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Homeopathy victim of PCT funding cuts
30 Jan 08
Homeopathy is becoming the highest profile victim of the Government’s drive to promote cost-effective use of NHS resources, with PCTs across the country stopping funding for the controversial treatment.
A Pulse investigation into the services provided by 132 PCTs reveals only 37% still have contracts for homeopathic services. More than a quarter of trusts have stopped or reduced funding over the past two years, with many cancelling contracts with homeopathic hospitals. Only one PCT said it funded homeopathy as an extra service in primary care.
Homeopathy is highly contentious but remains popular in general practice, with a survey finding it was the second most used complementary treatment after acupuncture last year. But PCTs have come under acute pressure to divert funding away from homeopathy, with a group of experts writing an open letter to directors of commissioning in May 2006, saying the treatment caused ‘cultural and social damage’ and was ‘unsupported by evidence’.
Homeopathic clinics in the UK are in crisis. Tunbridge Wells Homoeopathic Hospital in Kent has announced it will close and the Royal London Homoeopathic Hospital is fighting for survival after eight trusts cancelled contracts over the past year, and a further six reduced referrals. Referrals to the hospital are down 20% in a year.
Professor Edzard Ernst, professor of complementary medicine at Peninsula Medical School, Exeter, and a former homeopath himself, said he supported moves to withdraw funding for homeopathy as it was nothing more than a placebo. ‘There can be no cost-effectiveness without effectiveness,’ he warned.
Dr Michael Dixon, chair of the NHS Alliance, said since the letter to PCTs, complementary therapies had been targeted in budget cuts by PCTs to reduce the NHS deficit. He said the future of homeopathy in primary care relied on practice-based commissioning. ‘In the fundholding years, the use of complementary medicine increased rapidly in the NHS, so we may well see the same again.’
Of 37 PCTs that responded, the majority would consider a PBC proposal for homeopathic services, although 28% would not or said such a proposal would be unlikely to succeed.
Dr Tim Robinson, a GP who provides a local homeopathic service in Dorset, said patients denied homeopathic treatments on the NHS might take risks by consulting non-medical practitioners. ‘They will have to pay someone and go to a non-doctor and there are potential risks with that,’ he said.
Pulse conducted its investigation through the Freedom of Information Act, and enquiries to the Royal National Homoeopathic Hospital and Sense About Science.
Readers' comments
Thousands of patients say they have been helped at these NHS homeopathic hospitals, many of them suffering from illnesses that failed to respond to orthodox treatment. I find it cruel and uncaring to deny them help on the NHS. If they say they feel better then they have benefited from homeopathy.
The attack on homeopathy in the name of cost-effectiveness is ridiculous. Homeopathy works on animals, is safe to use on children, has been used in the UK by doctors for nearly 200 years.
It is cheap, organic, natural and safe and used by many privileged people who could choose whatever medicine they want. A good example of this is the Royal family.
As a GP who uses homeopathy as part of my armamentarium and refers to the homeopathic hospitals when all the local secondary care consultant expertise has been exhausted, I have good evidence that homeopathy helps. I
In the week that we have seen the ENHANCE Trial question the evidence base of conventional medicine in the use of a cholesterol lowering drug (that I am sure would have been accepted to date by the likes of Professor Ernst) we need to acknowledge the quality of observational evidence, that the likes of me and my fellow GPs, who look laterally at alternative and complementary therapies when we run out of effective treatments, have to hand.
The process of Practice Based Commissioning needs to reflect this experience.
GPs who are trained to understand the principles of evidence-based medicine will look to ensure that we prescribe medicines that work, rather than ones that don't work.
To say that homeopathy 'works' is in itself a bizarre statement. The question should be 'which homeopathic therapy for which illness'? with defined end-points. The best quality evidence shows that no homeopathy has been found to be effective in any condition.
To be recommending homeopathy in the face of current evidence (which GPs should aim to know about) is dishonest and is indistinguishable from quackery. PCTs should withdraw funding in order to preserve the integrity of the NHS.
As a doctor who has used homeopathy alongside conventional medicine both in general practice and an NHS Homeopathic Hospital, I have repeatedly seen patients improve with homeopathy when other treatments have failed.
