Marketing Complementary and Alternative Medical Therapies

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Abstract
Abstract Complementary and alternative therapies are increasingly popular in both the UK and the USA. This is a ,sector in which ,most practitioners operate as micro- businesses, and are far more concerned about their therapeutic expertise than about their marketing skills. Nevertheless, it is a sector of growing economic and medical importance, and one in which marketing is being practised, even if largely implicitly. The paper has twin aims, one practical and one theoretical. From a practical point of view, the aim is to begin to identify appropriate marketing strategies and ,tactics for ,complementary and ,alternative therapists. From a theoretical point of view, the aim is to shape a research agenda for the exploration ofmarketing frameworks – such as service quality, consumer behaviour and relationship marketing – in the new and rather unusual context of complementary and alternative medicine. Initial research suggests that factors ancillary to the main therapeuticpurpose ofthe medical treatment, particularly the level of personal care felt by the client, can have a substantial effect on client satisfaction.It is suggested that this is a sector in which marketing through relationships, networks and alliances is practised extensively and implicitly, and, therefore, that it would be a fruitful context in which to research and toapply relationship marketing principles. Keywords
Marketing Complementary and Alternative
Medical Therapies
Authors & affiliations
Lynn Vos and Ross Brennan
Middlesex University Business School
The Burroughs
Hendon
NW4 4BT
Contact details
l.vos@mdx.ac.uk
0208 411 5000
Marketing Complementary and Alternative Medical Therapies
Abstract
Complementary and alternative therapies are increasingly popular in both the UK
and the USA. This is a sector in which most practitioners operate as micro-
businesses, and are far more concerned about their therapeutic expertise than
about their marketing skills. Nevertheless, it is a sector of growing economic and
medical importance, and one in which marketing is being practised, even if largely
implicitly. The paper has twin aims, one practical and one theoretical. From a
practical point of view, the aim is to begin to identify appropriate marketing
strategies and tactics for complementary and alternative therapists. From a
theoretical point of view, the aim is to shape a research agenda for the exploration
of marketing frameworks – such as service quality, consumer behaviour and
relationship marketing – in the new and rather unusual context of complementary
and alternative medicine. Initial research suggests that factors ancillary to the main
therapeutic purpose of the medical treatment, particularly the level of personal care
felt by the client, can have a substantial effect on client satisfaction. It is suggested
that this is a sector in which marketing through relationships, networks and
alliances is practised extensively and implicitly, and, therefore, that it would be a
fruitful context in which to research and to apply relationship marketing principles.
Keywords
Complementary medicine; alternative medicine; consumer behaviour.
Introduction
Complementary and alternative medicine (CAM) is a phenomenon of growing
importance to the worlds of medicine and business. Increasing numbers of people in the
Western world are visiting CAM practitioners, either as an alternative to conventional
medicine, or as a supplement to it. Although exact figures are difficult to come by, a
House of Lords Select Committee concluded, having examined the available evidence,
that ‘CAM use in the United Kingdom is high and is increasing’ (House of Lords 2000,
paragraph 1.21). Most CAM practitioners operate as sole trader or small partnership
businesses, having little time, and perhaps little regard, for professional marketing.
Nevertheless, the rapid growth of the CAM sector raises a number of interesting issues
for marketing. From a practical point of view, there is the important issue of whether
conventional SME marketing techniques are appropriate to the sector, or if these are
singularly inappropriate given the nature of the service provided. However, a logical
precedent to the development of marketing strategies and tactics is the appreciation of
the marketing environment and of consumer behaviour. The aim of this paper is to
develop a research agenda for the study of marketing and consumer behaviour in the
CAM sector. In pursuing this aim we will explore the meaning of ‘complementary and
alternative medicines’, explain the structure and regulation of the CAM sector in the UK
and the USA, and begin to explore the choice processes used by CAM consumers.
1
Methodologically the paper is primarily based on secondary sources, both academic
sources and industry or government sources dealing with CAM and its regulation. We
will also refer to the results of a small (n=59) survey of users of CAM therapies that we
administered over the Internet. Since this was an exploratory study only, and did not use
rigorous sampling protocols, the results must be treated with caution. Additionally, one
of the authors delivers a university-level marketing course for CAM practitioners, and
has gathered data both from interactions with students (i.e. CAM therapists) in class and
from qualitative interviews conducted with practitioners, with access negotiated through
the course participants. These experiences have shown that CAM practitioners in
general are poorly informed about marketing, having little idea of how or why their
clients come to them, and why they choose to come back or never return.
This paper is exploratory in nature. Very little research has been published on marketing
in the CAM sector, but this is an interesting field in which to explore some of the
emerging themes in marketing theory and practice. It is largely populated by micro-
businesses, whose owner-managers are often much more concerned with the therapies
they provide than with marketing per se. Little is known about consumer choice
processes when selecting either a therapy or a therapist, or about the loyalty of
consumers to a chosen therapy or therapist. Our exploratory research has suggested
that most marketing in the sector takes place through customer relationship
development, word-of-mouth, and social networks. We will suggest, therefore, that this
may be a fruitful new field within which to investigate relationship marketing (O’Malley
2003) and marketing through networks and alliances (Shaw 2003).
