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Ask an expert - about acupuncture - NHS & private healthcare
Q: I'm with AXA/PPP healthcare insurance do you deal with them?
A: We are sorry to say that BAcC members are not recognised by AXA/PPP for reimbursement of acupuncture treatment. The current entry requirement for recognition is:
Acupuncturist – a medical practitioner with full registration under
the Medical Acts, who specialises in acupuncture who is registered
under the relevant Act; and who, in all cases, meets our criteria for
acupuncturist recognition for benefit purposes in their field of practice,
and who we have told in writing that we currently recognise them as
an acupuncturist for benefit purposes in that field for the provision of
out-patient treatment only.
This is quite a hard-hitting criterion which applies to only a small number of the members of the British Medical Acupuncture Society who could claim to 'specialise' in acupuncture.
There are a number of reasons why the two large medical insurers (the other being BUPA) adopt such stringent criteria, but these schemes are largely designed by actuaries who want to be able to predict with some accuracy what costs are likely to be incurred. There is not enough accepted research in acupuncture which says 'do ten sessions and the problem will go away', and in the absence of that actuaries take fright at what may become an open-ended treatment plan.
There are signs of change. BUPA has recently decided to offer limited recognition for BAcC members, and where they go it is possible that AXA will follow. In the short term, however, there is not a great deal of likelihood that you would be able to seek reimbursement for treatment from a BAcC member, but there will almost certainly be a list of accredited practitioners held by AXA which may contain details of medical doctors who meet their criteria and who work in your area.
Q: I was just wondering if NHS physios are limited by only being able to offer treatments for conditions which are evidence based?
If so, is the evidence base from NICE guidelines?
A: This is a very complex issue!
To begin with, NICE guidelines are as much about cost-effectiveness as efficacy. It is theoretically possible, for example, that NICE could approve something as a treatment option which the Advertising Standards Authority, through the Committee on Advertising Practice, might not allow to be advertised because it uses a more strict definition of evidence, the randomised double blind control trial. Under this definition of evidence base, only half a dozen or so named conditions can be advertised by a professional acupuncturist, although some of these have not made it through to NICE guidelines because they may not seem to be a cost-effective option for the problems which they address.
On the surface, though, NICE guidelines and the shortlist of conditions approved by the ASA/CAP are the working guidelines for evidence base. It is clear, however, that there are degress of evidence, and in the list created by the World Health Organisation
there is a sub-division into four categories of evidence of differing degrees of certainty. Within the professional guidelines of regulated bodies it would be possible to make a case, if challenged, for degrees of evidence, and the chiropractors whose websites were turned over three or four years ago certainly sustained this case when taken to the GCC for advertising outside the ASA guidelines.
The question of what physios can offer by way of acupuncture treatment falls within this general background. At one stage the Chartered Society of Physiotherapists was very emphatic with the Acupuncture Association of Chartered Physiotherapists that a physio could use acupuncture within their existing scope of practice if and only if there was an evidence base for its effectiveness. The argument was raised, however, that as another tool within the toolbox, i.e. that acupuncture was not an adjunct but a legitimate technique for musculo-skeletal work, acupuncture could be used within the overall scope of physio work even where there were no trials which provided RCT-driven evidence. This made a certain amount of sense. If a physio uses a trigger point or segmental approach to acupuncture, of the kind which is used by doctors who have trained and joined the British Medical Acupuncture Society, then it is in truth a technique like any other which could be used to free up tight muscles or to encourage a greater range of movement.
The problem lies in the fact that some training which physios undertake starts to look at the Traditional Chinese medicine protocols for dealing with problems. This in itself is not a problem; the overlap between the points used is East and West is considerable, even when the theoretical basis is entirely different. However, it is quite tempting to extend the range of treatments considered into areas which are more naturally the province of TCM, and there have been courses for physios and other healthcare professionals which have begun to address areas like gynaecological problems and headaches. One could make a case for a musculo-skeletal element in all areas of physical health, but some of the treatment protocols offered in these courses owe a great deal to an eastern understanding of what is happening.
Not unsurprisingly some of our members have taken considerable umbrage at what they see as poaching and cherry-picking of elements of TCM. The concern is that like any system of medicine TCM forms a coherent whole in which all aspects of the person have to be considered. Treating on the basis of inadequate knowledge could be less effective, and in extreme cases potentially a high risk activity. This is fuelled by a deeper sense of annoyance that in a recession-driven economy the physios are becoming a direct competitive threat.
In reality, this is not the case. Most physios work within the NHS, and are constrained by the rules of evidence base and NICE guidelines. The patients who have acupuncture treatment with a physio are not necessarily likely to set about seeking acupuncture treatment from a professional acupuncturist. In fact, many acupuncture patients seeing BAcC members often have acupuncture as a part of their concurrent physio treatment, and see a very clear distinction between someone who uses it as a technique in specific circumstances and someone who uses it as a full-time professional. There is, however, a small risk that someone who has had treatment from a physio which hasn't worked may conclude that acupuncture doesn't work when in fact it might have done in the hands of someone who uses it as a main treatment, but this would be unverifiable.
