Tuesday, 3 October 2017

NHS Homeopathy #1 - GP Prescribing

There have been a number of stories about proposed cuts to NHS homeopathy in England. Not just in specialist media but also in mainstream national media. There has also been considerable interest on social media.

One of common theme of both is that the reporting or reaction is often substantially wrong in detail or that key details are missing. This is not surprising given the complex structure of the NHS and its complex processes.

However, the inaccuracies of these reports/reactions pales beside how wrong supporters of homeopathy can be...

"Save NHS Homeopathy and Herbal Medicines!!!"
The 4Homeopathy group have a poster that can be found here although other branded versions appear on the British Homeopathic Association website, Friends Royal London Hospital for Integrated Medicine website and is linked to by many other websites, social media posts and email newsletters.

It states -

The NHS is deep into a consultation aiming to abolish prescriptions of homeopathic and herbal medicines
Act now before it affects your choice of all complimentary and alternative medicines
The consultation ends on the 21st October. Act before it's too late to save Homeopathy and Complementary Medicine on your NHS
1. Complete the consultation document
2. Sign the petition
3. Write to your MP
4. Help spread the word: share this with your friends
CAM can reduce NHS prescribing costs of £9.2bn
70% of patients reported positive health changes following homeopathic treatment
Bullying tactics a small group of activists is campaigning to deprive you of choice in NHS treatments 
The thin end of the wedge Once NHS services disappear they're gone for good
Homeopathy gives you a safe and natural choice 

There is much that is incorrect here.

The consultation is called Items which should not be routinely prescribed in primary care: A Consultation on guidance for CCGs. It is being carried out by NHS England. Scotland and Wales have their own NHS services. In Northern Ireland, social care and healthcare are integrated, but that doesn't matter. What matters is that this is NHS England.

The consultation's focus is very broad. To describe it as "aiming to abolish prescriptions of homeopathic and herbal medicines" is misleading to say the least. It is essentially about reducing NHS England prescribing costs and homeopathic and herbal medicines represent a tiny proportion of the potential savings.
Often patients are receiving medicines which have been proven to be ineffective or in some cases dangerous, for which there are other more effective, safer and/or cheaper alternatives.
Cheaper means cheaper to the NHS and it is not just about providing an alternative medicine via the NHS, it can be advising the patient to purchase the medicine over-the-counter. Indeed, this can often lead to a cost saving for the patient.

The title of the consultation includes the word "guidance". NHS England does not have the power to prevent the prescribing of any medicines in the consultation. The power to blacklist medicines resides with the Department of Health (DH) via the National Health Service (General Medical Services Contracts) (Prescription of Drugs etc.) Regulations 2004. A list of prohibited products can be found in Schedule 1 of the Regulations but is periodically updated by amendments. At the time of writing, no homeopathic medicine was on that list. This will be discussed later.

Clinical Commissioning Groups (CCGs) are effectively a local tier below NHS England. CCGs have guidelines on medicines that should only be prescribed by GPs in certain circumstances or not all. The term "locally agreed formulary" or similiar is often used. An example can be found here. And these formularies cover much of the same ground as the Consultation.

Note that again, CCGs have no power to enforce what are essentially guidelines. As the next post will show, in the case of homeopathic medicines, many CCGs have had zero prescribing for years and in reality the majority of the prescriptions are written by a handful of GPs.

CAM can reduce prescription costs
There is no compelling evidence of this despite literature. Although some supporters of homeopathy will cite the French EPI-3 cohort studies, the studies only make mention of lower usuage of certain other classes of drugs by GPs qualified in homeopathy vs those not. This does not translate to lower costs. And France is not England.

In England, the standard prescription charge is now £8.60. The linked to article explains some are exempt from the charge. Prescription charges do generate income for NHS England, but the cost implications are complicated. What is simple to understand that many patients, if drug costs less than the prescription charge and it available over the counter, a GP will almost always advise a patient to do this.

A previous post explains the complexities of medicines regulations but in short, from the perspective of this post, there are two sorts of homeopathic medicines - registered ones that can be bought over the counter in many outlets and unregistered ones which can only be legally obtained from specialist pharmacies/manufacturers (and are treated as "specials").

The registered products are those most often used (unsurprisingly) and their costs vary but the majority of them seem to be around the £5-6 range. Certainly less than the prescription charge. So clearly, for many it would make economic sense to buy them themselves. This is also true for the unregistered products although generally a mail order will need to place and there maybe a delivery cost but even so.

The actual cost of prescribing a medicine to NHS England is complicated - this is a simplified explanation. It is important to understand that Community Pharmacies are not part of NHS England. They are private businesses contracted to fulfill NHS prescriptions (and sometimes other NHS services). They may process the prescription charge but it goes to NHS England. NHS England pays community pharmacies for a notional of an item of medicine determined by the Drug Tarrif. If the medicine is not in Tarrif (homeopathic medicines aren't), the pharmacy is effectively paid the cost of the medicine (but the process is more complicated). A browse of the Tarrif will reveal that many medicines cost less than homeopathic medicines do (see here).

The Tarrif also determines the fees paid to pharmacies for dispensing the medicines. This is currently £1.25. However, whilst this fee would be payable on registered homeopathic medicines, it would not on unregistered. They would attract a "specials" fee of £20.00. The proportion of registered/unregistered products is not currently known but it is certainly the case that unregistered homeopathic medicines are de facto more expensive than many medicines. 

Reported Positive Health Changes
The 70% figure comes from an observational study Homeopathic Treatment for Chronic Disease: A 6-Year, University-Hospital Outpatient Observational Study conducted at the Bristol Homeopathic Hospital (which no longer exists and actually an outpatient clinic not a "hospital" in itself) from 2003. Unfortunately the study is behind a paywall.

