Ask an expert - about acupuncture - NHS & private healthcare

21 questions

Q:  I've had treatment for my neck,shoulders,and back.  After the treatments I feel great but when I wake up the next day I feel achy and tired.

A:  This is not an unusual reaction after treatment. We often alert patients especially after the first and second session, that they may experience a resurgence of the pains they have had to an even greater extent. This is not a bad thing, and if nothing else shows that the treatment is having an effect. Since lasting adverse effects are very unusual after treatment it is usually a good sign. We only get concerned if an episode of tiredness and achiness lasts for a great deal longer or if the pattern continues without any discernible improvement in the problems for which someone came to treatment.

The mechanism for this is not clearly understood. Since Chinese medicine is premised on a flow of energy, called qi, there are explanations which borrow the analogy of chilblains which can be very painful when they are warmed up after a walk in the cold. Not a very positive analogy but gets across the idea of a circulation being restored not always being a comfortable process. More plausible is the fact that treatment is aimed at restoring proper function in the body, and ultimately this will impact on structure. If the body starts to realign then various muscle groups are going to rearrange themselves. Treatment is also aimed at expelling pathogens, and we often find that the outward travel of these can make someone feel like they are on the edge of a cold.

However, whatever the explanation in either system of medicine, we can reassure you that this is not uncommon, and while we would not want to state as a general principle that things sometimes get worse to get better, it is a frequent enough event to be predictable in cases of muscular problems in the neck and back.

The only other factor which we would explore is whether someone is cashing in their 'feeling good' after treatment by over-doing it a little. The mild euphoria and relaxation after treatment Is quite common, and we do find that people can sometimes take this sense of well-being down the gym or into the park for a run. We usually advise our patients to take it easy after treatment while the system is in flux, and leave it time to settle.


 

A:  This is not as easy as you might think.

Very few of our members are now contracted to provide acupuncture services within the NHS. Although in theory the change to commissioning groups should have given GPs more flexibility in how they spend their budgets, at the same time these budgets were cut and a series of cuts equivalent to one doctor per practice are now in mid flow. Such contracts as do exist mainly develop from personal friendships between consultants or GPs, where there is a good understanding of the longer term benefits of acupuncture.

In theory you could look at the websites of the two largest medical acupuncture bodies, the British Medical Acupuncture Society and the Acupuncture Association of Chartered Physiotherapists. This gives you potential access to about 9000 practitioners but the reality is that you would need to get a referral to a physio who also does acupuncture or to a doctor within your practice or nearby practises. This may not be as easy as it sounds, since all are bound to a degree to work within scope and where there is an evidence base for the condition being treated. Given that the bar for this is set high at the entirely inappropriate randomised double blind trial, the chances of a match are poor.

We are assuming that your need for an NHS acupuncturist is driven by finances, and apologies if we have guessed wrong. Most of our members are willing to make concessions in case of genuine financial hardship and an increasing number are now operating out of community/multibed clinics, a list of the main ones of which can be found here http://acmac.net/acu/clinics. It may be worth checking out what can be obtained locally at low cost because once you look at the whole package, including travel time and costs, a modest fee may well still be within your range.

Q: I wondered if there was a list of NHS approved acupuncture treatments that can be carried out by GP's /doctors. In other words, what the NHS recognises as a treatment of equivalent quality to that of conventional western medicine? I have seen the WHO list on your website but going through NHS choices website, it seemed quite restrictive.

Also what is the professional level of care provider in the NHS that can offer acupuncture, I presume it is more than nursing level, and is at GP/Doctor level? 

A: This is quite a complex question that touches on one or two controversial (within the acupuncture profession!) issues.

As far as the use of acupuncture by conventional medical practitioners is concerned, the usual requirement for inclusion within scope of practice is evidence at the level of randomised double blind control trial. For several very cogent reasons this is not a very appropriate mechanism for testing what by its very nature is a dynamic and evolutionary diagnostic and treatment process - diagnosis informs treatment which it turn further refines diagnosis. It would be highly unusual to use a single point prescription ad nauseam.

However, in the medical versions of acupuncture this is certainly how the process is viewed, and where trials are conducted on this basis it is considered acceptable to use acupuncture within a conventional framework. There are only two areas - chronic low back pain and cluster headaches - where NICE has adopted acupuncture as a firm recommendation. There was a ' near miss' for the treatment of osteoarthritis of the knee, where the evidence was good but the evidence for the 'sham' control group was nearly as good. Both were better than conventional treatment but the evidence of efficacy depends on outstripping the sham. Apart from that there are a few trials for post-chemotherapy nausea, dental pain and a couple of minor conditions which meet the criteria. These, at least, form the list which the Advertising Standards Authority allows us to talk about.

In practice, however, most codes of conduct inside statutory registers say that a registrant can do pretty much what they please as long as they can provide satisfactory evidence which assures them of patient safety and qualified efficacy. As you will have seen from the WHO website there are thousands of Level 2 trials which show positive results for acupuncture treatment, and many conventional practitioners extend their work in this field. The deterrent from radical use is that their protected title is at risk, on which basis a great deal of professional judgement and latitude is extended by the regulators.

