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Exploring General Practitioners’ attitudes to homeopathy in Dumfries and Galloway
ARTICLE IN PRESS Homeopathy (2003) 92, 190–194 r 2003 The Faculty of Homeopathy doi:10.1016/j.homp.2003.06.001, available online at www.sciencedirect.com
ORIGINAL PAPER
Exploring General Practitioners’ attitudes to homeopathy in Dumfries and Galloway E Hamilton* Glasgow Homoeopathic Hospital, Glasgow, Scotland, UK
This comparative quantitative study explored General Practitioners’ (GPs) attitudes to homeopathy in Dumfries and Galloway, a predominantly rural area in South West Scotland where there is a local British Homeopathic Association Funded Homeopathic Clinic. It aimed to determine whether there was an association between expressed attitudes to homeopathy and a number of variables. Issues arising from the House of Lords Report on CAM were also explored. A self-administered questionnaire was addressed to all 135 GPs within Dumfries and Galloway. Descriptive statistics were used in the data analysis. The response rate was 75%. The NHS GP clinic accounted for 47% of total referrals for homeopathy. A total of 86.1% of GPs within Dumfries and Galloway were in favour of a local NHS Homeopathic Specialist Clinic. Forms of evidence most influential to GPs regarding homeopathy were: randomised controlled trials; audit data on patient outcomes; safety and patient satisfaction. Homeopathy (2003) 92, 190–194.
Keywords: homeopathy; CAM; Scotland; General Practitioners; attitudes; integration; evidence-based medicine; quantitative
Introduction This study was carried out as a part of a BSc (Hons) nursing degree in homeopathy, which involved clinical placement at the British Homeopathic Association (BHA) Funded Homeopathic Clinic, New Galloway. This clinic was established in April 2000. Patients are referred from Stewartry Local Health Care Cooperative (LHCC) area: one of four LHCC areas in Dumfries and Galloway. The data were primarily quantitative with some additional qualitative information. This article focuses on the quantitative data. Exploring General Practitioners’ (GPs) attitudes to homeopathy is relevant due to the increasing popularity of complementary and alternative medicine
*Correspondence: E Hamilton, Homeopathic Nurse Practitioner, Glasgow Homoeopathic Hospital, 1053 Great Western Road, Glasgow G12 0XQ, Scotland, UK. E-mail: [email protected] Received 22 October 2002; revised 13 March 2003; accepted 26 June 2003
(CAM).1 The House of Lords Report2 acknowledges this trend and to ensure public protection recommends: provision of evidence base on the effectiveness of CAM; establishment of self-regulatory bodies; provision of information on CAM; provision of CAM within the NHS for those therapies that fulfil the specified criteria.
Literature review The literature review explored the following issues: the current position of homeopathy within the NHS in Scotland; GPs’ and other health professionals’ attitudes to CAM including homeopathy and evidencebased medicine on the subject. In Scotland, GPs are structured into LHCCs with authority residing with the local Health Boards. Homeopathic patient referrals within the NHS are either to the Glasgow Homeopathic Hospital, local homeopathic services within various health boards or the two BHA funded clinics in Ayr and Stewartry. A
ARTICLE IN PRESS GPs attitudes E Hamilton
191
survey by Wyllie and Hannaford3 revealed that 74% of GPs would welcome a local NHS homeopathic clinic. This interest is also reflected in the fact that 25% of Scottish GPs have undergone basic homeopathic training at the Glasgow Homeopathic Hospital.4 General Practitioners attitudes to CAM including homeopathy The accessibility of homeopathy within Primary Care is linked to GPs’ attitudes as GPs are influential in purchasing healthcare.5 The literature review reveals several authors who have researched GPs’ attitudes to CAM, including homeopathy, over the last decade.3,5–9 Only one of these studies is specific to homeopathy.6 Some publications include other health professionals’ views.7–9 Homeopathy and evidence-based medicine Evidence-based medicine involves incorporating the best available evidence of efficacy into healthcare systems.10 Whilst the House of Lords Report acknowledges the evidence for homeopathic isopathy in the treatment of asthma and allergic rhinitis11–14 it recommends larger independent trials over longer periods. Linde and Melchart15 in their overview of randomised controlled trials of individualised homeopathy identify the problems of double-blind placebocontrolled trials and suggest that clinical research in homeopathy should include a more pragmatic approach, incorporating realistic tools for research, involving case studies and observational studies prior to more formalised trials.16–18
Method The method of data collection was a self-administered questionnaire, to provide primarily quantitative data from a non-probability purposive sample group. Approval for the study was granted by the Medical Director of Dumfries and Galloway Primary Care NHS Trust. Access to information concerning GPs and Practice Managers names and addresses was also given and it was also determined that Practice Managers would be useful contacts for encouraging GPs to complete the questionnaires.19 The content of the questionnaire was based on issues arising from the House of Lords Report and previous research.1–3 The questionnaire was validated by a statistician, SPSS (version 11.0) was used for analysis. An introductory letter gave a brief explanation of the aim of the study. Anonymity was promised to all respondents, responses are identifiable by LHCC area only. A pilot study involved six medical professionals, four of whom were GPs not participating in the main survey and two hospital consultants. Amendments entailed changing the format of two questions.
