Memorandum submitted by Dr Sara Eames
(HO 22)
THE EVIDENCE FOR HOMEOPATHY AND ITS PROVISION
WITHIN THE NHS.
1. The Faculty of Homeopathy represents
over 1000 healthcare professionals in the UK who choose to incorporate
homeopathy into their everyday work. Many of these members have
become interested in homeopathy because they have seen patients
who have been helped by this therapy when conventional treatments
have failed.
2. What is Homeopathy?
It is well known that the choice of a homeopathic
medicine is made by matching the symptoms of a patient with a
substance which is known to cause those particular symptoms when
taken in larger doses. What is less widely appreciated however
is that the whole homeopathic consultation is a complex process
and is an ideal way to practice good medicine. It starts with
a careful history taking, involving not only the main problem,
but also other current problems, past medical, family and social
history and factors about the patient's physiology, interests
and concerns. It is mandatory to enquire about the patient's lifestyle
and identify those factors inhibiting healing and good health.
These can include poor diet and lack of or excessive exercise
as well as living in difficult emotional situations. The doctor
will work with the patient to identify ways in which these blocks
may be removed and only then will a homeopathic medicine be prescribed.
It thus becomes obvious that when considering the role of homeopathy
in the management of patients it is the whole process rather than
just the action of the medicine which is to be considered.
3. What is Evidence?
3.1. The concept of evidence is multi-faceted,
but in recent years it has become progressively reduced to accepting
double blind trials as the gold standard. While these can be useful
in assessing the effects of a single intervention on a single
symptom or outcome, they are far less suitable when studying the
overall effects of a holistic therapy in a complex organism with
multiple problems. Notwithstanding this there have been over 100 double
blind trials in homeopathy with far more positive than negative
outcomes. These are summarised in the submission by my colleague
Dr Robert Mathie, on behalf of The British Homeopathic Association.
3.2. There are also many other types of
evidence for homeopathy:
Hundreds of thousands of case histories, recording
successful cases. (NICE accepts case series as evidence in its
review of treatments)
3.3 Outcome studies from the Homeopathic
Hospitals, show consistent results in improving not only the presenting
symptoms but also overall well-being and in reducing the use of
conventional medicine. [1] The majority of patients in these surveys
have chronic conditions, and many have multiple pathologies. All
have been referred to the hospitals by their GP or hospital consultants
and many have not responded to previous conventional treatment.
The outcome studies from the hospitals are discussed in greater
detail in the submission by my colleague Dr Hugh Neilsen.
3.4. The Department of Health is now advocating
the use of patient reported outcome measures (PROMs) as a way
of assessing improvements in patients with complex health care
needs.
The NHS website requests patient feedback on their
hospital experiences and the Royal London Homeopathic Hospital
has very positive results.
4. How Should Evidence be Used in Medicine?
It is the role of scientists to research and
discover new treatments in medicine, but it is the role of the
doctor to practice the art of medicine. Pure science and the results
of randomised controlled trials (RCTs) are tools in this practice,
but should never become the master. A wise physician will use
his wisdom and experience to consider a range of treatment options
suitable for the individual patient in their particular situation
and many conventional doctors find that having homeopathy as an
additional tool at their disposal allows them to help more patients
in a safe and cost effective way.
5. The Case for and against Homeopathy.
5.1 There has been a surprising amount of
negative publicity around homeopathy when one considers the tiny
proportion of the NHS spending it involves and the fact that it
is a remarkably safe therapy which is both popular with and helpful
for patients.
There are three main strands to these negative arguments
which are the dispute of the evidence from RCTs, the denial of
any possibility that an ultra dilute homeopathic medicine can
have any action and the publicity given to the few unfortunate
cases involving homeopathy where there have been poor outcomes.
5.2 1. The consideration of the trial
results in homeopathy is fascinating. As stated above in over
100 RCTs there are far more positive than negative results
in spite of the fact that in the trials involving classical homeopathy,
all trial participants, including those in the placebo group,
will have benefited from the homeopathic process as outlined above.
This becomes even more compelling in terms of health economics
when considering that many of the trial patients will have noticed
additional improvements in other health problems which were not
recorded as they were not included in the original trial parameters
and also that participants suffer from very few, expensive to
treat, side effects. All meta-analyses of these trials have been
broadly positive, [2,3,4,5] until the last one published by Shang
et al in the Lancet [6]. Critics of homeopathy have selectively
accepted this outcome as the final word in the argument against
homeopathy, but it is worth noting that Shang's work did not include
many new trials and was merely a different statistical reworking
of the old information. Perhaps the most important conclusion
from this is that responsible decision makers should not rely
on statistics alone!
5.3 It is important to note however that
the Shang meta-analysis has been widely criticised for not adhering
to even the very basic principles of good meta-analysis as outlined
in the QUOROM guidelines. [7]
5.4 Some of the main points of the critique
to be aware of include:
Statisticians involved in a meta-analysis should
not have prior knowledge of the subject. At least one of the authors
of this study had already critiqued homeopathy although this was
not declared in the conflict of interests.
Enough information about trial selection must
be given for the study to be reproducible, yet the article said
nothing about the detailed methodology of trial selection and
indeed did not even name the trials which had been involved.