In the next section we move on to provide some background on the nature or CAM, and
on the structure and regulation of the industry in the UK and the USA. After this, we
explore what is already known and what are key gaps in knowledge about consumer
behaviour in the CAM sector. We conclude by outlining a marketing research agenda for
the CAM sector, from both the applied and the theoretical perspectives.
Market structure and regulation
The literature on CAM divides medical services into those that are government regulated
or mandated and all others. Government regulated medicine is referred to by a number
of titles such as mainstream medicine, mainstream biomedical care, orthodox medicine,
conventional medicine, allopathic medicine, scientific medicine and evidence based
medicine (Leibovici 1999, Weeks 2001, Jancin 2000, Barrett & Marchand 2000).
CAM comprises a wide range of healing approaches. Until the late 20
th
Century these
other approaches were, for the most part, called ‘alternative’. In the 1980s, the term
complementary became popular, particularly in the United Kingdom, to refer to therapies
that were recommended in addition to mainstream treatments and not as an alternative
to them. However, no clear definition emerged. Today, the term ‘integrative’ is fighting
to take the place of CAM as the best definition for medical pluralism in which the
consumer has access to a range of complementary and mainstream treatments that
work in harmony to treat the ‘whole’ person, rather than focusing purely on manifest
symptoms (Callahan 2000, Capsi et al 2001).
2
In general, CAM therapies approach treatment from a preventative philosophy the
objective of which is to stimulate the body’s own natural healing mechanisms. Most
CAM therapies seek to strengthen the body or spirit or change patterns of living and diet
so that the client’s health problem disappears or is ameliorated and they become more
resistant to illness. Beyond that similarity, however, the CAM industry offers an
incredibly diverse range of approaches and philosophies to healing.
There is no clear or accepted industry definition as to what constitutes a CAM therapy.
We have identified 62 different treatment approaches (see appendix) that appear to fit
within a sector that seeks to heal people either outside the realm of conventional
medicine or in complement to it. The diversity of therapies includes the more established
fields of osteopathy, chiropractic, homeopathy, acupuncture and massage; and the more
esoteric such as crystal and psychic healing. Most practices could be classified into one
of the following therapy categories: eastern; nutritional and herbal; manipulative and
bodywork; mind/body; spiritual and esoteric; and psychological, but practitioners tend to
resist classification of their therapies and many practise across categories.
The UK marketing environment for CAM
The CAM sector of the UK health industry comprises two major components:
supplements, such as vitamins and herbs, and therapeutic practices, such as
acupuncture and homeopathy. A 1997 Mintel report valued the supplement component
at £72 million annually and, in 2000, expenditure on alternative healthcare was
estimated at £581 million or 1% of the UK healthcare market (Mintel 1997, Keynote
2003). An estimated 15 to 22 million visits were made to CAM therapists in 1998 (Mintel,
1997, Burne 2000, Thomas et al 2001). A survey conducted by the Centre for
Complementary and Alternative Medicine at the University of Exeter in 2000 suggested
that there are between 48,000 and 60,000 practitioners of Complementary and
Alternative Medicine in the United Kingdom. Since there is no single body that tracks the
whole of the sector and therapists are not required to obtain a licence in order to
practise, exact figures and values are difficult to establish (Mills & Peacock 2000).
The CAM sector operates within a weak regulatory regime. The UK government does
not require CAM practitioners to be licensed in order to operate a business, so almost
anyone with the inclination can establish a practice. Some therapies do have well-
established training standards and professional protocols – among them are
acupuncture, homeopathy, herbalism, massage, naturopathy and nutritional therapy.
Therapists in these fields are encouraged to complete rigorous training programmes,
belong to therapy associations, and adhere to professional standards of conduct and
practice. Osteopathy and chiropractic are the only two CAM therapies to have achieved
statutory self-regulation, although acupuncture and herbalism are expected to achieve
this level of regulation within the next two years.
Under the Medical Act of 1858, conventional physicians have the right to legally
administer any unconventional medical treatment as long as it is viewed not to do harm
(Mills 2001, Zollman and Vickers 1999c). UK Common Law gives consumers a right to
choose their own treatment and practitioners the right to establish themselves in various
healthcare professions as long as they do not claim to be medical practitioners, do not
3
prescribe medicines set out by the MCA (Medical Control Agency) restricted list, and do
not practice in one of the statutorily regulated or protected disciplines. In addition to
doctors and specialists in medical fields, dentist, midwives, veterinarians, osteopaths
and chiropractors are protected by law and statute (Saks 2003) All other healing
approaches are free to set up and regulate as they see fit. Needless to say, educational
and practice standards in these unregulated areas vary widely.
In terms of the CAM products sector, the UK government does not currently require
manufacturers of vitamins, minerals, supplements, herbals, or other remedies to
rigorously test their products or their product claims. However, new European Union
directives are soon to be implemented that will harmonise legislation governing herbal
products in relation to their classification as either for medicinal purposes or for other
use. EU legislation is also pending that limits the quantity of active ingredient in
individual vitamins and minerals. In the near future, many herbal preparations may no
longer be available for sale and vitamin supplements will be sold with much lower
dosages (Keynote 2003).