Data collection methods All 33 Practice Managers within Dumfries and Galloway were contacted by telephone 1 week prior to distribution of questionnaire. This phone call consisted of an explanation of the forthcoming questionnaire including brief details of the researcher, purpose of survey, method and date of distribution with collection and return date. The researcher also checked with the Practice Managers the current list of GPs’ names and adjustments were made to ensure that the list of possible participants was valid. Four GPs were absent due to sickness, maternity leave and holidays. A reminder phone call was also made to all Practice Managers 5 days prior to the deadline for completion of the questionnaire.
Results Descriptive statistics were used in the analysis as this was a non-randomised sample and therefore statistical inferences pertaining to the general population of GPs could not be made.20 Out of the 101 (75%) GPs who responded, the response rate was greatest in Wigtownshire (82.8%) and Stewartry LHCC areas (78.2%). Response was slightly higher in male GPs (67/88 77%), than female GPs (33/47, 70%). House of Lords report/ interest in using CAM/ qualifications in CAM GPs were questioned on their awareness of the House of Lords Report. Forty-seven out of 67 male respondents (70.1%), compared with 25/34 females (73.5%) were interested in CAM. Twenty-three GPs had a CAM qualification (19 males, four females). Five GPs possessed more than one qualification in CAM. Fortyfour per cent of GPs were interested in local training in homeopathy. In all, 55.9% (19/34) of female GPs respondents were in favour of further training in homeopathy compared to 37.9% (25/66) male GPs. Patient requests for homeopathy Forty-one per cent of GPs had patients requesting homeopathic treatment in the last month. In Wigtownshire LHCC area 39% (16) GPs had received patient requests for homeopathy, Stewartry LHCC 36.6% (15), Annandale and Eskdale 19.5% (8) and Upper Nithsdale and Dumfries 4.9% (2). GPs who had referred patients were asked to specify where they had referred. The NHS GP Clinic accounted for 16 (47%) of the total referrals. There were 13 referrals (38.2%) to the Glasgow Homoeopathic Hospital. Only three GPs had referred to Private Practice. Two GPs had referred to GP Colleagues {1 General Practitioner from Annandale and Eskdale and one from Upper Nithsdale and Dumfries had referred to both NHS GP and NHS Hospital clinics}. Homeopathy
ARTICLE IN PRESS GPs attitudes E Hamilton
192
Reasons for non-referrals for homeopathy The 69 GPs who did not refer patients for homeopathy within the previous month were asked to tick or state reasons for non-referrals. The most common reason for non-referral was ‘not appropriate situation’ (38). In Wigtownshire some non-referrals (6) were due to homeopathy being practised within this GP practice. Some GPs ticked more than one reason indicating possible validity problems with this question. Local NHS homeopathic clinic GPs were asked if they would use a local NHS Homeopathic Clinic, 86.1% replied yes, 11.9% no and 1% unsure and 1% answer missing. 100% of Stewartry GPs were in favour. Forms of evidence regarding homeopathy GPs were asked to rank in terms of influence from 1 (most important) to 9 (least important) the forms of evidence regarding homeopathy listed in Table 1. Only 87/101 answered this question satisfactorily. In the first four ranked forms of evidence were randomised controlled trials, audit data regarding efficacy, safety profile and patient satisfaction. In the final five: cost-effectiveness, personal experience, patient demand, colleagues opinions and theory of homeopathy also had the greatest number of missing answers, revealing possible reliability and validity factors in the design of this question.
