist, and an
estimated 24.6% of partnerships (95% CI 22%-27%) make NHS referrals for
complementary therapies. Of the therapies investigated, acupuncture and
homoeopathy are the most commonly provided, although the most frequently
employed independent practitioners were osteopaths.
Fund-holding practices are significantly more likely to offer complementary therapies
via a member of the primary health care team than non-fund-holding practices,
(P = <0.05), and single-handed GPs are significantly less likely to offer this service
(P = <0.01
In most cases, the complementary therapies provided within the practice were offered
by GPs (64%), and provision was split equally between regular clinics and normal
surgery time. 17.4% of the provision within the practice (including that offered by
independents) was paid for by the patient. 12% of fund-holding practices in the
sample (20/161) used savings or practice funds to purchase complementary therapies
for their patients within the practice.
Of the referrals, those to NHS homoeopathic hospitals were the most commonly cited,
followed by referrals to other NHS hospitals for acupuncture. The scale of this
provision cannot be ascertained accurately, but one referral per month was the
frequency most commonly cited by those GPs who made any such referrals. Of the
fund-holding practices an estimated 9% (14/161) reported using savings to fund such
referrals.
It is estimated that 45% of GPs recommend or endorse a complementary therapy in
their consultations in an average week, 21% refer a patient for complementary therapy
(private or NHS), and 10% treat a patient with one of the named complementary
therapies. On this basis, it is estimated that 14,900 (95% CI 12507/17302) treatments
with one of these complementary therapies are given by GPs in an average week,
750,000 in a year.
Conclusions: Access to complementary therapies in general practice is widespread
amongst practices, but appears to affect a relatively small number of patients.
Acupuncture and homoeopathy are the therapies most commonly offered within
practices by the primary health care team, and also the therapies for which NHS-
funded referrals are most commonly made. Manipulative therapies are more likely to
be offered by independent therapists working within practices, the majority of whom
appear to be NHS funded and offer their services free to NHS patients. This type of
provision is found in relatively few practices, but has the potential to affect a greater
number of patients.
BACKGROUND
The popularity of complementary medicine continues to be asserted by the
professional associations and umbrella organisation’s related to these therapies(1) and
this has been confirmed to some extent in pilot work recently undertaken here in the
MCRU(2). The BMA report on complementary therapies was very much more
favourable than its predecessor published in the 1980’s(3,4) and work undertaken by
the National Association of Health Authorities and Trusts (NAHAT) of the views of
NHS purchasers towards complementary therapies in 1992 also revealed largely
positive attitudes towards its provision on the NHS.
Within primary care, provision has been facilitated by changes in the GP contract (in
1990) and the subsequent introduction of GP fundholding. Non-fundholding GPs, for
example, are using the ancillary staff budget to employ complementary therapists,
whilst fundholders are able to use the staff element of their budgets and `practice
savings’ for this purpose (for which prior approval of the FHSA is not required) (5) In
addition, GPs may make private referrals or provide a complementary therapy, such
as homoeopathy, themselves.
A study of GP fundholders undertaken by NAHAT in 1992 has reported that
independent complementary therapists practised in 14 out of a sample of 101 fund-
holding practices, half of whom provided the service free of charge to NHS patients(6).
However, the low response rate achieved (43%) gives cause for concern that the
results may be biased in favour of those practices which have a positive attitude
towards complementary health care, and it is therefore unlikely that 14% of all fund-
holding practices offer such a service to their patients. The NAHAT survey did not
obtain information on activity within non-fund-holding practices.
A survey of a representative national sample of GP practices was therefore
undertaken to ascertain the extent to which access to complementary health care is
currently gained through general practice.
AIMS AND OBJECTIVES OF STUDY
This nationally representative survey has the following three aims;
1) To describe the patterns of access to complementary health care via general
practice (mode of delivery, type of practitioner) with particular reference to
acupuncture, chiropractic, homoeopathy, medical herbalism and osteopathy.
2) To quantify the scale of provision, including NHS referrals to practitioners
outside the practice, and the volume of treatments conducted within the
practice.
3) To describe the relationship between practice characteristics (including
location) and the distribution of access to complementary health care gained
via general practice.
METHODS Sample size and character
The study focuses on GP partnerships as the main unit of analysis and this was
reflected in the sampling strategy employed.
Random cluster sampling was used to select partnerships from all those in England
(fund-holding and non-fund-holding) within a geographically distributed sample of
FHSAs. As activity with respect to complementary therapies may be related to local
FHSA policy, a large sample of 24 FHSAs (one in four) were sampled, three chosen at
random from each of the eight new Health Regions. Within each FHSA we randomly
sampled one in two practices. In this way, a sample of approximately 1226 practices
was identified (one in eight practices in England).
One GP in each sampled partnership received a letter requesting their participation in
the study. Within each practice, the GP was chosen randomly from the list provided
by the FHSA, so as to achieve a distribution of senior partners and other partners
across the sample, thus giving a further sample of GPs for the analysis of data relating
to individual behaviour.
Pilot study
A small pilot study was undertaken locally to assess the feasibility of the data
collection method, and to obtain feedback on the design of the survey instrument.
Following the pilot, the format of the questionnaire was revised substantially to aid
ease and speed of completion and comprehension. Writing to a random GP within
each practice did not appear to adversely affect response, and this method was
employed in the main study.
Two further questions were added to the questionnaire relating to activity in the
responding GP’s own consultations in the previous week.
The final questionnaire design consisted of two distinct parts which were colour-
coded. The first two sides contained questions which related to the GP’s personal
experiences in their consultations in the past week and the three key “screening”
questions relating to provision of complementary therapies in the practice as a whole.
The second, more substantial part of the questionnaire was structured with a page for
each therapy covering details of provision. This section was only completed by GPs
reporting activity in their practice.
Data collection
The majority of FHSAs provided printed address labels for use in the study and these
were used in all correspondence with the GPs. The sampled GP from each of the
1226 partnerships received the questionnaire with a covering letter from the
researcher.
After a period of two weeks approximately half the GPs who had not yet responded
received a post-card reminding them about the study and requesting them to return a
completed questionnaire. All other non-responders received a reminder letter and a
second questionnaire. After a further two weeks the post-card group received a
second questionnaire. A further letter and third questionnaire were dispatched where
necessary.
A follow-up of all those GPs in the sample who did not respond to any of these
contacts was conducted nine weeks after the initial mailing. This entailed a brief letter
and a request to answer the three key “screening” questions from the questionnaire.
For all mailings, letters were sent out in franked envelopes bearing the University
crest. Printed, reply-paid envelopes were provided for the return of completed
questionnaires.
RESULTS
Response rate
After three mailings, 760 completed forms were returned, giving a response rate of
62%. Of those who did not return forms, 33 wrote declining to participate (2.7%) and
9 questionnaires were returned with an indication that the GP had retired, was on
long-term sick leave, or had left the practice.
A fourth mailing, containing the letter and 3 “screening” questions only, was sent to
the 423 non-responding GPs. Of these, 204 (48.2%) replied, answering the three
questions as requested. Including these responses, information was obtained on a
total of 964 partnerships, 78.6% of the original sample of 1226 partnerships (Table 1).
Table 1 Response rate: by mailings
Sent Returned Completed
Questionnaires returned completed
No. % No. Cumulative %
1st mail 1226 469 38.2 469 38.2
2nd mail 747 150 12.2 619 48.8
3rd mail 556 141 11.5 760 62.0
4th mail (letter only) 423 204 16.5 964 78.6
Table 2 Comparison of response rates: all national studies, involving postal questionnaires to GPs, published in 1992-1994 in the British Journal of General Practice.
Title Coverage Sample size No of GP’s in sample
Reported sick, retired, 1 gone away
Response rate %
Involvement of the primary health care team in coronary heart disease prevention(7)
England 2000 305 64.4
(n=1092)
Annual assessment of patients aged 75 years & over: GPs’ & practice nurses’ views and experiences(8)
England & Wales
10002 none reported 69.3
(n=693)
Telephone & postal surveys of GPs: methodological considerations(9)
England & Wales
1732 49 52.3
(n=881)
Attitudes towards practice nurses - survey of a sample of GPs in England & Wales(10)
England & Wales
48002 41.9
(n=2013)
Patient access to GPs by telephone: the doctor’s view(11)
England & Wales
19802 none reported 74.0
(n=1459)
Access to complementary medicine via general practice
England 1226 33 refused
9 retired gone away.
