BHA

Homeopathic hospitals

Homeopathy - a waste of time?

In response to the negative homeopathy trials of asthma treatment, arnica and the BBC Horizon programme... David Spence poses the question: Homeopathy - a waste of time?

“To begin with, what is homeopathy? If you were to ask 100 people indiscriminately, you would scarcely get a satisfactory answer. The result would generally be either complete ignorance, or prejudice based on ignorance, except for some vague idea of small doses, or the ‘hair of the dog that bit you’.” That was the opening statement of Dr Blackie’s presidential address in 1950, when she started her second year as President of the Faculty.

Dr Blackie always included some case histories, with every lecture, of people who had been treated in the real world successfully with homeopathic treatment. And her inaugural address when she became the first-ever lady President of the Faculty in October 1949 was no exception. She finished up with these words: “These are only isolated spectacular cases you will say and prove nothing. I don’t think that is true. How are we ever going to get [a] hundred consecutive cases to prove our arguments?”

I would like to answer this call from Dr Blackie for a hundred consecutive cases treated homeopathically in the real world with data taken from the Bristol Outcome Assessment Study, which has been running for about five and a half years, and which represents the work of 14 physicians, our Audit Facilitator, Sue Barron, and other members of staff who enter all the data into the database, particularly Gill Pinnegar. This study is what one might reasonably call homeopathic treatment in the real world.

Let me define the real world, because that’s very important. We are an NHS University teaching hospital outpatient department. So we are not some funny little thing that is happening in a corner, although some people would like to think that we are. Many critics who say that homeopathy doesn’t work and is a waste of time, have tended to say that it is all an issue of the time you give patients. They point out that everyone will get better if they are given an hour or two every time they are seen by a clinician and people will always get better when they are paying for treatment.

Table One (see PDF version of article) shows comparative durations of appointments at United Bristol Healthcare Trust (UBHT). You will see that, in actual fact, we are very similar to a number of other specialties; there’s no great difference in time. This is the NHS and of course it’s free. So time and money really are not particularly strong factors when we look at this data.

Conditions we see
I am indebted for this work to one of our fifth-year undergraduates, who analysed 1350 new patients who had been seen in 2002. The spread is enormous as you will see from Table Two. It truly is a generalist field in which we work. The single most common condition – 11 per cent of patients we see – is eczema. More than 85 per cent of these patients have attended other secondary care specialists in the NHS and they have either failed to respond to the treatment they have been given or they have been unable to tolerate that treatment. They are the patients who have been told by another consultant “There’s nothing more that can be done for you”. It is often at that point in time that they get referred to the homeopathic hospital.

Doctors often ask me: “What sort of patients do you see?” and I reply “everybody else’s failures”. That’s about the long and the short of it. You might think that it’s not a very promising starting caseload and that it’s only chronic disease. But, as the BMJ cover so graphically reminded us last autumn, chronic disease is the biggest issue that we face in healthcare today: nearly 50 per cent of our national healthcare activity in 1990, rising to 70 per cent by 2020. And they are not just elderly people. The majority of the patients that we see are actually under 48 years old. So that’s the setting of the real world.

Selection criteria
Every patient is seen consecutively. There are no exclusions. So what are the inclusion criteria? Well, there’s only one – attended alive!

I thought, as many years have elapsed since Dr Blackie’s call for a hundred consecutive cases, that there ought to be some sort of adjustment for inflation. If we multiplied the number of years that had elapsed by one hundred, it might be somewhere near reasonable. We have studied 23,643 consecutive outpatient attendances in these five years, and looked at 5,729 consecutive patients treated.

We get some very simple data from them: date, type of consultation, demographic details, the clinical diagnosis with its ICD10 code (the International Classification of Disease version 10 code), the treatment given with varying amounts of details (we have gathered different amounts of details in the various years that the study has gone on). They then get an outcome score, and then “disposal”, that is are they coming back for another appointment or are they discharged from outpatients. And there’s a form to fill in at every single consultation that takes place

Is homeopathy effective?
How do we judge the effect of homeopathic intervention on patients’ health? This is the difficult part, because inevitably one wants to work with as much objectivity as possible into the assessment process. Where possible, one can do peak flow values for asthmatics, one can (and this is something we monitor very carefully) monitor the reduction in mainstream medication that patients are needing to take – so that one can actually have some definitive parameters of the effect of homeopathic intervention on patients’ health.

We use an outcome score that has zero in the middle, with three below the line and three above the line, with cured on the top. With the type of patients that we see, it is extremely rare to give somebody a cured score because, for me, cured means you are completely better and you will never get it again. And I think with chronic disease that is something that is very difficult to say honestly, so that +3 is really the point at which they are better and can be discharged from outpatients. We followed these patients over long periods of time in order to be able properly to assess how they are progressing.

Of the overall outcome figure for these 5,729 patients, just over 70 per cent of patients, actually improve. And starting from the standpoint of treating everybody else’s failures, this figure is very interesting. If you break that down into men, women and children, it is interesting to note that this truly is a generalist field in which we work. The only one, I suspect, that exists within hospital practice today because these are the sort of figures that general practitioners’ workload involve: roughly 60 per cent women, 20 per cent children, 20 per cent men. It is no surprise really to see that the children, actually do very much better. And if we look at one of the commonest conditions – or the commonest condition – that we see, the under-16 patients with eczema, nearly 71 per cent of them fall in the +2, +3, or even cured category, so there is a very good response amongst young children. And there is a very good response amongst children over all.