Discussion The response rate of 75% to the questionnaire was very good;21 the following factors may have contributed to this result: Practice Managers are influential team members within the Primary Health Care setting, involving them improved response rates: the author had also worked previously in Wigtownshire area which had the highest response rate (82.8%); the Stewartry LHCC area following closely with 78.2%. These areas had the highest number of GPs qualified in CAM (16/23), and a higher incidence of GPs with patient requests for homeopathy. This suggests higher
Table 1 GPs rating of forms of evidence on a 1–9 scale (1 = very important, 9 = least important)
Randomised controlled trials Audit data regarding efficacy Safety profile Patient satisfaction Cost-effectiveness Personal experience Patient demand Colleagues opinions Theory of homeopathy Valid N (listwise)
Homeopathy
N
Mean score
95 93 92 93 91 89 90 89 90 87
3.35 3.52 3.71 3.88 5.40 5.54 5.74 5.80 6.83
awareness of CAM within Wigtownshire and Stewartry areas. Overall 71.3% of GPs in Dumfries and Galloway indicated they be would be interested in using CAM. Forty-four per cent of GPs were in favour of local training in homeopathy, 55.9% females, compared to 37.9% males. But more men already had qualifications in CAM. Also interest in local training in homeopathy was less (44.6%) than interest in using CAM in practice (71.3%), reflecting that GPs may wish further training in other areas of CAM apart from homeopathy.7 Perry and Dowrick6 had similar results, 22.8% with qualifications in this study vs 21% with training in CAM, 6.9% vs 8% in homeopathy, 4% vs 6% in acupuncture and 6.9% vs 6% in hypnotherapy. In this survey 5% had training in more than one area of CAM. This information is inline with previous findings; the CAM therapies most frequently endorsed are: acupuncture, homeopathy and hypnotherapy.2,5,7–9 Forty-one per cent of GPs in Dumfries and Galloway had patients requests for homeopathy within the last month. Whilst this question does not reveal the number of patients referred, it does give an indication of the possible demand. The figure reveals increased patient demand for homeopathy in the Stewartry (15 of 20 GPs reporting) and Wigtownshire (16 of 29 GPs reporting) with a similar referral number indicated for Stewartry areas (14/20). In Wigtownshire only eight out of 16 patient request resulted in referrals because homeopathy was ‘available within this GP practice’. This pattern suggests that the numbers of patients choosing a CAM therapy may be due to the following factors: availability of such a therapy and the influence of someone who has had a positive outcome.22 In all, 69.3% GPs of the total respondents had declined requests for referral of homeopathy; 55.1% of these were because referral was inappropriate and 11.6% indicated more than one reason for nonreferrals, which included ‘not appropriate situation’, ‘lack of information’, ‘did not think of using’ and ‘personal beliefs’. This suggests a possible need for the provision of information and guidelines for healthcare practitioners.23 In all, 86.1% of GPs expressed interest in using a local NHS homeopathic clinic and 100% of Stewartry LHCC respondents agreed. This suggests that irrespective of their views on CAM including homeopathy GPs are willing to support a local NHS homeopathic clinic.3,5 The results of the question regarding forms of evidence most influential to GPs yielded results similar to Van Haselen and Fisher’s24 study. In order of importance were: randomised controlled trials, audit data of patient outcomes regarding efficacy, safety profile and patient satisfaction. The evidence from this study reinforces the view that randomised controlled trials are considered to be the gold standard of clinical research. Randomised controlled trials can
ARTICLE IN PRESS GPs attitudes E Hamilton
193
