BHA Response Part 3: NHS funding and provision

In the third of a linked series, the BHA provides detailed comments on the recommendations of the Science & Technology Committee’s “Evidence Check 2: Homeopathy” issued on 22 February 2010.

Part 3: The evidence check: NHS funding and provision (Recommendations 7-17)

7. We conclude that the principle of like-cures-like is theoretically weak. It fails to provide a credible physiological mode of action for homeopathic products. We note that this is the settled view of medical science. (Paragraph 54)

This is not the “settled view of medical science”; the assertion ignores the phenomena of hormesis, rebound effects, paradoxical pharmacology, etc., which are the subjects of a substantial body of research literature.  This literature provides insight into potential modes of action.  It was referenced and briefly summarised inDr Peter Fisher’s written submission, but is largely ignored by this report.

8. We consider the notion that ultra-dilutions can maintain an imprint of substances previously dissolved in them to be scientifically implausible. (Paragraph 61)

There is a growing and convergent body of scientific evidence, from methods including low temperature thermoluminescence, that the homeopathic method of preparation may induce long-lasting structural changes in water.  This evidence was included in Dr Fisher’s submission, but is not mentioned in the report.  The Committee is entitled to its opinion, but it should not ignore the evidence that challenges it.  In any event, a number of homeopathic medicines are diluted to a much lesser extreme, where molecules of the active ingredient undoubtedly remain in solution.

9. Research funding is limited and highly competitive. The Government should continue its policy of funding the highest quality applications for important scientific research determined on the basis of peer review. (Paragraph 63)

We agree, and in this we urge the inclusion of research in homeopathy.  The committee should respect the conclusions of the GO-Science Review of the Department of Health (2008), Annex 1, para 3.16:

“Flagship trials [in homeopathy] should be run in the most promising areas, chosen on plausibility, and patient demand. These should be well planned, including pre-defined agreement on what constitutes a minimally important clinical effect, and adequate resource, so that the results were clear-cut. […] The Health Technology Assessment Programme provided a framework that should be as applicable to research on homeopathy as to any other therapy.”

10. We recommend that the Government Chief Scientific Adviser and Professor Harper, Chief Scientist at the DH, get together to see if they can reach an agreed position on the question of whether there is any merit in research funding being directed towards the claimed modes of action of homeopathy. (Paragraph 64)

We would welcome funding support to reproduce experiments investigating the possible modes of action of homeopathy.

11. In our view, the systematic reviews and meta-analyses conclusively demonstrate that homeopathic products perform no better than placebos. (Paragraph 70)

The BHA does not share the committee’s conclusions from systematic reviews and meta-analyses.  Comprehensive systematic reviews overall are not conclusive either way; the majority have reached the conclusion, qualified by a number of caveats, that homeopathy differs from placebo.

Most importantly, the committee has failed to take into account the 17 systematic reviews that focused on specific medical conditions.  As stated in the BHA’s submission (Ev 37), “Five reviews concluded there was positive evidence for homeopathy (childhood diarrhoea; post-operative ileus; seasonal allergic rhinitis; vertigo); three concluded there was little or no evidence (attention-deficit hyperactivity disorder; delayed-onset muscle soreness; headache and migraine prevention); nine did not offer a clear conclusion either way (anxiety; chronic asthma; dementia; depression; headache and migraine treatment; HIV/AIDS; induction of labour; influenza; osteoarthritis).”

As Dr Robert Mathie, the BHA’s Research Development Adviser, pointed out to the Committee during its hearing on 25 November 2009, the interpretation of the findings of systematic reviews in areas of research that possess small and heterogeneous data sets (such as complementary medicine) varies considerably according to the perspective of the individual reader (Ev 47).  There is no good reason to accept, as final authority, the views of one opinion leader in homeopathy research such as Professor Ernst over those of his peers, such as Dr Mathie or Dr Peter Fisher.

12. We recommend that the Government Chief Scientific Adviser and Professor Harper get together to see if they can reach an agreed position on the question of whether there is any good evidence for the efficacy of homeopathy and whether there is a genuine scientific controversy over the efficacy of homeopathy and publish this. (Paragraph 72)

This is a helpful recommendation.  However, it is very obvious that opinion leaders differ markedly in their interpretation of the research evidence in homeopathy (see under Recommendation 11 above).  The committee has reflected almost exclusively the negative perspective.  Nevertheless, the List of Written Evidence (Ev 1–216 of the report) accounts overall for a more balanced, though still contentious, set of observations and facts.  We therefore recommend that a suitable third-party expert in systematic review – and who has a declared neutral stance as regards homeopathy – be invited to take part in the suggested discussion between the Government Chief Scientific Adviser and Professor Harper.

