GPs call for end of NHS homeopathy

How wonderful to know 20% of GP's are keen on homeopathy. In Scotland, 60% of GP's have had training in homeopathic practice and meld it effortlessly into their daily repertoire. Scottish medicine always seems somewhat ahead of the curve - even refusing to admit private providers into primary care provision.

Yes indeed Andrew, the main point is that a significant minority of GPs approve of homeopathy being available on the NHS to those that want it. Of course some of the GPs who don't use it or want it on the NHS, would undemocratically, vindictively and vengefully seek to bully the GPs and patients who do want it provided. The money issue is a complete red herring. Homeopathy presents good value for patients who use it on the NHS as patients have been visiting homeopathic hospitals for the past two centuries have always been more satisfied with their treatment. The money apparently 'wasted' on homeopathy is totally dwarfed by huge wastages on conventional medicines that have been proved not to work. An excellent example is the use of anti-depressants in general practice. A highly regarded meta-analysis (http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050045) of these medicines showed that they are useless in most cases of depression, being only of some minimal use in the 'most severe' cases. It would seem obvious to any GP that huge amounts of money is being wasted on prescribing anti-depressants to patients who are not in the 'most severe' rubric but we don't see anything in Pulse or the media about that do we? And as for the 500 million wasted on Tamiflu for treatment of swine flu? All I can say is that the annual budget for NHS homeopathic prescriptions is 10 million. And I won't even begin to discuss 'side effects' of some anti-depressants such as increased rate of suicide! As for the NHS funding unproven treatments, I've consistently referred people to the BMJ's Clinical Evidence pie chart http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp showing that only 12% of common treatments are actually backed by solid evidence. The attempts to debunk my understanding of what this chart is saying by the likes of Edzard Ernst and Les Rose are very weak indeed: Edzard Ernst: (in Pulse blog of 30/9/09): 'The figures on 'Clinical Evidence' are an under-estimate; but even if they were correct, they would be about 6 times higher than in alternative medicine. q.e.d.' (Not only is that less than a 'refutation' of my interpretation of the pie chart, it is an insult to the BMJ for producing such an apparently dangerously misleading chart - in my opinion.) Les Rose: (in Pulse in response to article by Ian Quinn) 'For a start, the database (ie the pie chart that I refer to) includes all treatments, including complementary and alternative. It is counting all those things which most doctors would not use simply because they are known not to work.' However the BMJ says 'commonly used' treatments and the chart clearly shows that many interventions used simply do not have evidence behind them. This of course is not to say they don't work - unlike the multi-million pound 'breakthrough of anti-depressants which a major meta-analysis (referred to above) shows that there is no evidence whatsoever (in fact quite the contrary) to use them in the great majority of cases diagnosed as 'depression'. Where is the campaign to ensure that the NHS does not waste money on inappropriate prescriptions of anti-depressants? Maybe someone from the BMJ will tell us exactly what their chart implies but until then can a rational reader of Pulse please tell me what I am missing when I see the jeering attack on the provision of NHS homeopathy as malicious, vindictive, disingenuous and blatantly anti-democratic.

Predictably Andrew Sikorski continues with his efforts to set back medicine to the end of the 18th century. He does raise one interesting point though. It does seem to be the case that belief in magic medicine is more prevalent in Scotland than England. That I find puzzling for a country that has produced so many fine doctors and, in the past, regarded itself as a leader in the field. Having been at Edinburgh university myself I find this rather saddening.

In defence of Scotland I would say not only does it produce more open-minded doctors, it also produces better comedians than England. My favourite three stand up comedians in the UK, Jerry Sadowitz, Billy Connolly and Arnold Brown all come from Glasgow. And if you think that this isn't medically relevant then please google the health benefits of laughter :-)

Predictably Colquhoun endeavours to limit patient choice in the face of evidence demonstrating treatments chosen by patients have higher efficacy than those dictated by doctors.

Not that pie chart again! One more reason why the percentage of evidence-based interventions is so low in that chart is that it includes all of alternative medicine, eg homeopathy.

Wonderful to see a comment from Professor Ernst, once again cherry picking the subject he will respond too. How about a view on the other issues raised Prof... please, ...pretty please???

Thank you Professor Ernst for your comment on the pie chart of the BMJ's Clinical Evidence. Professor, could you please teach me how to interpret this chart correctly. What does it mean exactly by 'commonly used' treatments? Does it include ALL alternative treatments such as magnet therapy, trepanning, Russian healing gadgets, faith-healing, and remedies prescribed by witch doctors or only some of these. How does the BMJ choose the treatments it calls 'commonly used' selected to be represented in the pie? I assumed it was referring to medicines listed in comprehensive pharmacopeae such as MIMS and the BNF. If I am utterly wrong please furnish with me a source that proves otherwise. I apologise for insisting on EVIDENCE to back up your claim that it includes 'all of alternative medicine, e.g. homeopathy'. Until I see this evidence (something I do understand you regard very highly) I will continue to use this BMJ chart to confuse with facts, those who persist in using EBM exclusively to attack homeopathy and CAM while remaining unperturbed by the fact that huge swathes of orthodox interventions are very much less than evidence-based e.g. the millions spent on antidepressives as I've written above.