62.0 (questionnaire) (n = 760)
78.6 (questionnaire & letter) (n = 964)
1 No refusals were reported. 2 Response from any GP in practice accepted.
Table 3 Comparison of response rate: all local studies, involving postal
questionnaires to GPs, published in 1994 in the British Journal of General Practice.
Title Coverage Sample
Reported sick, retired, gone away
Response rate %
Provision of obstetric care by GPs in the SW region of England(12)
South West RHA
424 random
GP’s
none reported
78.5
Anti depressant prescribing: a comparison between GPs and psychiatrists(13)
Cardiff East
123 random
GP’s
none reported
60.0
Written lists in the consultation! Attitudes of GPs to lists and the patients who bring them.(14)
Leicester 58 GP trainers
none reported
84.0
Monitoring anticoagulant control in general practices(15)
Lothian & Fife H. B.
198 senior partners
none reported
Fife 89.1
Lothian 89.6
Fear of aggression at work among GPs who have suffered a previous episode of aggression(16)
West Midlands RHA
2694 random GPs
not reported 40.6
Exploratory study of GPs’ orientation to general practice and response to change(17)
Leicester 110 young principals
none reported
44.5
Fundholders’ referral patterns and perceptions of service quality in hospital provision of elective general surgery(18)
Trent RHA
115 senior partners
none reported
67.0
GPs are frequently pressed for time and do not tend to give research questionnaires
priority. For these reasons, surveys of GPs tend not to achieve high response rates.
Those surveys which are published are likely to have the best response rates. We
identified all national surveys of GPs published in the British Journal of General
Practice between January 1992 and December 1994. The response rate of 62%
obtained from three mailings in our survey compares well with that achieved by these
five national surveys published recently (Table 2). Local surveys are often done to
obtain higher response rates due to saliency and ease of access for follow-up (e.g.
telephone). However, published data suggest such surveys obtain a wide range of
response rates, and that local surveys with smaller sample sizes cannot guarantee
response rates (Table 3).
An analysis of the effect of the post-card reminder sent to half our sample who did not
respond initially, shows that final response rates achieved were identical in this group
and in the group not receiving the post-card (46.3% v. 45.4% respectively). However,
the post-card may have had an effect on the timing of the response; after the second
mailing, 32% of the 404 GPs who received the post-card had responded, compared to
22.4% of those who had not.
Table 4 Representativeness of data: analysis of partnership size1
Single handed Partnerships of:
% 2-3 %
4-6 %
7+ %
Total n = 100%
All partnerships England2 31.5 35.4 28.2 4.9 9111
Partnerships in 24 sampled FHSAs 27.5 34.1 32.5 5.9 2452
1 in 2 sample of partnerships from 24 FHSAs
27.7 33.6 32.9 5.8 1226
Partnerships responding to questionnaire
23.5 34.7 34.9 6.9 760
Partnerships responding to 4th letter with “screening” questions only
29.4 32.4 32.8 5.4 204
All partnerships responding to letter or questionnaire
24.8 34.2 34.4 6.5 964
1 Calculated from information provided by FHSAs, summer 1994.
2 GMS statistics 1st April 1994 England and Wales, National and Regional Tables Department of Health, NHS Exec. HQ., PD (STATS) C, 6E43, Quarry House, Leeds, LS2 7UE Table E&W 07.
Table 5 Representativeness of data: analysis of fund-holding status1
Fundholder2 Non Fundholder Total
n (%) n (%) n = 100%
Partnerships in England and Wales3 2040
(21.1) 7616 (78.9) 9656
Partnerships in 24 sampled FHSAs
517 (21.1) 1935 (78.9) 2452
1 in 2 sample of partnerships from 24 FHSAs
254 (20.7) 972 (79.3) 1226
Partnerships responding to questionnaire
163 (21.4) 597 (78.6) 760
Partnerships responding to 4th letter with “screening” questions only
48 (23.5) 156 (76.5) 204
Total partnerships responding by questionnaire or letter
211 (21.9) 753 (78.1) 964
1 Calculated from FHSA information obtained summer 1994.
2 As at April 1st 1994 (includes 4th wave)
3 Department of Health, NHS Exec. HQ., PD (STATS) C, 6E43, Quarry House, Leeds, LS2 7UE information on 1.12.94.
Representativeness of the samples
The representativeness of the sample of 1226 partnerships and GPs was assessed
by comparing it with all practices and GPs in England with respect to known
characteristics of practice size, fund-holding status, age and sex of GPs. The
achieved sample was also assessed using the same characteristics (Tables 4-7).
Table 4 shows that the sample of 1226 partnerships contained a smaller proportion of
single-handed GPs than are found nationally (27.5% v. 31.5%) and a correspondingly
higher proportion of larger partnerships. The achieved sample of 760 partnerships
also contained proportionally fewer single-handed GPs, although respondents to the
4th mailing containing only the three “screening” questions were more representative
of the population as a whole (Table 4).
Fund-holding partnerships were appropriately represented in the sample of 1226
partnerships, and the achieved sample was equally representative of the population
as a whole in this respect (Table 5).
Despite the good overall representativeness of the achieved sample as measured,
there was a large variation in the response rate achieved for the questionnaires
between the 24 FHSAs sampled, with a range of 47% to 81% around the mean of
62%. Many of this range of responses (16 out of 24 FHSAs) fall outside the response
expected within a 95% confidence interval for response if there was no `clustering’ of
response (59% to 65%), and we therefore examined available information on the
FHSAs to test whether the response rates obtained across the FHSAs confirmed any
of the following hypotheses:
a) Response rates could be negatively correlated with the proportion of single-
handed practices in the FHSA as these practices were known to be under-
represented in the sample as a whole.
b) Response rates might be negatively correlated with the proportion of GPs in
the FHSAs known to have been born outside the UK It has been suggested
that this group of GPs may be less likely to respond.
c) Response rates might be negatively correlated with Jarman Deprivation
Scores for each FHSA.
d) Response rates might be positively correlated with the proportion of
responders in each FHSA stating that in the past week they had treated a
patient with a complementary therapy, referred them for such treatment, or
recommended/endorsed such treatment, or stating that access to
complementary therapies was provided in their practice, i.e. the issue of
saliency and response.
Spearman Rank correlation co-efficients calculated for each of these relationships
showed only poor correlations in each case. With only 24 observations, none of these
correlations reached statistical significance (Table 6).
While no significant, systematic relationship was found between any of the
measurable characteristics and FHSA response rates, it remains possible that the
differences in response rates could still bias the results towards the characteristics of
the FHSAs with the higher response rates. We therefore weighted the data by FHSA,
according to the response rates achieved, and compared weighted and unweighted
estimates of access to complementary therapies (Table 7). The weighted estimates
remained similar to the unweighted estimates. The data were not, therefore, weighted
according to FHSA prior to the analyses presented in this report.
Finally, and perhaps most importantly, are the results obtained from the three
“screening” questions asked in the follow-up letter to non-responders, and returned by
204 GPS (48% of non-responders) These provide strong evidence that the 760
responders to the main questionnaire are broadly representative of the population as
a whole with respect to access to complementary therapies via the practice. The
higher level of GPs reporting any NHS referrals from their practice amongst the ‘non-
responders’ (Table 8) is probably attributable to the inclusion of an exemplification of
the category of NHS referral (e.g. “homoeopathic hospital”) in the screening questions
sent in the follow-up letter to non-responders. This suggests that the proportion of
responders stating that their practice make any referrals for Complementary therapies
might have been higher had we included a prompt for them.
The principal estimates calculated in this report relating to access to complementary
therapies via GP practices have taken the answers given by those non-responders
who returned the follow-up letter to be representative of all ‘non-responders’.
Estimates for the whole practice population have therefore been calculated by
combining estimates for responders to the main questionnaire with estimates for non-
responders, based on responses to the non-responders’ follow-up letter.
An alternative, more conservative, estimate is offered for some key results in which
all practices not replying to the non-responders follow-up letter are assumed to be
non-active.