There is plenty of positive evidence for the effects of homeopathy and this is increasing all the time. The majority of systematic reviews of double blind controlled trials show homeopathy to be more effective than placebo and there are positive focused meta-analyses for a number of specific clinical conditions including childhood diarrhoea, influenza, rheumatic diseases, hay fever and vertigo.
These are all conditions which are common in general practice and the incorporation of homeopathy into patient care can improve outcomes and compliance, while reducing costs and side effects. It can thus be used in an evidence based and cost effective way and I recommend all pratice based commisssioning groups to seriously consider it.
It seems remarkable that Professor Ernst could have at one time been a homeopath and now to say that homeopathy is simply placebo effect. How can one profess without the conviction of what he is so professing?
An examination of the treatment statistics of cholera, typhoid, diphtheria and other serious fatal illnesses, reported by non-homeopathic sources, evidences the remarkable differences in mortality rates from homeopathically treated cases and non-homeopathically treated (allopathic) cases.
Even the records of the surgeon general, which are readily accessible in medical libraries, repeat these statistics and evidence the sometimes ten-fold increased mortality rate of patients treated allopathically when compared to those treated homeopathically.
To assert this is all "placebo" is quite incredible and can only come from a failure to investigate the evidence (even the profusion of animal studies) and it is from such people who find themselves in the practice of medicine that we now see the call for evidence-based prescribing itself an admission of the speculative disposition in mainstream medical practices.
Is it too much to ask, no, require, those who proffer an opinion on homeopathy to detail the actual basis (factual data, evidence) of their thesis, whatever be their conclusions, so that the onlookers may examine the evidence and draw their own conclusions?
Let us ensure we reserve our opinions until we have gathered and examined the facts. The only requirement is an open and honest examination, without pre-conception.
"I have repeatedly seen patients improve with homeopathy when other treatments have failed."
Of course you have. But do you systematically record all of them and also those that don't?
Even so, we know that anecdote is essentially worthless as a guide to causality in medicine and I find it extraordinary that a member of my sister profession would advance anecdote as evidence in this way.
If this discussion continues, I am sure one of the homeopathy's apologists will feel compelled to cite Spence's survey of Bristol Homeopathic Hospital patients, published in 2005, which reported that 70% of patients, asked in an unblinded manner by their own therapist at a time of that therapist's choosing, were prepared to say that their condition had improved at least a little.
If we apply Dr Eames' thinking to its logical conclusion, Spence equally showed that homeopathy caused the deterioration or stasis in the condition of 30% of patients. Live by anecdote and false inference. Die by anecdote and false inference.
It should be trivially obvious that blinding and controls are required to determine whether a causal relation really exists between therapy and disease history, but the Faculty of Homeopathy, whose membership is restricted to vets and medics and should be at the top of this game, seemed to find this a concept too far when they headlined their Press Release of Spence's results "Homeopathy improves health of 70% of follow-up patients in study".
This desire to infer causality from anecdote seems deep-seated in homeopathy's defenders. However, it is often concealed behind a proxy argument such as "we need to acknowledge the quality of observational evidence", where it rather depends on what you mean by "quality". Even the most systematically recorded and objective observational evidence is merely the start of a process which leads to properly controlled trials. It cannot be the end-point in a chain of investigation.
Homeopaths really must cease with this appeal to anecdote and survey and draw their conclusions from better quality evidence more suited to the purpose, however I am not sure which trials and meta-analyses Dr Eames has read.
Well-controlled, high-quality, adequately large, single trials of homeopathy have never shown it to be effective and the meta-analyses confirm this. The better the trial the more clearly homeopathic remedies become synonymous as placebos. To say otherwise is becoming increasingly perverse.
From the Faculty of Homeopathy's Press Release; "The majority of comprehensive reviews of randomised controlled trials in homeopathy suggest that homeopathy is more than the placebo effect and there have been positive meta-analyses for a number of specific clinical conditions including childhood diarrhoea, influenza, rheumatic diseases, hay fever and vertigo." From Dr Eames' post above; "The majority of systematic reviews of double blind controlled trials show homeopathy to be more effective than placebo and there are positive focused meta-analyses for a number of specific clinical conditions including childhood diarrhoea, influenza, rheumatic diseases, hay fever and vertigo." Synchronicity presumably.