Practitioners tend to operate within three business structures – freelance, in a dedicated
CAM clinic, or within an NHS or ‘integrative’ practice. Integrative medicine seeks to
combine conventional with alternative and complementary healing within an established
clinic. The vast majority of practitioners are freelance. In our survey of 59 CAM users we
found that the most common venue to visit a therapist was a general complementary
health clinic, followed closely by the private clinic of the practitioner, while other venues
(e.g. NHS clinic, gym or health club) were much less frequent. Some practitioners are
now offering their services to businesses, where they operate a weekly on-site treatment
programme for employees. Approximately 20% of all NHS general practitioners are
trained in at least one complementary therapy and a further 20% of primary health care
teams provide some form of complementary therapies in their clinic settings (Zollman
and Vickers 1999b). Some UK private health insurance plans offer full or partial cover
for CAM treatments such as osteopathy, chiropractic and acupuncture, but 90% of CAM
is purchased privately (Thomas et al 2001).
The US marketing environment
CAM is more widely accepted in the USA than in the UK. Given that health insurance is
a private financial outlay, the health sector in the US has been much more market driven
than the UK. Overall the CAM industry, comprising both therapeutic treatments and
CAM products is worth $48 billion per year. In 1998 there were 629 million office visits to
complementary therapists worth $27 billion (Eisenberg 1998, Landmark Healthcare
1998). Chiropractic is the most commonly used CAM therapy in the US (Alleger 2001).
Although visits to CAM practitioners remained fairly stable from 1993 to 1998, use of
vitamins, minerals, and other supplements (VMS) greatly increased (Nahin and Straus
2001). The passing of the 1994 DSHEA (Dietary Supplement Health and Education
Act) was a boon for the VMS sector as the Act limited the power of the Federal Drug
Administration (FDA) to regulate dietary supplements. Manufacturers of these products
do not have to subject them to rigorous testing or clinical trials and can sell them as long
as they do not claim to solve or cure certain medical conditions.
4
The growth in the sector and heightened consumer interest led Congress to create the
Office of Alternative Medicine in 1992 as part of the Department of Health. In 1998, this
Federal body was renamed the National Centre for Complementary and Alternative
Medicine (NCCAM) with an initial budget of $50 million annual budget to research the
efficacy and safety of CAM therapies and products and to make recommendations on
their use to both consumers and practitioners (Kimbal 2003, Josefek 2000).
In the US registration and monitoring of practitioners is at the State level. Most State
medical practice statutes have given most practitioners the right to treat people as long
as they meet certain guidelines of responsible care (Saks 2003, La Puma and Eiler
1998). While most CAM visits in the US are paid for out of pocket, by 1997, nearly 40
medical insurers covered aspects of CAM therapies either fully or partially (La Puma and
Eiler 1998). Many large insurers are engaged in joint ventures with complementary
therapists to test the cost effectiveness of including CAM therapies in a client’s
treatment regime (Weeks 2000). For example, ‘Lifestyle Advantage’, a joint venture
between Blue Cross-Blue Shield and the Dean Ornish Preventative Research Institute
for people with cardiovascular disease offers a one year programme for patients.
Patients see a range of mainstream and other therapists, including cardiologists,
exercise physiologists, nutritional therapists, behavioural health specialists and others.
Current research shows that those who complete the one year programme save the
health plan $17,000 per year. Such results mean that more insurers are likely to offer
such integrative and preventative programmes in the future (Lipman 2001, Grandinetti
1999). More hospitals and large health organisations are offering CAM to their patients
alongside mainstream care and the sector has seen the rise of a new player – the CAM
network. This is a specialised insurance provider that sells discounted CAM services to
insurance companies or employers that want to provide CAM therapies to their
beneficiaries (Michalczyk 2000). In September 1998 64% of all US medical schools,
including those at Duke, Harvard, and Yale, offered CAM electives or courses to their
students (Eisenberg 1998). Over 100 medical schools had ‘integrative clinics’ or
research institutes to investigate CAM (Berman et al 1999, Healthcare Review 2003).
Since the creation of the NCCAM, the United States has become the centre for research
into the efficacy of CAM treatments and prescriptions of vitamins, herbals, and other
substances (Cohen 2000). Currently, hundreds of meta-analyses and random controlled
trials are being undertaken into previous CAM research studies or into prescribed
compounds. A few studies have already demonstrated that some commonly prescribed
compounds such as St. John’s Wort and glucosamine, do not provide the benefits
claimed by CAM practitioners (Ernst 2003, Frazier 2002, Cornbleet & Ross 2001). CAM
supporters claim that their treatment protocols can not be tested using only the gold
standard “random controlled trial” (RCT) as the vast majority of prescribed regimes are
too individualised and too complex to allow for the rigours of the RCT regime. How the
research debate will be resolved and what affect the new studies will have on consumer
usage are yet to be determined (Nahin & Straus 2001).
The CAM Consumer
What motivates someone to consider complementary or alternative medicine? Table 1
shows the results from our own survey of 59 CAM users.
