Real-world evidence leads to complementary medicine referrals on the NHS

Real-world evidence leads to complementary medicine referrals on the NHS

Getting NHS referrals to your practice can be tough. We look at the importance of collecting evidence, and the new NICE guidelines for acupuncture to treat chronic pain

We know that seeing the positive impact your work has on your patients but not receiving referrals for new patients from GPs can be frustrating . 

For a GP to recommend anything to a patient, from a specific drug to a physiotherapy appointment, they will be guided by the National Institute of Health and Care Excellence (NICE). NICE writes guidelines recommending to healthcare professionals which services are suitable for most people with a specific condition or need. Their guidelines are written based on clear evidence which demonstrates that intervention’s benefit; the type of evidence which so far has rarely been collected for complementary medicines. 

Now, that is changing. A number of high-quality studies have been carried out to show the clear benefit that acupuncture can have for treating chronic pain, and NICE have issued a draft guideline which recommends its use. This recommendation means that, after careful assessment of the patient, a GP will be able to refer a person over 16 years with chronic pain to an acupuncture practitioner, through the NHS.

What is acupuncture?

Acupuncture is a technique that originates from ancient Chinese medicine, which uses fine needles inserted just under the skin, or deeper so that they reach the muscle, at specific points. In Western medicine, the belief is that the needles stimulate the sensory nerves, which results in the body producing natural substances such as the pain-relieving endorphins. Traditional Chinese medicine explains acupuncture as restoring the flow of Qi (pronounced ‘Chee’), which is the energy or ‘life force’ that flows through the body, causing illness when interrupted. 

Currently, it is only recommended by NICE as a treatment option for chronic tension-type headaches and migraines, although private practitioners also use it to treat other conditions, such as chronic pain. The recent NICE draft guideline for chronic pain in people over 16 years includes acupuncture as a recommended therapy. The draft guideline is currently being reviewed and is due to be published in January 2021; you can read the draft here.

How are NICE guidelines developed?

Each of NICE’s guidelines are developed through a structured process. First, the topic is chosen and then agreed by bodies such as NHS England and the Department for Health and Social Care. Decisions on which topics to develop guidelines on are based on factors such as the health and care burden, and the potential to improve outcomes and quality of life. The scope of the guideline is then assessed: what is the context of the guideline, including current policy and practice; what will the guideline cover and what will it not cover; what are the key issues that will be considered. 

Following these first two stages, the guideline is then written. This involves reviewing all of the evidence related to the topic and assessing its quality. Recommendations within the guideline are based on the trade-off between benefits and harms of an intervention such as acupuncture for managing chronic pain, as well as the quality of the underpinning evidence. The evidence is considered by a committee made up of practitioners, professionals, care providers, commissioners, those who use the services and family members or carers. In addition, a cost-impact assessment is carried out.

Evidence for the use of acupuncture to manage chronic pain

The NICE guideline for assessing and managing chronic pain in people aged 16 years and over recommends considering a course of acupuncture, and gives its rationale based on the evidence reviewed. The committee found 27 studies which showed that acupuncture reduced pain and improved quality of life in the short term (3 months) compared with usual care or sham acupuncture (blunt needles). However, there was not enough evidence to determine the longer-term benefits. In addition, two economic evaluations showed that acupuncture offered a good balance of benefits and costs for people with chronic neck pain. 

Overall, the committee agreed that there was a large evidence base showing that acupuncture can be clinically effective in the short term, but they took into account the lack of evidence for long-term benefit and the high-resource impact of implementation. They therefore suggested its use only if the course is delivered by a band 7 (or lower) health professional, and if it is made up of a maximum of 5 hours of healthcare professional time. This would ensure the intervention is cost-effective. 

What kind of evidence is needed?

NICE will tend to prioritise published studies as their evidence base. For example, studies included as evidence for the use of acupuncture to treat chronic pain would have compared the amount of pain a person reports before and after acupuncture therapy, with reported pain after sham acupuncture. Now, we can’t expect practitioners to carry out a controlled experiment by offering their patients a sham/placebo therapy, or even to have the time to design these sorts of studies. But, by collecting simple data about patient outcomes after you treat them, studies can be carried out using the data, thus providing NICE with the evidence they need to recommend that healthcare professionals refer patients to you.

Look out for more of our upcoming blog posts on how you can collect useful evidence in your practice.