I have resisted writing a blog for quite a while, mainly because I was searching for a theme. My interest is in critical thinking, science, and scepticism, but there are many such resources on the net and I wanted this to be different. I didn’t want it to be another outlet for railing against the tide of irrational thought that is the hallmark of this age. Such sites are valuable, as we have to stand up and be counted, but I wanted this to be of practical value. So I will try to make this somewhere you can come to find tools that you can use to redress the balance in favour of truth and especially science.
Now I don’t expect to have all the answers. Please contribute your own ideas here. I hope it will become an armamentarium for warriors in the cause of reason.
I’ll start with the item which really kicked me into action. It is a debate in the UK Parliament. For those who don’t know, David Tredinnick is a Member of the lower House (I am using generic terms for the benefit of foreign readers) who never misses an opportunity to plug alternative medicine. His ignorance of science goes without saying, and his speech here in my view misleads the House – a serious offence. I may come back to that, but right now I am more interested in the reply from the government (Tredinnick is in the Opposition). The minister’s reply contains many distortions, bordering on frank untruths, and I am going to answer these here. So read on for the truth. I have pasted the whole speech here, with my annotations italicised.
Ivan Lewis (Parliamentary Under-Secretary, Department of Health)
I congratulate the hon. Member for Bosworth (David Tredinnick) on securing this adjournment debate, and on his passionate advocacy of the case for complementary therapies over many years in this House. Whatever people’s opinions and differences of view and perception, it is impressive when an hon. Member feels so passionately about an individual cause. Clearly, the hon. Gentleman feels that homeopathy makes a massive difference to the quality of people’s lives both in his constituency and up and down the country. I pay genuine tribute to him for the work that he does in making the case.
What is impressive about totally ignoring the evidence? Then there are not many politicians who know what evidence is. I have not forgotten the Butler Report, which bizarrely concluded that Tony Blair didn’t need to verify the evidence on which we were taken to war.
I am also aware that there is a growing interest among patients in complementary therapies generally—for instance, as an adjunct to conventional medicine in palliative care, although I accept that it goes beyond that. Choice is absolutely fundamental to the delivery of a truly patient-centred national health service, and it gives providers the incentive to tailor services to the needs and preferences of patients. In turn, this leads to better outcomes and, over time we hope, a reduction in health inequalities. Primary care trusts are encouraged to provide access to complementary therapies where there is evidence to support the virtues of their use.
The truth is that primary care trusts are now dropping homeopathy like hot bricks because they have started to look at the evidence.
Of course, doctors are accountable for any treatment that they give their patients, and have to satisfy themselves of the safety and clinical and cost-effectiveness of the treatment, as well as the availability of suitably qualified practitioners. They have a range of options for treating different conditions, and they must advise on which treatment or combination of treatments will be most suitable for individual patients. Many GPs now give access to some form of complementary or alternative medicine, but if a doctor decides not to recommend a complementary therapy, it is likely that he or she will have a good reason.We genuinely want people to have free choice about their health care, but we also want to make sure that the choice that they make is an informed one and gives assurance that treatments meet key standards of safety and quality. To achieve this, the Department and the NHS have been ensuring that as much quality information as possible is available and accessible to those who need it.
Not quite right. The NHS Direct website still carries inaccurate and partisan information on CAM.
For example, the Department of Health commissioned the Prince’s Foundation for Integrated Health to produce a patient guide on popular forms of CAM, which was published in 2005. It is encouraging to know that several thousand copies have been downloaded from the website and multiple copies have been ordered by intermediary organisations such as hospices.
This is an outrageous distortion of the truth. The published Guide contained no information whatever on evidence of efficacy. In fact advice on this point from Professor Edzard Ernst was rejected, and all references to evidence removed from the draft. The DoH insisted that evidence of efficacy was not a condition of the grant to the Foundation, but my Freedom of Information Act request revealed that it was. The DoH refused to account for the anomaly.
NHS Direct Online and the national electronic library for health are also authoritative sources of advice on all health topics. NHS Direct already includes some material on complementary and alternative therapies and in future the national electronic library for health will also have a separate section dedicated to research on such therapies. In June last year NHS Choices was launched—a new online health information service, which also includes information on homeopathy.
As noted above, NHS Direct carries misleading information, and NHS Choices is little better. Here is material entitled “What to ask” about homeopathy. Note that, although one question is “Is it effective”, this is far too simplistic and the question really should be `What evidence is there?”. But much more damning is the page with `Useful Links’. Is there anything here about real evidence? No, these are all entirely partisan sites with a vested interest in selling homeopathy. These are not by any stretch of the imagination “authoritative sources”. Why do they not direct users to objective evidence sites such as FACT, Cochrane or Bandolier? Of course, if they really wanted to be balanced and fair they would have included sceptical sites, but I have long since given up such a hope.
Of course I hear the dissent from those who oppose the NHS commissioning complementary medicine. Most, if not all, of that opposition is focused on treatments for which, in some people’s view, there is a lack of evidence of effectiveness. We know that there are strong views, which are sometimes articulated in the House. That is why the Government are investing in developing the evidence base for complementary therapies. We are supporting the research capacity for CAM through the £3.4 million CAM personal award scheme. The scheme was launched following publication of a House of Lords Select Committee report on CAM about eight years ago. As a result of two calls, we have successfully created a cohort of 18 CAM researchers at doctoral and post-doctoral level; as the hon. Gentleman will be aware, they are working on a broad range of research issues.
This is perhaps the most appalling piece of obfuscation in the whole speech. Firstly, there is no lack of published research on homeopathy. Over a dozen meta-analyses and systematic reviews have concluded that homeopathy is no better than placebo. The evidence base is not there, not because homeopathy hasn’t been tested, but because it has and it has failed repeatedly. Not only that, but many homeopaths claim it works in children, who are less susceptible to the placebo effect. Sorry, not true either – here’s a systematic review which nails that one.
