Warning: fopen(/home/dcscience/public_html/wp-content/wflogs/rules.php): failed to open stream: No such file or directory in /home/dcscience/public_html/wp-content/plugins/wordfence/vendor/wordfence/wf-waf/src/lib/waf.php on line 325

Warning: flock() expects parameter 1 to be resource, boolean given in /home/dcscience/public_html/wp-content/plugins/wordfence/vendor/wordfence/wf-waf/src/lib/waf.php on line 326

Warning: include(/home/dcscience/public_html/wp-content/wflogs/rules.php): failed to open stream: No such file or directory in /home/dcscience/public_html/wp-content/plugins/wordfence/vendor/wordfence/wf-waf/src/lib/waf.php on line 328

Warning: include(): Failed opening '/home/dcscience/public_html/wp-content/wflogs/rules.php' for inclusion (include_path='.:/usr/share/php:/usr/share/pear') in /home/dcscience/public_html/wp-content/plugins/wordfence/vendor/wordfence/wf-waf/src/lib/waf.php on line 328

Warning: flock() expects parameter 1 to be resource, boolean given in /home/dcscience/public_html/wp-content/plugins/wordfence/vendor/wordfence/wf-waf/src/lib/waf.php on line 329

Warning: fclose() expects parameter 1 to be resource, boolean given in /home/dcscience/public_html/wp-content/plugins/wordfence/vendor/wordfence/wf-waf/src/lib/waf.php on line 330
Department of Health – DC's Improbable Science

LOB-vs
Download Lectures on Biostatistics (1971).
Corrected and searchable version of Google books edition

Download review of Lectures on Biostatistics (THES, 1973).

Latest Tweets
Categories
Archives

Department of Health

This article has appeared, in nearly identical form, on the UK Conversation . You can leave comments there or here.


charles X2
The modern major-general

A constitutional monarch is purely ceremonial and plays no part in politics.  Well actually in the UK it isn’t quite as simple as that. The first problem is that we have no constitution.  Things haven’t changed much since the 19th century when Walter Bagehot said "the Sovereign has, under a constitutional monarchy… three rights—the right to be consulted, the right to encourage, the right to warn."

These are not inconsiderable powers in a country which is meant to be run by elected representatives.  But nobody knows how these powers are used: it is all done in secret.  Well, almost all. Charles, Prince of Wales, has been unusually public in expressing his views.  He told a conference at St James’s Palace “I was accused once of being the enemy of the Enlightenment” “I felt proud of that.”  That’s a remarkable point of view for someone who, if he succeeds, will become the patron of that product of the age of enlightenment, the Royal Society.

I have no doubt that Prince Charles means well.  He can’t be blamed for his lack of education.  But his views on medicine date from a few centuries ago, and he has lost no opportunity to exploit his privileged position to proclaim them. 

Euphemisms for quackery

He set up the Prince’s Foundation for Integrated Health (PFIH) to promote his views. ( “Integrated”, in this context, is, of course, just the latest euphemism for “alternative” or “quack”.)   When the Foundation collapsed because of a financial scandal in 2010, it was replaced by the “College of Medicine”.  The name changed, but not the people behind it.  Initially this phoenix was to be named the “College of Integrated Health”, but by this time the prince’s views on medicine had become sufficiently discredited that the word “integrated” was quickly dropped.  This might be thought less than frank, but it is just employment of the classic bait and switch technique, beloved by used car salesmen.

His views were well publicised in a PFIH publication, “Complementary Healthcare: a Guide for Patients”. That volume either omitted or misrepresented the evidence about the one question that matters most to patients – does the treatment work or not?  It caused me to write a much shorter, but more accurate, version, the Patients’ Guide to Magic Medicine.  The PFIH guide was arguably a danger to public health. When, very properly, it was criticised by Edzard Ernst, a letter was sent from from the prince’s private secretary to Ernst’s vice-chancellor, Steve Smith.  Instead of defending Ernst’s public spirited action, Smith instituted disciplinary proceedings against Ernst that lasted for a year.  The prince had intervened directly in the affairs of the university.  Steve Smith was rewarded with a knighthood in 2011.

None of this criticism has dimmed the prince’s enthusiasm for barmy medical ideas.  He is well known to write many letters to government ministers to try to persuade them to adopt his ideas in a whole range of areas.  In July 2013, the Minister of Health, Jeremy Hunt, visited the prince at Clarence House.  The visit was reported to be to persuade the minister to defend homeopathy, though it was more likely to have been to press the case to confer a government stamp of approval on herbalists and traditional Chinese Medicine practitioners by giving them statutory regulation.  This is a matter that was recently raised again in parliament by Charles’ greatest ally, David Tredinnick MP (Con, Bosworth) who got into trouble for charging astrology software to expenses.  We shall never know what pressure was applied.  A ruling of the Information Commissioner judged, reasonably enough, that there was public interest in knowing what influences were being brought to bear on public policy.  But the Attorney General overruled the judgement on the grounds that “Disclosure of the correspondence could damage The Prince of Wales’ ability to perform his duties when he becomes King.”  That, of course, is exactly what we are worried about.

Influence on politics

The prince’s influence seems to be big in the Department of Health (DH).  He was given £37,000 of taxpayers’ money to produce his guide, and an astonishing £900,000 to prepare the ground for the setting up of the hapless self-regulator, the Complementary and Natural Healthcare Council (CNHC, also known as Ofquack).  When NHS Choices (itself set up by DH to assess evidence) tried to rewrite its web page about that most discredited of all forms of quackery, homeopathy, officials in DH referred the new advice to Michael Dixon, the medical director of the Prince’s Foundation and, were it not for the Freedom of Information act, the DH would have caused inaccurate information to be provided. The DH has a chief medical officer and two scientific advisors, but prefers to take the advice of the Prince of Wales.

The Prince of Wales’ business, Duchy Originals, has been condemned by the Daily Mail, (of all places) for selling unhealthy foods. And when his business branched into selling quack “detox” and herbal nonsense he found himself censured by both the MHRA and the Advertising Standards Authority (ASA) for making unjustifiable medical claims for these products.

Ainsworth’s homeopathic pharmacy is endorsed by both Prince Charles and the Queen: it has two Royal Warrants.  They sell “homeopathic vaccines” for meningitis, measles, rubella and whooping cough. These “vaccines” contain nothing whatsoever so they are obviously a real danger to public health.  Despite the fact that Ainsworth’s had already been censured by the ASA in 2011 for selling similar products, Ainsworth’s continued to recommend them with a “casual disregard for the law”. The regulator (the MHRA) failed to step in to stop them until it was eventually stirred into action by a young BBC reporter, Sam Smith, made a programme for BBC South West.  Then, at last, the somnolent regulator was stirred into action.  The MHRA “told Ainsworths to stop advertising a number of products” (but apparently not to stop making them or selling them).  They still sell Polonium metal 30C and Swine Meningitis 36C, and a booklet that recommends homeopathic “vaccination”. Ainsworth’s sales are no doubt helped by the Royal Warrants.  The consequence is that people may die of meningitis. In 2011, the MHRA Chief Executive Professor Kent Woods, was knighted.

It runs in the family

The Prince of Wales is not the only member of the royal family to be obsessed with bizarre forms of medicine. The first homeopath to the British royal family, Frederick Quin, was a son of the Duchess of Devonshire (1765-1824).  Queen Mary (1865-1953), wife of King George V, headed the fundraising efforts to move and expand the London Homeopathic Hospital. 

King George VI was so enthusiastic that in 1948 conferred the royal title on the London Homeopathic Hospital.  The Queen Mother loved homeopathy too (there is no way to tell whether this contributed to her need for a colostomy in the 1960s).

The present Queen’s homeopathic physician is Peter Fisher, who is medical director of what, until recently was called the Royal London Homeopathic Hospital (RLHH).  In 2010 that hospital was rebranded as the Royal London Hospital for Integrated Medicine (RLHIM) in another unsubtle bait and switch move. 

The RLHIM is a great embarrassment to the otherwise excellent UCLH Trust.  It has been repeatedly condemned by the Advertising Standards Authority for making false claims.  As a consequence, it has been forced to withdraw all of its patient information.

The patron of the RLHIM is the Queen, not the Prince of Wales.  It is hard to imagine that this anachronistic institution would still exist if it were not for the influence, spoken or unspoken, of the Queen.  Needless to say we will never be told.

Queen Fisher
The Queen and Peter Fisher
Observer 8 April 2007

The attorney general, while trying to justify the secrecy of Charles’ letters, said

“It is a matter of the highest importance within our constitutional framework that the Monarch is a politically neutral figure”.

Questions about health policy are undoubtedly political, and the highly partisan interventions of the prince in the political process make his behaviour unconstitutional. They endanger the monarchy itself.  Whether that matters depends on how much you value tradition and how much you value the tourist business generated by the Gilbert & Sullivan flummery at which royals excel. 

The least that one can ask of the royal family is that they should not endanger the health of the nation.  If I wanted to know the winner of the 2.30 at Ascot, I’d ask a royal. For any question concerning science or medicine I’d ask someone with more education.


Here is some more interesting reading

Michael Baum’s “An open letter to the Prince of Wales: with respect, your highness, you’ve got it wrong”

Gerald Weissman’s essay Homeopathy: Holmes, Hogwarts, and the Prince of Wales.

Channel 4 TV documentary HRH “meddling in politics”
 

Observer April 2007 "Royals’ favoured hospital at risk as homeopathy backlash gathers pace. The Queen loves it. But alternative medicine centre’s future looks uncertain as more NHS trusts axe funding"

Follow-up

It’s hard to know what to make of  David Tredinnick MP (Cons, Bosworth). He is certainly an extreme example of the scientific ignorance of our parliamentary representatives, but he isn’t alone in that. Our present minister of Education, Michael Gove, memorably referred to Newton’s Laws of Thermodynamics, blissfully unaware that thermodynamics was a 19th century development. And our present Minister of Health seems to think that magic water cures diseases.

But Mr Treddinick breaks every record for anti-scientific nonsense. That, no doubt, is why he was upset by the recent revision of come NHS Choices web pages, so that they now give a good account of the evidence (that’s their job, of course). They did that despite two years of obstruction by the Department of Health. which seemed to think that it was appropriate to take advice from Michael Dixon of the Prince’s Foundation for integrated Health. That shocking example of policy based evidence was revealed on this blog, and caused something of a stir.

Treddinick’s latest letter

A copy of a letter from Mr Tredinnick to the Minister of Health, Jeremy Hunt, has some into my possession by a tortuous route [download the letter]. It’s a corker. Here are a few quotations.

"1. UKIP moving onto our ground
Attached is an extract from a recent UKIP policy statement. The position which UKIP has taken is one with which most of our Daily Mail reading supporters of complementary medicine would agree."

It seems that Treddinick’s preferred authority on medicine is now Nigel Farage, leader of the UK’s far right party. UKIP’s policy on health is appended to the letter, and it’s as barmy as most of the other things they say.

"2. Herbal Medicine
. . .there is very real concern that the Government will not regulate Herbal Medicine and Traditional Chinese Medicine. The current situation is unacceptable, because herbal practitioners need regulation and cannot function as herbal therapists, nor can they cannot obtain stocks of their herbal remedies, without it.

This refers to a saga that has been running for at least 10 years. Herbalists are desperate to get a government stamp of approval by getting statutory regulation, much like real doctors have, despite the fact that they make money by selling sick people "an unknown dose of an ill-defined drug, of unknown effectiveness and unknown safety" (as quoted recently in the House of Lords).

Even  the US National Center for Complementary and Alternative Medicine (NCCAM) doesn’t claim that a single herbal treatment is useful. The saga of herbal regulation is long and tedious. The short version is that a very bad report, The Pittilo report, recommended regulation of herbalists. After years of prevarication, Andrew Lansley ignored the impartial scientific advice and yielded to the pressure from the herbal industry to accept the Pittilo report. But still nothing has happened.

Could it be that even Jeremy Hunt realises, deep down, that the regulation of nonsense is a nonsense that would harm the public?

We can only hope that a letter from Mr Tredinnick is the kiss of death. Perhaps his continuous pestering will only reinforce the doubts that seem to exist at the Department of Health.

Then Tredinnick returns (yawn) to his obsession with magic water. He vents his rage at the now excellent NHS Choices page on homeopathy.

3. Homeopathy

"Recently this wording has been removed and instead a comment by the Chief Medical Officer that homeopathy is placebo inserted in its place, as well as links to external organisations which campaign against homeopathy. For instance, there is a link to the Sense About Science website, and Caroline Finucane, who is Editor of new content at NHS Choices, also writes for the Sense About Science website. This is an organisation which has no expertise in homeopathy and traces its roots back to the ultra-left Revolutionary Communist Party (RCP)."

"I respectfully suggest that the original wording be reinstated and these links to external organisations be removed or changed to ensure a balanced view.".

So it seems that he prefers the medical views of Nigel Farage and the Prince of Wales to those of the Chief Medical Officer and the government’s chief scientist. Disgracefully, Tredinnick picks out one particular employee of NHS Choices among many, and one who does an excellent job. And he raises the hoary old myth that Sense About Science is a communist organisation. Odd, since others accuse it of being neo-libertarian. The actual history is here. The organisation that is a bit too libertarian for my taste is Spiked Online. I haven’t agreed with every word that Sense about Science has printed, but they have a totally honest belief in evidence.

To drag in the name of one person out of many, and to justify it by a false history shows, once again, how very venomous and vindictive the advocates of delusional medicine can be when they feel cornered.

A bit more information about Mr Treddinick

This is what the BBC News profile says about him.

David Tredinnick is an old style Conservative MP, being an Eton-educated former Guards officer, who has sat in the Commons since 1987.

However, his ambition for high office was thwarted by his role in one of the sleaze stories which helped to sink the Major government. He accepted £1,000 from an undercover reporter to ask parliamentary questions about a fictitious drug. He was obliged to resign from his role as a PPS and was suspended from the Commons for 20 sitting days. He has not sat on the frontbench since.

He is an orthodox Conservative loyalist, though he is more supportive of the European Union than many of his colleagues.

He has, however, carved himself a niche as the Commons’ most enthusiastic supporter of complementary medicine. He has wearied successive health secretaries with his persistent advocacy of any and all homeopathic remedies. He has also supported their use in prisons and even suggested them as an aid in alleviating the foot and mouth crisis.

Tredinnick has also asserted that he was aware of a psychiatric hospital that doubled its staff at full moon (this is an old urban myth, and is, of course, quite untrue).

His advocacy of homeopathic borax as a way to control the 2001 epidemic of foot and mouth diease can be read here. Luckily it was ignored by the government. I hope his latest letter will be treated similarly.

Picture of David Tredinnick MP from the Conservative Party

tredinnick

Follow-up

Jump to follow-up

“In causing NHS Choices to publish content that is less than completely frank about the evidence on homeopathy, the DH have compromised the editorial standards of a website that they themselves established”. . . . . . they have failed the general public, by putting special interests, politics, and the path of least resistance (as they saw it) before the truth about health and healthcare.”

David Mattin, lately of NHS Choices

 

NHS Choices is usually a good source of information for the public. But there is one exception: the information they provide about alternative medicine is poor. A Freedom of Information Act request has revealed that the attempt of NHS Choices to rewrite their pages more accurately was censored by the Department of Health in conjunction with the late Prince’s Foundation for Integrated Health. The Department of Health (DH) has misled the public.

The earliest version of the homeopathy information page recorded by the Wayback Machine was November 12 2007. It was still there on December 5 2010. The comments were mostly critical. One said, quite correctly,

I find it most regrettable that the way NHS has covered this subject is to give uncritical voice to the claims of homoeopathy without giving readers the information they need to evaluate those claims. To refer readers to the websites of the British Homeopathy Association is like settling the question of the shape of planet by a reference to the website of the Flat Earth Society

 

There were a lot of complaints, and to the credit of NHS Choices, the page vanished. Throughout 2011, and up to October 2012 the information page on homeopathy read

Introduction

Content on homeopathy has been removed from the website pending a review by the Department of Health policy team responsible for complementary and alternative medicines.

Homeopathy is not part of mainstream medicine. Instead it is defined as a complementary or alternative medicine. If you are considering using homeopathy, talk to your GP first.

For more information about homeopathy see the House of Commons Science and Technology Committee report on homeopathy published on 8 February 2010 and the Department of Health response to that report published in July 2010 (PDF, 69KB).

 

Then, at the end of 2012, the page reappeared. It was a bit better than the original, but not much. Many of the comments criticise the misleading nature of the information (as well as the usual “it worked for me” comments). The “useful links” still has six links to flat-earth organisations like the Society of Homeopaths, and only one to a sensible source, the excellent pamphlet from Sense about Science. They do link at the end to the 2010 Science and Technology Committee Report: Evidence Check 2: Homeopathy (PDF, 1.61Mb), and to the Government Response to the Science and Technology Committee Report, Evidence Check 2: Homeopathy (PDF, 69kb) but no comment is made on the findings.

Policy-based evidence

I wondered why the NHS Choices page, after an absence of almost two years, had returned in such an unsatisfactory form. So I asked them. After a reminder, I was told that my queries were being dealt with not by NHS Choices, but had been referred to Dr Sunjai Gupta “the DH official with responsibility for this area”. Dr Sunjai Gupta OBE is Deputy Director of Public Health Strategy and Social Marketing, Department of Health.

Dr Gupta is not obviously sympathetic to woo. It’s hard to tell since he doesn’t seem to have published much. But one is not reassured by an article that he wrote for the Journal of Holistic Healthcare. It appears straight after an article by fantasy herbalist, Simon Mills.

Despite assurances that I’d hear from Dr Gupta shortly, nothing happened. So I sent a request for the correspondence under the Freedom of Information Act (2000). Although the request was addressed to NHS Choices, a public body, strenuous efforts were made to divert it to the Department of Health. These were resisted. Nevertheless when, after a long delay, the material arrived, it came not from NHS Choices, but from DH, who had evidently vetted it,. The emails were rather shocking [download all].

A mail dated 1 December 2009 said

nhs1

This is the most direct statement I’ve seen that, in the Department of Health, policy dictates evidence. NHS Choices is meant to provide evidence, but what they say has to be checked by DH to make sure they “don’t clash with any policy messages”.

The re-written page

The original version of the re-written page was sent to me by David Mattin, who worked for NHS Choices until September 2012. You can download the whole draft here. It is an enormous improvement on the original page. For example, it says

Does it work?
Many independent experts would respond to this question ‘no, homeopathy does not work’

There is no good quality clinical evidence to show that homeopathy is more successful than placebo in the treatment of any type of condition.
A placebo is the unusual but well-documented psychological effect that sometimes occurs when a person is given a ‘dummy’ medication, such as a sugar pill. They feel better after taking the pill because they think that they are being given real medication.

Furthermore, if the principles of homeopath were true it would violate all the existing theories of science that we make use of today; not just our theory of medicine, but also chemistry, biology and physics.

 

This original draft was sent to Mattin on 29 January 2010. After editing it for length Mattin sent it to DH for approval. Over the next two years, DH removed much of the accurate content.  Mattin’s own comments on this evisceration are reproduced below.

The DH emails

All the names have been redacted. Needless to say, nobody is willing to take responsibility. But the number of people who support magic medicine is really quite small so the main players were easy to identify.

During the nearly 2 year absence of the homeopathy page, dozens of changes were made by DH. It seems that the policy message with which the NHS Choices draft failed to comply were those of the Prince’s Foundation for Integrated Health, and its successor (after April 2010), the College of Integrated Health, now known as the College of Medicine.

NHS Choices sought advice about their redrafted pages from the right person, Sir Iain Chalmers, one of the founders of the Cochrane Collaboration. On 3 Nov 2009, Chalmers advised

  The most reliable source in the country - and one of the most reliable in the world - is Professor Edzard Ernst, professor of Complementary Medicine at the Peninsular Medical School,

 

Ernst returned his suggestions in July 2010, but it seems that few of them survived the subsequent 18 months of revisions by DH.

On 2 December 2009, a mail from the NHS headquarters (Quarry House, Leeds) was sent to NHS Choices

nhs2

This makes it perfectly clear that DH regards the Prince’s Foundation, and the equally flaky Complementary and Natural Healthcare Council (CNHC: known on the web as Ofquack) as appropriate guides for public health policy. The fact of the matter is that regulation of magic medicine by the government has been a total disaster, because, it seems, DH regards the Prince of Wales as a reliable source.

On 29 December 2009, the Prince’s Foundation went on the attack.

nhs6

On 10th January 2010, two more letters were sent to DH by the Prince’s Foundation. At 13.48 they wrote

nhs4

And at 22.14 on the same day, it was followed up with

nhs5

The references to Devon and to Thought Field Therapy, make it very obvious that these letters were written by Dr Michael Dixon OBE, who was medical director of the Prince’s Foundation, and who is now a director of the “College of Medicine”. And the object of Dixon’s bile is obviously Edzard Ernst (the quotation is from his book, Trick or Treatment).

