Ian Appleyard Research and Policy Managers encourages all to take part in the government Change NHS initiative.
One of the most common inquiries that we have at the British Acupuncture Council is whether acupuncture is available on the NHS. Unfortunately, the availability of acupuncture within the NHS is very limited. The government Change NHS initiative is currently consulting the public and healthcare workers on how to improve the NHS. This gives everyone the opportunity to have their say.
Change NHS: help build a health service fit for the future
The British Acupuncture Council has completed the organisation questionnaire as part of Change NHS: help build a health service fit for the future. You can read the BAcC response below.
Anyone can take part in this consultation, so if you, or someone you know, have benefited from acupuncture and feel it should be more widely available in the NHS Please follow the links below to make your voice heard.
To share your experience of healthcare
https://change.nhs.uk/en-GB/projects/your-experiences-public
To put forward Your Idea for Change
https://change.nhs.uk/en-GB/projects/your-ideas-for-change
The BAcC feedback to the government Change NHS initiative
The British Acupuncture Council (BAcC) wishes to propose three interrelated objectives for the 10-year health plan:
1. a wider provision of acupuncture within the NHS
2. a more long-term and pragmatic approach to the commissioning of services
3. greater awareness of professional standards authority accredited registers
The evidence supports the use of acupuncture for two conditions that, as set out in the Independent Investigation of the National Health Service in England (Darzi, 2024), have long waiting lists and a significant impact on long term sickness: musculoskeletal and mental health. The evidence for acupuncture in the treatment of chronic pain is particularly strong. As such, the reasons why acupuncture is not more widely available should be assessed.
National Institute of Health and Care Excellence (NICE) guidelines are used by a variety of stakeholders including commissioners and service providers. NICE has highlighted the importance of real-world data in its strategic plan[1] and produced guidance for including real-world data[2]. However, in the evaluation of acupuncture, the decision-making process is often insufficiently pragmatic, focusing on idealised placebo-controlled trials.
NICE can only evaluate evidence that has already been produced. Therapies such as acupuncture hold no promise of generating wealth through a successful patent. This limits the funding available to conduct the necessary primary research. Therefore, even though a NICE Guideline may identify the need for research, there is no clear route for the evidence gap to be filled. As a result, patients may be denied the opportunity to benefit from an effective therapy indefinitely.
We will highlight some of the problematic decisions made by NICE in the development of guidance for osteoarthritis (NG226) and depression (NG222). This will shed light on the limitations of the current guidelines. Naturally, the guidelines affect the capacity of acupuncture to be commissioned within the NHS.
A high-quality meta-analysis first published in 2012 of individual patient data demonstrated that acupuncture is an effective treatment for chronic pain and that it is not a placebo [3]. This study has been updated and now includes the pooled results of over 20,000 patients who participated in 39 high-quality trials[4]. Many of these trials were conducted in western countries with populations similar to the U.K. Clinical guidelines from other countries now recommend acupuncture for chronic pain, such as back pain and osteoarthritis: Germany, USA, and Scotland [5-7].
Acupuncture was not included in the guidance for depression and osteoarthritis[8, 9]. The reason acupuncture was excluded from the osteoarthritis guidelines (NG226) was that it failed to clear a specific hurdle: namely, a clinically significant difference when compared to sham acupuncture [10]. This decision is founded on the flawed understanding that sham acupuncture is an idealised inert placebo [11]. Sham acupuncture is not inert, consequently, the effect size is likely to be an underestimate. Moreover, the acupuncture versus sham acupuncture is not a clinically relevant comparison [12]. For a more detailed analysis please see the Appleyard (2022)[12].
The Independent Investigation of the National Health Service in England makes clear the ‘patient voice’ is not loud enough. If patients are to make informed decisions about their healthcare choices, they should be told the relative benefits of different therapies. These are the real-world decisions that patients must make: should I use therapy X or therapy Y? A Network Meta Analysis (NMA) compares three or more therapies. A high-quality NMA demonstrates that acupuncture is more effective than the therapies that are recommended in NG226 [13]. It is illogical not to include acupuncture within the clinical guidelines when it has been shown to be more effective than the recommended therapies.
Decisions on choice of therapy also must take account of side effects. Acupuncture is a safe intervention, with the vast majority of adverse events being temporary and minor [14]. Oral NSAIDs and opioids are recommended within the guidance despite their known side effects.