And how many of this `broad range of research issues’ have anything to do with efficacy? The truth is that the first round of awards (£1.7 million) funded seven research projects, of which only one was a randomised controlled trial (of acupuncture). All the rest were studies of a sociological nature (eg altitudes to CAM) or uncontrolled surveys. Significantly, a majority on the grant awarding committee comprised CAM practitioners. One has to wonder (or perhaps not) why RCTs were so studiously avoided.
The National Co-ordinating Centre for Research Capacity Development is responsible for the personal award scheme. It also funds the CAM evidence online database, which is the result of collaboration between the Research Council for Complementary Medicine and the University of Westminster’s school of integrated health. It involves a detailed review and critical appraisal of the published research on specific complementary therapies, focusing on their use for NHS priority issues, such as cancer, mental ill health, heart disease, stroke, and chronic conditions.
The University of Westminster and its Research Council for Complementary Medicine are of course very well known for taking a partisan stance on CAM. Why was the UK’s only medical school with a chair in CAM not invited to do this? Clearly because Edzard Ernst and his team apply rigorous science to the subject, having published well over 400 high quality papers, including RCTs, over the last 10 years.
We are actively addressing the important issue of appropriate regulation of the treatments and their practitioners. At present only two CAM professions are subject to statutory regulation in our country: chiropractic and osteopathy. Our first priority is to decide whether to put in place statutory regulation for herbal medicine, traditional Chinese medicine and acupuncture, which carry significant risk because they involve skin piercing and/or the ingestion of potentially harmful substances.
Er….aren’t you forgetting that chiropractors are a significant cause of strokes? And this is with regulation!
Proposals for regulation of herbal medicine, traditional Chinese medicine and acupuncture were made in a report by the House of Lords Select Committee on Science and Technology in 2000. The Department of Health consulted on proposals in March 2004 and published an analysis of the results in February 2005. As a result, a steering group was established in June 2006 to recommend whether and how those professions should be statutorily regulated. The group, chaired by Professor Mike Pittilo of Robert Gordon University, has completed its work, as the hon. Gentleman will know. Its report will be submitted to Ministers shortly, and a decision will then be taken about whether legislation should be brought before the House, and if so, how soon. We expect unregulated CAM professions to develop their own unified systems of voluntary self-regulation, and to support that process we have commissioned and funded the Prince’s Foundation for Integrated Health to develop voluntary self-regulation among a range of professions, including homoeopathy. The result of the work is a voluntary regulator called the complementary and natural healthcare council, which, as the hon. Gentleman will be aware, will be up and running from April.
I have to restrain myself here. There is a great deal that needs to be said about this, but it warrants a whole story of its own. I will at this stage just say that the outcomes of this spending are confined to a set of frankly laughable National Occupational Standards in just about every flavour of pseudo-medicine you care to imagine (here’s an example), with nary a word about ensuring that it works, and a regulation scheme that is a clone of the GMC one.
In 2005, the Medicines and Healthcare Products Regulatory Agency undertook a public consultation on proposals that would enable companies to market their products with indications. As the hon. Gentleman will know, indications are descriptions of diseases or conditions for which the product is intended to be used, but we are talking about minor, self-limiting conditions only—the types of conditions that people normally self-treat with over-the-counter products. Following widespread support for the proposals, the scheme was introduced in the United Kingdom in September 2006. Companies marketing homoeopathic medicinal products have the option of obtaining a full marketing authorisation for each product, provided they satisfy the requirements for demonstrating safety and efficacy set out in directive 2001/83/EC. However, at present no homoeopathic products are licensed with a marketing authorisation because of the difficulty of demonstrating efficacy under the rigorous conditions of controlled clinical trials.
At this point I start to wonder where in the queue some politicians were when brain cells were being handed out. Why does he think homeopathy has this difficulty? Controlled experiments are what we use in all branches of science. If they don’t show anything for homeopathy, why is it so difficult to draw a conclusion? The new licensing scheme is by now well established as an appalling scandal, in which some very senior scientists were involved. The whole thing was carefully slid onto the statute book during the summer recess, to avoid the risk of debate, with the express purpose (admitted by the MHRA) of placating the homeopathy companies. The minister talks about minor self-limiting diseases – does he include among these malaria and AIDS, for which Tredinnick reports amazing results? Why does he choose to ignore such dangerous claims?
The hon. Gentleman raised a number of issues to do with the future of specific services, and he referred to several hospitals. There is a constant tension in debate inside and outside the House about the balance between national command and control and devolution to local decision makers—the local people and organisations to whom we give the responsibility of making the best decisions for local communities.
The fascinating thing, as I have said in previous debates in the House, is that on the whole, politicians of all parties are united around the notion of maximum devolution and localism, until they find a decision that is made in their locality that they do not like very much. Then, the same politicians advocate national intervention and command and control from Westminster and Whitehall. That perpetual tension is evident in the House.
In this case we must maintain the principle that, based on patient choice, demand and a needs assessment of their local population, local commissioners are best placed to make commissioning decisions on behalf of their local populations. It is extremely important that we retain the integrity and credibility of that process if we are to move towards a world class commissioning system in health care.
In other words, he washes his hands of the whole thing. He is not going to face head on, or even side on, any of the difficult issues. Why are we paying these people? Why do we elect them?
Well, I broke my first rule and ranted on about irrational thinking. I can’t promise to be a good boy henceforth, because heaven knows there’s an inexhaustible supply of extremely annoying material. But do chip in and encourage me to post some more meaty stuff soon.