I find it fascinating to see just how venomous quacks become when the evidence contradicts their views. The cuddly “holistic” veneer quickly vanishes.

It gets worse. On 21 January 2010, a mail from NHS Choices to DH said

nhs3

The only person in the country who fits this description is the (in)famous George Lewith. It is simply mind-boggling that DH regards him as an appropriate person to advise on anything.

After that, NHS Choices kept asking DH to sign off the documents, and changes continued to be made. Almost two years later, DH were still stalling.

nhs7

The admission that “We are a bit short of doctors within DH these days” is interesting.

A bit short of anyone capable of critical thinking would be more accurate.

The most interesting document that I got from DH was an intermediate draft of the rewritten page on homeopathy (undated). Download the document. Here are a couple of extracts.

It’s a story of two years of meddling and procrastination. The end result misinforms the public.

nhs8

Right at the start, the NHS Choices draft says, reasonably enough

A House of Commons Science and Technology Committee report said that homeopathic remedies perform no better than placebos and that the principles on which homeopathv is based are “scientifically implausible”.

But a comment, added apparently by DH, says

Can we remove this statement? This report is really quite contentious and we may well be subject to quite a lot of challenge from the Homeopathic community if published.

What on earth? The DH seems to think that that its job is not to present the evidence, but to avoid challenges from the homeopathic community! And true enough, this piece is missing from the final version.

A bit later, the NHS Choices draft was censored again

nhs9

“A 2010 Science and Technology Committee report said that scientific tests had shown that homeopathic treatments don’t work”

But again this doesn’t appear in the final version. The comment, apparently from DH, says

“The DH response to this report (point 24) doesn’t support this statement though”

That’s a gross distortion of point 24, which actually concludes

“The Government Chief Scientific Adviser cannot envisage scientifically credible proposals for funding for research into homeopathy in the future”

NHS Choices was not happy with the result

Shortly before the revised page was published, Paul Nuki, Editor in Chief of NHS Choicea, sent an email to DH.

Date: 7th September 2011

Time: 3:33:42 pm

Hi

I’ve been through the CAM articles and asked that we publish them asap as requested.
XYZ has asked that we get a couple of points checked ….

For the record, we will be publishing these pieces outside of the normal editorial process. Although originally signed off by a suitably qualified clinician, the time lapse and policy changes have been so substantial as to render that null and void. We also don’t have a formal
written policy sign off from XYZ and you should be aware that the process followed is unlikely to satisfy the of the Information Standard were the file to be audited.

 

It doesn’t need much reading between the lines to see that he was unhappy with the result. It will be interesting to see whether the Information Standard people at the Royal Society for Public Health do anything about it.

The Department of Health has not just ignored evidence but actively opposed it.

That’s the only possible conclusion from the documents that I was sent. And it’s pretty shocking that the DH has preferred advice from the Prince’s Foundation and its handful of acolytes (in particular Michael Dixon and George Lewith) to the findings of the Science and Technology Select Committee and the views of the Chief Scientific Advisor.

In January this year, the Chief medical Officer, Dame Sally Davies, said, in a rare outburst of candour

‘I’m very concerned when homeopathic practitioners try to peddle this way of life to prevent malaria or other infectious disease,” she said.

“I am perpetually surprised that homeopathy is available on the NHS.”

Dame Sally, who is England’s most senior doctor, concluded by remarking that homeopathy “is rubbish”.

Davies

 

So one part of DH is working to contradict another part. the Chief Medical Officer. Perhaps Sally Davies should have a word with Dr Gupta.

This all predates the advent of Jeremy Hunt (and known defender of homeopathy) as health minister. But the sympathies of some DH people are made obvious by the presence on the DH web site of an article “Personal health budgets: A new way of accessing complementary therapies?”. This astonishing piece confirms the worst fears that quacks will see personal health budgets as a commercial opportunity to peddle their wares. The article is by Jim Rogers of Lincoln University. What his paper does not mention is Rogers’ conflict of interest. He’s a homeopath, and he has a paper in the International Journal of High Dilution Research (yes, there is a journal for every form of make-believe). You can download a reprint of this paper. It advocates more research into homeopathic provings, something that even George Lewith seems to have given up on.

It’s about time that the DH started to listen to the Chief Medical Officer. As it is, some people at DH seem to prefer the advice of the Prince’s Foundation, and to actively suppress employees who prefer evidence to anecdote.

One thing is clear. The DH is an unholy mess. Parts of it are intent on producing policy-based evidence.

Comment by David Mattin, who edited the first draft for NHS Choices

David Mattin left NHS Choices in September, 2012. He edited the new version and lived through the two years of wrangling with DH during which much of the best content was eviscerated. He sent me this statement about the affair.

As an editor at NHS Choices, I viewed it as my job to present evidence-based information to the public. The article we prepared on homeopathy stayed true to that central purpose: it made clear to readers that there is no good quality evidence that homeopathy is an effective treatment for any health condition, and also presented the broad scientific consensus that the supposed method of action of homeopathy is implausible.
What followed was a two year story of delay, and eventual suppression, of that article. My strong impression was of DH civil servants who lacked the courage, and, frankly, the energy to stand up to the criticism from special interest groups that they anticipated would arise because of the article; and that did indeed arise when a draft of the article and other draft content on complementary and alternative medicines fell into the hands of the Prince’s Foundation and other CAM groups.
The attitude of DH civil servants, broadly, was simply to tell us ‘we can’t say this about homeopathy, people will complain’. They seemed to have no interest in making an appraisal of the evidence on homeopathy themselves to see if what we were saying was actually true or not. We repeatedly pushed back with the message: ‘some people may very well complain, but if what we are saying about the evidence base is true – and it is – then we must simply weather those complaints, and stand by our content. Our duty is to supply our readers with the best information, not to please the homeopathy community.’ But these arguments were disregarded. The DH civil servants were almost entirely concerned with the politics of the situation – that is, the politics as they saw them – and the possibility that this article may create new work for them, and very little concerned with the evidence itself, or the presentation of this evidence to the public.

The whole episode is an insight into the way special interest groups can influence the workings of government and the public sector simply by making a lot of noise, and having a few powerful friends.

In causing NHS Choices to publish content that is less than completely frank about the evidence on homeopathy, the DH have compromised the editorial standards of a website that they themselves established, and that they fund. They have sold out the NHS Choices editorial team, who work tirelessly to fulfil their remit. And, most seriously, they have failed the general public, by putting special interests, politics, and the path of least resistance (as they saw it) before the truth about health and healthcare.

 

Follow-up

13 February 2013 The Guardian version of this story, written by Sarah Boseley, is Prince’s charity lobbied government to water down homeopathy criticism. It’s fine as far as it goes but it doesn’t name any names. There are some good comments though.

14 February 2013. The printed Guardian gave the story full 5 column-width coverage. [download print version]

Guardian 14 Feb

And news has reached the USA: there’s an account of the affair on the Neurologica blog: Politics trumping science at the NHS.

On 14 February, the Guardian version was Editor’s Choice by lunchtime, and the Guardian web version already had 414 comments, mostly sensible (though this blog got far more referrals from twitter than from the Guardian)

ed choice

 

And news has reached the USA: there’s an account of the affair on the Neurologica blog: Politics trumping science at the NHS.

15 February 2013. The Daily Mail had very fair coverage of the story.

Mail 15 Feb

The Guardian closed the comments on the story when it had got 642 comments, most of them very sensible. And this page got almost 6000 hits in 24 hours. The majority of the referrals came from Twitter rather than from the Guardian, despite the direct link to the page from the Guardian.

18 February 2013. The affair featured in BMJ News [download the reprint]. The item featured prominently on the BMJ news page.

bmj logo
bmj news page

19 February 2013 Only six days of this post, the NHS Choices page has been re-written again, in a much improved form. That looks like bloggers 1, DH 0. It is baffling that it’s left to bloggers, working for nothing, to extract a bit of sense from the highly-paid civil servants at the Department of Health. But at least they listened this time, which is a lot more than happens often. Paul Nuki, who runs NHS Choices, deserves congratulations. Of course the revised page still doesn’t call a spade a spade, but it gets close at times. I like the way it starts "Homeopathy is a ‘treatment’ based". Notice the quotation marks.

   Reputation management?

Incidentally, NHS Choices is outsourced to the (in)famous company, Capita. And the moderation of the comments on their site is outsourced again to Tempero, which describes itself as a "reputation management" company. Each of them creams off money meant of patient care. This discovery might explain why I and others have had comments rejected by NHS Choices several times. "Reputation management" is the antithesis of evidence. It is public relations, i.e. paid lying. That is quite wrong for a site that is meant to provide dispassionate information.

21 February 2013. Sadly a step backwards. Part of the improved page was removed. This bit.

The Chief Medical Officer, Professor Dame Sally Davies, has said there is no scientifically plausible way that homeopathy can prevent or cure diseases. She has made it clear she is particularly concerned about the use of homeopathy in developing countries as a so-called cure for malaria.

We can only speculate why this was removed, because it was true. In fact she accurately described homeopathy as "rubbish". Why she should not be quoted beats me.

Jump to follow-up

The Scottish Universities Medical Journal asked me to write about the regulation of alternative medicine. It’s an interesting topic and not easy to follow because of the veritable maze of more than twenty overlapping regulators and quangos which fail utterly to protect the public against health fraud. In fact they mostly promote health fraud. The paper is now published, and here is a version with embedded links (and some small updates).

We are witnessing an increasing commercialisation of medicine. It’s really taken off since the passage of the Health and Social Security Bill into law. Not only does that mean having NHS hospitals run by private companies, but it means that “any qualified provider” can bid for just about any service.  The problem lies, of course, in what you consider “qualified” to mean.  Any qualified homeopath or herbalist will, no doubt, be eligible.  University College London Hospital advertised for a spiritual healer. The "person specification" specified a "quallfication", but only HR people think that a paper qualification means that spiritual healing is anything but a delusion.

uclh-spirit

The vocabulary of bait and switch

First, a bit of vocabulary.  Alternative medicine is a term that is used for medical treatments that don’t work (or at least haven’t been shown to work).  If they worked, they’d be called “medicine”.  The anti-malarial, artemesinin, came originally from a Chinese herb, but once it had been purified and properly tested, it was no longer alternative.  But the word alternative is not favoured by quacks.  They prefer their nostrums to be described as “complementary” –it sounds more respectable.  So CAM (complementary and alternative medicine became the politically-correct euphemism.  Now it has gone a stage further, and the euphemism in vogue with quacks at the moment is “integrated” or “integrative” medicine.  That means, very often, integrating things that don’t work with things that do.  But it sounds fashionable.  In reality it is designed to confuse politicians who ask for, say, integrated services for old people.

Put another way, the salespeople of quackery have become rather good at bait and switch. The wikepedia definition is as good as any.

Bait-and-switch is a form of fraud, most commonly used in retail sales but also applicable to other contexts. First, customers are “baited” by advertising for a product or service at a low price; second, the customers discover that the advertised good is not available and are “switched” to a costlier product.

As applied to the alternative medicine industry, the bait is usually in the form of some nice touchy-feely stuff which barely mentions the mystical nonsense. But when you’ve bought into it you get the whole panoply of nonsense. Steven Novella has written eloquently about the use of bait and switch in the USA to sell chiropractic, acupuncture, homeopathy and herbal medicine: "The bait is that CAM offers legitimate alternatives, the switch is that it primarily promotes treatments that don’t work or are at best untested and highly implausible.".

The "College of Medicine" provides a near-perfect example of bait and switch. It is the direct successor of the Prince of Wales’ Foundation for Integrated Health. The Prince’s Foundation was a consistent purveyor of dangerous medical myths. When it collapsed in 2010 because of a financial scandal, a company was formed called "The College for Integrated Health". A slide show, not meant for public consumption, said "The College represents a new strategy to take forward the vision of HRH Prince Charles". But it seems that too many people have now tumbled to the idea that "integrated", in this context, means barmpottery. Within less than a month, the new institution was renamed "The College of Medicine". That might be a deceptive name, but it’s a much better bait. That’s why I described the College as a fraud and delusion.

Not only did the directors, all of them quacks, devise a respectable sounding name, but they also succeeded in recruiting some respectable-sounding people to act as figureheads for the new organisation. The president of the College is Professor Sir Graham Catto, emeritus professor of medicine at the University of Aberdeen. Names like his make the bait sound even more plausible. He claims not to believe that homeopathy works, but seems quite happy to have a homeopathic pharmacist, Christine Glover, on the governing council of his college. At least half of the governing Council can safely be classified as quacks.

So the bait is clear. What about the switch? The first thing to notice is that the whole outfit is skewed towards private medicine: see The College of Medicine is in the pocket of Crapita Capita. The founder, and presumably the main provider of funds (they won’t say how much) is the huge outsourcing company, Capita. This is company known in Private Eye as Crapita. Their inefficiency is legendary. They are the folks who messed up the NHS computer system and the courts computer system. After swallowing large amounts of taxpayers’ money, they failed to deliver anything that worked. Their latest failure is the court translation service.. The president (Catto), the vice president (Harry Brunjes) and the CEO (Mark Ratnarajah) are all employees of Capita.

The second thing to notice is that their conferences and courses are a bizarre mixture of real medicine and pure quackery. Their 2012 conference had some very good speakers, but then it had a "herbal workshop" with Simon Mills (see a video) and David Peters (the man who tolerates dowsing as a way to diagnose which herb to give you). The other speaker was Dick Middleton, who represents the huge herbal company, Schwabe (I debated with him on BBC Breakfast), In fact the College’s Faculty of Self-care appears to resemble a marketing device for Schwabe.

Why regulation isn’t working, and can’t work

There are various levels of regulation. The "highest" level is the statutory regulation of osteopathy and chiropractic. The General Chiropractic Council (GCC) has exactly the same legal status as the General Medical Council (GMC). This ludicrous state of affairs arose because nobody in John Major’s government had enough scientific knowledge to realise that chiropractic, and some parts of osteopathy, are pure quackery,

The problem is that organisations like the GCC function more to promote chiropractic than to regulate them. This became very obvious when the British Chiropractic Association (BCA) decided to sue Simon Singh for defamation, after he described some of their treatments as “bogus”, “without a jot of evidence”.

In order to support Singh, several bloggers assessed the "plethora of evidence" which the BCA said could be used to justify their claims. When, 15 months later, the BCA produced its "plethora" it was shown within 24 hours that the evidence was pathetic. The demolition was summarised by lawyer, David Allen Green, in The BCA’s Worst Day.

In the wake of this, over 600 complaints were made to the GCC about unjustified claims made by chiropractors, thanks in large part to heroic work by two people, Simon Perry and Allan Henness. Simon Perry’s Fishbarrel (browser plugin) allows complaints to be made quickly and easily -try it). The majority of these complaints were rejected by the GCC, apparently on the grounds that chiropractors could not be blamed because the false claims had been endorsed by the GCC itself.

My own complaint was based on phone calls to two chiropractors, I was told such nonsense as "colic is down to, er um, faulty movement patterns in the spine". But my complaint  never reached the Conduct and Competence committee because it had been judged by a preliminary investigating committee that there was no case to answer. The impression one got from this (very costly) exercise was that the GCC was there to protect chiropractors, not to protect the public.

The outcome was a disaster for chiropractors, wno emerged totally discredited. It was also a disaster for the GCC which was forced to admit that it hadn’t properly advised chiropractors about what they could and couldn’t claim. The recantation culminated in the GCC declaring, in August 2010, that the mythical "subluxation" is a "historical concept " "It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease.". Subluxation was a product of the fevered imagination of the founder of the chiropractic cult, D.D. Palmer. It referred to an imaginary spinal lesion that he claimed to be the cause of most diseases. .Since ‘subluxation’ is the only thing that’s distinguished chiropractic from any other sort of manipulation, the admission by the GCC that it does not exist, after a century of pretending that it does, is quite an admission.

The President of the BCA himself admitted in November 2011

“The BCA sued Simon Singh personally for libel. In doing so, the BCA began one of the darkest periods in its history; one that was ultimately to cost it financially,”

As a result of all this, the deficiencies of chiropractic, and the deficiencies of its regulator were revealed, and advertisements for chiropractic are somewhat less misleading. But this change for the better was brought about entirely by the unpaid efforts of bloggers and a few journalists, and not at all by the official regulator, the GCC. which was part of the problem. not the solution. And it was certainly not helped by the organisation that is meant to regulate the GCC, the Council for Health Regulatory Excellence (CHRE) which did nothing whatsoever to stop the farce.

At the other end of the regulatory spectrum, voluntary self-regulation, is an even worse farce than the GCC. They all have grand sounding "Codes of Practice" which, in practice, the ignore totally.

The Society of Homeopaths is just a joke. When homeopaths were caught out recommending sugar pills for prevention of malaria, they did nothing (arguably such homicidal advice deserves a jail sentence).

The Complementary and Natural Healthcare Council (CNHC) is widely know in the blogosphere as Ofquack. I know about them from the inside, having been a member of their Conduct and Competence Committee, It was set up with the help of a £900,000 grant from the Department of Health to the Prince of Wales, to oversee voluntary self-regulation. It fails utterly to do anything useful.. The CNHC code of practice, paragraph 15 , states

“Any advertising you undertake in relation to your professional activities must be accurate. Advertisements must not be misleading, false, unfair or exaggerated”. 

When Simon Perry made a complaint to the CNHC about claims being made by a CNHC-registered reflexologist, the Investigating Committee upheld all 15 complaints.  But it then went on to say that there was no case to answer because the unjustified claims were what the person had been taught, and were made in good faith. 
This is precisely the ludicrous situation which will occur again and again if reflexologists (and many other alternative therapies) are “accredited”.  The CNHC said, correctly, that the reflexologist had been taught things that were not true, but then did nothing whatsoever about it apart from toning down the advertisements a bit. They still register reflexologists who make outrageously false claims.

Once again we see that no sensible regulation is possible for subjects that are pure make-believe.

The first two examples deal (or rather, fail to deal) with regulation of outright quackery. But there are dozens of other quangos that sound a lot more respectable.

European Food Standards Agency (EFSA). One of the common scams is to have have your favourite quack treatment classified as a food not as a medicine. The laws about what you can claim have been a lot laxer for foods. But the EFSA has done a pretty good job in stopping unjustified claims for health benefits from foods. Dozens of claims made by makers of probiotics have been banned. The food industry, needless to say, objects very strongly to be being forced to tell the truth. In my view, the ESFA has not gone far enough. They recently issued a directive about claims that could legally be made. Some of these betray the previously high standards of the EFSA. For example you are allowed to say that "Vitamin C contributes to the reduction of tiredness and fatigue" (as long as the product contains above a specified amount of Vitamin C. I’m not aware of any trials that show vitamin C has the slightest effect on tiredness or fatigue, Although these laws do not come into effect until December 2012, they have already been invoked by the ASA has a reason not to uphold a complaint about a multivitamin pill which claimed that it “Includes 8 nutrients that can contribute to the reduction in tiredness and fatigue”

The Advertising Standards Authority (ASA). This is almost the only organisation that has done a good job on false health claims. Their Guidance on Health Therapies & Evidence says

"Whether you use the words ‘treatment’, ‘treat’ or ‘cure’, all are likely to be seen by members of the public as claims to alleviate effectively a condition or symptom. We would advise that they are not used"

"Before and after’ studies with little or no control, studies without human subjects, self-assessment studies and anecdotal evidence are unlikely to be considered acceptable"

"Before and after’ studies with little or no control, studies without human subjects, self-assessment studies and anecdotal evidence are unlikely to be considered acceptable"

They are spot on.

The ASA’s Guidance for Advertisers of Homeopathic Services is wonderful.

"In the simplest terms, you should avoid using efficacy claims, whether implied or direct,"

"To date, the ASA has have not seen persuasive evidence to support claims that homeopathy can treat, cure or relieve specific conditions or symptoms."

That seems to condemn the (mis)labelling allowed by the MHRA as breaking the rules.. Sadly, though, the ASA has no powers to enforce its decisions and only too often they are ignored. The Nightingale collaboration has produced an excellent letter that you can hand to any pharmacist who breaks the rules

The ASA has also judged against claims made by "Craniosacral therapists" (that’s the lunatic fringe of osteopathy). They will presumably uphold complaints about similar claims made (I’m ashamed to say) by UCLH Hospitals.