The evidence shows that even sham acupuncture is superior to weight loss and exercise, both of which are recommend in the osteoarthritis guidelines (NG226)[8, 13]. In other words, acupuncture is more effective than sham acupuncture; sham acupuncture is more effective than weight loss and exercise; acupuncture is not recommended but weight loss and exercise are. This is not to say that weight loss and exercise aren’t important. However, it shows the exclusion of acupuncture on the basis that it was not sufficiently superior to sham acupuncture is even less defensible.
The evidence base for acupuncture in the treatment of depression is not as strong as that for chronic pain. Nevertheless, there is evidence that acupuncture is effective[15]. Importantly, a high-quality clinical trial conducted in the UK demonstrates that acupuncture is at least as effective as counselling[16]. The acupuncture in this trial was delivered by members of the British Acupuncture Council.
The NICE guideline (NG222) Depression in adults: treatment and management, does not recommend acupuncture. Some of the decisions made by the committee, and contained within the comments pages, can shed light on the limitations of the current system when trying to evaluate a therapy such as acupuncture.
In considering the cost effectiveness of acupuncture for depression it was stated that data from a study by Spackman et al (2014) was limited because the ‘intervention cost for acupuncture was not taken from an NHS source’[17, 18]. This appears to set up a catch-22: acupuncture cannot be included in the guidelines because there is no data on the cost of acupuncture delivered within the NHS; acupuncture services cannot be provided within the NHS because acupuncture is not in the NICE guidelines.
The committee made a research recommendation:
What is the effectiveness and cost-effectiveness of combination treatment with acupuncture and antidepressants in people with more severe depression in the UK? (p113)[9]
In essence there is no clear way to move forward. Funding needs to be made available for the research. If the research is to be carried out within an NHS setting, then there needs to be appropriately trained practitioners within the NHS.
The committee appears to have lacked sufficient knowledge of acupuncture and the profession in the UK. In the guidelines they state:
There was some evidence of effectiveness and cost effectiveness for the combination of acupuncture and antidepressants but the committee were aware this evidence was based on Chinese acupuncture which is different to Western acupuncture and so these results may not be applicable to the UK population (p100)[9]
It is not clear how they differentiated the two, Western or Chinese acupuncture. This is not simply a matter of whether the trial was conducted in China. In the largest high-quality trial, which was conducted in the UK, the acupuncture was provided by BAcC members. BAcC members practice traditional (Chinese) acupuncture. Consequently, it is not unreasonable to consider the results of this study alongside those conducted in China.
In the consultation feedback the committee stated:
… availability of appropriately trained and competent people to deliver acupuncture for the treatment of depression was limited and that there was uncertainty about the consistency of the methods for delivering acupuncture
The British Acupuncture Council is an Accredited Register of the Professional Standards Authority (PSA), which provides assurance of safety and professionalism. In short, the UK already has qualified and competent practitioners. Although, for the most part they are not working in the NHS.
The acupuncture profession in the UK is one of the most developed in Europe, with rigorous educational standards. The British Acupuncture Accreditation Board (BAAB) accredits courses on behalf of the BAcC. Many people come to the UK to train as acupuncturists at a BAAB accredited course. The Report to Ministers from The Department of Health Steering Group on the Statutory Regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine and Other Traditional Medicine Systems Practised in the UK (2008) recommends that acupuncture should be statutory regulated. The report stated in regard to BAAB accreditation
This, clearly, will form the qualification for a high proportion of acupuncture practitioners when the new register is opened and will fit easily with the basic standard required by the HPC (p48)[19]
In summary, the UK has a PSA accredited professional body and the capacity to train highly qualified professional acupuncturists. Consequently, it should be relatively easy expand the provision of acupuncture within the NHS. Moreover, although the provision of acupuncture within the NHS is very limited, there are some services. These could be replicated elsewhere, for example: the Gateway Clinic in Guys and St Thomas’ NHS Foundation Trust (chronic pain), Inner Gloucester PCN (anxiety), Dimbleby Cancer Care at Guys Hospital, James Cook University Hospital (perioperative pain/anxiety).
Professional Standard Authority Accredited Register
Osteoarthritis and depression have been used to highlight some of the issues that prevent acupuncture from being included in NICE guidelines. Acupuncture is recommended in NICE guidelines for headache and primary chronic pain[20, 21], yet, for the majority of the UK population, acupuncture is not available on the NHS. Around four million acupuncture treatments are given in the UK annually, the majority of these are with private practitioners[22]. These out-of-pocket expenses reduce the burden on the National Health Service.
