NATIONAL SURVEY OF ACCESS TO COMPLEMENTARY HEALTH CARE VIA GENERAL PRACTICE

Transcription

1 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

2 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

3 Index of Tables and Figures Page Table 1 Response rate: by mailings 7 Table 2 Table 3 Comparison of response rates: all national studies, involving postal questionnaires to GPs, published in in the British Journal of General Practice Comparison of response rate: all local studies involving postal questionnaires to GPs, published in 1994 in the British Journal of General Practice 7 8 Table 4 Representativeness of data: analysis of partnership size 10 Table 5 Representativeness of data: analysis of fund-holding status 11 Table 6 Table 7 Table 8 Spearman Rank correlation co-efficients for relationship between response rates for each FHSA and for known characteristics of FHSAs 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 Unweighted data: proportion of practices indicating access to complementary therapies by number of mailings received 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 Table 14 Proportion of partnerships providing access to complementary therapies via treatment within the practice or NHS referrals. Estimates of provision weighted by type of response Characteristics of practices offering access to complementary therapies via primary health care team, independent therapist or NHS referral Table 15 Complementary therapy provided by type of provision 23 Table 16 Table 17 Complementary therapy via general practice by FHSA of responding practice and response rate Provision within the practice by type of practitioner and therapy offered Table 18 Mode of provision within practice by therapy 27 Table 19 Table 20 Who pays for complementary therapies provided within general practice by therapy If NHS provision, source of funding for complementary therapies in general practice by type of practitioner Page

4 Table 21 Table 22 Table 23 Table 24 Table 25 Table 26 Table 27 Table 28 Table 29 NHS Referrals outside the practice for complementary therapies by place of reference NHS referrals outside the practice for complementary therapies by source of funding 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) 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) 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) Complementary therapies in consultations in the past week: estimated proportion of GPs treating, referring or endorsing treatment by location of practice (weighted data) Estimated proportion of GPs treating, referring or endorsing complementary therapies by therapy (weighted data) Estimated proportion of GPs giving neutral or negative response to enquiries about complementary therapies by therapy (weighted data) 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) 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

5 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 nonresponders 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,

6 (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 NHSfunded 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.

7 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 fundholding 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 fundholding 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.

8 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

9 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 colourcoded. 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

10 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).

11 Table 1 Response rate: by mailings Sent Returned Completed Questionnaires returned completed No. % No. Cumulative % 1st mail nd mail rd mail th mail (letter only) Table 2 Comparison of response rates: all national studies, involving postal questionnaires to GPs, published in in the British Journal of General Practice. Title Coverage Sample size No of GP s in sample Involvement of the primary health care team in coronary heart disease prevention (7) Annual assessment of patients aged 75 years & over: GPs & practice nurses views and experiences (8) Telephone & postal surveys of GPs: methodological considerations (9) Attitudes towards practice nurses - survey of a sample of GPs in England & Wales (10) Patient access to GPs by telephone: the doctor s view (11) Reported sick, 1 retired, gone away Response rate % England England & Wales England & Wales England & Wales England & Wales (n=1092) none reported 69.3 (n=693) (n=881) (n=2013) none reported 74.0 (n=1459) Access to complementary medicine via general practice England refused 9 retired gone away (questionnaire) (n = 760) 78.6 (questionnaire & letter) (n = 964) 1 No refusals were reported. 2 Response from any GP in practice accepted.

12 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 Provision of obstetric care by GPs in the SW region of England (12) South West RHA 424 random GP s none reported Response rate % 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

13 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 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.

14 Table 4 Representativeness of data: analysis of partnership size 1 Single handed Partnerships of: % 2-3 % 4-6 % 7+ % Total n = 100% All partnerships England Partnerships in 24 sampled FHSAs in 2 sample of partnerships from 24 FHSAs Partnerships responding to questionnaire Partnerships responding to 4th letter with screening questions only All partnerships responding to letter or questionnaire Calculated from information provided by FHSAs, summer 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.

15 Table 5 Representativeness of data: analysis of fund-holding status 1 Fundholder 2 Non Fundholder Total n = 100% Partnerships in England and Wales (21.1) 7616 (78.9) 9656 Partnerships in 24 sampled FHSAs 517 (21.1) 1935 (78.9) 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) Calculated from FHSA information obtained summer 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

16 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 singlehanded practices in the FHSA as these practices were known to be underrepresented 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.

17 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 nonresponders (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

18 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 nonresponders, 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.