demonstrate efficacy but are not appropriate to test cost-effectiveness and safety issues in a Primary Care setting.24 This is where clinical audit, also rated highly in this study, can provide evidence of efficient, costeffective and safe patient care. Evidence of safety is rated highly by these respondents. The House of Lords Report states that safety should not just concern adverse effects of drugs but also the avoidance of situations where conventional treatment could be denied and the assurance of a competent CAM Practitioner. The evidence that patient satisfaction is more important than patient demand and even personal experience echoes other studies.24 Patient satisfaction should be evaluated using standardised quality of life assessments. There was a slight variation in the rating of cost-effectiveness in this study compared with Van Haselen and Fisher’s,24 which could be due to the influence of the healthcare commissioners in the latter. There is a lack of evidence of cost-effectiveness of homeopathy due to the complexity of undertaking this research effectively.4 Theoretical evidence pertaining to homeopathy was rated least important in these results, this is consistent with Reilly’s2 findings. Also revealed is evidence that colleagues opinions and patient demand is only of moderate importance. Regardless of the increase in patient demand for CAM including homeopathy, GPs do not rate this form of evidence as important.24
Conclusion This quantitative, comparative study exploring GPs’ attitudes to homeopathy in Dumfries and Galloway revealed positive attitudes towards CAM and homeopathy. But inferences cannot be generalised to the whole population of GPs. Taking into account the weaknesses and strengths of this study a larger quantitative study would be justified to determine the use of homeopathy and other forms of CAM. Discretion should be exercised when correlations are explored between different studies due to disparity between methodology, survey populations and the types of therapies being considered. This study also produced evidence of a disparity between LHCC areas. CAM is not a homogenous phenomenon and therefore further qualitative research would be advantageous in this field to ascertain the individual traits, ambitions and aspirations of GPs who choose to pursue or disapprove of such therapies.25 Increased patient demand for homeopathy in the LHCC areas where a BHA clinic was situated may be a result of the greater availability of this therapy and the effects of positive outcomes. Substantial evidence has also been produced supporting the provision of a local NHS Homeopathic Clinic. As GPs have both financial and clinical influence, an evidence base is necessary for homeopathy to compete with other NHS priorities.
Therefore, confirmation of efficacy, safety and costeffectiveness is required using appropriate research and audit tools designed specifically to address the research or clinical question.26
References 1 Reilly D. The Evidence Profile for Homeopathy—Creating the Verification Mosaic. Glasgow: Glasgow Academic Departments of Homeopathy, 1998, pp 1–14. 2 House of Lords Select Committee on Science and Technology. Complementary and Alternative Medicine, 6th Report. London: The Stationery Office, 2000. 3 Wyllie M, Hannaford P. Attitudes to complementary therapies and referral for homeopathic treatment. A Survey of General Practitioners in Lothian, Scotland: Br Hom J 1998; 87: 13–16. 4 The Faculty of Homeopathy. Opportunities for Homeopathy within the New NHS. London, 2000, p 9. 5 White AR, Resch KL, Ernst E. A survey of complementary practitioners fees practice and attitudes to working within the National Health Service. Complement Ther Med 1997; 5: 210– 214. 6 Perry R, Dowrick C. Homeopathy and general practice: an urban perspective. Br Hom J 2000; 89: 13–16. 7 Perkin M, Pearcy R, Fraser J. A comparison of the attitudes shown by general practitioners, hospital doctors and medical students towards alternative medicine. J R Soc Med 1994; 87: 523–525. 8 Franklin D. Medical practitioners attitudes to complementary medicine. Complement Med Res 1992; 6: 69–71. 9 Hunter A. Attitudes to complementary medicine. A survey of General Practitioners and medical students in the Tayside Area. Commun Br Hom Res Group 1988; 17: 34–51. 