The private examination company Edexcel sets exams in antiscientific subjects, so miseducating children. The teaching of quackery to 16 year-olds has been approved by a maze of quangos, none  of which will take responsibility, or justify their actions. So far I’ve located no fewer than eight of them. The Office of the Qualifications and Examinations Regulator (OfQual), Edexcel, the Qualifications and Curriculum Authority (QCA), Skills for Health, Skills for Care, National Occupational Standards (NOS), private exam company VTCT and the schools inspectorate, Ofsted.. Asking any of these people why they approve of examinations in imaginary subjects meets with blank incomprehension. They fail totally to protect tha public from utter nonsense.

The Department of Education has failed to do anything about the miseducation of children in quackery. In fact it has encouraged it by, for the first time, giving taxpayers’ money to a Steiner (Waldorf) school (at Frome, in Somerset). Steiner schools are run by a secretive and cult-like body of people (read about it). They teach about reincarnation, karma, gnomes, and all manner of nonsense, sometimes with unpleasant racial overtones. The teachers are trained in Steiner’s Anthroposophy, so if your child gets ill at school they’ll probably get homeopathic sugar pills. They might well get measles or mumps too, since Steiner people don’t believe in vaccination.

Incredibly, the University of Aberdeen came perilously close to appointing a chair in anthroposophical medicine. This disaster was aborted by bloggers, and a last minute intervention from journalists. Neither the university’s regulatory mechanisms. nor any others, seemed to realise that a chair in mystical barmpottery was a bad idea.

Trading Standards offices and the Office of Fair Trading.

It is the statutory duty of Trading Standards to enforce the Consumer Protection Regulations (2008) This European legislation is pretty good. it caused a lawyer to write " Has The UK Quietly Outlawed “Alternative” Medicine?". Unfortunately Trading Standards people have consistently refused to enforce these laws. The whole organisation is a mess. Its local office arrangement fails totally to deal with the age of the internet. The situation is so bad that a group of us decided to put them to the test. The results were published in the Medico-Legal Journal, Rose et al., 2012. "Spurious Claims for Health-care Products: An Experimental Approach to Evaluating Current UK Legislation and its Implementation". They concluded "EU directive 2005/29/EC is
largely ineffective in preventing misleading health claims for consumer products in
the UK"

Skills for Health is an enormous quango which produces HR style "competences" for everything under the son. They are mostly quite useless. But those concerned with alternative medicine are not just useless. They are positively harmful. Totally barmy. There are competences and National Occupational Standards for every lunatic made-up therapy under the sun. When I phoned them to discover who’d written them, I learned that the had been drafted by the Prince of Wales’ Foundation for Magic Medicine. And when I joked by asking if they had a competence for talking to trees, I was told, perfectly seriously, “You’d have to talk to LANTRA, the land-based organisation for that.”

That was in January 2008. A lot of correspondence with the head of Skills for Health got nowhere at all. She understood nothing and it hasn’t improved a jot.

This organisation costs a lot of taxpayers’ money and it should have been consigned to the "bonfire of the quangos" (but of course there was no such bonfire in reality). It is a disgrace.

The Quality Assurance Agency (QAA) is supposed to ensure the quality of university courses. In fact it endorses courses in nonsense alternative medicine and so does more harm than good. The worst recent failure of the QAA was in the case of the University of Wales: see Scandal of the University of Wales and the Quality Assurance Agency. The university was making money by validating thousands of external degrees in everything from fundamentalist theology to Chinese Medicine. These validations were revealed as utterly incompetent by bloggers, and later by BBC Wales journalist Ciaran Jenkins (now working for Channel 4).

The mainstream media eventually caught up with bloggers. In 2010, BBC1 TV (Wales) produced an excellent TV programme that exposed the enormous degree validation scam run by the University of Wales. The programme can be seen on YouTube (Part 1, and Part 2). The programme also exposed, incidentally, the uselessness of the Quality Assurance Agency (QAA) which did nothing until the scam was exposed by TV and blogs. Eventually the QAA sent nine people to Malaysia to investigate a dodgy college that had been revealed by the BBC. The trip cost £91,000. It could have been done for nothing if anyone at the QAA knew how to use Google.

The outcome was that the University of Wales stopped endorsing external courses, and it was soon shut down altogether (though bafflingly, its vice-chancellor, Marc Clement was promoted). The credit for this lies entirely with bloggers and the BBC. The QAA did nothing to help until the very last moment.

Throughout this saga Universities UK (UUK), has maintained its usual total passivity. They have done nothing whatsoever about their members who give BSc degrees in anti-scientific subjects. (UUK used to known as the Committee of Vice-Chancellors and Principals).

Council for Health Regulatory Excellence (CHRE), soon to become the PSAHSC,

Back now to the CHRE, the people who failed so signally to sort out the GCC. They are being reorganised. Their consultation document says

"The Health and Social Care Act 20122 confers a new function on the Professional Standards Authority for Health and Social Care (the renamed Council for Healthcare Regulatory Excellence). From November 2012 we will set standards for organisations that hold voluntary registers for people working in health and social care occupations and we will accredit the register if they meet those standards. It will then be known as an ‘Accredited Register’. "

They are trying to decide what the criteria should be for "accreditation" of a regulatory body. The list of those interested has some perfectly respectable organisations, like the British Psychological Society. It also contains a large number of crackpot organisations, like Crystal and Healing International, as well as joke regulators like the CNHC.

They already oversee the Health Professions Council (HPC) which is due to take over Herbal medicine and Traditional Chinese Medicine, with predictably disastrous consequences.

Two of the proposed criteria for "accreditation" appear to be directly contradictory.

Para 2.5 makes the whole accreditation pointless from the point of view of patients

2.5 It will not be an endorsement of the therapeutic validity or effectiveness of any particular discipline or treatment.

Since the only thing that matters to the patient is whether the therapy works (and is safe), accrediting of organisations that ignore this will merely give the appearance of official approval of crystal healing etc etc. This appears to contradict directly

A.7 The organisation can demonstrate that there either is a sound knowledge base underpinning the profession or it is developing one and makes that explicit to the public.

A "sound knowledge base", if it is to mean anything useful at all, means knowledge that the treatment is effective. If it doesn’t mean that, what does it mean?

It seems that the official mind has still not grasped the obvious fact that there can be no sensible regulation of subjects that are untrue nonsense. If it is nonsense, the only form of regulation that makes any sense is the law.

Please fill in the consultation. My completed return can be downloaded as an example, if you wish.

Medicines and Healthcare products Regulatory Agency (MHRA) should be a top level defender of truth. Its strapline is

"We enhance and safeguard the health of the public by ensuring that medicines and medical devices work and are acceptably safe."

The MHRA did something (they won’t tell me exactly what) about one of the most cruel scams that I’ve ever encountered, Esperanza Homeopathic Neuropeptide, peddled for multiple sclerosis, at an outrageous price ( £6,759 for 12 month’s supply). Needless to say there was not a jot of evidence that it worked (and it wasn’t actually homeopathic).

Astoundingly, Trading Standards officers refused to do anything about it.

The MHRA admit (when pushed really hard) that there is precious little evidence that any of the herbs work, and that homeopathy is nothing more than sugar pills. Their answer to that is to forget that bit about "ensuring that medicines … work"

Here’s the MHRA’s Traditional Herbal Registration Certificate for devils claw tablets.

vitabiotics

The wording "based on traditional use only" has to be included because of European legislation. Shockingly, the MHRA have allowed them to relegate that to small print, with all the emphasis on the alleged indications. The pro-CAM agency NCCAM rates devil’s claw as "possibly effective" or "insufficient evidence" for all these indications, but that doesn’t matter because the MHRA requires no evidence whatsoever that the tablets do anything. They should, of course, added a statement to this effect to the label. They have failed in their duty to protect and inform the public by allowing this labelling.

But it gets worse. Here is the MHRA’s homeopathic marketing authorisation for the homeopathic medicinal product Arnicare Arnica 30c pillules

It is nothing short of surreal.

hom1
hom2

Since the pills contain nothing at all, they don’t have the slightest effect on sprains, muscular aches or bruising. The wording on the label is exceedingly misleading.

If you "pregnant or breastfeeding" there is no need to waste you doctor’s time before swallowing a few sugar pills.

"Do not take a double dose to make up for a missed one". Since the pills contain nothing, it doesn’t matter a damn.

"If you overdose . . " it won’t have the slightest effect because there is nothing in them

And it gets worse. The MHRA-approved label specifies ACTIVE INGREDIENT. Each pillule contains 30c Arnica Montana

No, they contain no arnica whatsoever.

hom3
hom4

It truly boggles the mind that men with dark suits and lots of letters after their names have sat for hours only to produce dishonest and misleading labels like these.

When this mislabeling was first allowed, it was condemned by just about every scientific society, but the MHRA did nothing.

The Nightingale Collaboration.

This is an excellent organisation, set up by two very smart skeptics, Alan Henness and Maria MacLachlan. Visit their site regularly, sign up for their newsletter Help with their campaigns. Make a difference.

Conclusions

The regulation of alternative medicine in the UK is a farce. It is utterly ineffective in preventing deception of patients.

Such improvements as have occurred have resulted from the activity of bloggers, and sometime the mainstream media. All the official regulators have, to varying extents, made things worse.

The CHRE proposals promise to make matters still worse by offering "accreditation" to organisations that promote nonsensical quackery. None of the official regulators seem to be able to grasp the obvious fact that is impossible to have any sensible regulation of people who promote nonsensical untruths. One gets the impression that politicians are more concerned to protect the homeopathic (etc, etc) industry than they are to protect patients.

Deception by advocates of alternative medicine harms patients. There are adequate laws that make such deception illegal, but they are not being enforced. The CHRE and its successor should restrict themselves to real medicine. The money that they spend on pseudo-regulation of quacks should be transferred to the MHRA or a reformed Trading Standards organisation so they can afford to investigate and prosecute breaches of the law. That is the only form of regulation that makes sense.

 

Follow-up

The shocking case of the continuing sale of “homeopathic vaccines” for meningitis, rubella, pertussis etc was highlighted in an excellent TV programme by BBC South West. The failure of the MHRA and the GPC do take any effective action is a yet another illustration of the failure of regulators to do their job. I have to agree with Andy Lewis when he concludes

“Children will die. And the fault must lie with Professor Sir Kent Woods, chairman of the regulator.”

Jump to follow-up

[Use Firefox if embedded videos do not show in Chrome]

cameron

Andrew Lansley’s Health Bill (HASSB) aims to change the NHS into something more like the US system, which gives worse results at twice the cost.

The only possible reason for wanting to do that is simple far-right ideology. No wonder that no hint was given of its intentions before the election.

On the contrary, David Cameron stated repeatedly that there would be no top-down reorganisation of the NHS. That turned out to be a straight lie.

“First let me tell you what we are not going to do. There will be no more of those pointless reorganisations that aim for change, but instead bring chaos.” [David Cameron speaking to Royal College of Nursing in 2009, before election].

We all know that money must be saved. But the two major disasters of the coalition government don’t save any money.

On the contrary, both tuition fees and NHS-wrecking will cost taxpayers’ money. The tuition fees are done (for the time being) but there is still time to save the NHS.

The best simple explanation that I’ve found is by Dr Max Pemberton in the Telegraph: Read this – and prepare to fight for your NHS. The Bill is three times longer than the 1946 Bill that brought the NHS into existence.

“The power to determine the services that make up the NHS will be transferred from the Secretary of State to newly created Clinical Commissioning Groups (CCGs), which are unelected. Members will include GPs but also company chief executives who can, if they wish, outsource decisions about the appropriate level of services offered to companies with commercial interests. This is what the Government means when it says it is handing GPs £60 billion of NHS money. ”

Monitor. This quango is composed of unelected and unaccountable individuals. It will not have overarching responsibility – which the Government does currently – to ensure that everyone’s health needs are met.” “It will have the power to decide, on purely financial grounds, if an area loses its existing range of hospital services, such as A&E departments, with no duty to consider alternative provision.

“With so many different providers of health care created under this Bill, those with complex health care needs may not receive the joined-up medical care that the NHS now works hard to provide.”

“Less profitable patients – those requiring complex levels of care from multiple individuals and areas of expertise, for example – may be sidelined by these private companies. ”

“the Bill allows CCGs to contract out commissioning functions to private accountancy, health insurance and management consultant firms, which will be able to decide what care is provided free at the point of use through the NHS and what is not. This means that profit-making companies will be able to provide your clinical care and also decide what you’re entitled to under the NHS and from which care providers.” “There is the potential for commercial conflicts when the needs of shareholders come between doctors and patients. ”

“Providers, too, can reduce levels of service provision and entitlement to NHS-funded care and there are no restrictions on charging for non-NHS care.”

“Now, up to 49 per cent of income can be generated from private income. This means that almost half the beds currently used for NHS care could be given over to private patients.” “This could create a two-tier system in hospitals” and “create a conflict of interest, with hospitals having a clear incentive to encourage as many patients as possible to use the private half of their facilities. Moreover, hospitals can decide when to discharge patients. The requirement for coordinated discharge and aftercare of patients between health and social care is abolished in the Bill. “

Why is the bill needed at all?

Most people believe that there is no need for a bill. The real aim appears to be in part 3, which proposes a vast increase in private providers. Oliver Huitson says

“A US report comparing the health services of 7 major economies ranked the NHS 1st in terms of efficiency, and 2nd overall. The US, which has vast private sector involvement and much greater use of GP commissioning, was ranked last despite spending more than twice as much per head as the UK”

” Despite being ranked as one of the most efficient and equitable health services in the developed world, the Conservatives are determined to remodel it in the image of one of the least efficient – all in the name of “improving efficiency”.”

Although most GPs are in favour of having more say in what happens, even the first parts of the bill are a mess. They are advertised as reducing bureaucracy and reducing costs. According to the Financial Times, they do exactly the opposite.

“Here was the original NHS bureaucracy in graphic form”

nhs-prev

Here is the new NHS bureaucracy in graphic form

nhs-new

Ed Miliband pointed out that the number of NHS statutory organisations was growing from 163 to 521 – including “health and wellbeing committees,” “national commissioning boards”, “clinical networks”, “clinical senates” and so on.

So much for reduced bureaucracy.

Who thinks this is not a good idea?

Almost everyone. Not just the BMA which Lansley dismisses as a Trade Union, despite the fact that now (unlike in 1948) the BMA is voting against the financial interests of its members.

The Royal College of General Practitioners says Drop the Bill. So do Royal College of Nursing. Royal College of Midwives, Faculty of Public Health, Chartered Society of Physiotherapists, the Patients’ Association, among others. Almost the only support left is from the NHS Alliance, a tiny organisation run by Michael Dixon, friend of the Prince of Wales and advocate of quack medicine. The NHS alliance ran its own poll. A total of 100 people have voted so far, 99 of them against the Alliance’s policy. Some support. A rather good infographic shows how the balance lies.

The BMA’s General Practitioners Committee, which represents all GPs in the UK says [read full letter]

“1. Formally reaffirms its opposition to the NHS Health and Social Care Bill;

2. Believes that if passed the Bill will be irreversibly damaging to the NHS as a public service, converting it into a competitive marketplace that will widen health inequalities and be detrimental to patient care; . . . .”

In contrast, the e-petition to the government, started by Dr Kailash Chand OBE, states simply that it “Calls on the Government to drop its Health and Social Care Bill.”. It now has over 167,000 signatories. But despite the fact that petitions with over 100,000 signatures are meant to trigger a debate in the House of Commons, the backbench business committee of MPs has decided not to debate the e-petition.

So many people have rallied to oppose the daftness that it’s invidious to single out names. Nonetheless special mentions must go to Clare Gerada (@clarercgp on Twitter) (chair of the RCGP), and to Clive Peedell (@cpeedell) (oncologist and co-chair NHS Consultants’ Association) -read his Bevan’s Run blog. Among academics, Allyson Pollock and Martin McKee have done superb work on the details.

Most telling of all, some of the people who started by supporting Lansley have changed their minds. One concern about the “any qualified provider” idea is that it could open the door to quackery. Any “qualified” homeopath could bid for business at a competitive rate -sugar pills don’t cost much. Michael Dixon is one such.

Dr Sam Everington of Tower Hamlets is another. Services provided by his practice include “referrals to Inside Out Health and Wellbeing Ltd“. This private company will sell you fraudulent scams like homeopathy and kinesiology at £50 per session, among other nonsense (according to Companies House, it was wound up on 17 January 2012). He’s also associated with the “College of Medicine” (the reincarnation of the Prince of Wales’ Foundation). See also, Dr Margaret McCartney’s blog. As chair of the first Clinical Commissioning Group (CCG) he was embraced by Cameron. His Bromley-by-Bow surgery was host for Andrew Lansley’s first speech as health secretary after the 2010 election, and also host to the Prince of Wales..

But now even Everington has turned against the Bill (read the full letter).

“Dear Prime Minister

The Board of NHS Tower Hamlets Clinical Commissioning Group ask you to reflect and to withdraw the Health and Social Care Bill.”

“We care deeply about the patients that we see every day and we believe the improvements we all want to see in the NHS can be achieved without the bureaucracy generated by the Bill.

Your government has interpreted our commitment to our patients as support for the bill. It is not.”

And, on 1st March, another request to drop the bill, from the East London Integrated Care (ELIC is a not-for-profit social enterprise which is owned and run by local people and health professionals”). Read the full letter.

“Thursday, 1 March 2012 N1 5LZ

Dear Prime Minister,

The Board of City & Hackney Clinical Commissioning Group (CCG) join Tower Hamlets
and most other GPs and nurses and ask you to withdraw the Health and Social Care Bill.”

Is it really privatisation?

If you feel reassured by Lansley’s assurances that his measures aren’t de facto privatisation, just watch this video. It reveals some of the network of lobby groups that are circling the NHS, eager to take your money. For example, the lobby group, Policy Exchange, “Cameron’s favourite”, co-founded by Francis Maude, a member of Cameron’s cabinet, and is lobbying for more private sector provision of NHS services. One of the companies that it’s taken money from is called Tribal, which wants to take over commissioning from GPs. One of the directors of Tribal has described Andrew Lansley’s reforms as being “denationalisation of health services in England”.

So you don’t need to listen to left-wingers. The industry itself is in no doubt that it’s privatisation, and it’s ready and waiting to grab our money..

And of all unlikely allies, the vice chair of the British Holistic Medical Association has written a powerful letter about how the bill really would result in privatisation.

The likely consequences have been put well by Ben Goldacre in his What will happen with the NHS bill, in 5 tweets.  The following points are based partly on this.

  • GPs know they’re being set up to fail by being given commissioning powers, which they have neither the time nor the expertise to do properly.
  •  After GPs fail, private commissioning expertise will be needed. Large private companies will be given the job and they will come to operate like health insurers.
  • These large bodies, like public/private insurance companies, will be able to pick and choose patients. They will naturally prefer the ones from whom they can make the most money (and not the sick or the old).  Note that there is no geographical responsibility in the bill
  • Small differences will gradually emerge in what services they offer. Top up plans will become available. And that will be the end of the NHS in the form in which we know it.

The only way that the proposals make any sense at all is if the underlying aim is to destroy the NHS, in anything like its present form.  I believe that Lansley’s aims are much more to do with his personal political ideologies than anything to do with health.  Those ideologies are far to the right of anything envisaged by Margaret Thatcher.

The politics. Where are the Lib Dems?

I voted Lib Dem in 2010, and I said precisely why. Of course I didn’t expect they’d get a majority. They were just the party that I found least objectionable. Like so many others I watched with horror as the numbers came out. There was no other option but to form a coalition with Conservatives. Well, I’d have been happier with no coalition, but the danger of that producing an overall majority for Conservatives after a year or so made that a very risky option.

When the coalition formed I was alarmed by the prospects for both education and for the NHS.  I was less alarmed by the latter, because Cameron had said so many times that he had no intention of messing with the NHS.  That turned out to be a direct lie.  I could scarcely believe it when Lansley produced a plan after the election for the biggest reorganisation ever in the NHS, something that had not been foreshadowed in any way in the Conservative manifesto.  This was one of the most dishonest bits of political manoeuvring that I’ve ever encountered.

Clearly we were spending more than we could afford. What’s unforgivable is to do things that actually cost the taxpayer more than before. Such actions are quite the opposite of cuts.  Yet they are being done in the two areas, than any others, that have got Lib Dem voters angry.

(a) The £9k tuition fees cost the taxpayer more than the £3k fees did, because of the financing arrangements.  I can see no conceivable reason for spending more taxpayers’ money than before apart from (Conservative) political ideology.  That’s done (for now) so back to the main topic of this post, the NHS.

(b)  It seems inevitable that Lansley’s proposals will cost money, not save money.  Presumably that was predicted in the risk register, the concealment of which is a disgrace. See Liberal Conspiracy and the Green Benches blogs. The Information Commissioner ordered the release of the risk register, but the coalition refused (so much for transparent government). They appealed so now it goes to an Information Tribunal.
An Early Day Motion in the House of Commons urged release. It was signed by only 16 Lib Dems.