5
Reason for using CAM
%
Long-term/chronic health problem 32.2
Therapy helped in past 45.8
Dissatisfied with conventional medicine 35.6
Desire to try new approach 22.0
New health problem 13.6
To improve general well-being 59.3
Stress-related condition 32.2
Table 1: Reasons for using CAM therapies (percentages do not add to 100 because
respondents could choose more than one option)
Our results are largely consistent with prior research. Research shows that people with
chronic health problems that are either partially or highly debilitating are more than twice
as likely to seek out CAM therapies as those with short-term acute conditions (Zollman
and Vickers 1999c, Thomas et al. 2001). Those suffering from musculoskeletal
problems such as back pain or osteoarthritis figure highest among the chronic sufferers
who seek CAM both in the UK and in the United States. Those with other chronic
conditions, such as depression, skin disorders, and allergies, and those with shorter
term conditions such as viral infections and injuries are also users of CAM (Cerrato
2002, Zollman and Vickers 1999c, Austin 1998).
For those with chronic health conditions, the choice to use CAM has usually come after
they have explored the options offered by mainstream medicine, and have not found a
solution or have faced adverse side effects (Rees and Weil 2001, Austin 1998).
Research shows, however, that most users of CAM tend to use therapies in conjunction
with orthodox medical care (Hanson 2003, Eisenberg 1998, Sharma 1995). They do so
for pragmatic rather than ideological reasons. While a small fringe of users tend to be
what could be termed ‘new agers’, the majority of CAM users are seeking help with an
intractable health problem and do so while intermittently consulting their GP (Rees and
Weil 2001, Zollman and Vickers 1999a, 1999c). However, studies show that CAM users
tend not to tell their doctors that they are also consulting a complementary therapist or
following a complementary treatment regime (Vernarec 2002).
We suggest that for those with clearly defined musculoskeletal conditions or short term
acute health conditions, the more mainstream CAM therapies like osteopathy,
acupuncture and chiropractic have almost become aligned with ‘orthodox medicine’ in
the client’s mind. While acupuncture may look a little strange to the occidental eye,
osteopathy and chiropractic bear sufficient superficial resemblance to conventional
physiotherapy to make them fairly readily accepted.
Clients of CAM practitioners tend to express satisfaction with their CAM experience,
even in cases where the treatment has not alleviated their condition (Sharma 1995). In
our survey of 59 CAM users we found that 86.5% of respondents were either very or
fairly satisfied with their experience, and that this varied little depending on whether or
6
not they felt their condition had improved. It seems that other benefits are being
delivered by the CAM experience besides a cure or the alleviation of symptoms. The
nature of these benefits, according to CAM clients, lies in the length of time that the
therapist spends with them (30 minutes to an hour), the emphasis on an extended
dialogue between therapist and client involving factors beyond the immediate
symptoms, the individual, customised treatment plan, and the opportunity to develop a
relationship with a single therapist over a period of time (Cerrato 2002, Zollman and
Vickers 1999a, Sharma 1995).
These findings can be contrasted with visits to orthodox doctors in the UK. There is
evidence that patients feel rushed with general practitioners, are concerned not to
‘waste the doctor’s time’, and often fail to remember the instructions for treatment that
the GP gave them (Mihill 2000). This is hardly surprising since the average length of
consultation with a GP in the UK is seven minutes (Mihill 2000, House of Lords 2000).
Naturally, experienced GPs know that a person’s circumstances and manifestations of
symptoms call for an individualised approach. In practice, many GPs lack the time or
resources to spend with patients (Mihill 2000). That this situation contrasts with the
typical consultation with a CAM therapist has been remarked upon in a key House of
Lords report as follows.
‘The NHS has long waiting lists for out-patient appointments in secondary care, and
there is a common impression among patients, even in primary care (with, on average,
seven-minute consultations throughout the NHS) that the doctor's time is precious and
must not be wasted. In comparison, CAM therapists are numerous and often easy to
access; they are very welcoming to patients, positively encouraging long consultations.
The Consumers' Association also suggest that some CAM therapists work in more
pleasant environments, and patients appreciate the better, and often more relaxing,
quality of their surroundings.’ (House of Lords 2000 paragraph 3.9)
While there is fairly substantial evidence of high client satisfaction levels with CAM, what
is not known is the extent of client loyalty in the CAM sector, whether loyalty to a
particular therapy or to an individual therapist. In our own survey of 59 CAM users we
found that much the largest group (49.2%) had been using CAM therapies for more than
five years, indicating high loyalty to this approach to medicine; however, we did not
measure loyalty to particular therapies or therapists. Clearly this is a high-touch service
‘industry’, and one in which some clients value the establishment of a personal, enduring
relationship with the ‘service provider’. Thus, the field looks like fertile ground for the
application of relationship marketing. As a starting point, however, some basic research
into the extent of client loyalty, and the factors driving it, are necessary. In health care,
consumers judge three broad domains of benefits. The first is results or what we
traditionally call quality. Patients want their problems diagnosed and treated properly,
their function restored, and/or symptoms relieved. If the results are unsatisfactory,
consumers will go elsewhere. However, providing good quality service is not enough to
be competitive in today's marketplace. Consumers are concerned not only about results
but also about the way in which the services are delivered. This is the so-called service
process domain. Some of the service process parameters that consumers consider
important are dependability, responsiveness, and co-ordination of care among individual
providers, and the knowledge, compassion, and empathy of staff. The third domain in
7
which a consumer will measure benefit is reputation, an intangible benefit that depends
on a provider's quality and service, record over time, fame, special services, and so on.