Table 6 Spearman Rank correlation co-efficients for relationship between response rates for each FHSA and known characteristics of FHSAs
Characteristic of FHSA r N p-value
Proportion of practices single-handed
- .28 24 0.18
Ranked Jarman deprivation scores - .16 24 0.45
Proportion of GPs born outside UK - .32 24 0.13
Proportion of GPs recommending complementary therapies in past week
.21 24 0.31
Proportion of responders from practices offering access to comp. therapies
- .00 24 0.99
Table 7 Access to complementary therapies: Estimates based on unweighted data compared with estimates based on data weighted to take variation in FHSA response rates into account
Access/provision Unweighted data estimates
n = 760
Weighted data estimates
n = 760
Provision by primary health care team
178 173.0
Provision by independent therapist
48 47.3
Referral 160 162.6
Any of these 280 279.6
Table 8 Unweighted data: proportion of practices indicating access to complementary therapies by number of mailings received Provision by
PHCT %
Provision by indep.
therapist %
Any NHS referrals
%
Any
%
N
Response to 1st mailing
27.5
6.6
22.6
40.1
469
2nd mailing 18.7 7.3 21.9 37.3 150
3rd mailing 15.2 4.3 17.4 27.7 141
Non-responders follow-up letter
18.1 5.9 30.4 43.1 204
Representativeness of individual GP data
Questionnaires were returned by 760 GPs. These included questions (in the form of a
grid or matrix) relating to their behaviour regarding the specified complementary
therapies in consultations in the past week. This sample of GPs is representative of
all GPs with respect to age and sex (Tables 9 and 10).
Table 9 Representativeness of data: analysis of age of GPs in years1
Under 30 %
30-34 %
35-44 %
45-54 %
55-64 %
64+ %
Total n =
100%
England2 1.9 16.2 37.1 28.6 14.6 1.6 26387
As % of those respondents giving age3
1.8 12.8 37.6 30.9 16.1 0.8 615
1 Study data obtained from respondents.
2 GMS Statistics 1st April 1994 England and Wales, National and Regional Tables. Department of Health, NHS Exec. HQ., PD (STATS) C, 6E43, Quarry House, Leeds, LS2 7UE. Table E & W 04
3 81% of responding GPs indicated their age group
Table 10 Representativeness of data: analysis by sex of GPs1
Male %
Female %
Total n = 100%
England2 70.8 29.2 28587
Study respondents as %
of those stating sex3
70.7 29.3 605
1 Study data obtained from respondents. 2 GMS statistics 1st April 1994 England or Wales, National and Regional Tables Department of Health,
NHS Exec. HQ. PD (STATS) C, 6E43, Quarry House, Leeds, LS2 7UE Table E&W 07. 3 79.6% stated sex.
The accuracy of the numerical data provided by GPs regarding actions in the past
week is subject to a number of caveats. While a one-week investigation period should
minimise problems associated with recall, it is possible that some GPs have described
a ‘typical’ week rather than an actual week. This may have resulted in an inflation in
the levels of activity reported. Activity levels may also have been misrepresented by
the small number of GPs (30/730) who entered ticks in the cells of the question rather
than giving a number, these entries have been counted as single events. The majority
of GPs (78%) did not fully complete either matrix. However, this appears to have
been due to interpretation of the instructions rather than random omission (i.e. they
did not want to write 0 in the, majority, negative cells). In these cases, a blank cell in a
matrix where at least one cell was completed has been counted as an indication that
no such action took place.
Finally, there is the effect of the response rate to consider; the follow-up exercise with
non-responders did not include questions about individual GP behaviour. However,
the non-responders were found to be similar to responders with respect to practice
provision. The estimates calculated in the following tables are based on the
assumption that GP activity among non-responders is similar to the lower level
reported by those GPs responding to the third mailing of the questionnaire (Table 11).
Where appropropriate, lowest likely estimates are also given, based on the
assumption that all non-responders were non-active with respect to complementary
medicine in the week surveyed. However, these lower estimates are likely to
underrepresent activity as it is unlikely that all non-responding GPs undertook none of
these actions in the week surveyed.
Table 11 Unweighted data: proportion of GPs indicating use of complementarytherapies by number of mailings received.
Response to;
Treatments
n (%)
Referrals
n (%)
Endorsements
n (%)
N
(100%)
1st mailing 68 (14.5) 110 (23.5) 212 (45.2) 469
2nd mailing 18 (12.0) 31 (20.7) 67 (44.7) 150
3rd mailing 10 (7.1) 25 (17.7) 49 (34.8) 141
The achieved sample included responses from a high proportion of single-handed
GPs, compared to the population of GPs in England. This is due to the fact that the
initial sample was of practices rather than GPs. As partnership size may be related to
activity in complementary therapies the data on GP behaviour have been weighted
according to partnership status to ensure that they are representative of all GPs in this
respect (Table 12).
Table 12 Weighted and unweighted data by partnership size of GP
Size of partnership
Unweighted sample n %
Weighted sample n %
England 1
n %
Solo 165 (22.1%) 133 (10.8) 2,870 (11%)
2-3 256 (34.2%) 367 (29.9) 7,880 (30%)
4-6 270 (36.1%) 566 (46.2) 12,192 (46%)
7+ 57 (7.6%) 160 (13.1) 1,485 (13%)
All 7482 (100.0) 1226 (100.0) 26,387 (100%)
1 Unrestricted principals: Source GMS Statistics 1 April 1994 England and Wales Table ETW O6 2 12 NK
Available data sets
Coded questionnaires were entered on to the computer using EPI-Info5 data entry
programme and exported into SPSS for analysis. The data form three subsets as
follows;
1) The data relating to provision and access to complementary therapies in the
practice as a whole, obtained from 760 partnerships initially, plus an additional
204 in response to the letter. (For the purpose of calculating national
estimates of access to complementary therapies, the data relating to these
204 partnerships are included and treated as representative of all non-
responders. In this way an overall estimate is calculated combining
separately weighted estimates for responders and non-responders.)
2) Data giving details of provision (e.g. provision by whom and how it is funded)
is available for the 280 partnerships which reported offering either treatment
within the practice or NHS referrals for complementary therapies (302
instances of provision).
3) Data relating to individual GP behaviour in the past week, obtained from a
sample of 760 GPs, weighted according to partnership size and response
category (n=1226).
THE AVAILABILITY OF COMPLEMENTARY THERAPIES VIA GENERAL PRACTICE
This part of the analysis utilises the 760 questionnaires received which indicated
whether or not the practice, as a whole, provided access to complementary therapies
via provision by the primary health care team, provision by an ‘independent’
complementary therapist not offering the therapy as part of a wider job remit, or
access via NHS referrals for treatment involving complementary therapies. In
addition, where appropriate, the 204 responses received to the fourth mailing are
included in the analysis. These responses are treated as being representative of the
sub-group of non-responders, rather than pooled with the data from questionnaire
respondents.
Table 13 shows that a significant proportion of GP partnerships in England, 39.5%
(95% CI 35%-43%), now provide access to complementary therapies for their NHS
patients. An estimated 21.4% of practices in England (95% CI 19%-24%) are offering
access to one of these therapies through the provision of treatment by a member of
the primary health care team and 24.6% (95% CI 22%-27%) make NHS funded
referrals for complementary therapies. The presence of an ‘independent’
complementary therapist within the practice is relatively rare, an estimated 6.1% of
practices (95% CI 2%-10%). This estimate has the widest confidence interval, but it is
very stable across the two samples and the estimate is probably more reliable than
these intervals suggest
These estimates are based on the assumption that responders are representative of
the population of practices. If non-responders are assumed to be non-providers, the
following estimates can be made; provision of complementary therapies by a member
of the primary health care team 17.5%, NHS referrals by practice 18.1% and provision
via an ‘independent’ complementary therapist 4.9%. However, there is no a priori
reason to believe that none of the non-responders make any provision at all and these
estimates should therefore be understood as the lowest likely estimates or ‘bottom
line’ with respect to provision of complementary therapies.
An analysis of the characteristics of practices offering complementary therapies via
the primary health care team, an ‘independent’ therapist or NHS referrals are shown in
Table 14. ‘Practice location’ was constructed from the answers given by responding
GPs relating to the best description of their practice and the population it served.