Bullying Tactics
This would appear to relate the Good Thinking Society. It is true that they have lobbied against NHS homeopathy but to describe that as "bullying" implies that NHS bodies are likely to be moved by lobby groups. Homeopathy supporters have discovered this not to be the case.

Thin End of the Wedge
This is a meaningless statement.

The misreprestation of the nature of the Consultation and suggesting NHS England could implement a ban is either scaremongering or represents a failure to understand how the NHS works. Neither is exactly good PR for UK homeopathy supporters.

The unevidenced claim that homeopathy etc could contribute to a reduction in NHS England prescribing costs is not good PR either. Again, this seems to represent a failure to understand how the NHS works.

The next post will analyse some of the prescription data.

Government has responded to the petition that was started by supporters of homeopathy. It's very clear that the details of the petition are wrong and the the government's response is predictable - 

It is for local NHS organisations to decide on the commissioning and funding of these healthcare treatments. NHS England’s consultation on low value prescription items includes homeopathic treatments.

Information from NHS England (NHSE) shows that in 2015, the cost for all prescriptions dispensed in primary care, not including any dispensing costs or fees, was £9.27 billion, a 4.7% increase on the previous year. Due to the increasing cost, NHSE is leading a review of medicines which can be considered as being of low clinical value and develop new guidance for Clinical Commissioning Groups (CCGs).

On 21 July, NHSE launched a three month consultation on the draft guidance on low value prescription items which is based on the latest clinical evidence, including that from the National Institute of Health and Care Excellence (NICE). Careful consideration has been given to ensure that particular groups of people are not disproportionately affected, and that principles of best practice on clinical prescribing are adhered to.

The commissioning guidance, upon which NHSE is consulting, will be addressed to CCGs to support them to fulfil their duties around the appropriate use of prescribing resources. This will need to be taken into account by CCGs in adopting or amending their own local guidance to their clinicians in primary care.

The aim of this consultation is to provide individuals with information about the proposed national guidance and to seek people’s views about the proposals. NHSE welcomes the views of the public, patients, clinicians, commissioners and providers through this consultation process to help inform the final guidance. The consultation ends on 21 October. Links to the consultation can be found here:
https://www.england.nhs.uk/2017/07/medicine-consultation/ and
It is the responsibility of local NHS organisations to make decisions on the commissioning and funding of any healthcare treatments for NHS patients, such as homeopathy, taking account of issues to do with safety, clinical and cost-effectiveness and the availability of suitably qualified and regulated practitioners.

Complementary and alternative medicine (CAMs) treatments can, in principle, feature in a range of services offered by local NHS organisations. A treating clinician would take into account an individual’s circumstances and medical history in deciding what would be the most appropriate treatment for their condition. CCGs will have specific policies on the commissioning and funding of CAMs, and may have also developed local policies on priorities with regards to the funding of treatments. A GP would have to work within such policies in providing any treatments on the NHS. 
The Department of Health supports an approach to evidence-based prescribing which does not support the commissioning of services which are not clinically and cost effective. We are not aware of any evidence that demonstrates the therapeutic effectiveness of homeopathic products. The National Institute for Health and Care Excellence (NICE) does not currently recommend that homeopathy should be used in the treatment of any health condition, whilst primary care prescribing data shows that there has been a significant decline in the prescribing of homeopathic products over the last 10 years. Furthermore, a good number of NHS organisations are reviewing their funding of homeopathic treatments and some have already stopped funding such treatment altogether.

As mentioned before, CCGs not have the power to enforce local policies on GPs. The Department of Health do have the power to black list products but seem not to want to. One cynical interpretation is that the DH want local CCGs to take the blame for unpopular decision whilst Government sits on its hands. It has been suggested that this may be due to politicians' erroneous perception that policy on CAM is important to many voters. In reality, this not the case as the low response rate to the petition shows.


  1. Pontificate watch30 October 2017 at 21:42

    You couldn't have been more wrong in 2012 when your declarations about homeopathy went pear shaped. Remember how confident you were? Why should anyone believe you this time?

  2. Did you read the above? Are you telling me that NHS England has the power to blacklist homeopathic medicines?

  3. Pontificate watch1 November 2017 at 16:24

    I assume that the petitions and letters to MPs are about showing public support. Politicians take note of public support. This is a fight between those who think that homeopathy is supported by millions ie >10% and want to promote it and those who think it is supported by <1% and want to restrict it. By all means get bogged down in regulatory detail and consolidate it all, however it is the evidence of the level of political support for homeopathy that will decide on the winner. You should know by now that political support helps at all levels. Dont be surprised if the demonstrated level of support for homeopathy ends up meaning that your campaign backfires completely. Many will also find out about vested interest groups and vexacious individuals campaigning against homeopathy. This bunch of bunch of tweets will all do more to advance homeopathy than any homeopathy advocate groups ever could.

  4. The petition reached the point where government is committed to respond a while ago, hence they responded. If the number of responses from UK persons reaches 100,000 it may be considered for debate in Parliament but given the Government response, the value of a debate is questionable.

    1. Pontificate watch4 November 2017 at 11:13

      Maybe a debate won't get very far as you imply. However, 100,000 signatures in a Gov petition would show to politicians that there is considerable support for homeopathy/herbalism. This then weakens any argument that homeopathy/herbalism is only taken seriously by a tiny < 1% of the population. A large demonstration of support would mean that homeopathy is a political issue. It is just a question of whether homeopathy/herbalism supporters can stand up for themselves and show that there is large scale support out there. Otherwise the 1% suggestion of support made by opponents may well be generally accepted.