10 Thomas K, Fitter M. Possible research strategies for evaluating CAM interventions. In: Lewith G, Jonas W, Walach H (eds). Clinical Research in Complementary Therapies. Principles, Problems and Solutions. Edinburgh: Churchill Livingstone, 2002, Chap 4, p 72. 11 Taylor MA, Reilly D, Llewellyn-Jones RH, McSharry C, Aitchison TC. Randomized controlled trial of homeopathy versus placebo on perennial allergic rhinitis with an overview of four trial series. Br Med J 2000; 321: 471–476. 12 Reilly DT, Taylor MA, Beattie NGM, Campbell JH, McSharry C, Aitchison TC. Is Evidence for homeopathy reproducible? Lancet 1994; 344: 1601–1606. 13 Reilly DT, Taylor MA, McSharry C, Aitchison T. Is homeopathy a placebo response? Controlled trial of homeopathic potency, with pollen in hay fever as model. Lancet 1986; 2: 881–886. 14 Reilly DT, Taylor MA. Potent placebo or potency? A proposed study model with initial findings using homeopathically prepared pollens in hay fever. Br Hom J 1985; 74: 65–75. 15 Linde K, Melchart D. Randomised controlled trials of individualised homeopathy: a state-of –the-art review. J Alternat Complement Med 1998; 4: 371–388. 16 White A, Ernst E. The case for uncontrolled clinical trials: a starting point for the evidence base for CAM. Complement Ther Med 2001; 9: 111–115. 17 Dean ME. More trials, fewer placebos, please. Br Hom J 2000; 89: 191–194. 18 Whitmarsh T. More lessons from migraine. Editorial. Br Hom J 2000; 89: 1–2. 19 Westland M, Grimshaw J, Maitland J, Campbell M, Ledingham E, Mcleod E. Understanding practice management: a qualitative study in general practice. J Manage Med 1996; 10: 29–37 20 Parahoo K. Nursing Research Principles Process and Issues. London: Macmillan Press Ltd, 1997, Chap 14, pp 338–359. Homeopathy
ARTICLE IN PRESS GPs attitudes E Hamilton
194 21 McColl E, Thomas R. The Use and Design of Questionnaires. London: Royal College of General Practitioners, 2000. 22 Vincent C, Furnham A. Why do patients turn to complementary medicine? An empirical study. Br J Clin Psychiatry 1996; 35: 37–48. 23 The NHS Confederation. Complementary Medicine in the NHS; Managing the Issues, Vol 4. Birmingham: The NHS Confederation, 1997, p 10. 24 Van Haselen R, Fisher P. Attitudes to evidence on complementary medicine: the perspective of British healthcare purchasers. Complement Ther Med 1999; 7: 136–141.
Homeopathy
25 Kelner M, Wellman B. Introduction complementary and alternative medicine: challenge and change. In: Kelner M, Wellman B, Pescosolido B, Saks M (eds). Complementary and Alternative Medicine. Challenge and Change. The Netherlands: Harwood Academic Publishers, 2000, pp 5–6. 26 Walach H, Jonas W. Homeopathy. In: Lewith G, Jonas W, Walach H (eds). Clinical Research in Complementary Therapies. Principles, Problems and Solutions. Edinburgh: Churchill Livingstone, 2002, Chap 14, p 240.
ORIGINAL PAPER
Exploring General Practitioners’ attitudes to homeopathy in Dumfries and Galloway E Hamilton* Glasgow Homoeopathic Hospital, Glasgow, Scotland, UK
This comparative quantitative study explored General Practitioners’ (GPs) attitudes to homeopathy in Dumfries and Galloway, a predominantly rural area in South West Scotland where there is a local British Homeopathic Association Funded Homeopathic Clinic. It aimed to determine whether there was an association between expressed attitudes to homeopathy and a number of variables. Issues arising from the House of Lords Report on CAM were also explored. A self-administered questionnaire was addressed to all 135 GPs within Dumfries and Galloway. Descriptive statistics were used in the data analysis. The response rate was 75%. The NHS GP clinic accounted for 47% of total referrals for homeopathy. A total of 86.1% of GPs within Dumfries and Galloway were in favour of a local NHS Homeopathic Specialist Clinic. Forms of evidence most influential to GPs regarding homeopathy were: randomised controlled trials; audit data on patient outcomes; safety and patient satisfaction. Homeopathy (2003) 92, 190–194.