‘Inner city’ includes all practices who mentioned this as the best description for all or
part of their practice population. The description ‘rural’ was constructed in a similar
way. ‘Else’ is composed mainly of practices described as having a ‘town’ or suburb
location. Information on fund-holding status includes fourth wave fundholders and
was obtained from the FHSAs, as was the information on the number of partners in
each practice. Table 14 shows that the estimates for the proportion of partnerships
making NHS referrals do not vary substantially with these practice characteristics and
all are below, or at the lower end of the range suggested by the 95% CI for the overall,
weighed estimate (22%-27%). Estimated provision via the primary health care team
varies more with these characteristics. Fund-holding practices are significantly more
likely to offer this type of provision, 27% compared with 21% (P = <.05), and single-
handed GPs are significantly less likely to offer such provision compared with larger
practices (14.3% v 24.8% and 25.4%, P = <.01). Practices serving mainly rural
populations were more likely to offer complementary medicine via the primary health
care team.
The number of practices reporting an ‘independent complementary medicine therapist
in the practice is small, and none of the differences observed in Table 14 reach
statistical significance. All of these estimates are within the 95% CI for the overall
estimate of provision (2%-10%) and the majority fall in the top half of this range.
Table 13 Proportion of practices providing access to complementary
therapies via treatment within the practice or NHS referrals. Weighted estimates of provision and 95% confidence intervals
Respondents
N
Weighted estimates of provision
95% CI for % sampling error1
Primary health care team provision
178 21.4 (19-24)
Independent complementary therapy practices working in practice
48 6.1 (2-10)
Any referral to NHS for treatment
160 24.6 (21-28)
‘Yes’ to any of these questions
283 39.5 (35-43)
1 Confidence intervals have been widened by rounding up and down to help adjust for additional variation not taken into account by treating the achieved sample as fixed.
Table 14 Characteristics of practices offering access to complementary
therapies via primary health care team, independent therapist or NHS referral
Practice characteristic
PHCT
n (%)
Independent1
n (%)
NHS referral2
n (%)
Any of these
n (%)
N
Fund-holding:
Yes 57 (27.0)* 14 (6.7) 53 (23.9) 95(45.5)** 209
No 152 (21.0) 46 (6.1) 152 (21.0) 276 (36.6) 755
964
Practice location:3
Inner City 21 (18.6) 8 (7.1) 25 (22.1) 39 (34.5) 113
Rural 47 (28.7) 14 (8.5) 33 (20.1) 67 (40.9) 164
Else 110 (22.9) 26 (5.4) 101 (21.0) 176 (36.7) 480
757
Partnership size:
1 GP 35 (14.3)** 20 (8.1) 61 (24.7) 86 (34.8) 247
2-3 GPs 81 (24.8) 19 (5.8) 80 (24.5) 137 (41.9) 327
4+ GPs 99 (25.4) 21 (5.4) 81 (20.8) 148 (37.9) 390
964
All (weighted) 21.4% 6.1% 24.6% 39.5%
1 NK 3 2 NK 17 3 NK 3 (excluding 4th mailing Chi square for difference in provision according to practice characteristic (* P = <0.05, ** P = <0.01)
Estimates for provision of any of the three types of provision suggest that
complementary therapy provision is more common in fund-holding practices
(45.5% compared with 36.6%, P = <.01), and appears to be less likely in single-
handed practices (34.8% compared with 39.7% for all other practices), although this
difference does not reach statistical significance.
Access to different complementary therapies
Data on the type of therapy offered is available for respondents to the full
questionnaire only, as the fourth mailing letter did not seek this information. Table 15
shows that access to the different types of complementary health care is not uniform.
Acupuncture and homoeopathy are clearly the most commonly provided forms of
complementary therapy provided by or via general practice. GPs have a long tradition
of offering homoeopathy as part of primary care, and this is reflected in the distribution
of therapies provided ‘in house’ by the primary health care team. More surprising
perhaps is the relative popularity of acupuncture amongst GPs and other memebrs of
the team. A much smaller proportion of ‘in house’ provison relates to the manipulative
therapies (chiropractic and osteopathy). This may be due to the training and
equipment requirements of certain therapies, rather than a reflection of their relative
popularity. Osteopathy is the most commonly provided therapy where an
‘independent’ therapist works in the practice and this form of provision may involve
relatively large numbers of patients.
The sample structure was designed to provide a random one in eight GP partnerships
in England. These partnerships were chosen as a one in two sample from 24 FHSAs.
There was no strong evidence of large variations in provision between the FHSAs
(p = 0.022), with only two FHSAs Humberside and West Sussex, indicating
statistically significant differences from the overall rate (Table 16).
Table 15 Complementary therapy provided by type of provision offered Therapy
Primary health care team
n (%)
Independent
n (%)
NHS referral
n (%)
All instances of provision
n (%)
Acupuncture 96 (43.0) 13 (16.9) 68 (30.0) 177 (33.6)
Chiropractic 5 (2.2) 5 (6.4) 15 (6.6) 25 (4.7)
Homoeopathy 51 (22.9) 6 (7.8) 95 (41.9) 152 (28.8)
Hypnotherapy 42 (18.8) 8 (10.4) 15 (6.6) 65 (12.3)
Medical Herbalism 4 (1.8) 3 (3.9) 4 (1.8) 11 (2.1)
Osteopathy 11 (4.9) 21 (27.3) 25 (11.0) 57 (10.8)
‘Other’ therapy2 14 (6.3) 21 (27.3) 5 (2.2) 40 (7.6)
Total
223 (100.0) 77 (100.0) 227 (100.0) 527 (100.0)
1 Practices may offer more than one therapy and/or have more than one type of provision 2 Other therapies mentioned more than once included aromatherapy (12 instances), reflexology (8), massage (4),
Alexander Technique (3) and ‘manipulation’ (2)
Table 16 Complementary therapy via general practice by FHSA1 of responding practice and response rate
FHSA
Any provision by practice
Responses to questionnaire
or to letter
n (%) (n = 100%)
Newcastle 7 (33.3) 21
S Tyneside 2 (20.0) 10
Humberside 14 (25.5) 55
Derbyshire 17 (26.6) 64
Barnsley 4 (22.2) 18
Rotherham 6 (37.5) 16
Suffolk 11 (33.3) 33
Cambridge 9 (31.0) 29
Oxfordshire 14 (42.4) 33
Essex 50 (43.1) 116
Redbridge 22 (46.8) 47
Kensington & Chelsea 19 (48.7) 39
W Sussex 24 (58.5) 41
Surrey 25 (40.3) 62
Croydon 5 (21.7) 25
Hampshire 37 (38.1) 97
Somerset 14 (46.7) 30
Avon 25 (35.2) 71
Coventry 12 (52.2) 23
Dudley 6 (26.1) 23
Shropshire 9 (34.6) 26
Cumbria 23 (50.0) 46
Oldham 4 (22.2) 18
Wirral
12 (52.2) 23
All 371 (39.5) 2 964
1 Overall X2 = 38.64 23df p = 0.0217
2 Weighted estimate using non-responders data to represent all non-responders
The sample of 24 FHSAs was not designed to produce accurate regional estimates
and the data have not, therefore, been aggregated regionally. Together, however, the
24 FHSAs form a good representative sample for England as a whole.
Provision within the practice: estimates and characteristics
Data were obtained giving details of the various types of complementary therapy
provision from 280 partnerships (302 instances of provision). There is no reason to
believe that there is any systematic bias in these data with respect to the information
provided. The data from these 280 partnerships are therefore treated as
representative of all partnerships currently offering complementary medicine in
England, an estimated 3,500 partnerships.
Complementary therapies were reported as being provided within the practice, either
by a member of the primary health care team or by an ‘independent’ therapist who
could be working on a sessional basis with NHS funding or on a private basis, making
a charge to patients attending. Although it is technically possible for any member of
the primary health care team to offer a therapy, in practice the majority of provision
reported (64%) was offered by one of the GPs. However, the manipulative therapies
were more likely to be provided by someone outside the primary health care team
(Table 17).