It is important that those who wish to receive acupuncture, and pay privately, can clearly identify qualified practitioners who adhere to professional codes. GPs, and other healthcare workers, should be able to direct patients to safe and competent practitioners. The current mechanism for this is the Professional Standards Authority Accredited Register scheme. Despite the scheme being in existence for over a decade, its public recognition is still not sufficient.
The recent issues of abusive conduct by counselling and psychotherapy practitioners with poor education and regulation, illustrates the risks of unregulated healthcare professions. By raising awareness Accredited Register scheme, the public will be better protected. If the public and healthcare workers feel more confident in identifying safe professional acupuncturists, then more people may choose acupuncture. This, in turn, will reduce the the burden on the NHS.
References
1. NICE, NICE strategy 2021 to 2026: Dynamic, Collaborative, Excellent. 2021, National Institute for Health and Care Excellence.
2. NICE, NICE real-world evidence framework (ECD9), N.I.f.H.a.C. Excellence, Editor. 2022.
3. Vickers, A.J., et al., Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis. Archives of Internal Medicine, 2012: p. E1-10.
4. Vickers, A.J., et al., Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. The journal of pain : official journal of the American Pain Society, 2018. 19(5): p. 455-474.
5. GBA, Zusammenfassender Bericht des Unterausschusses “Ärztliche Behandlung” des Gemeinsamen Bundesausschusses über die Bewertung gemäߧ135 Abs.1 SGB V der Körperakupunktur mit Nadeln ohne elektrische Stimulation bei chronischen Kopfschmerzen chronischen LWS-Schmerzen chronischen Schmerzen bei Osteoarthritis. 2007, Gemeinsamer Bundesausschuss Akupunktur.
6. SIGN, Management of chronic pain SIGN 136, in A national clinical guideline. 2019, Scottish Intercollegiate Guidelines Network.
7. Kolasinski, S.L., et al., 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis care & research, 2020. 72(2): p. 149-162.
8. NICE, Osteoarthritis in over 16s: diagnosis and management NG226, in NICE Guidelines 2022, National Institute for Health and Care Excellence.
9. NICE, Depression in adults: treatment and management. 2022, National Institute for Health and Care Excellence.
10. NICE, Osteoarthritis in over 16s: diagnosis and management NG226: [F] Evidence review for the clinical and cost-effectiveness of acupuncture for people with osteoarthritis, in NICE Guidelines 2022, National Institute for Health and Care Excellence.
11. Appleyard, I., T. Lundeberg, and N. Robinson, Should systematic reviews assess the risk of bias from sham–placebo acupuncture control procedures? European Journal of Integrative Medicine, 2014. 6(2): p. 234-243.
12. Appleyard, I., Acupuncture out, dogma in: The U.K. National Institute for Health and Care Excellence guideline for osteoarthritis 2022. European Journal of Integrative Medicine, 2023. 61: p. 102262.
13. Corbett, M.S., et al., Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis. Osteoarthritis And Cartilage, 2013. 21(9): p. 1290-1298.
14. Bäumler, P., et al., Acupuncture-related adverse events: systematic review and meta-analyses of prospective clinical studies. BMJ Open, 2021. 11(9): p. e045961.
15. Armour, M., et al., Acupuncture for Depression: A Systematic Review and Meta-Analysis. Journal of Clinical Medicine, 2019. 8(2077-0383 (Print)).
16. MacPherson, H., et al., Acupuncture and Counselling for Depression in Primary Care: A Randomised Controlled Trial. PLOS Medicine, 2013. 10(9): p. e1001518.
17. Spackman, E., et al., Cost-Effectiveness Analysis of Acupuncture, Counselling and Usual Care in Treating Patients with Depression: The Results of the ACUDep Trial. PLOS ONE, 2014. 9(11): p. e113726.
18. NICE, Depression in adults: treatment and management: History, in NICE Guidelines 2022, National Institute for Health and Care Excellence.
19. Pittilo, M., Report to Ministers from the Department of Health Steering Group on the Statutory Regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine and Other Traditional Medicine Systems Practised in the UK. 2008.
20. NICE, Headaches in over 12s: diagnosis and management, in Clinical guideline CG150. 2021, National Institute for Health and Care Excellence.
21. NICE, NG 193 Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. 2021.
22. Hopton, A.K., et al., Acupuncture in practice: mapping the providers, the patients and the settings in a national cross-sectional survey. BMJ Open, 2012. 2(1): p. 1-9.