Some conditions have proved extremely interesting, particularly inflammatory bowel disease (IBS) which tends either to respond very well or not at all, or they are getting worse and the homeopathic treatment isn’t having any effect on the course of their condition. IBS is a condition we are seeing in increasing numbers. Again there is overall a very positive trend of effect on these patients’ health patterns. We have a vast amount of data and can call up any diagnosis that gets referred to the hospital and actually see what sort of impact homeopathic treatment has on that particular condition.

Now, some might say we could have made all these figures up. However in the first year of the study, the Independent Consumer Involvement Unit at UBHT Trust Headquarters, did a survey of 200 patients and asked them what effect the homeopathic treatment was having. They repeated that in the third year of the study and then, in the fifth year, we carried out an independent study of adverse events caused by homeopathic prescriptions. All three of these studies confirm the “size” of the effect that homeopathic intervention was having on these patients’ lives and health.

Will such a study change opinion? Two Dutchmen, writing in 2001in the Annals of Internal Medicine about homeopathic trials and positive results from them commented “how seriously clinicians take these findings depends on their prior beliefs” and Professor Gene Feder, writing in the BMJ last year, said that “opponents of homeopathy have made it clear that no number of well-designed trials will overcome their prior belief that homeopathy cannot work”. For someone to say that something “cannot work”, they are assuming a position of possessing all knowledge.

Cost effectiveness
The Director of Pharmacy Services gave me these figures taken from around the middle of the study. The total drug costs in the UK is £6.3 billion in 1999 and 80 per cent of this is spent by GPs. I found that fact very interesting. In 1999 a GP spent on average £105 per patient per annum on drugs. One must remember that less than 30 per cent of patients in the UK pay prescription charges: children, the elderly, and various other people are exempt. So, at best, prescription charges contribute very minimally, maybe 10 to 15 per cent to the UK drug costs.

The total drug costs for the five years of the Bristol study were £63,265, a drug cost per consultation of £2.70. Each patient has maybe three or four consultations a year, so the cost of drugs per patient per annum is only about £8.10 to £10.80. Now here’s the very interesting thing: the income from NHS prescription charges for the five years of the study was £44,670. And this is 72 per cent of the drug costs and, because of the relative inexpensive nature of homeopathic medicines, it actually means that patients in the NHS contribute hugely to the cost of the drugs that are used. It becomes even more interesting when you break it down to items prescribed because some patients have more than one prescribed item. During the five years of the study, 47,312 items were prescribed at a cost of £63,265. This gives an average cost per item of £1.34, which compares with the current average cost of an item on an NHS prescription (figure issued by the DoH) of £11.09 – almost ten times as much!

So, will an observational study change the mindset? Let me tell you a salutary tale. In 1553, Admiral Richard Hawkins reported to the Admiralty that, during his years at sea, 10,000 seamen had died of scurvy under his command. He also reported that oranges and lemons cured the condition completely and he presented a number of anecdotal cases to prove the point. He was completely ignored. Then James Lind, the Edinburgh naval physician, wrote a paper in 1753 reporting a controlled trial, where he had given oranges and lemons (or lemon juice I think it was) to half the seamen and there had been no cases of scurvy. I’m not sure it would have passed the Ethical Committee, because the seamen in the non-treated part of the study died! But it was the first ever controlled study. James Lind was ridiculed and ignored.

Ironically in the year after he died, 40 years later, the Admiralty actually equipped a squadron with orange and lemon juice before they went off on a long voyage. Not one single seaman died. This however was still ignored for a further ten years, until finally in 1804 regulations came into force that all seamen would have orange and lemon juice on voyages – 251 years. Perhaps we have some way to go yet!

But we should not be discouraged. Not a bit of it. The call to physicians is still the same one that Dr Blackie always championed: to practise high-quality integrated medical care, providing the best form of treatment that is most appropriate for each individual patient. Sadly there will always be those who take the arrogant stance, who know it all, who think there is nothing more for them to know, and who will always dismiss the existence of anything that doesn’t actually fall within the boundaries of their particular knowledge base. But, as two writers put it in the BMJ in 1995, “absence of evidence is not evidence of absence”. After all, before Sir Isaac Newton’s discovery, were we all floating around on the ceiling? No, of course not. Gravity always existed. It was just outside our particular knowledge base at that time.

So back to where we came in. Homeopathy – is it a waste of time? Well this particular piece of real-world evidence would suggest that it is not. And what about the patients? I don’t think you have to imagine too hard what the 5,000 patients in this study would respond to that particular question, and after all in the final analysis, what matters, as Dr Blackie would have said, is “The Patient Not the Cure”.

This article was adapted from the Blackie Memorial Lecture held Thursday 3 April 2003.

David Spence MB BS FFHom MRCS LRCP DRCOG is chairman of the BHA and Clinical Director of Bristol Homeopathic Hospital.