The bill started to fall apart in a major way when, on February 6th, The Times reported that

“Andrew Lansley should be taken out and shot,” says a Downing Street source. “He’s messed up both the communication and the substance of the policy.”

But Cameron, instead of grasping the chance, decided to back a loser.

Some Lib Dems have stuck to their principles. For example

John Pugh MP, Co-Chair of the Lib Dem Parliamentary Health Committee, re-established the Beveridge group, and wrote a letter to parliamentarians to explain why.

Andrew George MP wrote Health Bill has no friends. Dignified withdrawal would be best.

On 13 February, hearts soared when Lib Dem peer Shirley Williams spoke out at last. She urged Lansley to drop part 3 of the bill, the part that deals with privatisation. The elation didn’t last long though. Nick Clegg told the BBC: “Andrew Lansley is the architect of the NHS bill. He cares passionately about the NHS. He’s the right man for the job and he must see it through.”. Yes, I know about Cabinet solidarity, but it’s hard to think of any surer way to lose elections than to make statements like that. Even many Conservatives don’t believe it: see, for example, Dr Rachel Joyce on Conservative Home.

On 24th February, the Lib Dem president, Tim Farron MP, spoke up at last. “Mr Farron told ITV the bill should have been “massively changed” or dropped earlier and he wanted plans for more competition in the NHS to be dropped”.

On 26 February, Nigel Crisp, described the bill as a confusing mess that risks setting the NHS back. Crisp was formerly NHS chief executive and the permanent secretary at the Department of Health from 2000 to 2006, and is now a crossbench peer. Like everyone else, he was ignored.

The elation about Shirley Williams intervention didn’t last long. On 27th February a joint letter from Williams and Clegg claimed that they’d fixed the bill. The letter was quickly subjected to a bullshitometer analysis, by Health Policy Insight. Bafflingly, Lansley declared in public that he’d “changed his mind” about the privatisation, while at the same time Lansley and Cameron claimed that nothing much had changed: see Downing Street in knots as it plays down Nick Clegg’s NHS concessions, and Paul Corrigan’s blog.

March 1st saw two more blows for Clegg and Lansley. First, as reported thus in the Independent.

“Graham Winyard, the former deputy Chief Medical Officer, resigned from the party in protest at the leadership’s backing for the Bill. Dr Winyard, who was chairman of Winchester Liberal Democrats until last year, told Mr Clegg in a letter: “It is just not sensible to impose this top-down reorganisation on an NHS struggling to meet the biggest financial challenge in its history. To continue to do so in the face of near unanimous opposition from patient, staff and professional organisations simply invites slow motion disaster both for the NHS and for the party.” He said that he had no option but to resign “with great sadness”. “

Then, also on 1st March, Dr Laurence Buckman, chairman of the BMA’s GPs committee, wrote to 22,000 GPs. [full letter]

  • Believes the bill will compromise the role of GPs, and could cause irreparable damage to the relationship between GPs and their patients.
  • Believes the bill to be complex, incoherent and not fit for purpose, and almost impossible to implement successfully, given widespread opposition across the NHS workforce.
  • Believes that passing the bill will be an irresponsible waste of taxpayers’ money, which will be spent on unnecessary reorganisation rather than on patient care, as well as increasing the running costs of the NHS from the processes of competition, and transaction costs

The chaos that the Lib Dems now find themselves in is illustrated clearly by a post on Liberal Democrat Voice by Andrew Tennant. He’s apparently an unreconstructed 19th century Whig, masquerading as a 21st century liberal. The comments on the post reveal the mess the party has got itself into by refusing to drop the bill.

More to the point, look at the proper detailed analyses done by people who are a lot more knowledgeable than Andrew Tennant, or Andrew Lansley.

There is one last chance for the Lib Dems to restore their reputation. Lib Dems hope to finally kill health reforms. “Liberal Democrat activists will defy Nick Clegg over the Government’s controversial health reforms by seeking to “kill” them at a party policy-making conference next week.”

Good luck to them. They could save the Lib Dems if they win. Much more importantly, they could save the NHS.

Follow-up

Sunday 4 March. Yet another story of corruption, this time in the Mail on Sunday.

“The head of the NHS regulator that is meant to ensure fairness when private-sector firms bid for public contracts is also the chairman of a huge company whose Health Service business is worth £80 million a year – and set to increase massively.

As the chairman of the NHS Co-operation and Competition Panel (CCP), Lord Carter of Coles is paid £57,000 for two days’ work each week. But his other role, as chairman of the UK branch of the American healthcare firm McKesson, is more generously rewarded. Last year it paid him £799,000.”

“Dr Clare Gerada, chairman of the Royal College of General Practitioners, said: ‘He cannot have any credibility when he is also heading a company with such huge interests in the very contracts his organisation is meant to police.”

See also Conflicts of Interest and NHS reform.

According to a tweet from James Ball

“Politics of the #NHSbill awful for lib dems: only 17% of their current supporters back it – and only 9% of their 2010 voters.”

Sounds plausible. Are you listening, Nick Clegg?

5 March 2012. The emergency motion for the Lib Dem Spring Conference (March 10 -11) has been published. See also the blog of the heroic Dr Charles West for more details. If Clegg manages to defeat this excellent motion, the last chance to save the NHS will be gone.

10 March 2012

Bitterly disappointed by vote at Lib Dem conference, not to debate the motion to drop the NHS bill. Who do I vote for now?

One thing that one can still do is to email all Lib Dem MPs give your views. Here is a list of their email addresses (via Lindy).

bakern@parliament.uk, danny.alexander.mp@parliament.uk, alan.beith.mp@parliament.uk, gordon.birtwistle.mp@parliament.uk, brookea@parliament.uk, braket@parliament.uk, brownej@parliament.uk, hernandeza@parliament.uk, burstowp@parliament.uk, lorely.burt.mp@parliament.uk, cablev@parliament.uk, menzies.campbell.mp@parliament.uk, carmichaela@parliament.uk, nick.clegg.mp@parliament.uk, mike.crockart.mp@parliament.uk, farront@parliament.uk, daveye@parliament.uk, simon.wright.mp@parliament.uk, willottj@parliament.uk, featherstonel@parliament.uk, fosterd@parliament.uk, andrew.george.mp@parliament.uk, duncan.hames.mp@parliament.uk, stephen.gilbert.mp@parliament.uk, stephenwilliamsmp@parliament.uk, kennedyc@parliament.uk, jo.swinson.mp@parliament.uk, julian.huppert.mp@parliament.uk,hunterm@parliament.uk, simon@simonhughes.org.uk, chris.huhne.mp@parliament.uk, martin.horwood.mp@parliament.uk, hemmingj@parliament.uk, david.heath.mp@parliament.uk, hancockm@parliament.uk, pagep@parliament.uk, lambn@parliament.uk, lawsd@parliament.uk, john.leech.mp@parliament.uk, stephen.lloyd.mp@parliament.uk, michaelmooremp@parliament.uk, greg.mulholland.mp@parliament.uk, teathers@parliament.uk, tessa.munt.mp@parliament.uk, john.thurso.mp@parliament.uk, david.ward.mp@parliament.uk, webbs@parliament.uk, williamsmf@parliament.uk, williamsr@parliament.uk, pughj@parliament.uk, reida@parliament.uk, contact@danrogerson.org, susan.hislop@parliament.uk, robert.smith.mp@parliament.uk, stunella@parliament.uk, ian.swales.mp@parliament.uk

And here are email addresses for (most) Lib Dem peers)

williamss@parliament.uk, walmsleyj@parliament.uk, wallacej@parliament.uk, wallacew@parliament.uk, tordoffg@parliament.uk, topeg@parliament.uk, thomascm@parliament.uk, thomass@parliament.uk, stephenn@parliament.uk, smitht@parliament.uk, shipleyj@parliament.uk, shuttd@parliament.uk, sharpm@parliament.uk, scottrc@parliament.uk, robertsr@parliament.uk, rennardc@parliament.uk, randersonj@parliament.uk, palmerm@parliament.uk, oakeshottm@parliament.uk, northoverl@parliament.uk, newbyr@parliament.uk, millers@parliament.uk, methuenr@parliament.uk, methuenr@parliament.uk, maddockd@parliament.uk, maddockd@parliament.uk, maclennanr@parliament.uk, loombar@parliament.uk, linklaterv@parliament.uk, lestera@parliament.uk, leej@parliament.uk, kramers@parliament.uk, jonesn@parliament.uk, ecem@parliament.uk, harrisa@parliament.uk, hamwees@parliament.uk, greavesa@parliament.uk, goodhartw@parliament.uk, germanm@parliament.uk, gardens@parliament.uk, falknerk@parliament.uk, ezrad@parliament.uk, dholakian@parliament.uk, cotterb@parliament.uk, clementjonest@parliament.uk, chidgeyd@parliament.uk, carlilea@parliament.uk, brintons@parliament.uk, willisg@parliament.uk, addingtond@parliament.uk , alderdicej@parliament.uk, allanr@parliament.uk, ashdownp@parliament.uk, barkere@parliament.uk, benjaminf@parliament.uk , bonhamcarterj@parliament.uk

13 March 2012. This is really last chance day. At 11 am, the Lords debate third reading of health bill and at 2 pm the Commons have emergency debate, triggered by the e-petition, which now has more than 173,000 signatures. I sent the following email to all Lib Dem peers and MPs this morning.

The idea that the changes to the health bill have solved its  problems is simply wrong. Before you vote, please read http://abetternhs.wordpress.com/2012/03/11/40points/ ,
That is written by a working GP who knows what he’s talking about.
For the truth about the 49% disaster, read this.

There are 27 professional organisations who are against the bill (see here).  Do you really understand the implications better than they do?

The vote at the lib dem conference gives you the mandate to vote according to your conscience.  Please vote to drop the bill and start again.

I voted Lib Dem at every election from 2001. If you let us down on the health bill, I will certainly not do so again.

David Colquhoun

16 March 2012. I have learned ( from Lord Shutt) that there will be a 3-line whip on Lib Dem peers to vote against Lord Owen’s amendment. And this despite the vote against the Clegg-Williams motion at the Lib Dem conference last week. This makes the much vaunted party democracy look like a bit of a joke. The only hope now is the bishops. Here is a list of their email addresses. You can also contact them through Dr Éoin Clarke’s site (from where I got the addresses)

bishop@bathwells.anglican.org, bishop@birmingham.anglican.org, chaplain@bishopofblackburn.org.uk, bishop@bristoldiocese.org, bpchester@chester.anglican.org, bishchichester@diochi.org.uk, bishop@bishopofderby.org, durham@durham.anglican.org, langrishm@parliament.uk, bshpglos@glosdioc.org.uk, bishop.christopher@cofeguildford.org.uk, bishop@hereford.anglican.org, bishop.tim@leccofe.org, bishop.lichfield@lichfield.anglican.org, bishopslodge@liverpool.anglican.org, bishop@londin.clara.co.uk, bishop@bishopscourt.manchester.anglican.org, bishop@newcastle.anglican.org, bishop@norwich.anglican.org, bishop@riponleeds-diocese.org.uk, bishop.nigel@stedmundsbury.anglican.org, bishop@bishopofwakefield.org.uk, contact@lambethpalace.org.uk, office@archbishopofyork.org

This is what I sent to them today.

Dear Bishop,

You will be aware of the widespread concerns about the commercialisation of the NHS.  No fewer than 27 medical organisations have now come out strongly against the bill and it’s clear that, despite (or because of?) over 1000 amendments, it is a real mess.

Despite the vote at the Lib Dems conference against the bill, I hear that there will be a 3-line whip in the Lords to force Lib Dem peers to vote against the very sensible proposal by Lord Owen to delay passing of the bill until the government release the assessment of the risks of passing it.  This means that the Bishops will be crucial.  I would like to ask you seriously to consider voting for Lord Owen’s motion on Monday.  The future of the National Health Service lies in your hands

Best regards
David Colquhoun

18 March 2012. Tomorrow is last hope for stopping the bill in the Lords. The 3-line whip will, I expect, ensure the defeat of Lord David Owen’s excellent amendment. The bill will probably become law. Two tweets express the impending death of the NHS quite poignantly. On 15 March @Heardin London wrote

"For a brief period during 20th century, people gave a fuck and looked after each other. Unfortunately this proved unprofitable."

and today, from @thewritertype,

"Years from now you’ll have to explain to children what the NHS was. Then you’ll have to explain what a LibDem was."

Poetry in 140 characters.

20 March 2012.

The hated bill was rammed through in the House of Commons, thanks to support from Lib Dems.

.The list of the peers and MPs who will make money out of privatisation is truly scary and deeply corrupt.

mirror

Yet another university has stopped its homeopathy course. The particular interest of this course was that it was being run at Robert Gordon University, Aberdeen, the vice-chancellor which was Michael Pittilo, until his recent premature death. Pittilo is the person who recommended to the government that herbalists and Chinese medicine practitioners should get honours degrees and be regulated like doctors. His report, was, in my opinions, disastrously bad

It recently emerged that this, very bad, advice would not be accepted by the Department of Health (DH), so the campaign against the Pittilo proposals, on this blog and elsewhere was successful. The alternative DH proposals look pretty silly, but we won’t really know until after the election exactly what will happen.

Robert Gordon University (RGU): is the ‘post-1992’ university in Aberdeen, as opposed the the University of Aberdeen (where my son is at the moment). Much of RGU does an excellent job, but like so many post-1992 universities they harm themselves by running courses in barmy alternative medicine. RGU ran an Introduction To Homeopathy module (saved 9 April 2010).

In July 2009, I asked RGU to see some samples of the teaching materials on this module, partly as part of the campaign against Pittilo’s proposals. I asked to see the powerpoints and handouts for three lectures, (1) evidence for homeopathy, (2) first aid remedies, and (3) allergies.

In September 2009, this request, made under the Freedom of Information Act (Scotland), was, as always, rejected by RGU, though they did tell me that the evidence lecture had been produced by a lecturer from The Faculty of Homeopathy and the other two had been produced by a local GP.

So, as usual, I asked for the mandatory internal review of the decision. In October, the review upheld the original decision, as they almost always do. I referred the decision to the Scottish Information Commissioner (the law is slightly different in Scotland) and they have still not responded.

But on 8 April 2010 I got a letter from RGU.

“The above course requested is no longer part of the School of Nursing and Midwifery’s provision, and it was cessated [sic] in Semester One 2009/10. This followed a formal review of all Nursing and Midwifery modules and their viability. In the light of this the university has decided to release the information.”

So yet another university has done the sensible thing. The course has been shut. Just for the record, I’ll reproduce a few of the slides from the lecture on “homeopathic remedies for allergies”.

Allergies can be dangerous, and occasionally lethal. To treat them with homeopathic pills, medicines that contain no medicine, is not just delusion, but a dangerous delusion which risks the lives of patients.

The "remedies" include nettles, sulphur, petroleum and arsenic.  They’d be pretty scary but in fact the pills contain, in most cases, not a jot of nettle, sulphur, petroleum or arsenic.  Homeopathic pharmacies stock thousands of bottles of identical sugar pills, each with a different label.

slide 5

slide 7

slide 8

slide 9

These dangerous delusions were being taught as fact in a UK university.  The shame of it..

Jump to follow-up

Every single request for information about course materials in quack medicine that I have ever sent has been turned down by universities,

It is hardly as important as as refusal of FoI requests to see climate change documents, but it does indicate that some vice-chancellors are not very interested in openness. This secretiveness is exactly the sort of thing that leads to lack of trust in universities and in science as a whole.

The one case that I have won took over three years and an Information Tribunal decision against the University of Central Lancashire (UCLAN) before I got anything.

UCLAN spent £80,307.95.(inc VAT at 17.5%) in legal expenses alone (plus heaven knows how much in staff time) to prevent us from seeing what was taught on their now defunct “BSc (Hons) homeopathy”. This does not seem to me to be good use of taxpayers’ money. A small sample of what was taught has already been posted (more to come). It is very obvious why the university wanted to keep it secret, and equally obvious that it is in the public interest that it should be seen.

UCLAN had dropped not only its homeopathy "degree" before the information was revealed, They also set up an internal inquiry into all the rest of their courses in magic medicine which ended with the dumping of all of them.

Well, not quite all, There was one left. An “MSc” in homeopathy by e-learning. Why this was allowed to continue after the findings of UCLAN’s internal review, heaven only knows. It is run by the same Kate Chatfield who ran the now defunct BSc. Having started to defend the reputation against the harm done to it by offering this sort of rubbish, I thought I should finish. So I asked for the contents of this course too. It is, after all, much the same title as the course that UCLAN had just been ordered to release. But no, this request too was met with a refusal

Worse still, the refusal was claimed under section 43(2) if the Freedom of Information Act 2000. That is the public interest defence, The very defence that was dismissed in scathing terms by the Information Tribunal less than two months ago,

To add insult to injury, UCLAN said that it would make available the contents of the 86 modules in the course under its publication scheme, at a cost of £20 per module, That comes to £1,720 for the course, Some freedom of information.

Because this was a new request, it now has to go through the process of an internal reviw of the decision before it can ne referred to the Information Commissioner. That will be requested, and since internal reviews have, so far, never changed the initial judgment. the appeal to the Information Commissioner should be submitted within the month. I have been promised that the Information Commissioner will deal with it much faster this time than the two years it took last time.

And a bit more unfreedom

Middlesex University

I first asked Middlesex for materials from their homeopathy course on 1 Oct 2008.  These courses are validated by Middlesex university (MU) but actually run by the Centre for Homeopathic Education. Thw MU site barely mentions homeopathy and all I got was the usual excuse that the uninsersity did not possess the teaching materials. As usual, the validation had been done without without looking at what was actually being taught. The did send me the validation document though [download it]   As usual, the validation document shows no sign at all of the fact that the usbject of the "BSc" is utter nonsense. One wonderful passage says

“. . . the Panel were assured that the Team are clearly producing practitioners but wanted to explore what makes these students graduates? The Team stated that the training reflects the professional standards that govern the programme and the graduateness is achieved through developing knowledge by being able to access sources and critically analyse these sources . . . “

Given that the most prominent characteristic of homeopaths (and other advocates of magic medicine) is total lack of critical ability, this is hilarious. If they had critical ability they wouldn’t be homeopaths. Hilarious is not quite the right word,  It is tragic that nonsense like this can be found in an official university document.

Middlesex, though it doesn’t advertise homeopathy, does advertise degrees in Traditional Chinese Medicine, Herbal Medicine and Ayurveda. On 2nd February 2010 I asked for teaching materials from these courses. Guess what? The request was refused. In this case the exemptions under FOIA were not even invoked but I was told that "All these materials are presently available only in one format at the University – via a student-only accessed virtual learning environment. ".  Seems that they can’t print out the bits that I asked for,  The internal review has been requested, then we shall see what the Information Commissioner has to say.

Two other cases are at present being considered by the Information Commissioner (Scotland), after requests under the Scottish FoIA were refused.  They are interesting cases because they bear on the decision, currently being considered by the government, about whether they should implement the recommendations of the execrable Pittilo report.

Napier University Edinburgh.  The first was for teaching material form the herbal medicine course at Napier University Edinburgh.  I notice that this course no longer appears in UCAS or on Napier’s own web site, so maybe the idea that its contents might be disclosed has been sufficient  to make the university do the sensible thing.

Robert Gordon University Aberdeen   The second request was for teaching material from the “Introduction to Homeopathy” course at the Robert Gordon University Aberdeen. The particular interest that attaches to this is that the vice-chancellor of Robert Gordon university is Michael Pittilo. The fact that he is willing to tolerate such a course in his own university seems to me to disqualify him from expressing any view on medical subjects.

Michael Pittilo, Crohn’s disease and Andrew Wakefield

Michael Pittilo has not been active in science for some time now, but Medline does show scientiifc publications for Pittilo RM, between 1979 anf 1998. Between 1989 and 1995 there are five papers published jointly with one Andrew Wakefield. These papers alleged a relationship between measles virus and Crohn’s disease. The papers were published before tha infamous 1998 paper by Wakefield in the Lancet (now retracted) that brought disgrace on Wakefield and probably caused unnecessary deaths.. The link between measles and Crohn’s disease is now equally disproved. 

