Commissioning Policy The use of Acupuncture in the Management of Musculoskeletal Pain July 2013 This commissioning policy applies to patients within: South Worcestershire Clinical Commissioning Group (CCG) Redditch & Bromsgrove Clinical Commissioning Group (CCG) Wyre Forest Clinical Commissioning Group (CCG) Version: V1.2 Ratified by (name of Committee): 1 st April 2013 this policy was formally adopted by: NHS South Worcestershire Clinical Commissioning Group NHS Redditch & Bromsgrove Clinical Commissioning Group NHS Wyre Forest Clinical Commissioning Group Date ratified: December 2010 Date issued: January 2010 reissued 1 st April 2013, July Expiry date: (Document is not valid after this date) 2013 Any revisions to the policy will be based on local and national evidence of effectiveness and cost effectiveness together with recommendations and guidelines from local, national and international clinical professional bodies. Minimum 3 yearly. Review date: July 2016 Name of originator/author: Original document, Ms Christina Emerson, Revisions, Mrs Helen Bryant Target audience: NHS Trusts, Independent Providers, CCGs, GP s, patients Distribution: NHS Trusts, Independent Providers, CCGs, GP s, patients, Public & Patient Involvement Forum Equality & Diversity Impact Historical document not applicable at time of Assessment original publication If you would like this document in other languages or formats (i.e. large print), please contact the Communications Team on 01905 733734 or email: communications@worcestershire.nhs.uk Ccg - Acupuncture V1.2 - July 2013 Page 1 of 6
Contribution list Key individuals involved in developing the document Name Rosemary Habershon Stuart Bourne Worcestershire Pain Management Stakeholder Group Designation FYII Trainee Consultant in Public Health Circulated to the following individuals/groups for comments Name Designation Worcestershire Pain Management Stakeholder Group Worcestershire Clinical Policy Collaborative, which includes: Commissioners Pharmacy/Medicines Management Public Health Patient and Public Representatives Table of Contents 1. Definitions... 3 2. Scope of policy:... 4 3. Background:... 4 4. Relevant National Guidance and Facts... 4 5. Commissioning Policy... 5 6. Clinically Exceptional Circumstances... 6 7. Documents Which Have Informed This Policy... 6 Ccg - Acupuncture V1.2 - July 2013 Page 2 of 6
Commissioning Statement: NHS Redditch & Bromsgrove Clinical Commissioning Group, NHS South Worcestershire Clinical Commissioning Group and NHS Wyre Forest Clinical Commissioning Group (also termed the Commissioner in this document) do not endorse the commissioning of conventional acupuncture as a stand alone service from either NHS or Independent Sector Providers. Between 6 and 10 sessions of conventional acupuncture will be available as one of a range of interventions offered by Physiotherapists to manage musculoskeletal pain. 1. Definitions 1.1 Exceptional clinical circumstances are clinical circumstances pertaining to a particular patient, which can properly be described as exceptional. This will usually involve a comparison with other patients with the same clinical condition and at the same stage of development of that clinical condition and refer to features of the particular patient which make that patient out of the ordinary, unusual or special compared to other patients in that cohort. It can also refer to a clinical condition which is so rare that the clinical condition can, in itself, be considered exceptional. That will only usually be the case if the NHS commissioning body has no policy which provides for the treatment to be provided to patients with that rare medical condition. 1.2 A Similar Patient refers to the existence of a patient within the patient population who is likely to be in the same or similar clinical circumstances as the requesting patient and who could reasonably be expected to benefit from the requested treatment to the same or a similar degree. When the treatment meets the regional criteria for supra-ccg policy making, then the similar patient may be in another CCG with which the Commissioner collaborates. The existence of one or more similar patients indicates that a policy position is required of the Commissioner. 1.3 An individual funding request (IFR) is a request received from a provider or a patient with explicit support from a clinician, which seeks funding for a single identified patient for a specific treatment. 1.4 An in-year service development is any aspect of healthcare, other than one which is the subject of a successful individual funding request, which the Commissioner agrees to fund outside of the annual commissioning round. Unplanned investment decisions should only be made in exceptional circumstances because, unless they can be funded through disinvestment, they will have to be funded as a result of either delaying or aborting other planned developments. Ccg - Acupuncture V1.2 - July 2013 Page 3 of 6
2. Scope of policy: 2.1 This policy should be considered in line with all other Worcestershire Commissioning Policies. Copies of these Commissioning Policies are available on the Commissioner s website at the following address: http://www.worcestershire.nhs.uk/policies-and-procedures/commissioningindividualfunding-requests-ifr/ 2.2 In developing this policy account has been taken of the National Institute for Health and Clinical Excellence clinical guideline 88 - Early management of persistent nonspecific low back pain which suggests that acupuncture should be available as a treatment option. 3. Background: 3.1. NHS principles have been applied in the agreement of this policy. 