Keywords: homeopathy; CAM; Scotland; General Practitioners; attitudes; integration; evidence-based medicine; quantitative
Introduction This study was carried out as a part of a BSc (Hons) nursing degree in homeopathy, which involved clinical placement at the British Homeopathic Association (BHA) Funded Homeopathic Clinic, New Galloway. This clinic was established in April 2000. Patients are referred from Stewartry Local Health Care Cooperative (LHCC) area: one of four LHCC areas in Dumfries and Galloway. The data were primarily quantitative with some additional qualitative information. This article focuses on the quantitative data. Exploring General Practitioners’ (GPs) attitudes to homeopathy is relevant due to the increasing popularity of complementary and alternative medicine
*Correspondence: E Hamilton, Homeopathic Nurse Practitioner, Glasgow Homoeopathic Hospital, 1053 Great Western Road, Glasgow G12 0XQ, Scotland, UK. E-mail: [email protected] Received 22 October 2002; revised 13 March 2003; accepted 26 June 2003
(CAM).1 The House of Lords Report2 acknowledges this trend and to ensure public protection recommends: provision of evidence base on the effectiveness of CAM; establishment of self-regulatory bodies; provision of information on CAM; provision of CAM within the NHS for those therapies that fulfil the specified criteria.
Literature review The literature review explored the following issues: the current position of homeopathy within the NHS in Scotland; GPs’ and other health professionals’ attitudes to CAM including homeopathy and evidencebased medicine on the subject. In Scotland, GPs are structured into LHCCs with authority residing with the local Health Boards. Homeopathic patient referrals within the NHS are either to the Glasgow Homeopathic Hospital, local homeopathic services within various health boards or the two BHA funded clinics in Ayr and Stewartry. A
ARTICLE IN PRESS GPs attitudes E Hamilton
191
survey by Wyllie and Hannaford3 revealed that 74% of GPs would welcome a local NHS homeopathic clinic. This interest is also reflected in the fact that 25% of Scottish GPs have undergone basic homeopathic training at the Glasgow Homeopathic Hospital.4 General Practitioners attitudes to CAM including homeopathy The accessibility of homeopathy within Primary Care is linked to GPs’ attitudes as GPs are influential in purchasing healthcare.5 The literature review reveals several authors who have researched GPs’ attitudes to CAM, including homeopathy, over the last decade.3,5–9 Only one of these studies is specific to homeopathy.6 Some publications include other health professionals’ views.7–9 Homeopathy and evidence-based medicine Evidence-based medicine involves incorporating the best available evidence of efficacy into healthcare systems.10 Whilst the House of Lords Report acknowledges the evidence for homeopathic isopathy in the treatment of asthma and allergic rhinitis11–14 it recommends larger independent trials over longer periods. Linde and Melchart15 in their overview of randomised controlled trials of individualised homeopathy identify the problems of double-blind placebocontrolled trials and suggest that clinical research in homeopathy should include a more pragmatic approach, incorporating realistic tools for research, involving case studies and observational studies prior to more formalised trials.16–18
Method The method of data collection was a self-administered questionnaire, to provide primarily quantitative data from a non-probability purposive sample group. Approval for the study was granted by the Medical Director of Dumfries and Galloway Primary Care NHS Trust. Access to information concerning GPs and Practice Managers names and addresses was also given and it was also determined that Practice Managers would be useful contacts for encouraging GPs to complete the questionnaires.19 The content of the questionnaire was based on issues arising from the House of Lords Report and previous research.1–3 The questionnaire was validated by a statistician, SPSS (version 11.0) was used for analysis. An introductory letter gave a brief explanation of the aim of the study. Anonymity was promised to all respondents, responses are identifiable by LHCC area only. A pilot study involved six medical professionals, four of whom were GPs not participating in the main survey and two hospital consultants. Amendments entailed changing the format of two questions.
Data collection methods All 33 Practice Managers within Dumfries and Galloway were contacted by telephone 1 week prior to distribution of questionnaire. This phone call consisted of an explanation of the forthcoming questionnaire including brief details of the researcher, purpose of survey, method and date of distribution with collection and return date. The researcher also checked with the Practice Managers the current list of GPs’ names and adjustments were made to ensure that the list of possible participants was valid. Four GPs were absent due to sickness, maternity leave and holidays. A reminder phone call was also made to all Practice Managers 5 days prior to the deadline for completion of the questionnaire.