The subject has been reviewed by Korzenik (2005) in Past and Current Theories of Etiology of IBD. Toothpaste, Worms, and Refrigerators

“Wakefield et al proposed that Crohn’s results from a chronic infection of submucosal endothelium of the intestines with the measles virus [Crohn’s disease: pathogenesis and persistent measles virus infection. Wakefield AJ, Ekbom A, Dhillon AP, Pittilo RM, Pounder RE., Gastroenterology, 1995, 108(3):911-6]”

"This led to considerable media interest and< public concern over use of live measles vaccine as well as other vaccines. A number of researchers countered these claims, with other studies finding that titers to measles were not increased in Crohn’s patients, granulomas were not associated with endothelium 49 , measles were not in granulomas50 and the measles vaccine is not associated with an increased risk of Crohn’s disease51–55 "

This bit of history is not strictly relevant to the Pittilo report, but I do find quite puzzling how the government chooses people from whom it wishes to get advice about medical problems.

Follow-up

I notice that the Robert Gordon university bulletin has announced that

“Professor Mike Pittilo, Principal of the University, has been made an MBE in the New Year Honours list for services to healthcare”.

That is a reward for writing a very bad report that has not yet been implemented, and one hopes, for the sake of patients, will never be implemented. I do sometimes wonder about the bizarre honours system in the UK.

Postcript.

On 16th February, the death of Michael Pittilo was announced. He had been suffeing from cancer and was only 55 years old. I wouldn’t wish that fate on my worst enemy.

Jump to follow-up

The Yuletide edition of the BMJ carries a lovely article by Jeffrey Aronson, Patent medicines and secret remedies. (BMJ 2009;339:b5415).

I was delighted to be asked to write an editorial about it, In fact it proved quite hard work, because the BMJ thought it improper to be too rude about the royal family, or about the possibility of Knight Starvation among senior medics. The compromise version that appeared in the BMJ is on line (full text link).

The changes were sufficient that it seems worth posting the original version (with links embedded for convenience).

The cuts are a bit ironic, since the whole point of the article is to point out the stifling political correctness that has gripped the BMA, the royal colleges, and the Department of Health when it comes to dealing with evidence-free medicine. It has become commonplace for people to worry about the future of the print media, The fact of the matter is you can often find a quicker. smarter amd blunter response to the news on blogs than you can find in the dead tree media. I doubt that the BMJ is in any danger of course. It has a good reputation for its attitude to improper drug company influence (a perpetual problem for clinical journals) as well as for clinical and science articles.  It’s great to see its editor, Fiona Godlee, supporting the national campaign for reform of the libel laws (please sign it yourself). 

The fact remains that when it comes to the particular problem of magic medicine, the action has not come from the BMA, the royal colleges, and certainly not from the Department of Health, It has come from what Goldacre called the “intrepid, ragged band of bloggers”. They are the ones who’ve done the investigative journalism, sent complaints and called baloney wherever they saw it. This article was meant to celebrate their collective efforts and to celebrate the fact that those efforts are beginning to percolate upwards to influence the powers that be.

It seems invidious to pick on one example, but if you want an example of beautiful and trenchant writing on one of the topics dealt with here, you’d be better off reading Andrew Lewis’s piece "Meddling Princes, Medical Regulation and Licenses to Kill” than anything in a print journal.

I was a bit disappointed by removal of the comment about the Prince of Wales.  In fact I’m not particularly republican compared with many of my friends.  The royal family is clearly good for the tourist industry and that’s important.  Since Mrs Thatcher (and her successors) destroyed large swathes of manufacturing and put trust in the vapourware produced by dishonest and/or incompetent bankers, it isn’t obvious how the UK can stay afloat.  If tourists will pay to see people driving in golden coaches, that’s fine.  We need the money.  What is absolutely NOT acceptable is for royals to interfere in the democratic political process.  That is what the Prince of Wales does incessantly.  No doubt he is well-meaning, but that is not sufficient.  If I wanted to know the winner of the 2.30 at Newmarket, it might make sense to ask a royal.  In medicine it makes no sense at all.  But the quality of the advice is irrelevant anyway.  The royal web site itself says “As a constitutional monarch, the Sovereign must remain politically neutral.”. Why does she not apply that rule to her son? Time to put him over your knee Ma’am?

Two of the major bits that were cut out are shown in bold, The many other changes are small.

BMJ editorial December 2009

Secret remedies: 100 years on

Time to look again at the efficacy of remedies

Jeffrey Aronson in his article [1] gives a fascinating insight into how the BMA, BMJ and politicians tried, a century ago, to put an end to the marketing of secret remedies.  They didn’t have much success. 

The problems had not improved 40 years later when A.J. Clark published his book on patent medicines [2]. It is astounding to see how little has changed since then.  He wrote, for example, “On the other hand the quack medicine vendor can pursue his advertising campaigns in the happy assurance that, whatever lies he tells, he need fear nothing from the interference of British law. The law does much to protect the quack medicine vendor because the laws of slander and libel are so severe.”>  Clark himself was sued for libel after he’d written in a pamphlet “ ‘Cures’ for consumption, cancer and diabetes may fairly be classed as murderous”. Although he initially tried to fight the case, impending destitution eventually forced him to apologise [3].  If that happened today, the accusation would have been repeated on hundreds of web sites round the world within 24 hours, and the quack would, with luck, lose [4].

As early as 1927, Clark had written “Today some travesty of physical science appears to be the most popular form of incantation” [5].  That is even more true today.  Homeopaths regularly talk utter nonsense about quantum theory [6] and ‘nutritional therapists’ claim to cure AIDS with vitamin pills or even with downloaded music files.  Some of their writing is plain delusional, but much of it is a parody of scientific writing. The style, which Goldacre [7] calls ‘sciencey’, often looks quite plausible until you start to check the references.

A 100 years on from the BMA’s efforts, we need once again to look at the efficacy of remedies.  Indeed the effort is already well under way, but this time it takes a rather different form.  The initiative has come largely from an “intrepid, ragged band of bloggers” and some good journalists, helped by many scientific societies, but substantially hindered by the BMA, the Royal Colleges, the Department of Health and a few vice-chancellors.  Even NICE and the MHRA have not helped much.  The response of the royal colleges to the resurgence in magic medicine that started in the 1970s seems to have been a sort of embarrassment.  They pushed the questions under the carpet by setting up committees (often populated with known sympathizers) so as to avoid having to say ‘baloney’.  The Department of Health, equally embarrassed, tends to refer the questions to that well-known medical authority, the Prince of Wales (it is his Foundation for Integrated Health that was charged with drafting National Occupational Standards in make-believe subjects like naturopathy [8].

Two recent examples suffice to illustrate the problems.

The first example is the argument about the desirability of statutory regulation of acupuncture, herbal and traditional Chinese medicine (the Pittilo recommendations) [9].

Let’s start with a definition, taken from ‘A patients’ guide to magic medicine’ [10]. “Herbal medicine: giving patients an unknown dose of an ill-defined drug, of unknown effectiveness and unknown safety”.

It seems to me to be self-evident that you cannot start to think about a sensible form of regulation unless you first decide whether what you are trying to regulate is nonsense, though this idea does not seem to have penetrated the thinking of the Department of Health or the authors of the Pittilo report.  The consultation on statutory regulation has had many submissions [11] that point out the danger to patients of appearing to give official endorsement of treatments that don’t work.  The good news is that there seems to have been a major change of heart at the Royal College of Physicians.  Their submission points out with admirable clarity that the statutory regulation of things that don’t work is a danger to patients (though they still have a blank spot about the evidence for acupuncture, partly as a result of the recent uncharacteristically bad assessment of the evidence by NICE [12]).  Things are looking up.  Nevertheless, after the public consultation on the report ended on November 16th, the Prince of Wales abused his position to make a well-publicised intervention on behalf of herbalists [13]Sometimes I think his mother should give him a firm lesson in the meaning of the term ‘constitutional monarchy’, before he destroys it.

The other example concerns the recent ‘evidence check: homeopathy’ conducted by the House of Commons Science and Technology Select Committee (SCITECH). First the definition [10]: “Homeopathy: giving patients medicines that contain no medicine whatsoever”.  When homeopathy was dreamt up, at the end of the 18th century, regular physicians were lethal blood-letters, and it’s quite likely that giving nothing saved people from them.  By the mid-19th century, discoveries about the real causes of disease had started, but homeopaths remain to this day stuck in their 18th century time warp. 

In 1842 Oliver Wendell Holmes said all that needed to be said about medicine-free medicine [14].  It is nothing short of surreal that the UK parliament is still discussing it in 2009.  Nevertheless it is worth watching the SCITECH proceedings [15].  The first two sessions are fun, if only for the statement by the Professional Standards Director of Boots that they sell homeopathic pills while being quite aware that they don’t work.  I thought that was rather admirable honesty.  Peter Fisher, clinical director of the Royal Homeopathic Hospital, went through his familiar cherry-picking of evidence, but at least repeated his condemnation of the sale of sugar pills for the prevention of malaria. 

But for pure comedy gold, there is nothing to beat the final session.  The health minister, Michael O’Brien, was eventually cajoled into admitting that there was no good evidence that homeopathy worked but defended the idea that the taxpayer should pay for it anyway.  It was much harder to understand the position of the chief scientific advisor in the Department of Health, David Harper.  He was evasive and ill-informed.  Eventually the chairman, Phil Willis, said “No, that is not what I am asking you. You are the Department’s Chief Scientist. Can you give me one specific reference which supports the use of homeopathy in terms of Government policy on health?”.  But answer came there none (well, there were words, but they made no sense). 

Then at the end of the session Harper said “homeopathic practitioners would argue that the way randomised clinical trials are set up they do not lend themselves necessarily to the evaluation and demonstration of efficacy of homeopathic remedies, so to go down the track of having more randomised clinical trials, for the time being at least, does not seem to be a sensible way forward.”  Earlier, Kent Woods (CEO of the MHRA) had said “the underlying theory does not really give rise to many testable hypotheses”.  These two eminent people seemed to have been fooled by the limp excuses offered by homeopaths.  The hypotheses are testable and homeopathy, because it involves pills, is particularly well suited to being tested by proper RCTs (they have been, and when done properly, they fail).  If you want to know how to do it, all you have to do is read Goldacre in the Guardian [16].

It really isn’t vert complicated.   “Imagine going to an NHS hospital for treatment and being sent away with nothing but a bottle of water and some vague promises.”  “And no, it’s not a fruitcake fantasy. This is homeopathy and the NHS currently spends around £10million on it.”

That was written by health journalist Jane Symons, in The Sun [17].  A Murdoch tabloid has produced a better account of homeopathy than anything that could be managed by the chief scientific advisor to the Department of Health.  And it isn’t often that one can say that.

These examples serve to show that the medical establishment is slowly being dragged, from the bottom up, into realising that matters of truth and falsehood are more important than their knighthoods.  It is all very heartening, both for medicine and for democracy itself.

David Colquhoun.

Declaration of interests. I was A.J. Clark chair of pharmacology at UCL, 1985 – 2004.

1.  Aronson, JK BMJ 2009;339:b5415

2.  Clark, A,J, (1938) Patent Medicines FACT series 14, London.  See also Patent medicines in 1938 and now  http://www.dcscience.net/?p=257
(A.J. Clark FRS was professor of Pharmacology at UCL from 1919 to 1926, and subsequently in Edinburgh).

3.  David Clark “Alfred Joseph Clark, A Memoir” (C. & J. Clark Ltd 1985 ISBN 0-9510401-0-3)

4.  Lewis, A. (2007) The Gentle Art of Homeopathic Killing

5.  A.J. Clark (1927) The historical aspect of quackery, BMJ October 1st 1927

6.  Chrastina, D  (2007) Quantum theory isn’t that weak,  (response to Lionel Milgrom).

7  Goldacre, B. (2008) Bad Science. HarperCollins

8. Skills for Health web site
   The ‘competences’ have been revised since the account at http://www.dcscience.net/?p=215#sfh, but are still preposterous make believe.

9. A very bad report: gamma minus for the vice-chancellor

10. A Patients’ Guide to Magic Medicine,  and also in the Financial Times.

11.  An excellent submission to the consultation on statutory regulation of alternative medicine (Pittilo report)

12.  NICE fiasco, part 2. Rawlins should withdraw guidance and start again

13. BBC news 1 December 2009 Prince Charles: ‘Herbal medicine must be regulated’.

14.  Oliver Wendell Holmes (1842) Homeopathy and Its Kindred Delusions.

15.  House of Commons Science and technology committee. Evidence check: homeopathy. Videos and transcripts available at  http://www.viewista.com/s/fywlp2/ez/1

16.  Goldacre, B.  A Kind of Magic  Guardian  16 November 2007.

17.   Homeopathy is resources drain says
Jane Symons.  The Sun 2 December 2009. 

Follow-up

There is a good account of the third SCITECH session by clinical science consultant, Majikthyse, at The Three Amigos.

16 December 2009.. Recorded an interview for BBC Radio 5 Live. It was supposed to go out early on 17th.

17 December 2009.  The editorial is mentioned in Editor’s Choice, by deputy editor Tony Delamothe. I love his way of putting the problem "too many at the top of British medicine seem frozen in the headlights of the complementary medicine bandwagon".  He sounds remarkably kind given that I was awarded (by the editor, Fiona Godlee, no less) a sort of booby prize at the BMJ party for having generated a record number of emails during the editing of a single editorial (was it really 24?). Hey ho.

17 December 2009.  More information on very direct political meddling by the Prince of Wales in today’s Guardian, and in Press Association report.

17 December 2009Daily Telegraph reports on the editorial, under the heading “ ‘Nonsense’ alternative medicines should not be regulated“. Not a bad account for a non-health journalist.

17 December 2009. Good coverage in the excellent US blog, Neurologica, by the superb Steven Novella.’ “Intrepid, Ragged Band of Bloggers” take on CAM‘ provides a chance to compare and contrast the problems in the UK and the USA.’

18 December 2009.  Article in The Times by former special advisor, Paul Richards. “The influence of Prince Charles the lobbyist is out of hand. Our deference stops us asking questions.”

“A good starting point might be publication of all correspondence over the past 30 years. Then we will know the extent, and influence, of Prince Charles the lobbyist.”

Comments in the BMJ Quite a lot of comments had appeared by January 8th, though sadly they were mostly from the usual suspects who appear every time one suggests evidence matters. A reply was called for, so I sent this (the version below has links).

After a long delay, this response eventually appeared in the BMJ on January 15 2010.

It’s good to see so many responses, though somewhat alarming to see that several of them seem to expect an editorial to provide a complete review of the literature.  I ‘ll be happy to provide references for any assertion that I made.

I also find it a bit odd that some people think that an editorial is not the place to express an opinion robustly.  That view seems to me to be a manifestation of the very sort of political correctness that I was deploring.  It’s a bit like the case when the then health minister, Lord Hunt, referred to psychic surgery as a “profession” when he should have called it a fraudulent conjuring trick.  Anything I write is very mild compared with what Thomas Wakley wrote in the Lancet, a journal which he founded around the time UCL came into existence. For example (I quote)

“[We deplore the] “state of society which allows various sets of mercenary, goose-brained monopolists and charlatans to usurp the highest privileges…. This is the canker-worm which eats into the heart of the medical body.” Wakley, T. The Lancet 1838-9, 1 

I don’t think it is worth replying to people who cite Jacques Benveniste or Andrew Wakefield as authorities.  Neither is it worth replying to people who raise the straw man argument about wicked pharmaceutical companies (about which I am on record as being as angry as anyone).  But I would like to reply directly to some of the more coherent comments.

Sam Lewis and Robert Watson. [comment] Thank you for putting so succinctly what I was trying to say.

Peter Fisher [comment].  I have a lot of sympathy for Peter Fisher.  He has attempted to do some good trials of homeopathy (they mostly had negative outcomes).  He said he was "very angry" when the non-medical homeopaths  were caught out recommending their sugar pills for malaria prevention (not that this as stopped such dangerous claims which are still commonplace).  He agreed with me that there was not sufficient scientific basis for BSc degrees in homeopathy.  I suppose that it isn’t really surprising that he continues to cherry pick the evidence.  As clinical director of the Royal London Homeopathic Hospital and Homeopathic physician to the Queen,  just imagine the cognitive dissonance that would result if he were to admit publicly that is all placebo after all.  He has come close though. His (negative) trial for homeopathic treatment of rheumatoid arthritis included the words "It seems more important to define if homeopathists can genuinely control patients’ symptoms and less relevant to have concerns about whether this is due to a ‘genuine’ effect or to influencing the placebo response” [2]. [download
the paper
].  When it comes to malaria, it matters a lot.

Adrian White [comment] seems to be cross because I cited my own blog.   I did that simply because if he follows the links there he will find the evidence.  In the case of acupuncture it has been shown time after time that "real" acupuncture does not differ perceptibly from sham.  That is true whether the sham consists of retractable needles or real needles in the "wrong" places.  A non-blind comparison between acupuncture and no acupuncture usually shows some advantage for the former but it is, on average, too small to be of much clinical significance [3]. I agree that there is no way to be sure that this advantage is purely placebo effect but since it is small and transient it really doesn’t matter much.  Nobody has put it more clearly than Barker Bausell in his book, Snake Oil Science [4]

White also seems to have great faith in peer review.  I agree that in real science it is probably the best system we have.  But in alternative medicine journals the "peers" are usually other true believers in whatever hocus pocus is being promoted and peer reveiw breaks down altogether.

R. M. Pittilo [comment] I’m glad that Professor Pittilo has replied in person because I did single out his report for particular criticism.  I agree that his report said that NHS funding should be available to CAM only where there is evidence of efficacy.  That was not my criticism.  My point was that in his report, the evidence for efficacy was assessed by representatives of Herbal Medicine, Chinese Medicine and Acupuncture (four from each).  Every one of them would have been out of work if they had found their subjects were nonsense and that, no doubt, explains why the assessment was so bad.  To be fair, they did admit that the evidence was not all that it might be and recommended (as always) more research   I’d like to ask Professor Pittilo how much money should be spent on more research in the light of the fact that over a billion dollars has been spent in the USA on CAM research without producing a single useful treatment.  Pittilo says "My own view is that both statutory regulation and the quest for evidence should proceed together" but he seems to neglect the possibility that the quest for evidence might fail. Experience in the USA suggests that is exactly what has, to a large extent, already happened.

I also find it quite absurd that the Pittilo report should recommend, despite a half-hearted admission that the evidence is poor, that entry to these subjects should be via BSc Honours degrees.  In any case he is already thwarted in that ambition because universities are closing down degrees in these subjects  having realised that the time to run a degree is after, not before, you have some evidence that the subject is not nonsense.  I hope that in due course Professor Pittilo may take the same action about the courses in things like homeopathy that are run by the university of which he is vice-chancellor.  That could only enhance the academic reputation of Robert Gordon’s University.

George Lewith [comment]  You must be aware that the proposed regulatory body, the Health Professions Council, has already broken its own rules about "evidence-based practice" by agreeing to take on, if asked, practitioners of Herbal Medicine, Chinese Medicine and Acupuncture.  They have (shamefully) excluded the idea that claims of efficacy would be regulated.  In other word they propose to provide exactly the sort of pseudo-regulation which would endanger patients   They are accustomed to the idea that regulation is to do only with censoring practitioners who are caught in bed with patients.  However meritorious that may be, it is not the main problem with pseudo-medicine, an area in which they have no experience.  I’m equally surprised that Lewith should recommend that Chinese evaluation of Traditional Chinese medicine should be included in meta-analyses, in view of the well-known fact that 99% of evaluations from China are positive: “No trial published in China or Russia/USSR found a test treatment to be ineffective” [5]. He must surely realise that medicine in China is a branch of politics.  In fact the whole resurgence in Chinese medicine and acupuncture in post-war times has less to do with ancient traditions than with Chinese nationalism, in particular the wish of Mao Tse-Tung to provide the appearance of health care for the masses (though it is reported that he himself preferred Western Medicine).

1. Lord Hunt thinks “psychic surgery” is a “profession”. http://www.dcscience.net/?p=258

2. Fisher, P. Scott, DL. 2001 Rheumatology 40, 1052 – 1055.   [pdf file]

3. Madsen et al, BMJ 2009;338:a3115  [pdf file]

4. R, Barker Bausell, Snake Oil Science, Oxford University Press, 2007

5. Vickers, Niraj, Goyal, Harland and Rees (1998, Controlled Clinical Trials, 19, 159-166) “Do Certain Countries Produce Only Positive Results? A Systematic Review of Controlled Trials”. [pdf file]

15 January 2010. During the SciTech hearings, Kent Woods (CEO of the MHRA) made a very feeble attempt to defend the MHRA’s decision to allow misleading labelling of homeopathic products. Now they have published their justification for this claim. It is truly pathetic, as explained by Martin at LayScience: New Evidence Reveals the MHRA’s Farcical Approach to Homeopathy. This mis-labelling cause a great outcry in 2006, as documented in The MHRA breaks its founding principle: it is an intellectual disgrace, and Learned Societies speak out against CAM, and the MHRA.