Much of the provision of these therapies within the practice was in regular (weekly,
fortnightly) clinics (41%), although almost half was provided as part of normal surgery,
with 26.7% being offered on a daily basis within surgery time (Table 18).
Overall, 17.4% of the instances of provision are paid for entirely or in part by the
patients. This appears to be more common if the provision is for manipulative
therapies, or “other” therapies of which aromatherapy and massage predominated. In
contrast, homoeopathy provision is almost entirely free to NHS patients (Table 19).
Table 17 Provision within the practice by type of practitioner and therapy offered
Therapy Provider
GP Practice Nurse
Other Independent therapist
All n %
Acupuncture 831 1 142 13 111 (36.8)
Chiropractic 4 - 1 5 10 (3.3)
Homoeopathy 49 1 1 6 57 (18.9)
Hypnotherapy 39 - 33 8 50 (16.6)
Med. Herbalism
4 - - 3 7 (2.3)
Osteopathy 11 - - 21 32 (10.6)
‘Other’ therapies4
6 2 6 21 35 (11.6)
All 196 (64.2%)
4 (1.3%)
25 (8.3%)
77 (18.5%)
3025 (100.0%)
1 In 2 cases this was provided with a practice nurse/physiotherapist 2 13 out of 14 were physiotherapists 3 2 out of 3 were community psychiatric nurses 4 Mostly aromatherapy and massage 5 Instances of provision
Table 18 Mode of provision within practice by therapy Therapy Provision
By regular clinic n (%)
In surgery daily n (%)
In surgery - ad hoc n (%)
By appointment only n (%)
Total (n = 100%)
Acupuncture 45 (42.1) 27 (25.2) 22 (20.6) 13 (12.1) 107
Chiropractic 4 (44.4) 3 (33.3) - 2 (22.2) 9
Homoeopathy 9 (17.0) 29 (54.7) 14 (26.4) 1 (1.9) 53
Hypnotherapy 19 (39.6) 4 (8.3) 14 (29.2) 11 (22.9) 48
Med. Herbalism 3 (50.0) 1 (16.7) 2 (33.3) - 6
Osteopathy 17 4 (54.8) 8 (25.8) (12.9) 2 (6.5) 31
‘Other’ therapies1 19 (61.3) 4 (12.9) 6 (19.4) 2 (6.5) 31
All 116 (40.8%)
76 (26.7%)
62 (21.8%)
31 (10.9%)
285 (100%)2
1 Mostly aromatherapy and massage 2 NK = 17
Table 19 Who pays for complementary therapies provided within general practice by therapy
Therapy Free on NHS
n (%)
Patient pays
n (%)
Mixture of both
n (%)
Other 1
n (%)
All
(n = 100%)
Acupuncture 87 (79.8) 11 (10.1) 10 (9.2) 1 (0.9) 109
Chiropractic 5 (55.5) 3 (33.3) - 1 (11.1) 9
Homoeopathy 47 (85.5) 3 (5.5) 5 (9.1) - 55
Hypnotherapy 42 (84.0) 5 (10.0) 3 (6.0) - 50
Med. Herbalism 5 (83.3) 1 (16.7) - - 6
Osteopathy 17 (54.8) 12 (38.7) 2 (6.5) - 31
‘Other’ therapies 14 (42.4) 16 (48.5) 2 (6.1) 1 (3.0) 33
All 1 217 (74.1%)
51 (17.4%)
22 (7.5%)
3 (1.0%)
293 2 (100.0%)
1 Donation, local business, patients’ association 2 NK = 9
Complementary therapies provided within the practice and paid for by the patient are
mostly provided by ‘independent’ therapists (42/51). GPs reported charging patients
for complementary therapies on nine occasions. However, independent therapists do
provide care free of charge to NHS patients where their post is funded by a Health
Authority or purchased with GP fund-holding moneys (Table 20). Independent
therapists are cited as providing osteopathy most frequently (21/78 instances of
provision), followed by acupuncture (14/78). “Other” therapies account for 21/78
instances of provision by ‘independent’ therapists, aromatherapy (5), reflexology (5),
massage (5), Alexander technique (3), relaxation (2) and spiritual healing (1).
Table 20 also shows that there were 22 occasions when a fund-holding practice used
practice funds to purchase complementary therapies for patients within their practice.
These 22 ‘occasions’ relate to 20 practices, or 12% (20/161) of all fund-holding
practices in the sample. On 21 occasions FHSA or DHA moneys were cited as the
source of funding (most frequently FHSA special development money). These 21
‘occasions’ relate to 19 practices, or 2.5% of all practices surveyed.
GPs were asked to indicate if the therapy provided was directed to a particular
condition or group of patients. The majority of GPs answered this negatively,
indicating that the therapies were provided for a range of conditions. Figure 1 lists the
conditions mentioned.
Table 20 If NHS provision, source of funding for complementary therapies1 in general practice by type of practitioner
Practitioner FHSA/DHA
n (%)
Practice-Fund-holding
moneys n (%)
Practice- non-Fund-
holding n (%)
No Costs
n (%)
NK n
GP/primary health care team
8 13 22 117 37
Independent therapist
13 9 0 3 7
All 21 22 22 120 44
% of known (n = 184)
(11.4) (12.0) (12.0) (65.2)
1 All, including ‘other’ therapies
Figure 1 Groups of patients or conditions mentioned by GPs treated by complementary therapies within the practice
Acupuncture: Smokers Back pain Joint pain Other pain Acute stress Migraine Chiropractic: Back pain Joint pain Homoeopathy: Depression Migraine Diabetes Pain Warts Hypnotherapy: Smokers Over 75’s Anxiety Psychological problems Acute stress Dental extraction Obesity Medical Herbalism: None given Osteopathy: Back pain Joint pain
4.43 NHS referrals for complementary therapies
One hundred and sixty respondents reported that their practice made any referral to
NHS funded provision for treatment with a complementary therapy. A total of 227
instances of such activity were described. The scale of this provision, in terms of the
number of patients affected, was not easy to ascertain from the questionnaire, but
those GPs offering an estimate of the number of such refrrals made by themselves in
one month indicated a range between one and five; one referral per month was the
most commonly cited frequency.
NHS hospitals, excluding homoeopathic hospitals, make up 40.1% of these instances
of referral, the majority of which are for acupuncture. Referral for homoeopathy was
the most common. Most of this activity related to NHS homoeopathic hospitals,
although a proportion (13%) were to ordinary NHS hospitals, and a similar proportion
entailed referral to care located in the private sector. Where the treatment was for
osteopathy, referral for treatment in the private sector was more common than referral
to an NHS location. (Table 21)
Funding for this type of referral appears to come largely from District Health
Authorities, although a significant proportion of this activity (27.5%) was funded
directly by the GP practices (Table 22). GP fund-holding practices reported 23
instances of referral for complementary therapies. This involved 14 practices, 8.7% of
all fund-holding practices in the survey.
Table 21 NHS Referrals outside the practice for complementary therapies by place of reference
Place of Referral
NHS Hospital
NHS homoeopathic hospital
Private Clinic or Consulting rooms
Other GP surgery
Other or not known
All
Therapy n n n n n n (%)
Acupuncture 52 3 5 3 5 68 (30.0)
Chiropractic 6 0 6 0 3 15 (6.6)
Homoeopathy 12 65 12 4 14 95 (41.9)
Hypnotherapy 8 0 3 2 2 15 (6.6)
Medical Herbalism
1 1 0 1 1 4 (1.9)
Osteopathy 9 0 13 1 2 25 (11.0)
Other therapies
3 0 1 0 1 5 (2.2)
Total 91
(40.1)
69
(30.4)
40
(17.6)
11
(4.8)
28
(12.3)
227
(100.0)
Table 22 NHS referrals outside the practice for complementary therapies by source of funding
Source of funding1
Therapy Fund-holding savings
Practice budget
FHSA DHA Other NHS All
Acupuncture 6 11 7 39 3 66
Chiropractic 3 2 2 5 1 13
Homoeopathy 9 15 21 41 1 87
Hypnotherapy 0 1 3 7 2 13
Medical Herbalism
0 1 0 1 1 3
Osteopathy 4 2 3 2 0 11
Other therapies 1 2 0 2 0 5
Total 23
(11.6)
34
(17.2)
36
(18.2)
97
(49.0)
8
(4.0)
198
(100.0)
1 NK source of funding = 29
GP BEHAVIOUR IN CONSULTATIONS IN THE PAST WEEK
Responding GPs completed a questionnaire matrix in which they gave the number of
occasions in consultations in the past week when they personally treated patients with
a complementary therapy, referred them for treatment (private or NHS) or
recommended/endorsed such treatment. Data on recommendations and
endorsements is perhaps more a measure of the GP’s opinion about complementary
therapy than an indication of the patient having received it. However, this category
serves to help distinguish between more formal ‘referrals’ and actions falling short of
this, i.e. endorsements of patients’ decisions to seek help from complementary
therapies, and thus makes the data on referrals more reliable. In the question matrix,
each of these three categories is applied to the listed therapies, and a category for
‘other’ (explicitly excluding psychotherapy and counselling).