As you can imagine this has become something of a hot potato as physiotherapists have started to extend their repertoire into areas like fertility treatment and internal problems which can only by a stretch of imagination be regarded as within the traditional scope of practice. There is also an increasing number of osteopaths and chiropractors extending their scope of practice, although there is nothing to indicate that this is at all included within their basic skill set. However, if they are taken to task and can show evidence that it was a legitimate extension of their skills based on reasonable evidence they would be unlikely to face censure. Our argument has always been that finding out that something was wrong after it has gone wrong is no way to run a railway, and that particularly in matters of safety where the standards are clearly defined it would make sense to enforce basic standards as a condition of use. However, acupuncture remains such a safe treatment that the risk, and therefore the urgency, is seen as less pressing. 

Our members get understandably upset, and see this as a form of subtle encroachment. Our slightly wider view is that at the moment the 'cake' which we are all sharing of prospective patients is minute in comparison to what we believe the overall use of acupuncture could and should be, and that rather than arguing about poaching we might be better advised to work together to create a much larger cake. However, there is a great deal of professional pride at stake where someone has trained to degree level for three years and then sees a person with a weekend's training offering to treat the same problems.

This abuts on your second question. Because acupuncture can be practised as a free-standing independent system or as a simple adjunct for specific circumstances (like the use of acupuncture in childbirth by midwives) you will find no simple statement of levels of attainment for its use. The basic line is that a practitioner must understand the scope of their practice and the limits of their competence, and know precisely what to do if they are out of their depth or if something goes wrong. This means that there are many nurse practitioners and low level use practitioners as well as doctors and physios who have usually undertaken significant training, although none as comprehensive as the WHO guidelines except by choice in a few cases.

This again is something of a debating point in the traditional acupuncture world. Since medical acupuncture does not have a great deal of content, it is quite common for conventional practitioners to cherrypick elements of traditional acupuncture, and this kicks of very lively debates about how safe it is for a practitioner to use a tiny part of the overall system. Would we be allowed, it is argued, to learn how to do a specific surgical procedure? However, we tend to take the view that this is going to happen increasingly as acupuncture is practised more widely because it is effective, and it is better for us to guiding the process and helping people to recognise their limitations than standing and taking pot shots at non-traditional users. Not a unanimous sentiment, it has to be said.

This is obviously a very complex field and we cannot hope to cover all of the subtleties here, but we hope that this has given you a flavour of the issues involved,


Q:  My GP has told me he will allow me to have acupuncture on the NHS for migraines,  but asked me to find out where I can go closest to me. Could you tell me what would be available in Essex

A:We are surprised and delighted to hear that your GP has agreed that you can have acupuncture treatment on the NHS. Although NICE have recommended acupuncture as one of the treatments for cluster headaches, we have seen very few referrals to practitioners outside the NHS itself.  The quickest way to identify a suitable practitioner is to use our online search facility at www.acupuncture.org.uk. On our home page you will see a search box which, if you enter your postcode, will show your the practitioners geographically closest to where you are. We have tried by using your postcode, and it generates a list of ten BAcC members in your area.

We hope that this helps you to find effective treatment for your problem.

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A: We are sorry to say that your chances of getting acupuncture on the NHS, by which we think you probably mean free at the point of delivery, are very slim. From our own experience there are very few people offering traditional acupuncture inside the NHS. Where such services exist they are usually based on some kind of personal knowledge and relationship to individual consultants or GP practices rather than a consequence of open tendering. The current commissioning arrangements have put budgetary power back in the hands of doctors at the cost of a large chunk of their budgets, and for many GPs the main target they try to achieve is saving money.

What provision there is will rest with doctors who also practise acupuncture (there are 2500 members in the British Medical Acupuncture Association) and physiotherapists (there are nearly 6000 members of the Acupuncture Association of Chartered Physiotherapists). The restriction which they face, especially the physios, is that the acupuncture has to be used within the scope of their practice and have a reasonable evidence base. This means that if your problem is musculo-skeletal and you can get a referral to an NHS physio you might, if you are lucky, find that acupuncture is a part of the treatment plan. GPs have slightly more flexibility, but many are reluctant to use acupuncture because the ten minute treatment slot doesn't really give much of a chance to do anything worthwhile.

This all sounds rather doom and gloom, but we think that you shouldn't rule out the possibility of traditional acupuncture. True, our members are highly trained professionals, and the average fees of £35-£50 per session do tend to price treatment out of some people's range. However, many practitioners are willing to offer fee reductions in case of genuine need. This often raises some interesting issues about genuine need; this expert was asked for a fee reduction because the patient's brand new 5-series BMW needed some urgent and costly repairs. Most practitioners are happy to drop fees considerably, though, but tend not to advertise the fact because it is usually people who don't need reductions who barter for a deal.

There is also a growing number of what are called multi-bed clinics which operate with three or more treatment beds in the same large open space. This concept, first used in the USA but highly reminiscent of a great deal of modern Chinese practice, was aimed at making treatment more widely available. Fees of between £10 and £20 a session are not unusual. Details of where these clinics are can be found here: http://acmac.net/acu/clinics

As a general comment, we remain disappointed that the national agencies are so reluctant to fund complementary medicine and especially acupuncture. Although the ancient concept was to stay well and get better, the modern version which sees people getting better and staying well could have immense benefits to the nation's budgets as well as the nation's health. Our day will come!

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