Results Descriptive statistics were used in the analysis as this was a non-randomised sample and therefore statistical inferences pertaining to the general population of GPs could not be made.20 Out of the 101 (75%) GPs who responded, the response rate was greatest in Wigtownshire (82.8%) and Stewartry LHCC areas (78.2%). Response was slightly higher in male GPs (67/88 77%), than female GPs (33/47, 70%). House of Lords report/ interest in using CAM/ qualifications in CAM GPs were questioned on their awareness of the House of Lords Report. Forty-seven out of 67 male respondents (70.1%), compared with 25/34 females (73.5%) were interested in CAM. Twenty-three GPs had a CAM qualification (19 males, four females). Five GPs possessed more than one qualification in CAM. Fortyfour per cent of GPs were interested in local training in homeopathy. In all, 55.9% (19/34) of female GPs respondents were in favour of further training in homeopathy compared to 37.9% (25/66) male GPs. Patient requests for homeopathy Forty-one per cent of GPs had patients requesting homeopathic treatment in the last month. In Wigtownshire LHCC area 39% (16) GPs had received patient requests for homeopathy, Stewartry LHCC 36.6% (15), Annandale and Eskdale 19.5% (8) and Upper Nithsdale and Dumfries 4.9% (2). GPs who had referred patients were asked to specify where they had referred. The NHS GP Clinic accounted for 16 (47%) of the total referrals. There were 13 referrals (38.2%) to the Glasgow Homoeopathic Hospital. Only three GPs had referred to Private Practice. Two GPs had referred to GP Colleagues {1 General Practitioner from Annandale and Eskdale and one from Upper Nithsdale and Dumfries had referred to both NHS GP and NHS Hospital clinics}. Homeopathy
ARTICLE IN PRESS GPs attitudes E Hamilton
192
Reasons for non-referrals for homeopathy The 69 GPs who did not refer patients for homeopathy within the previous month were asked to tick or state reasons for non-referrals. The most common reason for non-referral was ‘not appropriate situation’ (38). In Wigtownshire some non-referrals (6) were due to homeopathy being practised within this GP practice. Some GPs ticked more than one reason indicating possible validity problems with this question. Local NHS homeopathic clinic GPs were asked if they would use a local NHS Homeopathic Clinic, 86.1% replied yes, 11.9% no and 1% unsure and 1% answer missing. 100% of Stewartry GPs were in favour. Forms of evidence regarding homeopathy GPs were asked to rank in terms of influence from 1 (most important) to 9 (least important) the forms of evidence regarding homeopathy listed in Table 1. Only 87/101 answered this question satisfactorily. In the first four ranked forms of evidence were randomised controlled trials, audit data regarding efficacy, safety profile and patient satisfaction. In the final five: cost-effectiveness, personal experience, patient demand, colleagues opinions and theory of homeopathy also had the greatest number of missing answers, revealing possible reliability and validity factors in the design of this question.
Discussion The response rate of 75% to the questionnaire was very good;21 the following factors may have contributed to this result: Practice Managers are influential team members within the Primary Health Care setting, involving them improved response rates: the author had also worked previously in Wigtownshire area which had the highest response rate (82.8%); the Stewartry LHCC area following closely with 78.2%. These areas had the highest number of GPs qualified in CAM (16/23), and a higher incidence of GPs with patient requests for homeopathy. This suggests higher
Table 1 GPs rating of forms of evidence on a 1–9 scale (1 = very important, 9 = least important)
Randomised controlled trials Audit data regarding efficacy Safety profile Patient satisfaction Cost-effectiveness Personal experience Patient demand Colleagues opinions Theory of homeopathy Valid N (listwise)
Homeopathy
N
Mean score
95 93 92 93 91 89 90 89 90 87
3.35 3.52 3.71 3.88 5.40 5.54 5.74 5.80 6.83
awareness of CAM within Wigtownshire and Stewartry areas. Overall 71.3% of GPs in Dumfries and Galloway indicated they be would be interested in using CAM. Forty-four per cent of GPs were in favour of local training in homeopathy, 55.9% females, compared to 37.9% males. But more men already had qualifications in CAM. Also interest in local training in homeopathy was less (44.6%) than interest in using CAM in practice (71.3%), reflecting that GPs may wish further training in other areas of CAM apart from homeopathy.7 Perry and Dowrick6 had similar results, 22.8% with qualifications in this study vs 21% with training in CAM, 6.9% vs 8% in homeopathy, 4% vs 6% in acupuncture and 6.9% vs 6% in hypnotherapy. In this survey 5% had training in more than one area of CAM. This information is inline with previous findings; the CAM therapies most frequently endorsed are: acupuncture, homeopathy and hypnotherapy.2,5,7–9 Forty-one per