What the doctor ordered

Most people want access to herbal remedies, and would like to get them at their GP's surgery. That day may not be far away, reports Jane Feinmann

Choice may be top of the agenda for healthcare across the political spectrum. But why are we only being offered a choice about which hospital we attend? Why can't we have a say in the type of treatment we're offered in primary care - including the option of herbal medicine, for which we demonstrate a preference by spending upwards of £126m every year on over-the-counter remedies?

Choice may be top of the agenda for healthcare across the political spectrum. But why are we only being offered a choice about which hospital we attend? Why can't we have a say in the type of treatment we're offered in primary care - including the option of herbal medicine, for which we demonstrate a preference by spending upwards of £126m every year on over-the-counter remedies?

Such questions were tackled head-on at last week's annual conference of the NHS Alliance, representing primary-care trusts. Its chair, the GP and researcher Dr Mike Dixon, is determined to confront what he sees as mainstream prejudice against herbal medicine, which proves its efficacy in treating chronic and difficult-to-treat conditions at every opportunity.

"Our job is to treat our patients as adults, which means giving them therapies that they want, and most people want herbal remedies," he says. "There's so much hocus-pocus talked about herbal medicine - that it will blow the NHS budget or put people at risk of dangerous side effects or interactions," he continues. "Of course, there are potential risks with herbal remedies, as with all medicines. But it's the responsibility of doctors to ensure that people are properly informed about these dangers. The real risk is that by simply disapproving, half of the people taking herbal remedies don't tell their GPs."

Fortunately for fans of herbal medicine, there are signs that the NHS Alliance campaign is pushing on a door that's already at least slightly ajar. So what kind of changes can we expect over the next few years?

First, there are signs that ordinary GPs are already open-minded about herbal remedies and can quickly become better informed. A trial due to start early next year, organised by Mid Devon Primary Care Trust Research Group with the support of the Peninsula Medical School of the Universities of Exeter and Plymouth, will assess the impact of training NHS GPs in the use, side effects and interactions of five widely used herbal remedies: "We will then measure the impact on prescribing costs and outcome when GPs provide information and advice about over-the-counter (OTC) herbal remedies for common conditions."

The trial will be lent weight by an EU Directive on traditional herbal remedies that will begin to regulate OTC herbal remedies, enforced in Britain by the Government's Medicines and Healthcare products Regulatory Agency (MHRA), from early next year. With the dodgier end of the market forced off the shelves, remedies that remain will be entitled to make "soft claims" about their products without going through the multimillion-pound testing system required to license a new drug. Packets of St John's wort, for instance, should be able to carry a claim that it is effective for low moods.

Far greater change, however, will come when herbal medicine becomes a statutorily regulated profession in the same way as medicine and nursing. Currently, anyone can set up shop as a medical herbalist, prescribing whatever they like. However, a determined campaign over the past three or four years by the Prince of Wales Foundation for Integrated Health has persuaded the Department of Health to introduce regulation for medical herbalists, who already undergo up to four years of training. A further move, just announced by the MHRA, will introduce a special system for ensuring a "safe supply of herbs for special purposes", as used by medical herbalists.

The move is occurring at the same time as a major expansion of medical- herbalism courses at universities throughout the UK - many of them distance-learning, and proving popular among complementary and mainstream practitioners. An MSc course, aimed largely at doctors, just starting at the University of East London, is also oversubscribed.

One likely result is an increase in herbalists working alongside GPs, an approach pioneered over the last 10 years by the GP Dr Derek Chase and the Japanese herbalist/acupuncturist Gretchen de Soriano at the NHS Cavendish Health Centre in central London. "Our priority from the beginning wasn't efficacy, it was safety," recalls De Soriano. "We took blood tests to ensure that there were no abnormalities attributable to the herbal treatment. And all the practitioners contributed to the records so that everyone involved in a patient's care knew exactly what was being used."

"Sharing of information has to be carried out within the bounds of confidentiality," says Dr Chase. "But if doctors can safely share information with nurses, they should also be able to share information with complementary practitioners, in the interest of their patients."

If efficacy was not the priority, it has certainly been the consequence. Penny Bates has suffered from severe asthma most of her life. But five years ago, aged 26, her asthma worsened: she was twice admitted to hospital as an emergency. Her GP, Dr Chase, referred her to De Soriano and, after a course of six treatments, she was much better: "I was able to cut down on my medication and eventually stop taking steroids at least part of the year," she recalls.