Reputation is very difficult to build, but it is often important to consumers.
Costs from the consumer's perspective can be broken down into two domains: the price
that the consumer must pay and the non-monetary cost of acquiring the services
including the amount of time, energy, and psychological stress that is required to access
the service. Different consumers have different concepts of value and weigh each of the
variables (both benefits and costs) in the equation differently. Thus, healthcare providers
must know what their core customers value, and they must design their services to
maximise that value. Of course, judgments of value are limited by available information.
Increasingly, however, consumers will have readily available information on which to
make these judgements. Up to this point, the main focus of the value equation has been
price. Managed care companies have focused their efforts on lowering the price (or
preventing the price rise) of healthcare. In the future, consumers will have more
information about quality, service process, reputation, and access costs, and will make a
choice based on these parameters in addition to price. Providers who measure quality
and process, who create a reputation, and who get that information to consumers will
have an advantage over those who do not. This implies an enhanced role for marketing.
Conclusion: towards a marketing research agenda for CAM
The CAM sector has a chameleon-like quality. Some therapies are quite respectable,
others are regarded as wacky by all but a few devotees. Some therapies have made
considerable progress towards organising themselves as credible professional
practises, including the development of extensive training and governing bodies, while
other have not. Even for those therapies which are best organised, the focus for the
development of professional bodies and continuing professional development programs
has been (quite naturally) the professional delivery of the therapy rather than the
marketing of the service. Of course, the formation of a professional body, and the
establishment of minimum standards of therapeutic competence, can themselves be
seen as manifestations of marketing. In particular, when prospective clients are
choosing between therapies, the existence of a professional body that maintains a
register of qualified practitioners is presumably expected to be a source of competitive
advantage to the therapist. However, even this – although apparently common sense –
cannot yet be confirmed by extensive research evidence. In our own survey of 59 CAM
users we found that 49% of respondents thought it ‘very important’ for their therapist to
be a registered practitioner. Four key areas for further research have emerged from our
discussion of the CAM sector – professionalisation, the CAM sector as a branch of
marketing for small and medium-sized firms (SMEs), consumer behaviour, and
marketing through relationships, networks and alliances.
Professionalisation
The research agenda here pertains to the impact of the professionalisation process on
competitive advantage and marketing expertise. Reputation is important among CAM
practitioners, and presumably one reason for joining a professional body is to be
8
perceived as more respectable by potential clients and therefore to improve the
likelihood of attracting new clients. Two key aspects that need to be investigated are the
impact of professional bodies on client choice processes, and the choice process made
by the CAM practitioner in the early stages of professionalisation – when to sign up to a
professional body, and how to choose between competing professional bodies where
there is more than one.
SME marketing
From a practical point of view, there is the important issue of whether conventional SME
marketing techniques are appropriate to the sector, or if these are singularly
inappropriate given the nature of the service provided. For example, Hill (2001) identified
a range of competencies that are required for effective SME marketing, including
‘foundation competencies’ (e.g. judgement, intuition), ‘transitional competencies’ (e.g.
vision, opportunity focus), and ‘marketing in practice competencies’ (e.g. listening skills,
honesty, motivation, aggression). One of Hill’s conclusions was that a sales focus is a
particular characteristic of SME marketing. While many of Hill’s proposed competencies
are equally applicable to CAM marketing, particularly those pertaining to relational
communication, our preliminary research suggests that certain other competencies
(such as aggression and ambition) are unlikely to be an aid to success in this sector. It
seems very unlikely that a sales focus would be widespread in the CAM sector. Rather,
we would hypothesize either a product focus (the practitioner believes implicitly in the
value of his/her therapeutic arts), or a client focus (the practitioner is concerned to
understand and respond to the holistic needs of the individual client) to be more
prevalent.
Consumer behaviour and relationship marketing
There is still considerable groundwork to be done to establish the basic choice criteria
and decision-making processes involved in client selection first among competing CAM
therapies, and second among therapists. While it seems clear that inter-personal
relationships are at the heart of successful marketing for CAM practitioners, much work
needs to be done to measure levels of client loyalty in the sector and to identify the
factors that differentiate successful from unsuccessful client relationships. The relative
importance of the intrinsic service quality (does the client’s health get better?), the
service process (does the client find the encounter satisfactory?) and practitioner
reputation in building successful marketing relationships deserves attention.
Furthermore, the degree to which consumer behaviour in this sector is affected or will be
affected by evidence from clinical trials that provide objective evidence about treatment
efficacy is also unknown.
Marketing through networks and alliances
Gilmore, Carson and Grant (2001) reported a qualitative study of 45 owner-managers of
SMEs. They argued that marketing for SMEs could be more effectively conceptualised
as the management of networks, particularly the competitor network and the customer
network, than as traditional marketing mix management. There are striking similarities
with our observations from the CAM sector. In particular, the extent of inter-competitor
co-operation and information exchange found by Gilmore et al is mirrored among CAM
practitioners. Networking with customers (clients) is less formalised in the CAM sector,
9
however – the majority of the sample studied by Gilmore et al were business-to-
business organisations, with frequent semi-formal opportunities for customer networking
organised through trade associations and social/business networks. The use of both
competitor and customer networks for marketing in the CAM sector merits further
research attention.
