2.  WHAT CONTRIBUTION CAN
COMPLEMENTARY MEDICINE
MAKE TO PRIMARY HEALTH CARE?
...Continued


2.2  The outcome of treatment

The outcome of treatment was measured in a number of different ways. This enabled different sources of data to be triangulated with one another, and also enabled the research to accommodate differences in patients’ expectations of outcome. The three main outcome measures were patients’ self assessment of improvement, an assessment of change made by the complementary practitioners and changes in scores on SF36 scales between referral and completion of treatment. There were also questions in the questionnaire completed by patients about the impact of treatment on problem management and coping strategies, their satisfaction with treatment, and for two subgroups of patients (those with musculo- skeletal problems, and those with psycho-social problems) a number of other symptom-specific scales.

On the whole there was a reasonable level of agreement between patient and practitioner assessed outcomes, but a low level of correspondence between patient assessed outcomes and SF36 scores. Part of this can be accounted for by the variability in the patient population; when scores were broken down according to different patient groups (according to their main symptoms), there was a closer correspondence between self-assessed outcome and SF36 score. However, the low correspondence could also be accounted for by the varying expectations of treatment: a minor change in symptoms might be viewed as a major improvement by one patient, while for another it might be seen as indicating little change in their overall condition.

2.2.1  Practitioner assessment of outcome of treatment

Overall, practitioners assessed that around 56% of their patients had shown a marked improvement in their main symptom following treatment, with a further 27% showing a small improvement. 38% were assessed to have shown an improvement in their overall well-being (Table 8).

Table 8  Practitioner assessment of change

Level of change reported by practitioners	In main problem %	In secondary problem %	In overall well-being %
Much improved/resolved	27.6	18.2	11
Improved	30.6	22.2	26.9
Slight improvement	27.2	37.9	29.4
No change	14	21.7	29.4
Became worse	.6	-	3.2
Number reported	533	198	309

The practitioners also rated patients’ response to treatment, which enabled them to indicate when there was a strong reaction to, or rejection of, the treatment approach. Half the patients were reported to have had a very positive response to treatment, and a further 30% quite a positive response; the number of patients who had a marked reaction to, or rejection of, the treatment was just under 6% (Table 9).

Table 9  Practitioner assessment of response to treatment

Practitioner’s assessment of response	Number	%
Very positive	173	50.6
Quite positive	106	31
None (good or bad)	43	12.6
Reaction/rejection	20	5.6
Number of whom data reported	342	-
Patient defaulted	44	13

There was a steady stream of patients who did not take their full course of treatment: mostly this was a mutually agreed decision between patients and practitioners, although there was a small group (13%) of patients who defaulted on their treatment part way through. Most defaulters did not complete an end of treatment questionnaire; however, for those who did complete questionnaires, the most common reasons for discontinuing treatment were that it hadn’t appeared to help the problem (3), they had moved away from the area (2), or because they hadn’t liked the treatment (1) or it had made the problem worse (1). There was, however, a steady 10% who cancelled prior to, or didn’t turn up to, their first appointment.

2.2.2  Patient assessment of outcome of treatment

Over 85% of patients, on completion of treatment, reported that there had either been some, or a great deal of change for the better in their condition. Almost all patients attributed the change in their condition to the treatment received and said the change took place during or just after treatment (Table 10).

Table 10  Patient assessment of change

Level of change	Number	%
Great deal of change for better	58	25.9
Some change for the better	138	61.6
Remained the same	22	9.8
Became worse	6	2.7
Total number	224	-

The service is popular with patients: 75% of those referred described themselves as generally or very satisfied with their treatment (Table 11) and 95.8% said that they had found the treatment useful.

Table 11  Satisfaction with treatment

Satisfaction with treatment	Number	%
Very satisfied	58	51.3
Mostly satisfied	27	23.8
Somewhat satisfied	23	20.3
Somewhat dissatisfied	2	1.8
Very dissatisfied	2	1.8
No information	1	1
Total	224	-

This high level of satisfaction is perhaps surprising considering the fact that there sometimes appeared to be quite a mismatch between the expectations patients had of treatment, and the actual outcome, either in terms of improvement in condition, or in terms of explanation and understanding.