The success of her treatment is tragically underlined by Bates's current predicament. In February, she moved out of the area and was unable to get the free consultation to see her herbalist. "I managed to pay for a consultation when I first knew I was pregnant. But I couldn't afford further treatments," says Bates, who works with refugees. "Since I stopped seeing her, my asthma has got increasingly bad. Now I'm off work and on so much medication that I'm having to have regular scans because the doctors are worried it might affect the baby."

Perhaps the greatest benefit afforded by herbal medicine from an expert practitioner, as opposed to OTC, is the opportunity for "synergy", when a mix of remedies enhances each other's impact, and can be tailored not just to a single problem but to changing health status.

Trish Dale, 69, was given three months to live when she was diagnosed with small-cell lung cancer five years ago. She has been under the care of a medical herbalist through four courses of chemotherapy and radiotherapy, during which time the cancer has spread to her liver and skin. As well as following advice on a healthy diet, including boosting her intake of antioxidants and omega-3, her anti-cancer herbal concoction, prescribed by a registered medical herbalist, is likely to include milk thistle, maitake mushroom, red clover, sweet violet and sheep's sorrel - with ginger and black horehound added to reduce the nausea caused by chemotherapy. "I trust my herbalist at least as much as I trust the hospital doctors," says Dale. And it's to herbal as much as mainstream medicine that she attributes her current good health, allowing her to play golf regularly, enjoy her new car and her seven grandchildren, all of whom have arrived since her diagnosis.

Another synergy enthusiast is Dr Ron Cutler, a microbiologist at the University of East London, who aroused worldwide interest when he reported research last December showing that allicin, a component of garlic, is "remarkably effective" in killing the so-called superbug MRSA (Methicillin Resistant Staphylococcus aureus). Further work suggests that even greater killing power is achieved when allicin is used with a particular antibiotic, and also with a species of oregano - "a combination that truly knocks its socks off".

Dr Cutler has already helped to set up a company to patent the "process" by which the ingredient has been isolated - "you can't patent garlic". But he complains that further development of anti-MRSA herbal remedies, as well as of a number of "very promising" African herbs that his team are investigating, is hampered by minimal financial support from central government, and a lack of clarity from the MHRA over exactly what constitutes a herbal remedy.

His view echoes Dr Dixon's - that mainstream medicine cannot justify using relatively fringe therapies such as osteopathy, chiropractic and massage while ignoring herbal medicine. "It's absurd and it has got to change," he says.

FLOWER POWER: USING NATURE'S PHARMACY

Lemon balm

Widely used, along with valerian, for anxiety and insomnia, it has only mild adverse effects, though evidence of efficacy is lacking. However, many experts believe that kava kava is the true herbal anxiolytic. This was banned by the Government in 2003 after reports of 79 suspected cases of liver damage, but the MHRA is reviewingthe evidence in January 2005.

Feverfew

With an anti-inflammatory active ingredient, this remedy has been extensively tested for its efficacy in relieving headaches and migraine, though with mixed results. This could be due to a differing quality of the herb being used in different trials. It's worth trying a good quality herbal remedy for at least a month, however. Feverfew has, at most, mild adverse effects.

St John's Wort

With depression recognised as "one of the great health problems of our age... and SSRIs [antidepressants] increasingly embroiled in controversy over their safety and efficacy," according to the BMJ (9 October), there is a solid evidence base for this remedy for mild-to-moderate depression.

Don't use it if: you're on the Pill, taking antidepressant prescription medicine, have epilepsy or asthma, or are taking warfarin or digoxin.

Pelargonium

Echinacea boosts the immune system, but pelargonium has been shown to attack the virus that causes coughs and colds directly. A major trial (reported last year in the journal Alternative Therapies in Health and Medicine) showed that it "significantly" shortened respiratory-tract infections, without any reported adverse effects.

Devil's Claw

Two recent studies published in Phytomedicine and the European Journal of Anaesthesiology showed that the remedy is as effective as prescription NSAIDs (non-steroidal anti-inflammatory drugs, about which there are currently major concerns) in reducing the pain of hip and knee arthritis, and that it significantly controls lower back pain compared with placebo.