3.2. Acupuncture is an ancient Chinese technique (dating back to 3000BC) of inserting and manipulating fine filiform needles (0.18 0.51mm) into specific points on the body. (1) 3.3. According to Chinese philosophy our health is dependent on the body s motivating energy ( Qi ) moving in a smooth and balanced way through a series of meridians or channels beneath the skin. Any illness or pain will disrupt the flow of Qi. The acupuncture points used lie along these meridians and provide means of altering and therefore restoring the flow of Qi. There are twelve main points and these loosely correspond to the organs of the body. (1) 3.4. There are a few modern day theories behind acupuncture. The main theory is that acupuncture stimulates the release of the body s natural endorphins. Several studies have proved this theory by administering naloxone (anti-dote to opioids) before the acupuncture treatment which then reduced the analgesic effect. (2) 4. Relevant National Guidance and Facts 4.1 A Cochrane review by Trinh et al looked at 10 trials with 661 patients suffering from neck pain for over 3 months. They showed that acupuncture was more effective than sham acupuncture as pain relief for mechanical neck disorders at the end of treatment and short-term follow-up 4.2 Another Cochrane review looked at 35 RCTs involving 2861 patients with nonspecific back pain lasting over 3 months. They showed that acupuncture was more effective than no treatment at all. Again this was at the end of treatment and at short-term follow up. Both reviews concluded that there was no difference at longterm follow up. 4.3 Thomas et al carried out a study looking at the use of acupuncture in chronic lower back pain comparing it to conventional treatment only. They concluded that acupuncture alongside conventional treatment was more effective than conventional treatment alone. Ccg - Acupuncture V1.2 - July 2013 Page 4 of 6
4.4 It should be noted that the majority of the studies looked at conclude with the fact that there is little evidence to support or refute acupuncture due to a small number of trials which are all clinically and methodically diverse. There are many reasons for this. Firstly, pain is as severe as how the patient perceives it to be and there is no quantitative measure for this. The other difficulty is carrying out blinded randomised controlled trials because unlike trials involving drugs where a placebo pill can be given, it is more difficult to give placebo acupuncture. Although sham acupuncture treatments were used in some trials, it is difficult to know whether or not there is a psychological aspect involved and also whether the sham acupuncture actually causes some sort of physiological process reducing pain. 4.5 The main regulatory body for the practice of acupuncture in the UK is the British Acupuncture Council who accredits institutions that provide training in acupuncture. Training courses are for a minimum of 3 years. (8) A physiotherapist wanting to become qualified in acupuncture needs 80 hours of training and is then regulated by the Acupuncture Association of Chartered Physiotherapists. (9) 5. Commissioning Policy 5.1 The Commissioners consider all lives of all patients whom it serves to be of equal value and, in making decisions about funding treatment for patients, will seek not to discriminate on the grounds of sex, age, sexual orientation, ethnicity, educational level, employment, marital status, religion or disability except where a difference in the treatment options made available to patients is directly related to the patient s clinical condition or is related to the anticipated benefits to be derived from a proposed form of treatment. 5.2 Acupuncture is not commissioned as a stand alone service from either NHS or Independent Sector Providers. Acupuncture will be available as one of a range of interventions offered by Physiotherapists to manage musculoskeletal pain. 5.3 Acupuncture is more often used as part of a patient s treatment package rather than a single intervention in its own right, as a step-up to reduce pain and enable patients to self manage. Patient may be offered up to 6-10 sessions of acupuncture used alongside conventional pain management therapy e.g. analgesia. 5.4 Acupuncture treatment is not supported as a long term management option for musculoskeletal pain. 5.5 Treatment Costs: 5.6 The tariff for acupuncture treatment will be as per the agreed physiotherapy contact price. 5.7 Requests for acupuncture not covered by this commissioning policy: 5.8 In the unlikely event of individual funding requests for acupuncture such requests will be considered on an exceptional case basis in line with the Commissioners Process for Managing Individual Patient Requests and Complex Cases. Ccg - Acupuncture V1.2 - July 2013 Page 5 of 6
6. Clinically Exceptional Circumstances 6.1 If there is demonstrable evidence of a patient s clinically exceptional circumstances, the referring practitioner should refer to Worcestershire s local Individual Funding Request Policy document for further guidance on the process for consideration. For a definition of the term clinically exceptional circumstances, please refer to the Definitions section of this document. 7. Documents Which Have Informed This Policy Worcestershire s local: Individual Funding Request Process Worcestershire s local: Prioritisation Framework for the Commissioning of Healthcare Services West Midlands Strategic Group Commissioning Policy 1: Guiding principles and considerations to underpin priority setting and resource allocation within collaborative commissioning arrangements West Midlands Strategic Group Commissioning Policy 4: Use of costeffectiveness, value for money and cost effectiveness thresholds West Midlands Strategic Group Commissioning Policy 16: Prior Approval West Midlands Strategic Group Commissioning Policy 9: Individual funding requests NICE CG59: Osteoarthritis: The care and management of osteoarthritis in adults issued February 2008 Ccg - Acupuncture V1.2 - July 2013 Page 6 of 6