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Appendix: List of CAM Therapies
1 Acupuncture 34 Herbalism (Chinese)
2 Alexander Technique 35 Herbalism (Western)
3 Anthroposophical Medicine 36 Homoeopathy
4 Aromatherapy 37 Horticultural Therapy
5 Astrology 38 Iridology
6 Aura Analysis 39 Kirlian Photography
7 Auricular Therapy 40 Lymphatic Drainage
8 Ayurvedic Medicine 41 Macrobiotics (Nutrition)
9 Bach Flower Remedies 42 Magnetic Therapy
10 Bates Eyesight Training 43 Massage Therapies
11 Bioenergetic Medicine 44 Meditation
12 Bodywork (Biodynamic Therapy) 45 Naturopathy
13 Bodywork (Craniosacral) 46 Nutritional Therapy
14 Bodywork (Hellerwork) 47 Osteopathy
15 Bodywork (Kinesiology) 48 Pilates
16 Bodywork (Light Touch Ther.) 49 Psychotherapy (Autogenic Training)
17 Bodywork (Polarity Therapy) 50 Psychotherapy(Biofeedback)
18 Bodywork (Reichian) 51 Psychotherapy (Counselling)
19 Bodywork (Rolfing) 52 Psychotherapy(Hypnotherapy)
20 Bodywork (Zero Balancing) 53 Psychotherapy (NLP)
21 Bodywork(Feldenkrais) 54 Psychotherapy (Arts and Drama Therapy)
22 Bodywork(Metamorphic) 55 Psychotherapies (All)
23 Bowen Technique 56 Pulsing
24 Chinese(Oriental) Medicine 57 Quantum Healing
25 Chiropody 58 Radionics
26 Chiropractic 59 Rebalancing
27 Colonic Irrigation 60 Reflexology
28 Colour Therapy 61 Reiki
29 Crystal Therapy 62 Shiatsu
30 Cymatics 63 Spiritualism
31 Feng Shui 64 Stress Management
32 Floatation Tank Therapy 65 Tibetan Medicine
12
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Others depend on more recent NHS reorganisations, like general practice fundholding and health commission contracting, or have been set up as evaluated pilot projects.View larger version:In a new windowDownload as PowerPoint SlideComplementary therapies have been available in the NHS since its inception Integrating complementary medicine into conventional settings Successful integration is more likely with Demand from patientsCommitment from high level staff in the conventional organisationProtected time for education and communicationOngoing evaluation of service (may help to defend service in the face of financial threat)Links with other conventional establishments integrating complementary medicineRealism and good will from all partiesJointly agreed guidelines or protocols between complementary and conventional practitionersSupport from senior management or health authorityCareful selection and supervision of complementary practitionersFunding from charitable or voluntary sector Problems are likely with Financial insecurityTime pressureLack of appropriate premisesUnrealistic expectationsOverwhelming demandInappropriate referralsUnresolved differences in perspective between complementary and conventional practitionersReal or perceived lack of evidence of effectivenessLack of resources and time for reflection and evaluation List adapted from the report of the Delivery Mechanisms Working Party of the Foundation for Integrated Medicine In general, development of these services has been demand led rather than evidence led. A few have published formal evaluations or audit reports. Some of these show benefits associated with complementary therapy—high patient satisfaction, significant improvements on validated health questionnaires compared with waiting list controls, and suggestions of reduced prescribing and referrals. However, data from other services are less clear, and many have not been formally evaluated These pilot projects have also identified various factors that influence the integration of complementary medicine practitioners within NHS settings. Causes for concern While much needed evidence is gathered, the debate about more widespread integration of complementary medicine continues. The idea of providing such care within a framework of evidence based medicine, NHS reorganisations, and healthcare rationing raises various concerns for the different parties involved. Conventional clinicians and managers want persuasive evidence that complementary medicine can deliver safe, cost effective solutions to problems that are expensive or difficult to manage with conventional treatment. Unfortunately, such evidence is both scarce and equivocal Only a moderate number of randomised trials and very few reliable economic analyses of complementary medicine have been conducted Moreover, no systematic process exists for collecting data on safety and adverse events. Patients—Public surveys show that most people support increased provision of complementary medicine on the NHS, but this question is often asked in isolation and does not mean that patients would necessarily prefer complementary to conventional care. When planning services, it is essential to try to distinguish between patients' desires and defined patients' needs that can be met by complementary medicine. Patients also want to be protected from unqualified complementary practitioners and inappropriate treatments. NHS provision might go some way to ensuring certain minimum standards such as proper regulation, standardised note keeping, effective channels of communication, and participation in research. It would also facilitate ongoing medical assessment. Organisations promoting interdisciplinary cooperation in complementary medicine Foundation for Integrated Medicine Initiative of Prince of Wales, convenes working parties and events on aspects of integrated medicine International House, 59 Compton Road, London N1 2YT Tel: 0171 688 1881. Fax: 0171 688 1882 British Holistic Medical Association Membership organisation for healthcare professionals with associate lay members 59 Lansdowne Place, Hove, East Sussex BN3 1FL. Tel/fax: 01273 725951. URL: www.bhma.org Complementary practitioners—Some practitioners support NHS provision because it would improve equity of access, protect their right to practise (currently vulnerable to changes in European and national legislation), and guarantee a caseload. It would also provide opportunities for inter-professional learning, career development, and research. Others fear an inevitable loss of autonomy, poorer working conditions, and domination by the medical model. Current provision in the NHS In primary care Most of the complementary medicine provided through the NHS is delivered in primary