A similar matrix was completed showing the number of occasions in the past week
when a consultation resulted in a ‘neutral’ response with respect to a particular
therapy or where the GP advised a patient against the use of a particular therapy on
that occasion. Neutral responses were exemplified on the questionnaire by the
phrase “It’s up to you”.
These data were weighted according to the partnership size of the GP and their
response category.
GP behaviour in relation to different therapies
Table 23 shows the weighted number of GPs treating patients with each of the listed
complementary therapies, referring a patient (NHS or privately) for such treatment or
recommending/endorsing such treatment. The distribution of these interventions
across the therapies suggests that osteopathy is the therapy most frequently
associated with treatment, referral or endorsement, followed by chiropractic,
Table 23: Complementary therapies in consultations in one week: a) the number of GPs treating patients with
complementary therapies, referring for such therapies, or recommending/endorsing treatments; b) the number of occasions each action was performed; and c) the average weekly interventions per GP reporting the action, d) the average weekly interventions per GP in England by therapy (weighted data)
N=1226 Treatments1 Referrals2 Recommend/ endorsements
Acupuncture GPs 62 57 165 Interventions3 310 68 188 Av.’active’ GP
Av. All GPs
5.0 0.25
1.2 0.05
1.1 0.15
Chiropractic GPs 8 94 249 Interventions3 13 119 338 Av.’active’ GP
Av. All GPs
1.6 0.01
1.3 0.09
1.4 0.27
Homoeopathy GPs 49 46 143 Interventions3 260 49 181 Av.’active’ GP
Av. All GPs
5.3 0.21
1.1 0.03
1.3 0.14
Hypnotherapy GPs 20 18 98 Interventions3 19 33 118 Av.’active’ GP
Av. All GPs
1.0 0.01
1.3 0.02
1.2 0.09
Medical Herbalism GPs 4 4 35 Interventions3 4 5 51 Av.’active’ GP
Av. All GPs
1.1 <0.00
1.3 <0.00
1.5 0.04
Osteopathy GPs 27 131 334 Interventions3 80 217 465 Av.’active’ GP
Av. All GPs
3.0 0.06
1.7 0.17
1.4 0.37
Reflexology GPs 0 8 30 Interventions3 0 12 32 Av.’active’ GP
Av. All GPs
0 0
1.5 <0.00
1.1 0.02
Aromatherapy GPs 1 8 54 Interventions3 1 9 58 Av.’active’ GP
Av. All GPs
1.0 <0.00
1.1 <0.00
1.10.04
1 Treated by responding GP 2 Referrals to NHS or private provision within and outside the practice 3 Probably equivalent to individual patients as all actions within a one week period
Table 24: Complementary therapies in consultations in a one week period a) number of GPs giving a neutral response to a patient enquiry
about complementary therapies or advising against their use; b) number of occasions each action was performed and c) the average interventons per GP reporting the action d) the average per GP in England, by therapy (weighted data)
N=1226 Neutral
response1 Advised against
Ratio of neutral responses to
advice against Acupuncture GPs 134 3 51:1 Interventions2 154 3 Av.’active’ GP
Av. All GPs
1.1 0.12
1.0 <0.00
Chiropractic GPs 146 28 8:1 Interventions2 186 28 Av.’active’ GP
Av. All GPs
1.3 0.05
1.0 0.02
Homoeopathy GPs 153 11 12:1 Interventions2 185 16 Av.’active’ GP
Av. All GPs
1.2 0.05
1.5 0.01
Hypnotherapy GPs 66 5 14:1 Interventions2 68 5 Av.’active’ GP
Av. All GPs 1.0
0.05 1.0
<0.00
Medical
GPs
54
20
3:1
Herbalism Interventions2 64 20 Av.’active’ GP
Av. All GPs
1.2 0.05
1.0 0.01
Osteopathy GPs 157 30 7:1 Interventions2 215 30 Av.’active’ GP
Av. All GPs
1.4 0.17
1.0 0.02
Reflexology GPs 27 9 3:1 Interventions2 29 9 Av.’active’ GP
Av. All GPs
1.1 0.02
1.0 <0.00
Aromatherapy GPs 39 4 12:1 Interventions2 48 4 Av.’active’ GP
Av. All GPs
1.2 0.03
1.0 <0.00
1 e.g. “Its up to you” 2 Probably equivalent to individual patients as all actions within a one week period
acupuncture and homoeopathy. GP treatments are more common for acupuncture
and homoeopathy, while referrals are more common for the manipulative therapies,
especially osteopathy.
Table 23 also gives the average number of interventions per GP reporting the action.
For example, GPs reporting the use of acupuncture undertook an average of 5.3
treatments in the week. For each therapy, GPs treating patients themselves reported
the highest number of interventions per action, whereas the greatest volume of activity
overall is associated with recommendations or endorsements.
As specific levels of neutral and negative responses reported for each therapy depend
on the number of occasions when the opportunity to offer either of these responses
arose, it may not be appropriate to make direct comparisons between therapies for
each of these responses. However, it is possible to gauge the relative balance of
neutral to negative response for each therapy. Thus Table 24 suggests that GPs may
view acupuncture differently from the other therapies, in that recommendations
against its use form a much smaller proportion of all non-positive response compared
to the other therapies. These ratios are, however, derived from small numbers and
these findings should be viewed as indicative rather than definitive.
Differentials in behaviour by characteristics of GPs
The data were analysed to test whether any of the known characteristics of the
responding GPs were associated with different behaviours relating to complementary
therapies in consultations in the past week. Female GPs appear to be more likely to
endorse or recommend than treat or refer patients, and age of GP seems to be
negatively related to endorsement. GPs who were identified as senior partners on the
FHSA lists were more likely to have treated patients with complementary therapies in
the past week than single-handed GPs or partners from group practices (Table 25).
The numbers in all these sub-groups are relatively small and none of these
differences reaches statistical significance. No significant differences were observed
Table 25: Complementary therapies in consultations in the last week: the
estimated number and percentage of GPs treating, referring or endorsing treatment by age group, sex and status of GP (weighted data)
Age of GP Treatments n (%)
Referrals n (%)
Recommend/ endorsements n (%)
All N
under 35 10 (6.6) 35 (22.7) 96 (61.9) 155
35-44 41 ( 11.7) 82 (23.4) 180 (51.6) 349
45-54 36 (12.7) 70 (24.4) 109 (38.2) 285
55+ 10 (5.6) 29 (16.6) 65 (37.6) 172
age not known 30 (11.4) 46 (17.3) 100 (37.8) 264 Female 28 (9.7) 60 (20.9) 172 (59.6) 289 Male 67 (10.2) 150 (22.7) 272 (41.0) 663 sex not known 31 (11.5) 50 (18.3) 105 (38.4) 274 Senior Partner 47 (13.3) 65 (18.5) 133 (37.9) 352 Single Handed 18 (10.7) 33 (18.8) 59 (33.3) 174 Other 62 (8.8) 163 (23.3) 358 (51.0) 700 All 127 (10.4) 261 (21.3) 550 (44.8) 1226
Table 26: Complementary therapies on consultations in the past week: the number and percentage of GPs treating, referring or endorsing treatment by location of practice (weighted data)
Location of practice
Treatments
n (%)
Referrals
n (%)
Recommend/ endorsements
n (%)
All
N
Inner city 17 (11.5) 27 (18.3) 36 (24.9) 146 Rural 35 (12.1) 62 (21.9) 156 (54.7) 285 Else 75 (9.5) 172 (21.8) 358 (45.3) 790
All 127 (10.4) 261 (21.3) 550 (44.8) 12211
1 NK = 5
between these groups with respect to negative or neutral responses. However, GPs
located in inner city areas were less significantly likely to recommend or endorse
treatments with complementary therapies (Table 26). This may be due to a higher
prevalence of patients in these areas who are unable to meet the costs of private
provision.