That said, the BAcC is maintaining a dialogue with the AACP about the use of acupuncture in physio work is extending and potentially expanding beyond the limits of scope of practice. This is not something new. Both bodies were a part of the Acupuncture Stakeholder Group for nearly a decade and were involved in the beginnings of an innovative mapping exercise which would have seen all acupuncture practice in the UK on a single grid. This was an exciting prospect, and would have opened up possibilities for people developing their skills within a coherent framework. However, the exercise was scuppered by some of the minor players in the acupuncture world who took exception to the idea that a degree-level training was the basis for effective independent practice. We hope, though, that this exercise will be resuscitated in the future.
As we said, this is a highly complex area for which it is very difficult to give a precise answer, and we hope that we have given you a flavour of the issues involved.
Q: Is there anywhere in the Brighton/Eastbourne area that would offer acupuncture to my daughter free? Training students, voluntary...anything? She suffers from cervical spondylitis and has used all her savings to have acupuncture, the only treatment that has worked for her. The NHS have offered her all manner of drugs including morphine but nothing has helped. Please, is there anyone who may help her? She is 40, positive and desperate to get on with her life. A perfect candidate for showing the NHS that acupuncture can work for more than lower back pain.
A: We know of no facility for obtaining free acupuncture except for the detox projects which are often run as, or by, charities. These tend to use protocol formula treatments for addiction, so would probably not be able to provide your daughter with what she needs.
There are a number of places in the area which offer a slightly different experience of acupuncture in a multi-bed setting. These offer treatment at significantly lower cost than usual, and the intention of the people who have started up clinics like this is to make acupuncture more accessible to people on low incomes. It may be worth contacting the Association of Community and Multibed Clinics (ACMAC http://acmac.net/acu/clinics ) whose website shows details of where these clinics are, and just looking briefly we see that there are six in your area. There may well still be a small cost involved, but it will be signifantly below the cost of private treatment and no less effective.
There is also a possibility that one of our members may do a pro bono treatment, but that would involve you ringing around the forty or more who work in the Brighton area to ask. We would not normally keep details of which members offered this level of flexibility.
The only teaching institution within easy reach of Brighton is based in East Grinstead which offers treatments for £5 in the teaching clinic. More details can be found at http://www.orientalmed.ac.uk/.
We hope that somewhere amongst all of this you find something which is suitable for your daughter.
Provision of acupuncture on the NHS is fairly limited. There are about 2000 doctors and 6000 physios who belong to special interest groups within their professions, but most use acupuncture only as another tool in the toolbox. They are also severely limited by only being able to offer treatment for conditions which have an accepted evidence base. These are few, not because there aren't any but because the standard test applied, the randomised control trial, was designed for drugs, not therapies like acupuncture, and the practice of acupuncture does not lend itself to such a design. There are hundreds of thousands of studies, mainly from China, which underpin the World Health Organisation's list of conditions which acupuncture can treat.
A small number of BAcC members have managed to secure funding to provide acupuncture within the NHS, but these projects are few and far between. In theory GPs are allowed to use their practice funds as they wish, and could refer patients for treatment within their budgets, but in practice this does not happen. There is immense pressure on funding right now, especially with the Commissioning Groups taking over from the Primary Care Trusts, and with savings being sought everywhere possible, there is less chance of either individual provision or the funding of units or projects.
The BAcC is keenly aware that with the average cost of a treatment being between £30 and £50, depending where you live, this puts treatment beyond the reach of many people. However, there are a growing number of innovative ways in which BAcC members are trying to reach people who otherwise could not afford acupuncture, and most members are willing to discuss reductions in fees if a small discount enables someone to have treatment. Ask your local BAcC members for advice.
Q: How can I find out if my PCT will fund acupuncture?
A: As you probably already know, there are some important variations to both the diagnosis and in the treatment and outcomes when you see NHS practitioners who provide acupuncture to when you see a qualified traditional acupuncturist.
GPs and physios working within the NHS are allowed to use acupuncture within their existing scope of practice, and there are one or two conditions, such as chronic low back pain, where the NICE guidelines allow doctors to make referrals for a number of sessions of acupuncture as a primary treatment. Although the guidelines do not specify who can administer the treatment, our experience is that this is invariably offered by existing NHS staff, who are often not members of the British Acupuncture Council, unfortunately. A small number of PCTs fund specialist acupuncture clinics, but these are few and far between.
In order to make a pitch for providing acupuncture services practitioners have to organise themselves as groups, satsify an immense number of requirements and then bid against all other providers for what has become a shrinking pot of funds, so there are likely to be less rather than more PCT-funded acupuncture services for the short term future until the new commissioning arrangements have settled down. Your starting point should be your local GP office or the GP who may be able to refer you onwards.