care. View larger version:In a new windowDownload as PowerPoint SlideModel of provision of complementary medicine Direct provision Over 20% of primary healthcare teams provide some form complementary therapy directly. For example, general practitioners may use homoeopathy, and practice nurses may use hypnosis or reflexology. Advantages of this system are that it requires minimal financial investment and that complementary treatments are usually offered only after conventional assessment and diagnosis. Also, practitioners can monitor patients from a conventional viewpoint, ensure compliance with essential conventional medication, and identify interactions and adverse events. A disadvantage is that shorter appointments may leave less time for non-specific aspects of the therapeutic consultation. Also, members of primary healthcare teams have often undertaken only a basic training in complementary medicine, and this generally forms only a small part of their work. Doubts about the effectiveness of the complementary treatments they deliver, compared with those given by full time complementary therapists, have been expressed. Although no comparative evidence is available, it is clear that limits of competence need to be recognised. In many general practices osteopathy is provided indirectly by an independent complementary practitioner Indirect provision Complementary practitioners without a background in conventional health care work in at least 20% of UK general practices. Osteopathy is the most commonly encountered profession. Such practitioners usually work privately, but some are employed by the practice and function as ancillary staff. An advantage for patients is that general practices usually check practitioners' references and credentials. Although some guidelines for referral may exist, levels of communication with general practitioners vary widely and true integration is rare. In specialist provider units Five NHS homoeopathic hospitals across the United Kingdom accept referrals from primary care under normal NHS conditions: free at the point of care. They offer a variety of complementary therapies provided by conventionally trained health professionals. They provide opportunities for large scale audit and evaluation of complementary medicine, but many services have been cut in recent years. View larger version:In a new windowDownload as PowerPoint SlideMarylebone Health Centre was one of the first general practices to offer multidisciplinary complementary therapies to NHS patients. It provides osteopathy, massage, naturopathy, and homoeopathy Some independent complementary medicine centres have contracts with local NHS purchasers. For example, Wessex Health Authority has a specific service contract with a private clinic to provide a multidisciplinary package of complementary medicine for NHS patients with chronic fatigue or hyperactivity. Some fundholding general practices have delegated patients to independent centres such as local chiropractic clinics rather than employ complementary practitioners in house. A few health authorities have set up pilot projects for multidisciplinary complementary medicine in the community or on hospital premises Advantages have included clear referral guidelines, evaluation, good communication with general practitioners, and supervised and accountable complementary practitioners. However, such centres are particularly vulnerable when health authorities come under financial pressure. Examples are the Liverpool Centre for Health and the former Lewisham Hospital NHS Trust Complementary Therapy Centre, which was closed when the local health authority had to reduce its overspend. In conventional secondary care Many NHS hospital trusts offer some form of complementary medicine to patients. This may be provided by practitioners with or without backgrounds in conventional health care. However, the availability of such services varies widely and depends heavily on local interest and high level support. View this table:View PopupView InlineExamples of complementary medicine in secondary care Funding for complementary medicine Complementary medicine can be provided by conventional NHS healthcare professionals as part of everyday clinical care. This requires no special funding arrangements. General practitioners cannot claim item of service payments for complementary treatments they give to their own NHS patients. Since 1991, health authorities can reimburse general practitioner principals who employ complementary therapists, although the staff budget is limited and a complementary practitioner is therefore employed at the expense of another member of staff. General practitioner fundholders have had additional control over staffing budgets and fundholding savings, which some have used to purchase complementary therapies. Primary care groups have greater power to allocate funds as they choose, but it remains to be seen whether complementary medicine will be identified as a priority by sufficiently large numbers of general practitioners for the creation of any new initiatives. Indeed, the change from general practice fundholding to primary care groups may mean that some established complementary services will be lost. An increasing number of hospital pain clinics now offer acupuncture as a treatment for chronic pain Local health commissions and authorities have sometimes used money for research and development, or for waiting list initiatives, to finance complementary medicine. Block service contracts or individual extracontractual referrals can be made with complementary medicine providers, but in practice financial constraints restrict this type of access. Funds from the voluntary sector or charities may also be sought. The complementary therapy service at the Marylebone Health Centre in London was initially funded by a research grant from a charitable trust. Fundraising and donations by the local patients are now essential to its ongoing financial viability. In addition, some charities, such as the London Lighthouse for people infected with HIV, subsidise complementary medicine for people who could not otherwise afford treatment. Some occupational health and private medical insurance schemes fund complementary therapies. Medicolegal