The final conclusions of the study were based on
the comparison of only eight homeopathy trials, although over
100 had initially been looked at. There is no clear information
about how this reduction was done and this number of eight trials
was not pre-stated in the methodology as required by QUOROM. One
of the chosen homeopathic trials was not even Medline listed,
although most of the published homeopathic trials are.
5.5 At best this is a very poor quality
meta-analysis and at worst an example of biased data dredging
searching for pre-determined results.
5.6 2. The possibility of action
of ultra-molecular substances is dismissed as completely implausible
by critics of homeopathy, in the face of increasing scientific
evidence to the contrary. This evidence has been comprehensively
listed and discussed by Dr Peter Fisher in his submission.
5.7 Some of the more intriguing results
include the experiments around the concept of hormesis, where
a small dose of a toxic substance will stimulate an organism,
even though a larger dose will be toxic. There is also an ever
growing group of in-vitro experiments from different centres showing
the blocking of basophil activity by highly diluted histamine.
5.8 It is also fascinating that both plant
and animal experiments show how growth can be stimulated or reduced
according to the level of dilution of the substance.
While there is certainly much more to discover
about the action of dilute substances, it is no longer scientifically
correct to say that they cannot work, with such an increasing
body of scientific evidence showing their activity.
5.9 3. Individual cases of poor outcomes
with homeopathic treatment are obviously to be regretted and
may constitute personal tragedy, but they are thankfully rare
and usually involve the failure to integrate homeopathy with the
best available conventional treatment rather than as an effect
of the homeopathic treatment per se.
It is somewhat surprising that great emphasis
and headlines are given to these individual incidents while many
thousands of successfully treated patients are dismissed as mere
anecdote.
5.10 There is also a great contrast with
the scant publicity given to the side effects of conventional
medicine which can produce many serious and expensive to treat
complications, but which receive little publicity. The Journal
of the American Medical Association (JAMA) has a series of illuminating
articles on this subject.
A study at Toronto University published in 1998 found
that over two million hospitalised Americans suffered serious
adverse drug reactions during the 12 month period of the
study and that 100,000 died as a result of these events.
The figures do not include accidental overdoses or errors in administration
and they account for more deaths than road traffic accidents each
year.
5.11 A study at John Hopkins School of Hygiene
and Public Health two years later found that iatrogenic disease
was the third largest killer in the US behind only cancer and
cardiovascular disease. It also showed that the largest sub group
of these deaths was caused by non-error adverse effects of medication,
larger even than deaths caused by hospital acquired infections.
[9]
5.12 It is also important to note that the
prescription of multiple conventional drugs concurrently is frequently
non-evidence based as little is known about the complicated reactions
between them and the effect on patients overall.
6. The Funding of Homeopathy within the NHS.
6.1 The two main settings in which homeopathy
is used in the NHS are in general practice and at the four homeopathic
hospitals.
6.2 There have been a number of reports
of outcomes of GPs prescribing for acute problems and they are
all low cost prescribing practices. A recent study published by
Robinson showed this and how he was able to use the homeopathic
medicines within the context of 10 minute consultations with
his patients. [10]
6.3 It is interesting that some of the positive
trials of specific conditions are of great relevance to commonly
occurring problems in general practice and include the treatment
of allergies, [11] the reduction in duration of influenza symptoms,
[12] and a reduction in the duration and severity of childhood
diarrhoea when homeopathy is added to conventional treatment.
[13]
6.4 The topic of the Homeopathic Hospitals
is discussed in the submission by my colleague Dr Hugh Nielsen,
but it is important to stress their unique role and importance
within the NHS. They offer an alternative for doctors and their
patients when conventional treatments have failed or are contra-indicated
and especially when patients suffer from multiple and chronic
conditions.
7. SUMMARY.
7.1 Homeopathy is a branch of medicine which
has an increasing evidence base, both from clinical studies and
basic scientific research, which confirms the clinical outcomes
reported by practitioners world-wide for over 200 years.
There is naturally always scope for further study as suggested
by the House of Lords CAM report in 2000.
7.2 Homeopathy can usefully contribute to
care within the NHS both in general practice and the hospital
setting. By reducing prescribing costs it will help with the current
economic challenges that the health service faces, by reducing
not only direct drug costs, but also the number of expensive to
treat and sometimes fatal adverse effects of conventional medicine.
It is popular with patients and can help with problems that have
not responded to conventional treatment including chronic and
multiple pathologies.
REFERENCES
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trials of homoeopathy and allopathy. Lancet, 366:
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7. Lüdtke R, Rutten AL (2008). The conclusions
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8. Jason et al (1998) Incidence of adverse
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10. Robinson TW (2006). Responses to homeopathic
treatment in National
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11. Taylor MA, et al. Randomised controlled
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12. Vickers A, Smith C. Homoeopathic Oscillococcinum
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(Cochrane review). In: The Cochrane Library. Chichester,
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DECLARATION OF
INTERESTS.
President of the Faculty of Homeopathy and Director
of Education and Women's Services at The Royal London Homeopathic
Hospital. I have a small private practice.
November 2009
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