22 January 2010 Very glad to see that the minister himself has chosen to respond in the BMJ to the editorial

Rt Hon. Mike O’Brien QC MP, Minister of State for Health Services

I am glad that David Colquhoun was entertained by my appearance before the Health Select Committee on Homeopathy. But he is mistaken when he says, “you cannot start to think about a sensible form of regulation unless you first decide whether or not the thing you are trying to regulate is nonsense.”

Regulation is about patient safety. Acupuncture, herbal and traditional Chinese medicine involve piercing the skin and/or the ingestion of potentially harmful substances and present a possible risk to patients.

The Pittilo Report recommends statutory regulation and we have recently held a public consultation on whether this is a sensible way forward.

Further research into the efficacy of therapies such as Homeopathy is unlikely to settle the debate, such is the controversy surrounding the subject. That is why the Department of Health’s policy towards complementary and alternative medicines is neutral.

Whether I personally think Homeopathy is nonsense or not is besides the point. As a Minister, I do not decide the correct treatment for patients. Doctors do that. I do not propose on this occasion to interfere in the doctor-patient relationship.

Here is my response to the minister

I am very glad that the minister himself has replied. I think he is wrong in two ways, one relatively trivial but one very important.

First, he is wrong to refer to homeopathy as controversial. It is not. It is quite the daftest for the common forms of magic medicine and essentially no informed person believes a word of it. Of course, as minister, he is free to ignore scientific advice, just as the Home Secretary did recently. But he should admit that that is what he is doing, and not hide behind the (imagined) controversy.

Second, and far more importantly, he is wrong, dangerously wrong, to say it I was mistaken to claim that “you cannot start to think about a sensible form of regulation unless you first decide whether or not the thing you are trying to regulate is nonsense". According to that view it would make sense to grant statutory regulation to voodoo and astrology. The Pittilo proposals would involve giving honours degrees in nonsense if one took the minister’s view that it doesn’t matter whether the subjects are nonsense or not. Surely he isn’t advocating that?

The minister is also wrong to suppose that regulation, in the form proposed by Pittilo, would do anything to help patient safety. Indeed there is a good case to be made that it would endanger patients (not to mention endangering tigers and bears). The reason for that is that the main danger to patients arises from patients being given “remedies” that don’t work. The proposed regulatory body, the Health Professions Council, has already declared that it is not interested in whether the treatments work or not. That in itself endangers patients. In the case of Traditional Chinese Medicine, there is also a danger to patients from contaminated medicines. The HPC is not competent to deal with that either. It is the job of the MHRA and/or Trading Standards. There are much better methods of ensuring patient safety that those proposed by Pittilo.

In order to see the harm that can result from statutory regulation, it is necessary only to look at the General Chiropractic Council. Attention was focussed on chiropractic when the British Chiropractic Association decided, foolishly, to sue Simon Singh for defamation. That led to close inspection of the strength of the evidence for their claims to benefit conditions like infant colic and asthma. The evidence turned out to be pathetic, and the result was that something like 600 complaints were made to the GCC about the making of false health claims (including two against practices run by the chair of the GCC himself). The processing of these complaints is still in progress, but what is absolutely clear is that the statutory regulatory body, the GCC, had done nothing to discourage these false claims. On the contrary it had perpetrated them itself. No doubt the HPC would be similarly engulfed in complaints if the Pittilo proposals went ahead.

It is one thing to say that the government chooses to pay for things like homeopathy, despite it being known that they are only placebos, because some patients like them. It is quite another thing to endanger patient safety by advocating government endorsement in the form of statutory regulation, of treatments that don’t work.

I would be very happy to meet the minister to discuss the problems involved in ensuring patient safety. He has seen herbalists and other with vested interests. He has been lobbied by the Prince of Wales. Perhaps it is time he listened to the views of scientists too.

Both the minister’s response, and my reply, were reformatted to appear as letters in the print edition of the BMJ, as well as comments on the web..

Two weeks left to stop the Department of Health making a fool of itself. Email your response to tne Pittilo consultation to this email address HRDListening@dh.gsi.gov.uk

I’ve had permission to post a submission that has been sent to the Pittilo consultation. The whole document can be downloaded here. I have removed the name of the author. It is written by the person who has made some excellent contributions to this blog under the pseudonym "Allo V Psycho".

The document is a model of clarity, and it ends with constructive suggestions for forms of regulation that will, unlike the Pittilo proposals, really protect patients

Here is the summary. The full document explains each point in detail.

Executive Summary
Statutory regulation lends prestige, but needs to be balanced by a requirement for practitioners to be competent, as is the case for doctors and nurses. Regulation almost exclusively deals with conduct, but the unique risks posed by alternative medicine are not addressed by this. The harms which will arise from licensing practitioners who are not required to show evidence of competence and efficacy are:

  • Harm 1. Misdiagnosis of serious conditions.  Alternative practitioners offer to diagnose illnesses without proper training. This can lead to avoidable death, such as treating an ectopic pregnancy with ginger.
  • Harm 2. Withdrawal from treatment. Clients of alternative practitioners risk being encouraged to withdraw from life saving treatments in favours of treatments without evidence, as in the death of baby Gloria Thomas.
  • Harm 3. Harms arising from the nature of the alternative practice, but not covered by the regulatory framework, such as adulterated herbal remedies.
  • Harm 4.  Lack of informed consent. If alternative practitioners are not required to study or show evidence of efficacy, how can they inform patients of their options?
  • Harm 5. Equity. Doctors and nurses have to use evidence based methods, but it is proposed that alternative practitioners are not held to this standard. Is this fair? Health Minsters should ask themselves if they advocate withdrawing the requirement for evidence based treatment from doctors and nurses. If not, why not? And if not, why should alternative practitioners be treated differently?
  • Harm 6. Promotion of irrationality. If no evidence of efficacy is required, where do you draw the line? Witch doctoring is a ‘traditional practice’ in communities in the UK, and astrology is used by some herbal healers.
  • Harm 7. Opportunity Costs. If no evidence of efficacy is required of alternative medicine, significant sums will be wasted by individuals and by the NHS.
  • Harm 8. Reputational harms for UK Higher Education. UK Honours Degrees are based on the ability to think critically and to assess evidence. Alternative medicine Degree programmes do not require this. These positions are not compatible.
  • Harm 9.  Health care futures. We are making slow but steady progress on health indicators through the use of evidence based methods. Why should the requirement for evidence be abandoned now?

Instead, safe regulation of alternative practitioners should be through:

  • The Medicines and Healthcare Products Regulatory Agency
  • The Office of Trading Standards via the Unfair Trading Consumer Protection Regulations,
  • A new Health Advertising Standards Authority, modelled on the successful Cancer Act 1939.

The first two recommendations for effective regulation are much the same as mine, but the the third one is interesting. The problem with the Cancer Act (1939), and with the Unfair Trading regulations, is that they are applied very erratically. They are the responsibility of local Trading Standards offices, who have, as a rule, neither the expertise nor the time to enforce them effectively. A Health Advertising Standards Authority could perhaps take over the role of enforcing existing laws. But it should be an authority with teeth. It should have the ability to prosecute. The existing Advertising Standards Authority produces, on the whole, excellent judgements but it is quite ineffective because it can do very little.

A letter from an acupuncturist

I had a remarkable letter recently from someone who actually practises acupuncture. Here are some extracts.

“I very much enjoy reading your Improbable Science blog. It’s great to see good old-fashioned logic being applied incisively to the murk and spin that passes for government “thinking” these days.”

“It’s interesting that the British Acupuncture Council are in favour of statutory regulation. The reason is, as you have pointed out, that this will confer a respectability on them, and will be used as a lever to try to get NHS funding for acupuncture. Indeed, the BAcC’s mission statement includes a line “To contribute to the development of healthcare policy both now and in the future”, which is a huge joke when they clearly haven’t got the remotest idea about the issues involved.”

“Before anything is decided on statutory regulation, the British Acupuncture Council is trying to get a Royal Charter. If this is achieved, it will be seen as a significant boost to their respectability and, by implication, the validity of state-funded acupuncture. The argument will be that if Physios and O.T.s are Chartered and safe to work in the NHS, then why should Chartered Acupuncturists be treated differently? A postal vote of 2,700 BAcC members is under-way now and they are being urged to vote “yes”. The fact that the Privy Council are even considering it, is surprising when the BAcC does not even meet the requirement that the institution should have a minimum of 5000 members (http://www.privy-council.org.uk/output/Page45.asp). Chartered status is seen as a significant stepping-stone in strengthening their negotiating hand in the run-up to statutory regulation.”

“Whatever the efficacy of acupuncture, I would hate to see scarce NHS resources spent on well-meaning, but frequently gormless acupuncturists when there’s no money for the increasing costs of medical technology or proven life-saving pharmaceuticals.”

“The fact that universities are handing out a science degree in acupuncture is a testament to how devalued tertiary education has become since my day. An acupuncture degree cannot be called “scientific” in any normal sense of the term. The truth is that most acupuncturists have a poor understanding of the form of TCM taught in P.R.China, and hang on to a confused grasp of oriental concepts mixed in with a bit of New Age philosophy and trendy nutritional/life-coach advice that you see trotted out by journalists in the women’s weeklies. This casual eclectic approach is accompanied by a complete lack of intellectual rigour.

My view is that acupuncturists might help people who have not been helped by NHS interventions, but, in my experience, it has very little to do with the application of a proven set of clinical principles (alternative or otherwise). Some patients experience remission of symptoms and I’m sure that is, in part, bound up with the psychosomatic effects of good listening, and non-judgemental kindness. In that respect, the woolly-minded thinking of most traditional acupuncturists doesn’t really matter, they’re relatively harmless and well-meaning, a bit like hair-dressers. But just because you trust your hairdresser, it doesn’t mean hairdressers deserve the Privy Council’s Royal Charter or that they need to be regulated by the government because their clients are somehow supposedly “vulnerable”.”

Earlier postings on the Pittilo recommendations

A very bad report: gamma minus for the vice-chancellor http://www.dcscience.net/?p=235

Article in The Times (blame subeditor for the horrid title)
http://www.timesonline.co.uk/tol/comment/columnists/guest_contributors/article4628938.ece

Some follow up on The Times piece
http://www.dcscience.net/?p=251

The Health Professions Council breaks its own rules: the result is nonsense
http://www.dcscience.net/?p=1284

Chinese medicine -acupuncture gobbledygook revealed
http://www.dcscience.net/?p=1950

Consultation opens on the Pittilo report: help top stop the Department of Health making a fool of itself  http://www.dcscience.net/?p=2007

Why degrees in Chinese medicine are a danger to patients  http://www.dcscience.net/?p=2043

One month to stop the Department of Health endorsing quackery.  The Pittilo questionnaire, http://www.dcscience.net/?p=2310
 

Follow-up

More boring politics, but it matters.  The two main recommendations of this Pittilo report are that

  • Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine should be subject to statutory regulation by the Health Professions Council
  • Entry to the register should normally be through a Bachelor degree with Honours

For the background on this appalling report, see earlier posts.

A very bad report: gamma minus for the vice-chancellor

The Times (blame subeditor for the horrid title), and some follow up on the Times piece

The Health Professions Council breaks its own rules: the result is nonsense

Chinese medicine -acupuncture gobbledygook revealed

Consultation opens on the Pittilo report: help stop the Department of Health making a fool of itself 

Why degrees in Chinese medicine are a danger to patients

The Department of Health consultation shuts on November 2nd.  If you haven’t responded yet, please do.  It would be an enormous setback for reason and common sense if the government were to give a stamp of official approval to people who are often no more than snake-oil salesman.

Today I emailed my submission to the Pittilo consultation to the Department of Health, at HRDListening@dh.gsi.gov.uk

The submission

I sent the following documents, updated versions of those already posted earlier.

  • Submission to the Department of Health, for the consultation on the Pittilo report [download pdf].
  • What is taught in degrees in herbal and traditional Chinese medicine? [download pdf]
  • $2.5B Spent, No Alternative Med Cures [download pdf]
  • An example of dangerous (and probably illegal) claims that are routinely made by TCM practitioners [download pdf]f

I also completed their questionnaire, despite its deficiencies. In case it is any help to anyone, this is what I said:

The questionnaire

Q1: What evidence is there of harm to the public currently as a result of the activities of acupuncturists, herbalists and traditional Chinese medicine practitioners? What is its likelihood and severity?

Harm

No Harm

Unsure

Comment

The major source of harm is the cruel deception involved in making false claims of benefit to desperate patients. This applies to all three.

In the case of herbal and TCM there is danger from toxicity because herbal preparations are unstandardised so those that do contain an active ingredient are given in an unknown dose. This is irresponsible and dangerous (but would not be changed by the proposals for regulation).

In addition TCM suffers from recurrent problems of contamination with heavy metals, prescription drugs and so on. Again this would not be the business of the proposed form of regulation.

Q2: Would this harm be lessened by statutory regulation? If so, how?

Yes

No

Unsure

The proposed form of regulation would be no help at all. The HPC has already said that it is not concerned with whether or not the drug works, and, by implication, does not see itself as preventing false health claims (just as the GCC doesn’t do this). False claims are the responsibility of Trading Standards who are meant to enforce the Consumer Protection Unfair Trading Regulations (May 2008), though they do not at present enforce them very effectively. Also Advertisng Standards. The proposed regulation would not help, and could easily hinder public safety as shown by the fact that the GCC has itself been referred to the Advertisng Standards Authority.

The questions of toxicity and contamination are already the responsibility of Trading Standards and the MHRA. Regulation by the HPC would not help at all. The HPC is not competent to deal with such questions.

Q3: What do you envisage would be the benefit to the public, to practitioners and to businesses, associated with introducing statutory regulation?

Significant benefit

Some benefit

No benefit

Unsure

This question is badly formulated because the answer is different according to whether you are referring to the public, to practitioners or to businesses.

The public would be endangered by the form of regulation that is proposed, as is shown very clearly by the documents that I have submitted separately.

In the case of practitioners and businesses, there might be a small benefit, if the statutory regulation gave the impression that HM and TCM had government endorsement and must therefore be safe and effective.

There is also one way that the regulation could harm practitioners and businesses. If the HPC received a very large number of complaints about false health claims, just as the GCC has done recently, not only would it cost a large amount of money to process the claims, but the attendant bad publicity could harm practitioners. It is quite likely that this would occur since false claims to benefit sick people are rife in the areas of acupuncture, HM and TCM.

Q4: What do you envisage would be the regulatory burden and financial costs to the public, to practitioners, and to businesses, associated with introducing statutory regulation? Are these costs justified by the benefits and are they proportionate to the risks? If so, in what way?

Justified

Not Justified

Unsure

Certainly not justified. Given that I believe that the proposed form of regulation would endanger patients, no cost at all would be justified. But even if there were a marginal benefit, the cost would be quite unjustified. The number of practitioners involved is very large. It would involve a huge expansion of an existing quango, at a time when the government is trying to reduce the number of quangos. Furthermore, if the HPC were flooded with complaints about false health claims, as the GCC has been, the costs in legal fees could be enormous.

Q5: If herbal and TCM practitioners are subject to statutory regulation, should the right to prepare and commission unlicensed herbal medicines be restricted to statutorily regulated practitioners?

Yes

No

Unsure

I don’t think it would make much difference. The same (often false) ideas are shared by all HM people and that would continue to be the same with or without SR.

Q6: If herbal and TCM practitioners are not statutorily regulated, how (if at all) should unlicensed herbal medicines prepared or commissioned by these practitioners be regulated?

They could carry on as now, but the money that would have been spent on SR should instead be used to give the Office of Trading Standards and the MHRA the ability to exert closer scrutiny and to enforce more effectively laws that already exist. Present laws, if enforced, are quite enough to protect the public.

Q7: What would be the effect on public, practitioners and businesses if, in order to comply with the requirements of European medicines legislation, practitioners were unable to supply manufactured unlicensed herbal medicines commissioned from a third party?

Significant effect

Some effect

No effect

Unsure

European laws,especialliy in food area, are getting quite strict about the matters of efficacy. The proposed regulation, which ignores efficacy, could well be incompatible with European law, if not now, then soon. This would do no harm to legitimate business though it might affect adversely businesses which make false claims (and there are rather a lot of the latter).

Q8: How might the risk of harm to the public be reduced other than by orthodox statutory regulation? For example by voluntary self-regulation underpinned by consumer protection legislation and by greater public awareness, by accreditation of voluntary registration bodies, or by a statutory or voluntary licensing regime?

Voluntary self-regulation

Accreditation of voluntary bodies

Statutory or voluntary licensing

Unsure

I disagree with the premise, for reasons given in detail in separate documents. I believe that ‘orthodox statutory regulation’, if that means the Pittilo proposals, would increase, not decrease, the risk to the public. Strengthening the powers of Trading Standards, the MHRA and such consumer protection legislation would be far more effective in reducing risk to the public than the HPC could ever be.  Greater public awareness of the weakness of the evidence for the efficacy of these treatments would obviously help too, but can’t do the job on its own.

Q10: What would you envisage would be the benefits to the public, to practitioners, and to businesses, for the alternatives to statutory regulation outlined at Question 8?

It depends on which alternative you are referring to. The major benefit of enforcement of existing laws by Trading Standards and/or the MHRA would be (a) to protect the public from risk, (b) to protect the public from health fraud and (c) almost certainly lower cost to the tax payer.

Q11: If you feel that not all three practitioner groups justify statutory regulation, which group(s) does/do not and please give your reasons why/why not?

Acupuncture

Herbal Medicine

TCM

Unsure

None of them. The differences are marginal. In the case of acupuncture there has been far more good research than for HM or TCM. But the result of that research is to show that in most cases the effects are likely to be no more than those expected of a rather theatrical placebo. Furthermore the extent to which acupuncture has a bigger effect than no-acupuncture in a NON-BLIND comparison, is usually too small and transient to offer any clinical advantage (so it doesn’t really matter whether the effect is placebo or not, it is too small to be useful).

In the case of HM, and even more of TCM, there is simply not enough research to give much idea of their usefulness,  with a small handful of exceptions.

This leads to a conclusion that DH seems to have ignored in the past. It makes absolutely no sense to talk about “properly trained practitioners” without first deciding whether the treatments work or not. There can be no such thing as “proper training” in a discipline that offers no benefit over placebo. It is a major fault of the Pittilo recommendations that they (a) ignore this basic principle and (b) are very over-optimistic about the state of the evidence.

Q12: Would it be helpful to the public for these practitioners to be regulated in a way which differentiates them from the regulatory regime for mainstream professions publicly perceived as having an evidence base of clinical effectiveness? If so, why? If not, why not?

Yes

No

Unsure

It might indeed be useful if regulation pointed out the very thin evidence base for HM and TCM but it would look rather silly. The public would say how can it be that the DH is granting statutory regulation to things that don’t work?

Q13: Given the Government’s commitment to reducing the overall burden of unnecessary statutory regulation, can you suggest which areas of healthcare practice present sufficiently low risk so that they could be regulated in a different, less burdensome way or de-regulated, if a decision is made to statutorily regulate acupuncturists, herbalists and traditional Chinese medicine practitioners?

Yes

No

Unsure

As stated above, the.only form of regulation that is needed, and the only form that would protect the public, is through consumer protection regulations, most of which already exist (though they are enforced in a very inconsistent way). Most statutory regulation is objectionable, not on libertarian grounds, but because it doesn’t achieve the desired ends (and is expensive). In this case of folk medicine, like HM and TCM, the effect would be exactly the opposite of that desired as shown in separate documents that I have submitted to the consultation.

Q14: If there were to be statutory regulation, should the Health Professions Council (HPC) regulate all three professions? If not, which one(s) should the HPC not regulate?

Yes

No

Unsure

The HPC should regulate none of them. It has never before regulated any form of alternative medicine and it is ill-equipped to do so. Its statement that it doesn’t matter that there is very little evidence that the treatments work poses a danger to patients (as well as being contrary to its own rules).

Q15: If there were to be statutory regulation, should the Health Professions Council or the General Pharmaceutical Council/Pharmaceutical Society of Northern Ireland regulate herbal medicine and traditional Chinese medicine practitioners?

HPC

GPC/PSNI

Unsure

Neither. The GPC is unlikely to care about whether the treatments work any more than the RPSGB did, or the GCC does now. The problems would be exactly the same whichever body did it.

Q16: If neither, who should and why?

As I have said repeatedly, it should be left to Trading Standards, the MHRA and other consumer protection regulation.

Q17:

a) Should acupuncture be subject to a different form of regulation from that for herbalism and traditional Chinese medicine? If so, what?

Yes

No

Unsure

b) Can acupuncture be adequately regulated through local means, for example through Health and Safety legislation, Trading Standards legislation and Local Authority licensing?