considerations If doctors participate in patients' seeking complementary therapies—by advising, treating, delegating, or referring—they need to be aware of the medicolegal implications. Although each case is judged on its merits, certain guidelines apply. Some complementary therapies, such as relaxation, can be delivered effectively in group sessions, which improves their cost effectiveness Doctors who practise complementary therapies Under the Medical Act of 1858, conventionally trained doctors can legally administer any unconventional medical treatments they choose However, as with most medical practice, the “Bolam test” is used to determine appropriate standards of care. This means that “a doctor is not guilty of negligence if he or she has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art as long as it is subject to logical analysis.” In other words, if a doctor has undergone additional training in a complementary discipline and practises in a way that is reasonable and would be considered acceptable by a number (not necessarily a majority) of other medically qualified complementary practitioners, his or her actions are defensible. Referral to medically qualified practitioners A doctor who asks another doctor to provide complementary medicine is in the same legal situation as when referring to a doctor for any other services. As long as the decision to make the referral is appropriate, all further responsibility regarding the complementary treatment is taken over by the doctor providing the specialist service. Medicolegally acceptable delegation to non-medically qualified complementary practitioners Initial decision to delegate to a practitioner must pass Bolam test Evidence based decisions are most persuasiveCommonly accepted but unproved indications are also acceptable Doctors must take reasonable steps to ascertain that practitioners are appropriately qualified It is usually sufficient for delegating doctors to ensure that they are a member of the main professional regulatory body responsible for that particular disciplineThe main bodies require members to be fully indemnified Doctors must retain “overall clinical responsibility”—that is, ensure appropriate follow up, reassessment, etc Doctors should not issue repeat complementary prescriptions without having or obtaining sufficient information to ensure safe prescribing Delegation to non-medically qualified practitioners This situation, more than any other, concerns doctors who wish to make complementary medicine available to their patients. Despite theoretical worries, however, it is considered a very low risk area by medical defence societies. The situation may change if complementary medicine becomes more widely used. Doctors must ask themselves three main questions: Is my decision to delegate to this complementary therapy appropriate?Have I taken reasonable steps to ensure that the practitioner concerned is qualified and insured?Has my medical follow up been adequate? To date, no claims or cases have been sustained against doctors who have delegated to complementary practitioners. Delegation to state regulated complementary practitioners Now that osteopaths and chiropractors are state regulated, delegating to these practitioners is medicolegally similar to delegating care to a physiotherapist or other conventional healthcare professional. Key evaluation reports from NHS complementary medicine services ReferencesRichardson J. Complementary therapy in the NHS: a service evaluation of the first year of an outpatient service in a local district general hospital. November 1995. Report prepared by Health Services Research and Evaluation Unit, Lewisham Hospital NHS Trust, LondonHotchkiss J. Liverpool Centre for Health: the first year of a service offering complementary therapies on the NHS. Liverpool: Liverpool Public Health Observatory, 1995 (Observatory Report Series No 25)Hills D, Welford R. Complementary therapy in general practice: an evaluation of the Glastonbury Health Centre Complementary Medicine Service. Somerset Trust for Integrated Health Care, 1998Rees R. Evaluating complementary therapy on the NHS: a critique of reports from three pilot projects. Complement Ther Med 1996: 254–7Scheurmier N, Breen AC. A pilot study of the purchase of manipulation services for acute low back pain in the United Kingdom. J Manipulative Physiol Ther 1998; 21: 14–8 Obtaining lists of the main professional registers Council for Complementary and Alternative Medicine (CCAM) Deals with registration of acupuncture, herbal medicine, homoeopathy, and osteopathy 63 Jeddo Road, London W12 6HQ. Tel: 0181 735 0632 British Complementary Medicine Association (BCMA) Deals with registration of wide range of complementary practitioners including reflexologists, aromatherapists, craniosacral therapists, nutritional therapists, and hypnotherapists 249 Fosse Road South, Leicester LE3 1AE. Tel: 0116 282 5511 Further reading ReferencesSharma U. Complementary medicine today: practitioners and patients. Rev ed. London: Routledge, 1995Fulder S. The handbook of alternative and complementary medicine. 3rd ed. Oxford: Oxford University Press, 1996Stone J, Matthews J. Complementary medicine and the law. Oxford: Oxford University Press, 1996Coates J, Jobst K. Integrated healthcare, a way forward for the next five years? J Alternative Complement Med 1998; 4: 209–47Complementary medicine: new approaches to good practice. Oxford: Oxford University Press, 1993 Acknowledgments The pictures of Royal London Homoeopathic Hospital and acupuncture are reproduced with permission of the Royal London Homoeopathic Hospital The picture of osteopathy is reproduced with permission of the General Osteopathic Council. The picture of group therapy is reproduced with permission of BMJ/Ulrike Preuss. Footnotes The ABC of complementary medicine is edited and written by Catherine Zollman and Andrew Vickers. Catherine Zollman is a general practitioner in Bristol, and Andrew Vickers will shortly take up a post at Memorial Sloan-Kettering Cancer Center, New York. At the time of writing, both worked for the Research Council for Complementary Medicine, London The series will be published as a book in spring 2000.
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