19 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 singlehanded Ranked Jarman deprivation scores Proportion of GPs born outside UK Proportion of GPs recommending complementary therapies in past week Proportion of responders from practices offering access to comp. therapies 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 Provision by independent therapist Referral Any of these Table 8 Unweighted data: proportion of practices indicating access to complementary therapies by number of mailings received Response to 1st mailing Provision by PHCT % Provision by indep. therapist % Any NHS referrals % Any % N nd mailing rd mailing Non-responders follow-up letter

20 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 years 1 Under 30 % % % % % 64+ % Total n = 100% England As % of those respondents giving age 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 % of responding GPs indicated their age group

21 Table 10 Representativeness of data: analysis by sex of GPs 1 Male % Female % Total n = 100% England Study respondents as % of those stating sex 3 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 % 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

22 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. Treatments Referrals Endorsements N Response to; (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%) (34.2%) 367 (29.9) 7,880 (30%) (36.1%) 566 (46.2) 12,192 (46%) (7.6%) 160 (13.1) 1,485 (13%) All (100.0) 1226 (100.0) 26,387 (100%) 1 Unrestricted principals: Source GMS Statistics 1 April 1994 England and Wales Table ETW O NK

23 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 nonresponders. 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).

24 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.

25 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 singlehanded 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.

26 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 Primary health care team provision Independent complementary therapy practices working in practice Any referral to NHS for treatment Yes to any of these questions Respondents N Weighted estimates of provision 95% CI for % sampling error (19-24) (2-10) (21-28) (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 Independent 1 NHS referral 2 Any of these 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) 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 Partnership size: 1 GP 35 (14.3)** 20 (8.1) 61 (24.7) 86 (34.8) GPs 81 (24.8) 19 (5.8) 80 (24.5) 137 (41.9) GPs 99 (25.4) 21 (5.4) 81 (20.8) 148 (37.9) 390 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)

27 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 singlehanded 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).

28 Table 15 Complementary therapy provided by type of provision offered Primary health care team Independent NHS referral All instances of provision Therapy 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 therapy 2 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)

29 Table 16 Complementary therapy via general practice by FHSA 1 of responding practice and response rate FHSA Any provision by practice Responses to questionnaire or to letter (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) Overall X 2 = df p = Weighted estimate using non-responders data to represent all non-responders

30 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).

31 Table 17 Provision within the practice by type of practitioner and therapy offered Therapy GP Practice Nurse Other Provider Independent therapist All n % Acupuncture (36.8) Chiropractic (3.3) Homoeopathy (18.9) Hypnotherapy (16.6) Med. Herbalism (2.3) Osteopathy (10.6) Other (11.6) therapies 4 All 196 (64.2%) 4 (1.3%) 25 (8.3%) 77 (18.5%) (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

32 Table 18 Mode of provision within practice by therapy Therapy Provision By regular clinic In surgery daily In surgery - ad hoc By appointment only Total (n = 100%) Acupuncture Chiropractic Homoeopathy Hypnotherapy 45 (42.1) 27 (25.2) 22 (20.6) 13 (12.1) (44.4) 3 (33.3) - 2 (22.2) 9 9 (17.0) 29 (54.7) 14 (26.4) 1 (1.9) (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 (54.8) 8 (25.8) 4 (12.9) 2 (6.5) 31 Other therapies 1 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

33 Table 19 Who pays for complementary therapies provided within general practice by therapy Therapy Free on NHS Patient pays Mixture of both Other 1 All (n = 100%) Acupuncture Chiropractic Homoeopathy Hypnotherapy Med. Herbalism Osteopathy 87 (79.8) 11 (10.1) 10 (9.2) 1 (0.9) (55.5) 3 (33.3) - 1 (11.1) 9 47 (85.5) 3 (5.5) 5 (9.1) (84.0) 5 (10.0) 3 (6.0) (83.3) 1 (16.7) (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 (74.1%) 51 (17.4%) 22 (7.5%) 3 (1.0%) (100.0%) 1 Donation, local business, patients association 2 NK = 9

34 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.

35 Table 20 If NHS provision, source of funding for complementary therapies 1 in general practice by type of practitioner Practitioner FHSA/DHA Practice- Fund-holding moneys Practicenon-Fundholding No Costs NK n GP/primary health care team Independent therapist All % 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: Chiropractic: Homoeopathy: Hypnotherapy: Smokers Back pain Joint pain Other pain Acute stress Migraine Back pain Joint pain Depression Migraine Diabetes Pain Warts Smokers Over 75 s Anxiety Psychological problems Acute stress Dental extraction Obesity Medical Herbalism: Osteopathy: None given Back pain Joint pain

36 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.

37 Table 21 NHS Referrals outside the practice for complementary therapies by place of reference NHS Hospital NHS homoeopathic hospital Place of Referral Private Clinic or Consulting rooms Other GP surgery Other or not known Therapy n n n n n Acupuncture (30.0) Chiropractic (6.6) Homoeopathy (41.9) Hypnotherapy (6.6) Medical Herbalism (1.9) Osteopathy (11.0) Other therapies Total (2.2) (40.1) 69 (30.4) 40 (17.6) 11 (4.8) 28 (12.3) 227 All (100.0) Table 22 NHS referrals outside the practice for complementary therapies by source of funding Therapy Fund-holding savings Practice budget Source of funding 1 FHSA DHA Other NHS All Acupuncture Chiropractic Homoeopathy Hypnotherapy Medical Herbalism Osteopathy Other therapies 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