Estimates of individual GP activity
GP treatments and NHS referrals both have clear resource implications with respect
to GP time or NHS facilities (e.g. a homoeopathic hospital referral may entail
approved extra contractual referrals). A recommendation or endorsement is resource-
free, but may still be constrained by access issues (i.e. available practitioners in the
area of suitable calibre). Estimates of the percentage of GPs undertaking treatments,
making referrals or endorsing/recommending treatments are given in Table 27. These
are based on the assumption that non-responding GPs were most similar to those
GPs who responded after the third mailing. Lowest estimate are calculated assuming
that all non-responders were non-active in the past week are reported in the text.
An estimated 10.4% (lowest estimate 8%) of GPs treat patients with one of the listed
complementary therapies in a week, 21.3% (lowest estimate 13.5%) of GPs refer a
patient for complementary medicine treatment (NHS or private) and an estimated
44.8% (lowest estimate 27%) of GPs recommend or endorse treatment (Table 27). In
contrast, an estimated 31.2% (lowest estimate 20.6%) of GPs give a neutral response
in the past week, and 7.4% (lowest estimate 4.4%) give specific advice against the
use of one of the named complementary therapies. (Table 28)
Of the individual therapies, acupuncture was the most frequently reported treatment,
offered by an estimated 5% of GPs (lowest estimate 3.8%). Referrals for osteopathy
were made by an estimated 10.7% of GPs (lowest estimate 7.1% ). Treatments or
referrals for homoeopathy were made by an estimated 7.2%of GPs (lowest estimate
Table 27 Estimated proportion of GPs treating, referring or endorsing complementary therapies in one week by therapy (weighted data)
Treatments1 Referrals2 Treatments or Recommend/ Any of these N=1226 referrals endorsements
n % n % n % n % n % Acupuncture 62 (5.0) 57 (4.6) 118 9.6 165 (13.5) 266 21.7 Chiropractic 8 (0.7) 94 (7.6) 101 8.2 249 (20.3) 335 27.3 Homoeopathy 49 (4.0) 46 (3.7) 92 7.5 143 (11.6) 208 17.0 Hypnotherapy 20 (1.6) 18 (1.5) 38 3.1 98 (8.0) 130 10.6 Medical Herbalism
4 (0.3) 4 (0.3) 8 0.7 35 (2.8) 40 3.3
Osteopathy 27 (2.2) 131 (10.7) 149 12.2 334 (27.3) 451 36.8 Reflexology 0 (0.0) 8 (0.6) 8 0.7 30 (2.5) 38 3.1 Aromatherapy 1 (0.1) 8 (0.7) 8 0.7 54 (4.4) 61 5.0
Any of these therapies
127 (10.4) 261 (21.3) 337 26.4 550 (44.8) 729 57.1
1 Treated by responding GP 2 Referrals to NHS or private provision within and outside the practice
Table 28 Estimated proportion of GPs giving neutral or negative response to
enquiry about complementary therapies in one week by therapy (weighted data)
N = 1226 Neutral
n (%) Advice against
n (%)
Acupuncture 134 (10.9) 3 (0.2)
Chiropractic 146 (11.9) 28 (2.3)
Homoeopathy 153 (12.5) 11 (0.9)
Hypnotherapy 66 (5.4) 5 (0.4)
Medical Herbalism 54 (4.4) 20 (1.7)
Osteopathy 157 (12.9) 30 (2.4)
Reflexology 27 (2.2) 9 (0.7)
Aromatherapy 39 (3.2) 4 (0.4)
Any of these therapies 399 32.5 94 7.7
6.2%) (Table 27). All GPs offering aromatherapy or reflexology also offered at least
one of the six established therapies.
The extent to which GPs are able to report the outcome of discussing a
complementary therapy with a patient is strongly related to the number of occasions
on which patients raise this issue in consultations. GPs with a reputation for being
open to the possibility of the use of alternative therapies are more likely to be
approached by patients than those not known to hold such views. Thus a higher
proportion of those treating, referring or recommending in the past week also gave a
neutral or negative response in the same period compared with those not reporting
such actions. (Table 29).
Using the estimates based on the assumption that non-responders were most similar
to responders to the third mailing, estimates have been calculated for the level of
activity by GPs in England in an average week of GP consultations (Table 30). Thus it
is estimated that 14,900 treatments with acupuncture, chiropractic, osteopathy,
homoeopathy, hypnotherapy and medical herbalism (95% CI 12,500 to 17,300) are
performed per week by GPs, and 10,800 referrals are made, (95% CI 9,650 to
11,900). An estimated 29,600 recommendations or endorsements are made (95% CI
27,800 to 31,400). On the assumption that these estimates are representative of an
average week, this gives crude annual estimates of 750,000 treatments, and half a
million referrals.
Table 29: Neutral responses and advice against the use of complementary therapy by postive actions reported using weighted data
Neutral response
Advised against
N
n (%) n (%) Treatments:
Yes 49 (38.3%) 10 (7.6%) 127
No 350 (31.8%) 84 (7.7%) 1099
Referrals:
Yes 123 (47.1%) 44 (16.7%) 261
No 276 (28.6%) 50 (5.2%) 965
Recommend/ endorsements:
Yes 216 (39.3%) 42 (7.7%) 550
No 183 (27.0%) 51 (7.6%) 676
Total 399 (31.2%) 94 (7.4%) 1226
Table 30 National estimates of treatment, referral and recommendation/endorsement of established complementary therapies1 in GP consultations in an average week n2 Estimated Average Estimated number 95% CI for estimated number of interventions per of interventions4 interventions/week active GPs3 active GPTreatments 127 2733 5.45 14905 (12507, 17302)Referrals 261 5617 1.92 10789 (9655, 11924)Treatment or referral 337 7253 3.54 25694 (23412, 27976) Recommend / endorsements 550 11838 2.50 29590 (27796, 31383) Any of these 729 15690 3.52 55284 (52787, 57780) Acupuncture: Treatments 62 1334 5.00 6675 (5094, 8257) Referrals 57 1227 1.20 1472 (1108, 1837)Chiropractic: Treatments 8 172 1.61 277 (90, 464) Referrals 94 2023 1.26 2559 (2073, 3045)Homeopathy: Treatments 49 1055 5.31 5597 (4097, 7097) Referrals 46 990 1.06 1045 (755,1334)Hypnotherapy: Treatments 20 430 1.36 585 (336, 833) Referrals 18 387 1.25 483 (267, 700)Medical Treatments 4 86 1.19 102 (5, 200)Herbalism: Referrals 4 86 1.20 103 (5, 202)Osteopathy: Treatments 27 581 2.97 1727 (1098, 2357) Referrals 131 2819 1.66 4671 (3932, 5409) 1 Acupuncture, chiropractic, homoeopathy, hypnotherapy, medical herbalism and osteopathy only 2 N = 1226 sample size = 760 3 GP population of England = 26387 unrestricted principals: source GMS Statistics 1 April 1994 4 Probably equivalent to ‘patients’ as data relates to one week period
DISCUSSION
A recent national survey of GP attitudes conducted on behalf of the GMSC suggests
that, assuming adequate resources, between 18% and 29% of GPs currently favour
the expansion of GP services to cover such treatments as homoeopathy, chiropractic,
hypnotherapy, osteopathy, and acupuncture respectively. However, even given
increased resources, the provision of such services would clearly have to compete
with the expansion of GP services in more established areas such as physiotherapy
and chiropody, which may have higher priority for the majority of GPs.