13. We regret that advocates of homeopathy, including in their submissions to our inquiry, choose to rely on, and promulgate, selective approaches to the treatment of the evidence base as this risks confusing or misleading the public, the media and policy-makers. (Paragraph 73)

The BHA most strongly refutes the allegation that its submission was one of any that offered a selective account of the research evidence in homeopathy.  We have already published a detailed rebuttal of the Committee’s unfounded criticisms.  The BHA’s submission is a well-rounded, factual and balanced summary of the available evidence, and whose key focus is on condition-specific research, including the conclusions from the 17 systematic reviews cited under Recommendation 11 above.  It is regrettable that the Committee chose to disregard this approach and the informative and constructive manner in which it was intended.

As noted above, the Committee’s report unquestioningly accepts as absolute fact the evidence of those who deny the existence of any positive clinical research in homeopathy.  We regret that those detractors of homeopathy, including in their submissions to the Committee’s enquiry, have chosen to rely on, and promulgate, a selectively negative approach to the treatment of the research evidence base.  The BHA does not claim there is currently unequivocal clinical research evidence in favour of homeopathy; the BHA’s submission presented a balanced position citing positive, negative and inconclusive research.  It is ironic and disturbing that the Committee’s allegation is made in the context of a report that omitted to mention the 17 condition-specific systematic reviews or the replicated biological model experiments and systematic reviews of those experimental studies.

14. There has been enough testing of homeopathy and plenty of evidence showing that it is not efficacious. Competition for research funding is fierce and we cannot see how further research on the efficacy of homeopathy is justified in the face of competing priorities. (Paragraph 77)

There is considerable clinical research evidence in homeopathy that is positive (see above).  As our submission made clear, there is also negative and non-conclusive evidence in different clinical diagnoses.  And, in total, there are only 80 medical diagnoses in which RCTs of homeopathy have been carried out (BHA written submission; Ev 39).  We repeat: the committee should respect the conclusions in the annex of the GO-Science Review of the Department of Health (2008), which commended new research in homeopathy within the context of the Health Technology Assessment Programme.

15. It is also unethical to enter patients into trials to answer questions that have been settled already. Given the different position on this important question between the Minister and his Chief Scientist, we recommend that the Government Chief Scientific Adviser, Professor John Beddington, investigate whether ministers are receiving effective advice and publish his own advice on this question. (Paragraph 78)

The BHA vigorously contests the notion that clinical research evidence in homeopathy is in any way “settled”.  On the contrary, we emphasise the need to extend the research to confirm or to refute the currently available evidence in specific medical conditions.  Our submission to the committee also made this clear (Ev 39).  We again highlight the 17 systematic reviews focusing on specific medical conditions, which were not mentioned in the report (see 11 and 13 above).

16. We do not doubt that homeopathy makes some patients feel better. However, patient satisfaction can occur through a placebo effect alone and therefore does not prove the efficacy of homeopathic interventions. (Paragraph 82)

The clinical outcome studies from the NHS homeopathic hospitals, for example, reflect much more than “patient satisfaction”; they illustrate patients’ own reports of changes in their symptoms and well-being over the course of treatment.  They are examples of patient-reported outcome measures (PROMs), which are being used as a matter of increasing importance in the NHS more generally.  None of the homeopathy outcomes studies makes any claims about being able to “prove the efficacy of homeopathic interventions”.

It is the case that patients attending the homeopathic hospitals do also report a very high degree of satisfaction with the quality of care they experience.  That a handful of decision-making MPs in a Westminster committee room deems itself better placed to judge the impact of treatment than the thousands of people who have experienced it first-hand is arrogance in the extreme.

17. We recommend that the Department of Health circulate NHS West Kent’s review of the commissioning of homeopathy to those PCTs with homeopathic hospitals within their areas. It should recommend that they also conduct reviews as a matter of urgency, to determine whether spending money on homeopathy is cost effective in the context of competing priorities. (Paragraph 86)

We find it wholly unacceptable that a parliamentary committee whose remit is science and technology is commenting and making recommendations on local provision of health services.  This recommendation comes without proper review of the evidence provided or, importantly, considering patients, provision of services in primary care and the impact on NHS resources.

In testimony, Dr James Thallon failed to provide detail of West Kent PCT’s review of research evidence.  In fact, the West Kent PCT review was similar to our own approach to the literature (though, in contrast to our review of the entire evidence base, it restricted the analysis to research published during the period 2000 to January 2007).  West Kent PCT examined the research mainly from a condition-specific perspective and, far from endorsing removal of services, the summary conclusion was, “…research about homeopathy for ill health [compared with research in acupuncture for people with some types of chronic pain] is less clear.  There are some positive trends, but there is insufficient evidence to recommend or refute claims of effectiveness or to describe cost-effectiveness.”
Dr Sara Eames, President, Faculty of Homeopathy
Dr Peter Fisher, Director, Royal London Homeopathic Hospital
Dr Robert T Mathie, Research Development Adviser, British Homeopathic Association
Ms Cristal Sumner, Chief Executive, British Homeopathic Association