It is odd that my fellow Edinburgh graduate (above) is puzzled at the high proportion of Scottish GPs who use homeopathy. Scottish students tend to be more open minded than their Southern counterparts. They are as individual as those indigenous sheep on remote Hebridean islands who refuse to be herded into flocks by snapping Border collies. And they tend to be better taught, about homeopathy as about other subjects. Perhaps if critics of homeopathy followed the Scottish approach, and learnt a little more of the homeopathic method, we might have a more worthwhile debate? Until that happy day dawns, critics will continue with their one dimensional approach; Homeopathy is impossible, therefore dismiss, sneer, denigrate. To base one’s argument on one such belief or observation is unwise. Joseph Bell, a surgeon in the Edinburgh Royal Infirmary in the mid nineteenth century, was famous for his observations and deductive reasoning in out patient clinics. One of his students, Arthur Conan Doyle, is said to have used Bell’s approach in his many subsequent descriptions of Sherlock Holmes' remarkable feats of reasoning. Joseph Bell was aware that if you take up a strong position on the basis of a single observation or belief, you are on unsafe ground. He told the story of visiting a patient, with his class of students. ‘Are you not a bandsma?’ Bell asked of the patient. ‘Aye,’ admitted the patient. ‘You see gentleman, I am right. This man has paralysis of the cheek muscles, the result of too much blowing at wind instruments. We need only enquire to confirm.’ ‘What instrument do you play my man?' asked Bell. 'The big drum' was the reply!

As a GP I use homeopathy in a complementary way. It does not seem to me or my patients that it is weird medicine. Feeling better and avoiding side effects goes down very well for practitioner and patient alike. I am trained and confident to prescribe homeopathy; it would be very odd to deny patients medicines which, in my experience, work very well in a significant number of patients.

There is nothing 'open minded' about belief in homeopathy. More 'empty minded'.

It is not simply the fact that homeopathy would require us to discard the known canon of physics, chemistry and pharmacology that makes sceptics and scientists - and presumably 80% of GPs - confident it is a placebo (though for its use in the classical format with extensive one-to-one consultation I prefer the term 'stealth psychotherapy' - which I would suggest also helps explains why many people report anecdotes of homeopathy 'working').//// Apart from the underlying scientific (im)plausibility, there is also the fact that, judged by the normal standards of assessing the totality of the clinical evidence (meta-analysis of controlled trials) homeopathy is ineffective beyond placebo.//// It is the coincidence of these two lines of evidence that leads people like Colquhoun to the inescapable conclusion that the argument is over. Certainly, we could go on running yet more trials to tell us what is already clear - but isn't it time to apply some 'triage' and put the money where it can do something more useful?

Please could someone tell me what the indications are for admission to a homeopathic hospital, and what treatments are provided? Are there any public statistics on lengths of stay and reason for admission?

It seems to me that any argument that a proportion of orthodox medicine has a limited amount of data is a classic case of 'whataboutery'. The issue is that homeopathy is not effective and should not be funded by the NHS - particularly given the fact that funding is going to be tight over the next few years. Even if we accept the point that some orthodox medicine has a limited evidence base, defenders of quackery like homeopathy seem to have missed the fact that orthodox medicine often dismisses medicines that are consider ineffective or dangerous. There are prescribing advisors attempting to increase rational prescribing, and organisations like NICE assessing cost-effectiveness. No such introspection is seen from the homeopathic faith group.

Apparently Einstein's mind was hydrocephalic with a thin rim of cerebral cortex - how we would all yearn to be as open/empty minded as he!

Brian Kaplan: OK, I'll try again. This has been extensively discussed on my blog (http://www.pulsetoday.co.uk/section.asp?navcode=961). Alternatively you could read Prof Garrow's letter in the BMJ 1 or my article in the BJGP 2. Also of interest is that, according to an optimistic estimate, about 7.4% of all CAM might be evidence-based 3. --- Reference List (1) Garrow J. What to do about CAM? How much of orthodox medicine is evidence based? BMJ 2007; 335:951. (2) Ernst E. How much of CAM is based on research evidence? eCAM 2009; May 21. [Epub ahead of print]. (3) Ernst E. How much of general practice is based on evidence? Br J Gen Pract 2004; 54:316-317.