Yes

No

Unsure

(a) No -all should be treated the same. Acupuncture is part of TCM

(b) Yes

Q18.

a) Should the titles acupuncturist, herbalist and [traditional] Chinese medicine practitioner be protected?

b) If your answer is no which ones do you consider should not be legally protected?

Yes

No

Unsure

No. It makes no sense to protect titles until such time as it has been shown that the practitioners can make a useful contribution to medicine (above placebo effect). That does not deny that placebos may be useful at times. but if that is all they are doing, the title should be ‘placebo practitioners’.

Q19: Should a new model of regulation be tested where it is the functions of acupuncture, herbal medicine and TCM that are protected, rather than the titles of acupuncturist, herbalist or Chinese medicine practitioner?

Yes

No

Unsure

No. This makes absolutely no sense when there is so little knowledge about what is meant by the ” functions of acupuncture, herbal medicine and TCM”.Insofar as they don’t work (better than placebo), there IS no function. Any attempt to define function when there is so little solid evidence (at least for HM and TCM) is doomed to failure.

Q20: If statutory professional self-regulation is progressed, with a model of protection of title, do you agree with the proposals for “grandparenting” set out in the Pittilo report?

Yes

No

Unsure

No. I believe the Pittilo report should be ignored entirely. The whole process needs to be thought out again in a more rational way.

Q22: Could practitioners demonstrate compliance with regulatory requirements and communicate effectively with regulators, the public and other healthcare professionals if they do not achieve the standard of English language competence normally required for UK registration? What additional costs would occur for both practitioners and regulatory authorities in this case?

Yes

No

Unsure

No. It is a serious problem, in TCM especially, that many High Street practitioners speak hardly any English at all. That adds severely to the already considerable risks. There would be no reliable way to convey what was expected of them. it would be absurd for the taxpayer to pay for them to learn English for the purposes of practising TCM (of course there might be the same case as for any other immigrant for teaching English on social grounds).

Q23: What would the impact be on the public, practitioners and businesses (financial and regulatory burden) if practitioners unable to achieve an English language IELTS score of 6.5 or above are unable to register in the UK?

Significant impact

Some impact

No impact

Unsure

The question is not relevant. The aim of regulation is to protect the public from risk (and it should be, but isn’t, an aim to protect them from health fraud). It is not the job of regulation to promote businesses

Q24: Are there any other matters you wish to draw to our attention?

I have submitted three documents via HRDListening@dh.gsi.gov.uk. The first of these puts the case against the form of regulation proposed by Pittilo, far more fluently than is possible in a questionnaire.
Another shows examples of what is actually taught in degrees in acupuncture, HM and TCM. They show very graphically the extent to which the Pittilo proposals would endanger the public, if they were to be implemented..

Jump to follow-up

The King’s Fund recently published Assessing complementary practice Building consensus on appropriate research methods [or download pdf].

Report title

It is described as being the “Report of an independent advisory group”. I guess everyone knows by now that an “expert report” can be produced to back any view whatsoever simply by choosing the right “experts”, so the first things one does is to see who wrote it.  Here they are.

  • Chair: Professor Dame Carol Black
  • Harry Cayton, Chief Executive, Council for Healthcare Regulatory Excellence
  • Professor Adrian Eddleston, then Vice-Chairman, The King’s Fund
  • Professor George Lewith, Professor of Health Research, Complementary and Integrated Medicine Research Unit, University of Southampton
  • Professor Stephen Holgate, MRC Clinical Professor of Immunopharmacology, University of Southampton
  • Professor Richard Lilford, Head of School of Health and Population Sciences, University of Birmingham

We see at once two of the best known apologists for alternative medicine, George Lewith (who has appeared here more than once) and Stephen Holgate

Harry Cayton is CEO of Council for Healthcare Regulatory Excellence (CHRE) which must be one of the most useless box-ticking quangos in existence. It was the CHRE that praised the General Chiropractic Council (GCC) for the quality of its work.  That is the same GCC that is at present trying to cope with 600 or so complaints about the people it is supposed to regulate (not to mention a vast number of complaints to Trading Standards Offices).  The GCC must be the prime example of the folly of giving government endorsement to things that don’t work. But the CHRE were not smart enough to spot that little problem.  No doubt Mr Cayton did good work for the Alzheimer’s Society.  His advocacy of patient’s choice may have helped me personally.  But it isn’t obvious to me that he is the least qualified to express an opinion on research methods in anything whatsoever. According to the Guardian he is “BA in English and linguistics from the University of Ulster; diploma in anthropology from the University of Durham; B Phil in philosophy of education from the University of Newcastle.”

Adrian Eddlestone is a retired Professor of Medicine. He has been in academic administration since 1983. His sympathy for alternative medicine is demonstrated by the fact that he is also Chair of the General Osteopathic Council, yet another “regulator” that has done nothing to protect the public
from false health claims (and which may, soon, find itself in the same sort of trouble as the GCC).

Richard Lilford is the only member of the group who has no bias towards alternative medicine and also the only member with expertise in clinical research methods  His credentials look impressive, and his publications show how he is the ideal person for this job. I rather liked also his article Stop meddling and let us get on.. He has written about the harm done by postmodernism and relativism, the fellow-travellers of alternative medicine.

Most damning of all, Lewith, Eddlestone and Holgate (along with Cyril Chantler, chair of the King’s Fund, and homeopaths, spiritual healers and Karol Sikora) are Foundation Fellows of the Prince of Wales Foundation for Magic Medicine, an organisation that is at the forefront of spreading medical misinformation.

I shall refer here to ‘alternative medicine’ rather than ‘complementary medicine’ which is used in the report. It is not right to refer to a treatment as ‘complementary’ until such time as it has been shown to work. The term ‘complementary’ is a euphemism that, like ‘integrative’, is standard among alternative medicine advocates whose greatest wish is to gain respectability.

The Report

Kings Fund logo

The recommendations

On page 10 we find a summary of the conclusions.

The report identifies five areas of consensus, which together set a framework for moving forward. These are:

  • the primary importance of controlled trials to assess clinical and cost effectiveness.
  • the importance of understanding how an intervention works
  • the value of placebo or non-specific effects
  • the need for investment and collaboration in creating a sound evidence base
  • the potential for whole-system evaluation to guide decision-making and subsequent research.

The first recommendation is just great. The rest sound to me like the usual excuses for incorporating ineffective treatments into medical practice. Notice the implicit assumption in the fourth point
that spending money on research will establish “a sound evidence base". There is a precedent, but it is ignored. A huge omission from the report is that it fails to mention anywhere that a lot of research has already been done.

Much research has already been done (and failed)

The report fails to mention at all the single most important fact in this area. The US National Institutes of Health has spent over a billion dollars on research on alternative medicines, over a period
of more than 10 years. It has failed to come up with any effective treatments whatsoever. See, for example Why the National Center for Complementary and Alternative Medicine (NCCAM) Should Be Defunded;   Should there be more alternative research?;   Integrative baloney @ Yale, and most recently, $2.5B Spent, No Alternative Med Cures found. .

Why did the committee think this irrelevant? I can’t imagine. You guess.

The report says

“This report outlines areas of potential consensus to guide research funders, researchers, commissioners and complementary practitioners in developing and applying a robust evidence base for complementary practice.”

As happens so often, there is implicit in this sentence the assumption that if you spend enough money evidence will emerge. That is precisely contrary to the experence in the USA where spending a billion dollars produced nothing beyond showing that a lot of things we already thought didn’t work were indeed ineffective.

And inevitably, and tragically, NICE’s biggest mistake is invoked.

“It is noteworthy that the evidence is now sufficiently robust for NICE to include acupuncture as a treatment for low back pain.” [p ]

Did the advisory group not read the evidence used (and misinterpeted) by NICE? It seems not. Did the advisory group not read the outcome of NIH-funded studies on acupuncture as summarised by Barker Bausell in his book, Snake Oil Science? Apparently not. It’s hard to know because the report has no references.

George Lewith is quoted [p. 15] as saying “to starve the system of more knowledge means we will continue to make bad decisions”. No doubt he’d like more money for research, but if a billion dollars
in the USA gets no useful result, is Lewith really likely to do better?

The usual weasel words of the alternative medicine industry are there in abundance

“First, complementary practice often encompasses an intervention (physical treatment or manipulation) as well as the context for that intervention. Context in this setting means both the physical setting for the delivery of care and the therapeutic relationship between practitioner and patient.” [p. 12]

Yes, but ALL medicine involves the context of the treatment. This is no different whether the medicine is alternative or real. The context (or placebo) effect comes as an extra bonus with any sort of treatment.

“We need to acknowledge that much of complementary practice seeks to integrate the positive aspects of placebo and that it needs to be viewed as an integral part of the treatment rather than an aspect that should be isolated and discounted.” [p. 13]

This is interesting. It comes very close (here and elsewhere) to admitting that all you get is a placebo effect, and that this doesn’t matter. This contradicts directly the first recommendation of the House of Lords report (2000).. Both the House of Lords report on Complementary and Alternative Medicine, and the Government’s response to it, state clearly

“. . . we recommend that three important questions should be addressed in the following order”. (1) does the treatment offer therapeutic benefits greater than placebo? (2)  is the treatment safe? (3) how does it compare, in medical outcome and cost-effectiveness, with other forms of treatment?.

The crunch comes when the report gets to what we should pay for.

“Should we be prepared to pay for the so-called placebo effect?

The view of the advisory group is that it is appropriate to pay for true placebo (rather than regression to the mean or temporal effects).” [p 24]

Perhaps so, but there is very little discussion of the emormous ethical questions:that this opinion raises: 

  • How much is one allowed to lie to patients in order to elicit a placebo effect?
  • Is is OK if the practitioner believes it is a placebo but gives it anyway?
  • Is it OK if the pratitioner believes that it is not a placebo when actually it is?
  • Is it OK for practitioners to go degrees taught by people who believe that it is not a placebo when actually it is?

The report fails to face frankly these dilemmas.  The present rather absurd position in which it is considered unethical for a medical practitioner to give a patient a bottle of pink water, but
perfectly acceptable to refer them to a homeopath. There is no sign either of taking into account the cultural poison that is spread by telling people about yin, yang and meridians and such like preposterous made-up mumbo jumbo.  That is part of the cost of endorsing placebos. And just when one thought that believing things because you wished they were true was going out of fashion

Once again we hear a lot about the alleged difficulties posed by research on alternative medicine. These alleged difficulties are, in my view, mostly no more than excuses. There isn’t the slightest
difficulty in testing things like herbal medicine or homeopathy, in a way that preserves all the ‘context’ and the ways of working of homeopaths and herbalists. Anyone who reads the Guardian knows
how to do that.

In the case of acupuncture, great ingenuity has gone into divising controls. The sham and the ‘real’ acupuncture always come out the same. In a non-blind comparison between acupuncture and no acupuncture the latter usually does a bit worse, but the effects are small and transient and entirely compatible with the view that it is a theatrical placebo.

Despite these shortcomings, some of the conclusions [p. 22] are reasonable.

“The public needs more robust evidence to make informed decisions about the use of complementary practice.

Commissioners of public health care need more robust evidence on which to base decisions about expenditure of public money on complementary practice.”

What the report fails to do is to follow this with the obvious conclusion that such evidence is largely missing and that until such time as it is forthcoming there should be no question of the NHS paying for alternative treatments.

Neither should there be any question of giving them official government recognition in the form of ‘statutory regulation’. The folly of doing that is illustrated graphically by the case of chiropractic which is now in deep crisis after inspection of its claims in the wake of the Simon Singh defamation case. Osteopathy will, I expect, suffer the same fate soon.

In the summary on p.12 we see a classical case of the tension

Controlled trials of effectiveness and cost-effectiveness are of primary importance

We recognise that it is the assessment of effectiveness that is of primary importance in reaching a judgement of different practices. Producing robust evidence that something works in practice – that it is effective – should not be held up by the inevitably partial findings and challenged interpretations arising from inquiries into how the intervention works.

The headline sounds impeccable, but directly below it we see a clear statement that we should use treatments before we know whether they work.  “Effectiveness”, in the jargon of the alternative medicine business, simply means that uncontrolled trials are good enough. The bit about “how it works” is another very common red herring raised by alternative medicine people. Anyone who knows anything about pharmacology that knowledge about how any drug works is incomplete and often turns out to be wrong. That doesn’t matter a damn if it performs well in good double-blind randomised controlled trials.

One gets the impression that the whole thing would have been a lot worse without the dose of reality injected by Richard Lilford. He is quoted as a saying

“All the problems that you find in complementary medicine you will encounter in some other kind of treatment … when we stop and think about it… how different is it to any branch of health care – the answer to emerge from our debates is that it may only be a matter of degree.” [p. 17]

I take that to mean that alternative medicine poses problems that are no different from other sorts of treatment. They should be subjected to exactly the same criteria. If they fail (as is usually the case) they should be rejected.  That is exactly right.  The report was intended to produce consensus, but throughout the report, there is a scarcely hidden tension between believers on one side, and Richard Lilford’s impeccable logic on the other.

Who are the King’s Fund?

The King’s Fund is an organisation that states its aims thus.

“The King’s Fund creates and develops ideas that help shape policy, transform services and bring about behaviour change which improve health care.”

It bills this report on its home page as “New research methods needed to build evidence for the effectiveness of popular complementary therapies”. But in fact the report doesn’t really recommend ‘new research methods’ at all, just that the treatments pass the same tests as any other treatment. And note the term ‘build evidence’.  It carries the suggestion that the evidence will be positive.   Experience in the USA (and to a smaller extent in the UK) suggests that every time some good research is done, the effect is not to ‘build evidence’ but for the evidence to crumble further

If the advice is followed, and the results are largely negative, as has already happened in the USA, the Department of Health would look pretty silly if it had insisted on degrees and on statutory regulation.

The King’s Fund chairman is Sir Cyril Chantler and its Chief Executive is Niall Dickson.  It produces reports, some of which are better than this one. I know it’s hard to take seriously an organisation that wants to “share its vision” withyou, but they are trying.

“The King’s Fund was formed in 1897 as an initiative of the then Prince of Wales to allow for the collection and distribution of funds in support of the hospitals of London. Its initial purpose was to raise money for London’s voluntary hospitals,”

It seems to me that the King’s Fund is far too much too influenced by the present Prince of Wales. He is, no doubt, well-meaning but he has become a major source of medical misinformation and his influence in the Department of Health is deeply unconstitutional.  I was really surprised to see thet Cyril Chantler spoke at the 2009 conference of the Prince of Wales Foundation for Integrated Health, despite having a preview of the sort of make-believe being propagated by other speakers. His talk there struck me as evading all the essential points. Warm, woolly but in the end, a danger to patients. Not only did he uncritically fall for the spin on the word “integrated”, but he also fell for the idea that “statutory regulation” will safeguard patients.

Revelation of what is actually taught on degrees in these subjects shows very clearly that they endanger the public.

But the official mind doesn’t seem ever to look that far. It is happy ticking boxes and writing vacuous managerialese. It lacks curiosity.

Follow-up

The British Medical Journal published today an editorial which also recommends rebranding of ‘pragmatic’ trials.  No surprise there, because the editorial is written by Hugh MacPherson, senior research fellow, David Peters, professor of integrated healthcare and Catherine Zollman, general practitioner. I find it a liitle odd that the BMJ says “Competing Interests: none. David Peters interest is obvious from his job description. It is less obvious that Hugh MacPherson is an acupuncture enthusiast who publishes mostly in alternative medicine journals. He has written a book with the extraordinary title “Acupuncture Research, Strategies for Establishing an Evidence Base”. The title seems to assume that the evidence base will materialise eventually despite a great deal of work that suggests it won’t. Catherine Zollman is a GP who is into homeopathy as well as acupuncture. All three authors were speakers at the Prince of Wales conference, described at Prince of Wales Foundation for magic medicine: spin on the meaning of ‘integrated’.

The comments that follow the editorial start with an excellent contribution from James Matthew May. His distinction between ‘caring’ and ‘curing’ clarifies beautifully the muddled thinking of the editorial.

Then a comment from DC, If your treatments can’t pass the test, the test must be wrong. It concludes

“At some point a stop has to be put to this continual special pleading. The financial crisis (caused by a quite different group of people who were equally prone to wishful thinking) seems quite a good time to start.”

This post has been translated into Belorussian..

Chinese medicine and herbal medicine are in the news at the moment.  There is a real risk that the government could endorse them by accepting the Pittilo report.

In my view traditional Chinese medicine endangers people.   The proposed ‘regulation’ would do nothing to protect the public.  Quite on the contrary, it would add to the dangers, by giving an official stamp of approval while doing nothing for safety.

The government’s idea of improving safety is to make sure that practitioners are ‘properly trained’.  But it is the qualifications that cause the danger in the first place.  The courses teach ideas that are plain wrong and often really dangerous. 

Why have government (and some universities) not noticed this?  That’s easy to see. Governments, quangos and university validation committees simply don’t look.  They tick boxes but never ask what actually goes on.  Here’s some examples of what goes on for them to think about. They show clearly the sort of dangerous rubbish that is taught on some of these ‘degrees’.

These particular slides are from the University of Westminster, but similar courses exist in only too many other places.  Watch this space for more details on courses at Edinburgh Napier University, Middlesex University and the University of East London

slide 1

Just a lot of old myths. Sheer gobbledygook,

slide 2

SO much for a couple of centuries of physiology,

slide 7

It gets worse.

slide 8

Plain wrong.

slide 21

Curious indeed.  The fantasy gobbledygook gets worse.

slide 16

Now it is getting utterly silly. Teaching students that the brain is made of marrow is not just absurd, but desperately dangerous for anyone unlucky (or stupid) enough to go to such a person when they are ill.

Here’s another herbal lecture., and this time the topic is serious. Cancer.

Herbal approaches for patients with cancer.

I’ve removed the name of the teacher to spare her the acute embarrassment of having these dangerous fantasies revealed.  The fact that she probably believes them is not a sufficient excuse for endangering the public. There is certainly no excuse for the university allowing this stuff to be taught as part of a BSc (Hons).

slide 1

First get them scared with some bad statistics.

slide 2

No fuss there about distinguishing incidence, age-standardisation and death rates. And no reference. Perhaps a reference to the simple explanation of statistics at Cancer Research UK might help? Perhaps this slide would have been better (from CDC). Seems there is some mistake in slide 2.

cance death rates

Straight on to a truly disgraceful statement in slide 3

slide 3

The is outrageous and very possibly illegal under the Cancer Act (1939).  It certainly poses a huge danger to patients.  It is a direct incentive to make illegal, and untrue claims by using weasel words in an attempt to stay just on the right side of the law. But that, of course, is standard practice in alternative medicine,

slide 11

Slide 11 is mostly meaningless. “Strengthen vitality” sounds good but means nothing. And “enhancing the immune system” is what alternative medicine folks always say when they can think of nothing else. Its meaning is ill-defined and there is no reason to think that any herbs do it.

The idea of a ‘tonic’ was actually quite common in real medicine in the 1950s. The term slowly vanished as it was realised that it was a figment of the imagination. In the fantasy world of alternative medicine, it lives on.

Detoxification, a marketing term not a medical one, has been extensively debunked quite recently.  The use of the word by The Prince of Wales’ company, Duchy Originals recently fell foul of the Advertising Standards Authority, and his herbal ‘remedies’ were zapped by the MHRA (Medicines and Health Regulatory Authority).

And of course the antioxidant myth is a long-disproved hypothesis that has become a mere marketing term. 

 

slide 16

“Inhibits the recurrence of cancer”!   That sounds terrific. But if it is so good why is it not even mentioned in the two main resources for information about herbs?

In the UK we have the National Library for Health Complementary and Alternative Medicine Specialist Library (NeLCAM), now a part of NHS Evidence.  It was launched in 2006.  The clinical lead was none other than Peter Fisher, clinical director of the Royal London Homeopathic Hospital, and the Queen’s homeopathic physician. The library was developed with the School of Integrated Health at the University of Westminster (where this particular slide was shown to undergraduates). Nobody could accuse these people of being hostile to magic medicine,

It seems odd, then, that NeLCAM does not seem to thnk to think that Centella asiatica, is even worth mentioning.

In the USA we have the National Center for Alternative and Complementary Medicine (NCCAM), an organisation that is so friendly to alternative medicine that it has spent a billion dollars on research in the area, though it has produced not a single good treatment for that vast expenditure. But NCCAM too does not even mention Centella asiatica in its herb list. It does get a mention in Cochrane reviews but only as a cosmetic cream and as an unproven treatment for poor venous circulation in the legs.

slide 21

What on earth is a “lymph remedy”. Just another marketing term?

especially valuable in the treatment of breast, throat and uterus cancer.