On the whole, patients tended to have quite modest expectations of what complementary medicine could achieve (Table 12). Only a small proportion of patients expected to be fully recovered after treatment, with less than a third of patients who bad bad their problem for a year or more expecting any major improvement at all. Patients with emotional problems had significantly lower expectations than those whose problems were primarily physical (ie. those with musculo-skeletal or ‘other’ problems).

Table 12  Expectations of treatment

	Patients with problem between 1-3 months %	Patients with problem over 1 year %	% of whole sample
To be fully recovered and back to normal	13.8	5.2	7.2
A great deal improved	44.8	23.6	30.8
Improved but still needing attention	41.4	67	58.4
The same	0	4.2	3.6
Number in group	29	212	410

Chi square significant at .001 level

What most patients did want was some improvement in symptoms, and to prevent the problem from getting worse. A surprisingly high proportion also rated as very important dimensions such as wanting to improve their general health, and gain an understanding of the problem and its cause.

Satisfaction was quite variable on these different dimensions, with satisfaction being most marked in relation to improvement in symptoms and in prevention of the problem getting worse (Table 13).

Table 13  Satisfaction compared to expectations

Patient would like treatment to...	% indicating this as very important	% satisfied
Improve the symptoms	92.1	75.8
Prevent the problem getting worse	91.7	71.2
Get rid of the problem	87.1	34.5
To improve my health in general	82.4	57.4
Help understand the cause of the problem	76	66.4
Help me understand what the complaint is saying to me: its meaning	72.9	47.8

However, even when the treatment had not removed or resolved the main symptom, some patients reported that the change in their condition following treatment had encouraged them to hope that further improvements might be possible with more treatment, or better management of the problem.

"Because the pain in my back has almost ceased I am far less tired and so can tackle more and enjoy this."

"Although the treatment has not a complete cure, the gradual easing of a long-term problem has been most welcome."

The high level of satisfaction could also be attributed to the satisfaction which most referrals bad with the competence and care provided by their practitioners: the match between expectations and satisfaction was rather better on these dimensions than on outcome of treatment, and on many elements the proportion expressing satisfaction was higher than the proportion who rated this as very important (Table 14).

Table 14:  Satisfaction with practitioner compared to expectations

Practitioners' qualities	% indicating this as very important	% satisfied
Competent and skilful	95.7	96.8
Easy to talk to	92.5	96.3
Understanding of my problem and how I am feeling	92.9	89.9
Able to explain my problem and its treatment clearly	91.4	87.6
Warm and committed	83.9	96.3
Holding a similar view of health to myself	68.8	78.1

The main cause of dissatisfaction was the number and length of sessions:  65% thought that the session number had been too few, and 33% felt that the sessions themselves had been too short. This was particularly frustrating for those who felt that they were just beginning to get somewhere when the sessions came to an end. Although most were able to ask for further referrals, in practice this often meant going to the end of the waiting list, and having a break of several months between sets of sessions. Only a quarter of referrals were for repeat sets of sessions (Table 15).

Table 15.  Number of courses of treatment received

Number of previous referrals	Numbers	%
First referral for problem	504	76.3%
Second referral for problem	112	16.9%
Third referral for problem	39	6%
Fourth referral for problem	5	.7%
Fifth referral for problem	1	.1%
Total	661	-

There were a small number of patients reported that they had ceased treatment before receiving their full complement of sessions; 34 (7.6%) said that they did so because they hadn’t liked the treatment, and a further 34 said that they felt they no longer needed treatment. A small number of patients (5, or 0.7% of all referrals) reported that their problem appeared to have been aggravated following treatment. The other reasons given for not liking treatments were insufficient explanation given by the practitioner of the treatment given (5), discomfort associated with the treatment (2), and sessions being too rushed (3).

In contrast to this, around half the patients reported things that they had particularly liked about the treatment: typically commenting on the warmth, friendliness or understanding of the practitioners, the relaxing nature of the sessions, or the fact that the treatment had been well explained.

"Treatment was well carried out and explained. it worked well for me, and I am a non-believer in this kind of treatment."

"I am extremely impressed with having the facility of complementary medicine, it seems very important to me to have this available through the NHS so that all people have access to this medicine. In my experience, I find complementary medicine far more effective and acceptable than allopathic medicines, it allows the body to heal itself."

"Having someone listen to me and support my decision that I needed to take some time out allowed me to be in control of my own situation. This allowed my own natural health process to take place."

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