Ernst and his ilk only seem to like 'evidence based medicine' when it can bash alternatives, and they ignore it when it points its fingers at conventional medicines. Ernst would still support the use of antidepressant drugs and many others that have been PROVEN to be ineffective. And further, no surgerical procedures have undergone double-blind placebo controlled trials. Further, whenever a patient was prescribed two or more drugs, very little 'evidence' supports this polypharmacy. And because most drugs are not tested on infants, children, or the elderly, we could save a lot of money by not funding any of their care. If we chose to only fund those treatments that are PROVEN to be effective, governments would save a lot of money. Maybe Ernst is onto something after all.

I'm sorry Prof Ernst, but you have not convinced me that I'm wrong in thinking that huge swathes of conventional medicine are simply not evidence based. The chart at least shows this. Anti-depressants (see the increased suicide risk as a digression to my argument) and many psychotropic drugs are good examples and the cost of these to the taxpayer utterly dwarf the NHS budge for homeopathy. My point is simple and has not been refuted: It is disingenuous and hypocritical to use 'lack of evidence' as a blunt instrument exclusively to attack homeopathy and CAM when much more NHS money is spent on orthodox interventions that are simply not based on evidence. If you want to be a champion of evidence-based medicine then do so but apply it as a litmus test across the board (ie to all medicines) and I suggest you start with anti-depressants. I think that an honest and in depth appraisal of the facts will make your realise that doctors in glass houses should not throw stones.

I am astounded at the double standards and hypocrisy which is evident in this article and some of the subsequent comments. Critics often accuse homeopathic physicians of misinterpreting the evidence and referring to small trials of low significance. Here we have a spectacular example of 'bad science' being used to try to discredit the practice of homeopathic medicine. We are told of nearly 800 GPs who have responded so far to Pulse's pre-election survey, 80% said the Department of Health should not continue funding for homeopathy. Firstly, we have a statistic without a reference or indeed any other details. OK, I accept this is an informal survey and of course makes a good news story, as attacking and maligning colleagues who practice homeopathic medicine seems to be popular at present. However, may I point out that N=800 in this 'study' actually represents 0.022% of Members of the Royal College of General Practitioners, whose membership was 36,000 in March 2009. (There are of course many other GPs who are not Members of the RCGP, and therefore the total number of GPs in the UK is considerably higher). Is this really a reliable statistic or an honest argument in any way? I think not. Secondly, we then get people like Austin Elliott who actually swallow this 'bad science' hook, line and sinker and re-iterates it to us - '...presumably 80% of GPs - confident it is a placebo...'. Again I point out 80% of 0.022% of Members of the RCGP, which I think he will find is actually 0.018% of GPs. Suddenly it isn't such a great news story, and a far cry from Richard Staines' 'Exclusive'. In case you missed my point 0.018% of Members of the RCGP seem to be against NHS funding for homeopathy - not 80%. Secondly, Austin Elliot then goes on to claim that '...judged by the normal standards of assessing the totality of the clinical evidence (meta-analysis of controlled trials) homeopathy is ineffective beyond placebo...'. Again we see a blatant disregard for science and for truth. Can he provide evidence for this wild accusation or is he simply ignorant of the facts? It seems to be getting easier for people to chant the 'no evidence' line over and over again, and perhaps they think that it gets easier to believe this, the more often it is said. Earlier generations would have advised us that it gets easier to lie, the more often it's done. Whilst he searches for evidence to back up his outrageous claim, can I refer him to the Research Summary compiled by the Faculty of Homeopathy which he can find at: http://www.facultyofhomeopathy.org/research/ or http://www.facultyofhomeopathy.org/export/sites/faculty_site/research/evidencesummary.pdf. When he examines the facts he will actually learn that 4 out of 5 meta-analyses of homeopathy have reached broadly positive conclusions, which is not surprising given that of the 138 RCTs performed to date in homeopathy, more have been positive than negative. In addition to this, there has been significant positive qualitative research, such as the Spence et al 2005 outcome study. Perhaps he is blinded by the infamous and flawed 5th meta-analysis by Shang et al in 2005, or Ernst's 'review of reviews', also in 2005. May I suggest that he, and others, consider the facts for themselves and look at the whole body of research which has actually been done, before buying into the 'bad science' we see here.