cent of GPs in Dumfries and Galloway had patients requests for homeopathy within the last month. Whilst this question does not reveal the number of patients referred, it does give an indication of the possible demand. The figure reveals increased patient demand for homeopathy in the Stewartry (15 of 20 GPs reporting) and Wigtownshire (16 of 29 GPs reporting) with a similar referral number indicated for Stewartry areas (14/20). In Wigtownshire only eight out of 16 patient request resulted in referrals because homeopathy was ‘available within this GP practice’. This pattern suggests that the numbers of patients choosing a CAM therapy may be due to the following factors: availability of such a therapy and the influence of someone who has had a positive outcome.22 In all, 69.3% GPs of the total respondents had declined requests for referral of homeopathy; 55.1% of these were because referral was inappropriate and 11.6% indicated more than one reason for nonreferrals, which included ‘not appropriate situation’, ‘lack of information’, ‘did not think of using’ and ‘personal beliefs’. This suggests a possible need for the provision of information and guidelines for healthcare practitioners.23 In all, 86.1% of GPs expressed interest in using a local NHS homeopathic clinic and 100% of Stewartry LHCC respondents agreed. This suggests that irrespective of their views on CAM including homeopathy GPs are willing to support a local NHS homeopathic clinic.3,5 The results of the question regarding forms of evidence most influential to GPs yielded results similar to Van Haselen and Fisher’s24 study. In order of importance were: randomised controlled trials, audit data of patient outcomes regarding efficacy, safety profile and patient satisfaction. The evidence from this study reinforces the view that randomised controlled trials are considered to be the gold standard of clinical research. Randomised controlled trials can
ARTICLE IN PRESS GPs attitudes E Hamilton
193
demonstrate efficacy but are not appropriate to test cost-effectiveness and safety issues in a Primary Care setting.24 This is where clinical audit, also rated highly in this study, can provide evidence of efficient, costeffective and safe patient care. Evidence of safety is rated highly by these respondents. The House of Lords Report states that safety should not just concern adverse effects of drugs but also the avoidance of situations where conventional treatment could be denied and the assurance of a competent CAM Practitioner. The evidence that patient satisfaction is more important than patient demand and even personal experience echoes other studies.24 Patient satisfaction should be evaluated using standardised quality of life assessments. There was a slight variation in the rating of cost-effectiveness in this study compared with Van Haselen and Fisher’s,24 which could be due to the influence of the healthcare commissioners in the latter. There is a lack of evidence of cost-effectiveness of homeopathy due to the complexity of undertaking this research effectively.4 Theoretical evidence pertaining to homeopathy was rated least important in these results, this is consistent with Reilly’s2 findings. Also revealed is evidence that colleagues opinions and patient demand is only of moderate importance. Regardless of the increase in patient demand for CAM including homeopathy, GPs do not rate this form of evidence as important.24
Conclusion This quantitative, comparative study exploring GPs’ attitudes to homeopathy in Dumfries and Galloway revealed positive attitudes towards CAM and homeopathy. But inferences cannot be generalised to the whole population of GPs. Taking into account the weaknesses and strengths of this study a larger quantitative study would be justified to determine the use of homeopathy and other forms of CAM. Discretion should be exercised when correlations are explored between different studies due to disparity between methodology, survey populations and the types of therapies being considered. This study also produced evidence of a disparity between LHCC areas. CAM is not a homogenous phenomenon and therefore further qualitative research would be advantageous in this field to ascertain the individual traits, ambitions and aspirations of GPs who choose to pursue or disapprove of such therapies.25 Increased patient demand for homeopathy in the LHCC areas where a BHA clinic was situated may be a result of the greater availability of this therapy and the effects of positive outcomes. Substantial evidence has also been produced supporting the provision of a local NHS Homeopathic Clinic. As GPs have both financial and clinical influence, an evidence base is necessary for homeopathy to compete with other NHS priorities.
Therefore, confirmation of efficacy, safety and costeffectiveness is required using appropriate research and audit tools designed specifically to address the research or clinical question.26
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