That is a very dramatic claim. It as as though the hapless students were being tutored in doublespeak. What is meant by “especially valuable in the treatment of”? Clearly a desperate patient would interpret those words as meaning that there was at least a chance of a cure. That would be a wicked deception because there isn’t the slightest reason to think it works. Once again there this wondrous cure is not even mentioned in either NELCAM or NCCAM.  Phytolacca is mentioned, as Pokeweed, in Wikipedia but no claims are mentioned even there. And it isn’t mentioned in Cochrane reviews either. The dramatic claims are utterly unfounded.

slide 23

Ah the mistletoe story, again.

NHS Evidence (NeLCAM) lists three completed assessments. One concludes that more research is needed. Another concludes that “Rigorous trials of mistletoe extracts fail to demonstrate efficacy of this therapy”, and the third says “The evidence from RCTs to support the view that the application of mistletoe extracts has impact on survival or leads to an improved ability to fight cancer or to withstand anticancer treatments is weak”.

NCCAM says of mistletoe

  • More than 30 human studies using mistletoe to treat cancer have been done since the early 1960s, but major weaknesses in many of these have raised doubts about their findings (see Question 6).
  • Very few bad side effects have been reported from the use of mistletoe extract, though mistletoe plants and berries are poisonous to humans (see Question 7).
  • The U.S. Food and Drug Administration (FDA) has not approved mistletoe as a treatment for cancer or any other medical condition (see Question 8).
  • The FDA does not allow injectable mistletoe to be imported, sold, or used except for clinical research (see Question 8).

Cochrane reviews lists several reviews of mistletoe with similar conclusions. For example “The evidence from RCTs to support the view that the application of mistletoe extracts has impact on survival or leads to an improved ability to fight cancer or to withstand anticancer treatments is weak”.

Anthroposophy is one of the highest grades of fantasy you can find.  A post on that topic is in the works.

slide 25

Indicated for cancers  . . . colon/rectal, uterine, breast, lung“. A cure for lung cancer? That, of course, depends on how you interpret the weasel words “indicated for”. Even Wikipedia makes no mention of any claims that Thuja benefits cancer. NHS Evidence (NeLCAM) doesn’t mention Thuja for any indication. Neither does NCCAM. Nor Cochrane reviews. That is not the impression the hapless students of this BSc lecture were given.  In my view suggestions that you can cure lung cancer with this tree are just plain wicked.

slide 27

Pure snake oil, and not even spelled correctly, Harry Hoxsey’s treatment centres in the USA were closed by court order in the 1950s.

slide 28

At least this time it is stated that there is no hard evidence to support this brand of snake oil.

slide 30

More unfounded claims when it says “treated successfully many cancer patients”. No references and no data to support the claim.  It is utterly unfounded and claims to the contrary endanger the public.

slide 31

Gerson therapy is one of the most notorious and unpleasant of the quack cancer treatments. The Gerson Institute is on San Diego, but their clinics are in Mexico and Hungary. It is illegal in the USA. According to the American Cancer Society you get “a strict low-salt, low-fat, vegetarian diet and drinking juice from about twenty pounds of fresh fruits and vegetables each day. One glass of juice is consumed each hour, thirteen times a day. In addition, patients are given several coffee enemas each day. Various supplements, such as potassium, vitamin B12, pancreatic enzymes, thyroid hormone, and liver extracts, are used to stimulate organ function, particularly of the liver and thyroid.”. At one time you also got several glasses of raw calf liver every day but after infections killed several people] carrot juice was given instead.

Cancer Research UK says “there is no evidence to show that Gerson therapy works as a cure for cancer”, and “The Gerson diet can cause some very serious side effects.” Nobody (except perhaps the Price of Wales) has any belief in this unpleasant, toxic and expensive folk-lore.

Again patients are endangered by teaching this sort of stuff.

slide 36

And finally, the usual swipe at vaccines. It’s nothing to do with herbalism. but just about every alternative medicine advocate seems to subscribe to the anti-vaccination lobby.. It is almost as though they have an active preference for things that are known to be wrong. They seem to believe that medicine and science are part of an enormous conspiracy to kill everyone.

Perhaps this dangerous propaganda might have been ameliorated if the students had been shown this slide (from a talk by Melinda Wharton).

Wharton slide 2
Click to enlarge

Left to people like this, we would still have smallpox, diphtheria. tetanus and rabies,  Take a look at Vaccine-preventable diseases.

This is the sort of ‘education’ which the Pittilo report wants to make compulsory.

Baltimore smallpox, 1939
Smallpox in Baltimore, USA, 1939. This man was not vaccinated.

Conclusion

This selection of slides shows that much of the stuff taught in degrees in herbal medicine poses a real danger to public safety and to public health.

Pittilo’s idea that imposing this sort of miseducation will help safety is obviously and dangerously wrong. The Department of Health must reject the Pittilo recommendations on those grounds.

Follow-up

Acupuncture has been in the news since, in a moment of madness, NICE gave it some credence,

Some people still seem to think that acupuncture is somehow more respectable than, say, homeopathy and crystal healing. If you think that, read Barker Bausell’s book ot Trick or Treatment. It is now absolutely clear that ‘real’ acupuncture is indistinguishable from sham, whether the sham control uses retractable needles, or real needles in the ‘wrong’ places. There has been no clear demonstration of long-lived benefits in any condition, and it is likely that it is no more than a theatrical placebo.

In particular, the indistinguishability of ‘real’ and sham acupuncture shows, beyond reasonable doubt that all the stuff about “energy flow in meridians” is so much hokum.

There is a small group of ‘medical acupuncturists‘ that believes that it is hokum. but who nonetheless maintain that acupuncture works, despite the evidence to the contrary. But most acupuncturists go for the wholesale gobbledygook.

If you don’t believe that, take a look at the exam paper that has come into my possession. It is this year’s exam from the University of Salford. Salford has, very sensibly, now decided to stop all its degrees in alternative medicine, so don’t hold this against the university too much.

You can download the entire exam paper. Here are a few highlights.

Q1

So students, in 2009, are being taught the crudest form of vitalism.

Q5

Oh really. Perhaps protons neutrons and electrons?

Q22

OK I’d fail that one because the words have no obvious meaning at all.

Q23

Perhaps an elementary textbook of embryology would help?

Q24

How one would love to see a set of model answers for these questions.

All this is ancient hokum being taugh to hapless students in the 21st century as though it were fact. The University of Salford has understood that and closed the course. All we need now is for NICE and the Department of Health to understand what it is that they are promoting.

NICE neglected the cultural cost of their guidance

When National Institute for Health and Clinical Excellence (NICE) included an acupuncture option on their low back pain guidance, they quite forget that one effect of their decision would be to ensure that new generations of students would have their minds poisoned with intellectual junk like this. That is why NICE really must think again. . See also
NICE falls for bait and switch by acupuncturists and chiropractors
NICE fiasco part 2 Rawlins should withdraw guidance and start again
NICE fiasco Part 3. Too many vested interests, not enough honesty

Pittilo and statutory regulation

Public consultation is due to open shortly on the appalling report of the Department of Health Steering Group on the Statutory Regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine and Other Traditional Medicine Systems Practised in the UK (see also, The Times)

One of the recommendations is that acupuncture and Chinese herbal medicine should have statutory regulation by the Health Professions Council (HPC), despite the fact that that would involve the HPC breaking its own rules. Another recommendation of Pittilo is that entry to the “profession” (his word, not mine) should be by means of honours degree only. So he wants to impose on students exams like this one in order to “protect the public”? The absurdity of that proposal should be obvious now. This exam paper will form part of my evidence to the consultation.

And there is one other small problem. Universities are busy shutting down their degrees in alternative medicine, now that the ridiculousness of what is taught has been exposed. They have shut down entirely at the University of Salford and at the University of Central Lancashire, And even the University of Westminster is working on closing them.

All we need now is for the common sense and integrity that has been shown by these universities to spread to the Department of Health (and NICE).

Follow-up

Jump to follow-up

.The University of Central Lancashire (UCLAN) is the first place I asked to see teaching materials that were used on its homeopathy “BSc” course. The request was refused, and subsequent internal appeals were refused too, Clearly UCLAN had something to hide.

UClan-logo

An appeal to the information commissioner took almost two years to be judged, but the case was won. The eventual decision by the Information
Commissioner rejected all the grounds that UClan had used to evade the Freedom of Information Act.

UClan appealed against the judgement and I still haven’t got the stuff but that hardly matters now, because the course in question shut its doors. In any case, plenty of stuff from similar courses has leaked out already.

Meanwhile, in September 2008, UCLAN announced an internal review of all its courses in magic medicine, The review seemed to be genuine. For a start they asked me to give evidence to the review (something that no other university has done). They also asked Michael Eslea to give evidence. He is the UCLAN psychologist, whose magnificent open letter probably tipped the authorities into holding the review.

Just in case it is useful to anyone, here is a copy of the written evidence that I sent [download pdf],

Report of the Working Party on the Review of issues associated with Homeopathy, Acupuncture and Chinese Herbal Medicine

1. Introduction

As a consequence of concerns expressed by some colleagues within the University of Central Lancashire (UCLan) Dr Malcolm McVicar, Vice Chancellor appointed a working party to review the issues associated with the University offering courses in Homeopathy, Acupuncture and Chinese Herbal Medicine.

MEMBERSHIP:

Eileen Martin (Chair)                Pro-Vice Chancellor and Dean of Faculty of Health and Social Care 
Professor Gordon Bromage      Head of Centre for Astrophysics
Professor Malcolm Edmunds    Emeritus; Built and Natural Environment
Professor Doris Schroeder        Director of Centre for Professional Ethics
Elaine Austin                               Project Manager, Faculty of Health and Social Care


The report was the subject of a special meeting of UCLAN’s Academic Board on 9th July 2009. The following resolutions were passed.

Resolutions

R1    That further minor revisions be made to the report prior to publication on the University’s website;

R2   That the University refrain from offering any practitioner-qualifying courses in Homeopathy, Acupuncture and Chinese Herbal Medicine until such disciplines have achieved statutory regulation status;

R3    That the University consider offering a limited number of postgraduate research studentships (leading to Masters by Research of PhD) to suitably qualified UCLan students and staff in these disciplines. They should have interdisciplinary supervisory teams to facilitate development of a broad range of research skills and to contribute to the generation of knowledge in CAM;

R4   That the University consider how more interdisciplinary teaching can be achieved, where appropriate, within both undergraduate and postgraduate teaching to facilitate greater exposure to subject expertise and different paradigms.

Resolutions 1, 3 and 4 say very little. Resolution 4 sounds thoroughly relativist. We are talking about medicine, about treating sick patients. There is only one “paradigm”. That is to find treatments that are as effective and safe as possible. There aren’t two sorts of medicine, regular and alternative. There is just medicine that works and medicine that doesn’t work. It’s a good illustration of DC’s rule number 2, “never trust anyone who uses the word paradigm”.

Resolution 2 is the really interesting one, because none if the topics, Homeopathy, Acupuncture and Chinese Herbal Medicine, is subject to statutory regulation.

If taken literally, resolution 2 means that all the UCLan courses in alternative medicine will close their doors. Bafflingly, this inevitable conclusion is not stated explicitly.

At least resolution 2 means that homeopathy, already closed, will stay closed. It is never likely to get statutory regulation.

For practical purposes, we can ignore for the moment the obvious fact that statutory regulation of nonsense subjects results only in nonsense. The only forms of alternative medicine that have got “statutory regulation” at the moment are chiropractic and osteopathy. The public has not been safeguarded by the General Chiropractic Council (GCC). The GCC, on the contrary, has endangered the public by allowing false health claims to be made with impunity. Perhaps the members of the review committee had not noticed that the Simon SIngh affair has resulted in almost 600 complaints being made to the GCC? The faith of the review in statutory regulation is clearly misplaced.

The Pittilo report is critical for what happens next

Acupuncture and Chinese Herbal Medicine are not subject to statutory regulation at present, so one would suppose that these degrees will close their doors too. However the infamous Pittilo report has proposed that they should become regulated by the Health Professions Council (HPC). The many problems of the Pittilo report have been documented here, in “A very bad report: gamma minus for the vice-chancellor“. There was also a high-profile critique of the report in The Times (and on this blog).

The HPC has, as one of its criteria for regulation, “evidence-based practice”. Disgracefully, the HPC has already shown its willingness to ignore its own rules and to act as statutory regulator for Acupuncture and Chinese Herbal medicine. This rather disgraceful behaviour is documented in “Health Professions Council ignores its own rules: the result is nonsense“.

The UCLAN report seems to assume that the recommendations of the Pittilo report will be accepted. But the long-awaited consultation has still not opened. We can be sure that when it does, the opposition to it will be very strong indeed.

The report in full

Here are a few comments on the report itself.    Download the full report (as of July 15th).

i have to say that when I visited Preston to give evidence, my views seem to be treated seriously, even sympathetically, so it was a great disappointment to see the outcome. So what’s wrong? The major disaster is declared early in the report.

Section 2, Context

The debate is centred on a number of key themes which relate to:-

1. The quality of and/or absence of an evidence base to support claims of the efficacy and benefits of such treatments, linked to issues of public safety/protection and professional regulation.

Sounds good. What matters about any sort of medicine is whether or not it works and whether it is safe. It therefore verges on the incredible that we read in section 4.1

“conclusions from research into the efficacy of the various CAM’s are outside the remit of this report.”

The whole point about CAM is that there is very little evidence that any of it works. So the review committee decided to ignore the most important problem of the lot.  I can’t see how any rational decision can be made without first deciding whether the treatment is better than placebo.  That, surely, is the main question, and it was dodged.

UCLAN has failed to grasp the nettle, just as the Department of Health has also consistently failed to do so.

Section 4,1  Efficacy   This section repeats the assertion, absurd to my mind, that it is possible to judge CAM courses while declining to assess whether they work or not.

Section 4.2 Role of Universities in Society.

There is universal agreement that critical thinking is crucial to the idea of a university, but the judgement of whether CAM teaches critical thinking is simply fudged. Again the report fails to grasp the nettle.

“Disagreements about critical thinking within CAMs arises because some will argue that such substantiation and assessment can occur within the discipline, whilst others will argue that the methodology for substantiation, that is evidence provision, is universal. As a result, the latter will demand that evidence is provided using methods from one field (e.g. randomised controlled trials) for use in another.”

Sadly, the report dodged the crucial judgement once again. The most obvious characteristic of every form of alternative medicine is their total lack of critical self-appraisal. It is very sad that the review committee could not bring itself to say so.

Section 4.4   Nomenclature of degrees

Recommendation
The nomenclature of courses, leading to a professional as well as an academic award, should reflect the professional route; for example Bachelor with Honours in Complementary Medicine, B Comp. Med.(Hons) or B Acupuncture (Hons).

This sounds to me like another truly pathetic fudge. What on earth is solved by changing the name of the degree? You’d still be teaching students the same load of gobbledygook and then letting them loose on sick people, whether you call it a Bachelor of Science, a Bachelor of Arts, or, as is recommended here, a Bachelor of nothing whatsoever.

Well, I suppose there is a (doubtless unintended) irony in calling CAM degrees “Bachelor of nothing whatsoever”.

Section 4.4   Ethical, non-harm and economic considerations

This section list a lot of reasons why teaching alternative medicine should be unethical. but nevertheless manages to conclude that

” . . . it is not unethical to offer courses in Homeopathy, Acupuncture and Chinese Herbal Medicine at a university.”

I find the logic by which this bizarre conclusion was reached quite impossible to follow. Like much of the rest of the report this conclusion seems to stem from a reluctance to grapple with the really important questions, like ‘does it work or not?’.

Despite this the recommendation is perhaps the most interesting of all.

Recommendation
• The University refrains from offering any CAM courses until such disciplines have achieved statutory regulation status.”

This recommendation was accepted, and passed as a resolution at Academic Board. If it is implemented now, than there will be no more alternative medicine degrees next year at the University of Central Lancashire. If and when this happens, the University must be congratulated on its return to rational medicine.

Follow-up

Michael Eslea, UCLAN’s hero in resisting nonsense from the inside, has posted on this topic.

17 July 2009. It seemed odd that that no announcement was made about the future if the remaining CAM courses at UCLAN. So I asked deputy Vice-Chancellor Patrick McGhee for clarification. After a couple of days, I got this response.

From: CTheobald@uclan.ac.uk

To: d.colquhoun@ucl.ac.uk
Subject: uclan clarification

Hi David,

I have been asked to respond to your question below on the running of acupuncture and Chinese herbal medicine at UCLan. It is correct to assume that UCLan will not be taking any new entrants onto these programmes until further notice.

Best Wishes

Chris

Chris Theobald
Corporate Communications
University of Central Lancashire

So the report may have been disappointing, but it has done the job. As several people have pointed out in comments, it would be asking too much to expect a university to say “sorry we just noticed that we have been running junk-science courses for years”. But they have done the right thing anyway.

Jump to follow-up

This is another short interruption in the epic self-destruction of chiropractors.  In a sense it is more serious.  One expects quacks to advocate quackery.  What you don’t expect is that the National Institute of Clinical Excellence (NICE) will endorse it.  Neither do you expect the Medicines and Healthcare products Regulatory Agency (MHRA) to betray its mandate to make sure that medicines work.

The saga of the NICE low back pain guidance has been the subject of a deluge of criticism, It seems doubtful that the guidance can survive, not least because of its absurd endorsement of chiropractic, at a time when chiropractic is undergoing self-immolation as a consequence of the persecution of Simon Singh by the British Chiropractic Association (see here, and here, and here, and here and thousands of other sites).

The other betrayal has come to the for after the MHRA approved highly misleading labelling of a homeopathic preparation.  At the time,
in 2006
, when the principle was approved by the MHRA, just about every scientific organisation, even the Royal Society, condemned the action.  What was discouraging that the clinical organisations all stayed silent.  It is still a mystery why the MHRA made this enormous mistake,  Some said that European regulations required it, but that is quite untrue, as Les Rose has shown.  It appears to have been the result of a pusillanimous MHRA bowing to pressure from a deeply unscientific Department of Health (a letter from Caroline Flint at the time borders on the surreal).

On 20 May 2009, the British Medical Journal printed an article Drugs agency grants its first licence to homoeopathic product by Deborah Cohen (available free). The comments were mostly highly critical of the MHRA. The BMJ asked, as it does from time to time, for my comment to be converted to a letter
for the print edition
. That isn’t freely available, so here it is.

Published 9 June 2009, doi:10.1136/bmj.b2333
Cite this as: BMJ 2009;338:b2333

Letters

Homoeopathic product licence

MHRA label seems to be illegal

The strap line for the Medicines and Healthcare products Regulatory Agency (MHRA) is “We enhance and safeguard the health of the public by ensuring that medicines and medical devices work and are acceptably safe.”

Yet the MHRA has made mockery of its own aims by ignoring the bit about “ensuring that medicines work” and allowing Arnica 30C pills to be labelled: “a homoeopathic medicinal product used within the homoeopathic tradition for the symptomatic relief of sprains, muscular aches, and bruising or swelling after contusions.”1

This label should be illegal anyway because the pills contain no trace of the ingredient on the label, but this deceit has been allowed through a legal loophole for a long time now. If you sold strawberry jam that contained not a trace of strawberry you’d be in trouble.

But I can see no legal loophole that allows the manufacturers of Arnica 30C to evade the provisions of the Consumer Protection from Unfair Trading Regulations 2008. One of the 31 commercial practices which are in all circumstances considered unfair is “falsely claiming that a product is able to cure illnesses, dysfunction, or malformations.”

The consumer protection laws apply to the way that “the average consumer” will interpret the label. The average consumer is unlikely to know that “used within the homoeopathic tradition” is a form of weasel words that actually means “there isn’t a jot of evidence that the medicine works.”

Since there is not the slightest evidence that Arnica 30C pills provide symptomatic relief of sprains, etc, the labelling that the MHRA has approved seems to be illegal. The MHRA is not selling anything itself, so I presume that it won’t find itself in court, but anyone who follows its advice could well do so.

Cite this as: BMJ 2009;338:b2333

David Colquhoun, research professor1

University College London, London WC1E 6BT


Competing interests: None declared.

References

  1. Cohen D. Drugs agency grants its first licence to homoeopathic product. BMJ 2009;338:b2055. (20 May.)

    [Free Full Text]

It is, I suppose, just a sign of the chaos that reigns in the multiple agencies and quangos responsible for ‘regulation’  that one arm of government proposes action that a different branch would consider illegal.  That is an inevitable consequence of trying to regulate something without first deciding whether it is nonsense or not.  The Department of Health appears to be quite incapable of grasping this simple and obvious fact.

Follow-up

Health: best treatments. The Guardian seems to the be picking up BMJ stories and ran this one.