The simple fact is that it is GPs who refer patients for treatment at the NHS homeopathic hospitals and it is registered medical practitioners who deliver the treatment. No GP is going to refer a patient to a homeopathic hospital who can treat the patient her/himself using standard conventional methods.
The fact is conventional treatments have their limitations with many conditions (as well as their risks) and GPs refer patients for homeopathy only when these limitations are reached. What is also damaging about these cutbacks is that they fly in the face of the Government's 'Choice" agenda and even more so, stop access for those who economically cannot afford to pay for private treatment.
The Government spends £47m on obesity drugs instead of tackling obesity prevention, it costs £5m a year to run the RLHH which provides homeopathy and other CAM therapies for the whole of London. Which gives better value and which is a waste of money?
As a full time homeopath in private practice, does any sensible person believe that people would pay me again and again if they did not get better? And what about them recommending their friends and relatives - 95% of my clients come from word of mouth!!.
We may not know at this point in time how Homeopathy works, but it does not mean that it does not work. After all, humankind was once told that the Earth was flat.
Perhaps the drug companies have finally realised that people are taking more responsibility for their own health and seeking therapies that really help them. I don't wish to denigrate conventional medicine here, for many times I recommend that people return to their GPs and I wish that we could work together in the spirit of collaboration and co-operation.
I know many GPs who work incredibly hard and would like to spend more time with their clients. I worked for 6 years in a GP's practice where one of the GPs, also a homeopath, wished that she could spend more time doing homeopathy, but she felt constrained because of the time factor.
I will end with a Ghandi's quote: "first they ignore us, then they ridicule us, then they fight us, and then......we win". Well, the war is certainly on, I doubt that they will win. Homeopathy has been around for 200 years, it is very unlikely that it will suddenly cease to exist. So Prof. Ernst, I feel that we will see you first.
As a full time practitioner of homoeopathic medicine for 27 years in Sydney, Australia I too have had times where I assumed the the results were too good to be true & thus must be placebo.
I certainly have criticised some of my colleagues of their claims of cure as been placebo, usually psycological cases. However, the difficult cases that come to me & fail the first few prescriptions & then clearly succeed on a more clearly indicated medicine throws out the window any suggestion of patient expected positive placebo effect.
The cases that have obviously become sicker on initial treatment then to resolve into a well managed success. The cases that respond with short 5-10 minute consultations, with very little apparent empathy. The cases that responded very effectively when I was only half convinced and at times very doubtful that I had prescribed as accurately as I could diffusing the criticism that the self confident physician scores well on the placebo chart (which often they do). Then there are the babies & animals!
Also, I would like to assure the professor that many of my best outcomes in serious pathological conditions have been with potencies still in the realm of detection less than one part in a million (3 & 6 centessimal preparations).
That homoeopathy is primarily 'like cures like' & the controversial infinite dose is a secondary consequence of observable & repeatable positive patient outcomes in the hands of competent homoeopathic practitioners.
On top of this we also enjoy for our clients the added benefit of about 30% placebo. So we are 60% there. Is that not good and an amazing cost saving for the NHS? There are many positive well proven medical drugs that have a needed place in treating disease, but there are many mischievious drug prescriptions based on 'well proven facts' that I would not wish on to any human or animal.
On the positive side, if it is all placebo then think of the cost benefit derived from the lack of serious drug induced & chronic diseases that are the consequence of 'tested & proved effective drugs' that frequently palliate & fool both client & doctor into believing it's a cure. Pity about the next serious progressive but 'new' diagnoses 6 months a year or 2 later.
If it is all placebo then 30+% effectiveness is not to be looked down upon but thoroughly investigated & maybe we need a new specific practitioner of placebo to practice placebopathy'?
Correction to last comment. I said less than 1 part per million. I meant to say less than one part per billion
As one of the two consultants working at the Tunbridge Wells Hospital I am very much aware of the benefits homeopathic treatments can offer for patients who had unsatisfactory outcome from conventional treatments.