Some information about the availability of complementary therapies in general
practice is available from a number of case-studies of experiments in the provision of
such treatments(19,20,21), but little is known about the scale and scope of provision
nationally. This study was designed to offer a ‘snapshot’ of the current situation using
a large random sample of GP partnerships in England (one in eight). There is always
a restriction of the type of information which it is possible to obtain via a postal
questionnaire, and the range of provision possible in terms of mode of delivery and
therapy offered made the questionnaire design quite complex. As a result of a local
pilot study, a questionnaire was developed which was relatively long (10 pages) but
easy to complete with easily identifiable sections for each possible therapy. Research
suggests that the sponsoring body for the research, the target population, the length
of the survey, the salience of the issue to responders and the number of times contact
is made are the key factors in influencing final response rates(22), however postal
surveys involving GPs tend to get relatively low response rates due to the heavy
workload of GPs and the fact that such requests tend to be allocated low priority by
GPs. As one GP commented in declining to participate in the study:
“I very much regret that I am at the present time totally overwhelmed and exhausted by my basic workload. I just do not have any spare capacity to undertake any work that is not directly necessary under my general medical services commitment. I can assure you that I am far from happy about this situation and wish you well with your research.”
The final response of 62% was not, therefore, unexpected. Responders were not
systematically biased according to available characteristics, but it was felt to be
important to investigate non-responders further in order to establish the
representativeness of responders with respect to the provision of complementary
therapies within the practice. The short letter, containing the three key “screening”
questions, was returned completed by almost half the non-responders. Given the time
lapse of 9 weeks some of these may not have remembered receiving three
questionnaires previously. However, it seems likely that the majority simply
responded to a request which could be completed in minutes and that, for this group
of respondents, the length of the questionnaire was a key factor in the response rates
achieved. The responses given to the screening questions provide strong evidence
that the 760 responding practices are representative of the population as a whole with
respect to the provision of complementary therapies.
With regard to the provision of complementary therapies via the general practice as a
whole, the data on 760 representative practices shows that such provision is
widespread but currently offered in a relatively small scale in terms of the patient
numbers involved. We estimate that 39.5% of all practices (95% CI 35%-43%) now
provide access to complementary therapies for their NHS patients.
The most frequently cited type of provision is NHS referral, reported by one in four
practices, mostly for homoeopathy or acupuncture at NHS hospitals. However, this
type of provision may influence the management of patients less than the availability
of treatment within the practice, which has the potential to affect a larger number of
individual patients.
Provision within the practice by a member of the primary health care team is relatively
common, affecting an estimated one in five practices. The employment of an
independent therapist is relatively rare, occurring in an estimated 6.1% of practices.
This is perhaps to be expected, as it is the least easily established form of provision,
but there may be considerable scope for growth in this area.
The study sample structure makes it hard to analyse these data by geographical area.
However, the national results are similar to those reported in a recent survey of 87 GP
practices in S.W. Thames(24). More local area studies are needed to establish any
regional variations in the pattern of provision. In contrast, the study findings do not
support the finding in the NAHAT survey that 14% of GP fund-holding practices
employ an independent practitioner (6). The level of such provision in this study was
similar for fund-holders and non-fund-holders (6.7% v 6.1% respectively). The level of
provision reported by the NAHAT survey is likely to be inflated by bias resulting from
their low response rates and the non-random selection of practices. Fund-holding
status was, however, associated with a significantly higher level of provision from the
primary health care team (27% v 21%) and a higher overall level of access (45.5%
compared with 36.6% respectively, Chi square P <0.01).
The practice data reflect the data on individual GP behaviour in so far as primary
health care team provision is dominated by GPs offering acupuncture and
homoeopathy but access via referrals is also most commonly associated with these
therapies in the practice-based data, with provision for referrals to manipulative
therapies being much less common. This reflects the change in emphasis from all
referrals (NHS and private) to those undertaken on the NHS only, and highlights a gap
between GP referring behaviour and NHS provision.
Reported funding for access to complementary therapies via primary care suggests
that patients are paying for a significant proportion of the treatments provided within
the practice, as well as for private referrals. This will inevitably lead to an uneven
distribution of provision and access between practices located in areas where patients
can afford to pay and those in areas where this is not an option.
Where the NHS is funding provision, the majority of provision within practices is
accomplished by absorbing costs into the practice. A significant proportion of fund-
holding practices surveyed, 22/161, reported using identified practice funds to cover
the costs of in-house provision. Just over 10% of all such provision was reported as
being funded directly by the FHSA or DHA, usually via special development moneys.
NHS referrals were largely reported as being funded by the DHA (51%) or FHSA
(17%). A smaller proportion, 11%, of referral schemes mentioned were reported as
being purchased with fund-holding savings (23 instances affecting 19 practices or
11.8% of all fundholding practices).
The study design provided a sample of 1226 GPs in England, covering single-handed
GPs, senior partners and other partners, from whom information was sought about the
previous week’s consultations. These data were weighted to take into account the
high proportion of single handed GPs in the sample. The most frequently reported
action was a recommendation or endorsement of complementary therapy treatment,
an estimated 45% of GPs. Such actions do not require any direct resources and may
be viewed as an indication of support for these therapies in a situation in which no
NHS provision is available via the GP. However, recommendations and
endorsements are likely to be influenced by two factors external to the GP; firstly, the
extent to which the GP is perceived to be sympathetic to enquiries about
complementary therapies and, secondly, the extent to which GPs believe there to be
provision in the private sector which is of a sufficient standard and which can be
afforded by patients. In this context, it is interesting to note that
recommendations/endorsements were less frequently reported by GPs working in
practices located largely in inner city areas. If recommendations/endorsements are
seen as indicators of unmet expressed demand for NHS complementary therapy
treatment, the additional referrals would be in the region of 25,000 per week.
However, this is likely to be an under-estimate of the potential demand as it is based
on a public perception of a lack of NHS provision(2) .
Recommendations and endorsements were explicitly distinguished from referrals in
order to strengthen the latter category. Even after allowing for this distinction, one in
five GPs (21%) reported making what they considered to be a referral for a
complementary therapy in the past week. Referrals (private and NHS) were most
frequently reported for manipulative therapies, especially osteopathy. A smaller
proportion of GPs (10.4%) reported having treated a patient with a complementary
therapy in the past week, and these treatments were most likely to be for acupuncture
or homoeopathy. This group of ‘active’ GPs made an average of 4 treatments each in
the week surveyed. Using these data, it is estimated that 2733 GPs in England are
active and perform a total of 14,900 complementary therapy treatments in an average
week (95% CI 12,500-17,300). Similarly it is estimated that 10,800 NHS referrals are
made (95% CI 9,650-11,900). However, to put these estimates into context,
assuming that the 14,900 treatments per week each represent a single patient
episode, this is equivalent to approximately 5 per 1,000 patients consulting their GP
(23) .
GPs were also asked about occasions on which they responded neutrally (e.g. “it’s up
to you”) or negatively to a patient enquiry about a complementary therapy in the past
week. GPs reported far more neutral than negative responses and GPs treating,
referring, recommending or endorsing were more likely than those not undertaking
any of these actions to report also having given a neutral or negative response. This
indicates a selective support of complementary therapies by GPs and reflects likely
levels of exposure to enquiries, i.e. some GPs will have a reputation for being
sympathetic. The fact that an estimated 31% GPs give a neutral response in an
average week suggests that GPs frequently feel unable to advise their patients in this
respect, presumably in part through a lack of appropriate knowledge or information
regarding the therapies. As the popularity of complementary therapies grows, there is
a corresponding need for GPs to have access to more information or training
regarding their possible benefits and disbenefits to patients. This need has been
expressed by GPs themselves in recent studies (6,24) .
In conclusion, this study has demonstrated that complementary therapy provision is
widespread in English general practices although the average level of provision to
patients within individual practices remains low. This suggests that complementary
therapies are acceptable to a growing proportion of GPs, and that the level of activity
reported reflects a stage in the development of the provision of complementary
therapies in general practice, rather than current demand by patients.
ACKNOWLEDGEMENTS
The authors wish to thank the FHSAs for their help and co-operation and to express
their gratitude to all the GPs who somehow found the time to complete our
questionnaire and return it to us. We would also like to thank Gwyneth Askham and
Sheila Bray for their contributions to the study and to the production of the report. The
Medical Care Research Unit is funded by the Department of Health. The opinions
expressed in this report are, however, those of the authors alone.
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