Well it seems that the more one challenges stupid politicians, the further down the peck order one goes. The latest reply from the Department of Health has been diluted down to the man who answers the phone. Here is my letter which prompted it:
The Earl Howe Parliamentary Under Secretary of State Department of Health Richmond House 79 Whitehall London SW1A 2NS
6th April 2011
Dear Lord Howe
I appreciated the opportunity to ask you about government policy on health care evidence, at the Institute of Clinical Research conference on 21st March. Of course, such a forum does not provide for detailed debate, so please permit me to explain the reasons for my question.
Whereas homeopathy may well have been uppermost in both our minds, the issue of evidence based practice is of course far wider. There remain substantial areas within the NHS where evidence from high quality studies is weak our even absent. For example, physiotherapy is considered mainstream but has little evidence for many of its techniques. My point is that permitting public funding of obviously useless practices such as homeopathy undermines the effort to deliver better outcomes for patients, by encouraging resources to be wasted on treatments that have no value. Your suggestion that such practices will naturally decline seems unsupported by the facts. Two weeks ago I noticed that a new ‘natural childbirth suite’ has been opened in a hospital on the south. It includes the provision of aromatherapy, a thoroughly discredited practice.
To claim that ministers cannot dictate therapeutic decisions to clinicians is simply not true. Various treatments that have been shown to be effective are not funded on the basis of cost. Yet such practices as homeopathy (I cannot call it a treatment as it does not treat anything) must have zero cost-effectiveness, and you insist on continuing to pay for them. What happens when decisions are delegated without clear standards and guidance was demonstrated by the recent GP commissioning pilot, when money was dissipated on practice overheads and alternative medicine.
As you are responsible for quality, then you will know that in any quality system, top management has to set the standards. Science tells us that clinical evidence delivers quality outcomes for patients. This is where the future of the NHS lies, not by translating post-modernist sociology into health care delivery.
I am copying this letter to my MP and to my colleagues at the charity HealthWatch (not the government’s HealthWatch – we were there first, many years ago). Therefore you should not regard it as privileged or confidential.
Finally, let me thank you for spending time at the ICR event, and I hope that you will have time to reply to this letter directly. I and my colleagues have had too many replies from junior ministers, using exactly the same wording every time.
You will see that I had the satisfaction of putting Howe on the spot at the ICR conference, when he gave the usual stuffed shirt political spiel about how wonderful the government is in supporting science. It is not wonderful enough to understand what evidence is. Here is the reply:
Thank you for your letter of ll April to Earl Howe about NHS bodies commissioning complementary therapies. I have been asked to reply. As you may be aware, the House of Commons Science and Technology Committee carried out an examination of the evidence to support the provision of homeopathy on the NHS. The Committee’s report was published on 22 February 2010. Ministers have considered its findings and recommendations and have published a full response.
The Department of Health will not be withdrawing funding for homeopathy on the NHS, nor will the licensing of homeopathic products be stopped. Decisions on the provision and funding of any treatment will remain the responsibility of the NHS locally.
A patient who wants homeopathic treatment on the NHS should speak to his or her her GP. If the GP is satisfied this would be the most appropriate and treatment then, subject to any local commissioning policies, he or she can refer them to a practitioner or one of the NHS homeopathic hospitals.
In deciding whether homeopathy is appropriate for a patient, the treating clinician would be expected to take into account safety, clinical and cost-effectiveness as well as the availability of suitably qualified and regulated practitioners. Neither ministers nor the Department of Health would intervene in such decisions.
I should clarify that ministers do not intervene in therapeutic decisions. The choice of treatments that are available in an area is a matter for local NHS commissioners, and ministers do not override the judgement of clinicians. As you may be aware, the National Institute for Health and Clinical Excellence (NICE) is an independent body which makes decisions on the clinical and cost
effectiveness of products based on thorough assessment of the best available evidence. NICE operates with great transparency and makes exhaustive efforts to involve stakeholders in its appraisal work. It consults widely in the development of guidance, publishes most key documents on its website, and holds its appeal panel hearings in public. NICE also consults stakeholders on the
methods and processes it uses to carry out its work.
Once NICE guidance is published, health professionals, NHS commissioners (and the organisations who employ them) are expected to take guidance fully into account when deciding what treatments should be available. However, NICE guidance does not replace the knowledge and skills of
individual health professionals who treat patients; it is still up to them to make decisions about a particular patient in consultation with the patient. The Department’s response to the Science and Technology Committee report explains the reasons behind its decisions in more detail. You can access the response through the Department’s website: http://www.dh.gov.uk, by typing ‘Government Response to the Science and Technology Committee report’ into the search bar and following the links.
I note that you have presented your views to your local MP, who can lobby the Government on your behalf on this matter if you would like to see changes to current Government policies.
I hope this reply clarifies the Department’s position on the matter.
Customer Service Centre
Perhaps what has rattled me more than anything is not the content, which I largely expected (albeit this version is even worse than before), but that I am not even considered worthy of a rubber stamp from an intellectually challenged junior minister. The message is clear – I am to stop doing this as nobody at the Department of Health is interested. Naturally, I am not going to stop sending letters, but I am now beyond being polite:
Dear Mr Morgan
I am in receipt of your letter of 6th May, which I am sorry to say I found rather insulting. I specifically took issue with earlier correspondence on this matter being met with standardised and meaningless replies, and what do I get? The same standardised and meaningless reply, this time with further illogical statements tacked on. Is this the `Big Society’?
It is demonstrably untrue that ministers do not intervene regarding which treatments are available to patients. NICE guidance has been overruled by ministers on occasions. Let me make crystal clear the matter of cost-effectiveness, which you say clinicians are expected to take into account. There can be no calculation of cost-effectiveness unless effectiveness has been measured. The government has agreed in its response to the Science and Technology Committee report that homeopathy is not effective. Therefore cost-effectiveness must be zero. Presumably it is the Department which expects clinicians to take cost-effectiveness into account. Can the Department therefore not point out to clinicians that this parameter is zero in the case of homeopathy?
The relevance of your words about NICE escapes me, as I did not mention it in my letter. I am well aware of what NICE does, but it has not evaluated any complementary or alternative medicines (CAMs). Indeed the previous government committed to referring CAMs for NICE appraisal, in response to the House of Lords Select Committee report on CAM in 2000. When challenged on this point, the incumbent minister Lord Warner issued a statement claiming that the process had been initiated (I have his letter on file), which was immediately exposed as false. After a whole decade, nothing has been done.
Your letter ignores my central point, which is that homeopathy is simply indicative of a dangerous disregard for evidence. Everything you and successive ministers have said indicates that the Department of Health simply does not care about evidence based practice. How you can consider that your letter “clarifies the Department’s position on the matter” is a total mystery – it is a continuing exercise in obfuscation. I would appreciate being afforded sufficient respect that the points I have made could be answered clearly and directly. Is this too much to ask?
I will probably get the usual “this dialogue is at an end” reply.
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