Our outcome survey shows we help 77% of these patients; 50% are moderately to much better. Late December 2007 West Kent PCT rescinded its decision to stop funding Homeopathy at the Tunbridge Wells Homeopathic Hospital. This was largely due to legal pressure from patients and will ensure funding at least until September 08 but probably longer.
We hope to use this time constructively to find a compromise ensuring long term funding in this area for this popular, very safe and seemingly effective therapy. With time , much more research funding and within the NHS we should be in a good position to help establish its evidence base.
The refusal of PCTs to refer patients for homeopathic treatment serves only to deny choice to their patients. It is part of the paternalism that pervades the NHS. The attitude appears to be - you have paid for treatment - and we decide what treatment you will get -and it will be conventional treatment - whether you like it or not.
While this kind of decision remains in the hands of PCTs the concept of patient choice will remain a distant and impossible dream. It is time for the NHS to give patients accurate information about what conventional and traditional medicine can offer them - and let each one of us choose according to our wishes.
The NHS should not be a monopoly supplier of conventional medicine. Unfortunately, this is what it has become.
We have come to expect homeopaths to attach more value to clinical anecdote than they do to science, but it's intolerable when they distort the science.
Graham Jagger - in what way does the ENHANCE trial "question the evidence base of conventional medicine in the use of a cholesterol lowering drug"? If you read the paper, you will see that it's a study of patients with homozygous familial hypercholesterolaemia, with a population prevalence of about 0.2%. Both arms got active treatment, and the purpose of the study was to see whether one of them, a combination, was better than monotherapy in this rare and extremely high risk group. It isn't, but in no way at all does that undermine the very well established benefits of cholesterol lowering therapy.
This is simply science - asking a question objectively, and getting an answer we can rely on, whether we like it or not. Something that is of course anathema to homeopaths.
I feel sad and disappointed that my contribution was edited so heavily. I had asked for the sacking of prof. Ernst with immediate effect. Why does this have to be edited? Surely we still live in a democracy where people can express their personal feelings, so long as it is not defamatory or incorrect.
It was felt the initial posting breached the code of conduct below which is why it was edited.
To Steve Scrutton
What can be more paternalistic than saying this to a patient? "Now I'm going to give you a medicine that's been diluted out of existence, and there's no clinical trial evidence that it works (and the MHRA agrees with me on that), so you just have to trust me - I'm a homeopath".
I note a repeat of the old claim that animals respond to homeopathy so it can't be placebo. Unfortunately the "response" always seems to be in the eyes of the owner and not the animal, a "placebo by proxy".
Absent any objective criteria of improvement, it's small wonder that hopeful owners are persuaded that their pets are getting better as wished for. A useful article here:http://www.skeptics.org.uk/article.php?dir=articles&article=it_works_in_animals.php
I believe homeopathy to be a kind of placebo. This misses the point.
Most traditional interventions have never been scientifically evaluated and usually perform no better than placebo anyway, yet often have appalling side-effects.
The problem with most medical research is that the double blind is almost never tested, even though it would be as simple as asking the participants whether they thought they took the medicine or the placebo. his is presumably because whenever the blind is tested, it has been penetrated 80% of the time (Fisher and Greenberg, 1993).
This indisputably proves that most medical research is invalid, a fact so disturbing that most will go to any lengths to avoid acknowledging it.
There are other tricks that the drug companies use to make their products look more effective, including suppressing unfavourable studies. The placebo effect has been responsible for many if not most miracle cures. So whilst you judge homeopathy on the basis of true double blind studies make sure you judge traditional medicine by the same standards - and let us find out what (and who) really helps patients.
To Les Rose. A more paternalistic attitude is a conventional doctor saying to a patient who wants homeopathic treatment (because he/she knows that it is both safe and effective) that they cannot have it because the NHS (and cheque-book science) know best.
If you believe that homeopathic remedies have been "diluted out of existence" and that "there's no clinical trial evidence that it works" you can have conventional medicine. It is called 'choice'. If you or anyone else wants to chance taking Thalidomide, Vioxx, Seroxat, HRT - et el - that is entirely up to you. I will trust homeopathy because it has always worked for me.