Thank you Prof. Ernst, for your answer. I've looked at all your references that can be seen online. Although it is clear that conventional medicine is MORE evidence-based than CAM, nothing I've read has shown me that I'm wrong in my interpretation of the BMJ pie which at least suggests that large swathes of orthodox interventions do not have solid evidence behind them. Take the issue of anti-depressants (and psychotropic drugs in general) as a good example as NHS money spent on these alone dwarfs the tiny proportion of the NHS budget spent on homeopathy. Putting aside the increased suicide risk some anti-depressants produce, a major meta-analysis (http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050045) shows that there is no evidence to support anything like the massive way they are prescribed in general practice and psychiatry. This is not to say they should not be used and based on the discretion and conscience of individual doctors, but if EBM is to become the legislated litmus test of efficacy, their usage would be legislatively slashed - saving the NHS hundreds of millions of pounds. My simple conclusion from the graph is that it does indeed show that a great deal of orthodox medicine (at huge expense to the taxpayer compared to homeopathy) is not evidence based. If you want to position yourself as a champion of evidence based medicine then you have every right to use it as a broom to attempt to sweep medicine clear of anything that doesn't have evidence behind it. Why you choose to use your unique professorial position in CAM in the UK to use EBM exclusively to attack homeopathy and other forms of CAM, only you can explain.

The only reason why homeopathy would work is because I had nothing wrong with me in the first place and shouldn`t have bothered the doctor. It`s solely a deceitful attempt by the PCTs to rake in the cash rather than spend money on drugs that do work which are expensive. This is in the same vein as PCTs forcing GPs to prescribe cough mixture (which is useless unless sedative) and paracetamol for 7 a throw. Homeopathy is the 'green collectivism' of the NHS and just about as much of a con.

Professor Ernst has given me the biggest LAUGH that I've had in a long long time. He actually blames homeopathy and alternative medicine (!) for creating the extremely low evidence base in conventional medicine. Wow! The good news here is that he provides solid evidence of his biased point of view that should make us all question the veracity of anything he writes or says.

HOMEOPATHY IS WIDELY USED PRACTICE IN MANY DEVELOPING COUNTRIES AND THERE ARE WELL QUALIFIED PRACTITIONERS IN THIS SYSTEM OF MEDICINE.WHETHER IT IS EVDENCE-BASED OR NOT AS FOR I KNOW MANY PATIENTS GET CURED WITH HOMEO TREATMENT. DURING MY VISITS TO INDIA I HAVE HEARD OF MANY GOOD RESULTS IN THE TREATMENT OF SKIN CONDITIONS, ASTHMA AND GASTROINTESTINAL PROBLEMS.SOME PAEDIATRIC TREATMENTS ARE I BELIEVE EXCELLENT. WHY ARE WE MAKING SUCH BIG FUSS IN UK? THE FINANCIAL BURDEN IS VERY SMALL COMPARED TO WHAT WE SPEND IN ADMIN COSTS TO RUN OUR PCTS AND HEALTH AUTHORITIES. WHEN OUR HEALTH SECRETARY IS WILLING TO FUND THIS AND PROVIDE A CHOICE OF ALTERNATIVE MEDICAL CARE WHY SHOULD THE PROFESSION OBJECT? GIVE HOMEOPATHY A CHANCE AND SEE THE UPTAKE OF THIS SERVICE BY THE PATIENTS WHO MAY BE SMALL IN NUMBER.

Correction: Those who have considered my previous post may have noticed that I wrongly dated Ernst's paper as 2005. It was of course 2002, and I apologise for this error. Sriramashetty Venugopal makes 2 interesting points - Firstly, it is helpful to consider the pathetic and vicious attacks on homeopathic medicine here in the UK within a world context. Indeed, in many countries homeopathic medicine is flourishing and is hugely popular. Having said that, its popularity here in the UK is well known, but yet a Stalinist minority is tying to bully everyone else to accept their point of view, to stifle patient choice and somehow convince themselves that they are either advocating evidence based medicine or else saving money. What unprofessional and unethical nonsense. Secondly, as Brian Kaplan also pointed out in an earlier post, the money issue is a complete red herring. According to the Department of Health, the NHS spend on homeopathic medicines is approximately 152,000 per year out of a total drugs budget of 11 billion, i.e. 0.001%. The arguments which are being put forward against homeopathic medicine are absurd and the attempts which are being made to mislead both the public and the profession are both unprofessional and unethical.

Unethical is, in my view, to promote therapies which are at best unproven and at worst disproven. Never mind the economics,this endangers the health of patients.

Exactly Edzard. It's homeopathy and that endangers the health of patients! You say 'never mind the economics'. I say: 'Never mind' that NHS homeopathic doctors are fully accountable for their actions. 'Never mind' studies showing the increased suicide risk of patients on antidepressants. (http://news.bbc.co.uk/1/hi/health/3656110.stm) Never mind studies showing that homeopathy in general practice (however it works!) is effective and highly cost-effective. Never mind the fact that we know homeopathy helps patients - HOWEVER you and others think it works.(http://www.facultyofhomeopathy.org/research/clinical_outcomes_studies.html) Never mind that a significant proportion of taxpayers want homeopathy, you know better than they do what is good for them and therefore are fully justified in using the particular type of universal healthcare system we have in the UK to call for the majority to bully this naive and infantile minority into submission. Never mind 'democracy' - Scientism Rules!