Monday, 28 May 2018

Reaccreditation of the Society of Homeopaths

As discussed previously, the Professional Standards Authority (PSA) imposed conditions on the reaccreditation of the Society of Homeopaths (SoH). The PSA are now satisfied that the conditions have been met. There's more to this than meets the eye...

To recap, the conditions imposed on the SoH were -
1. The Society must:  
a. Develop and submit to the Panel for review its position statement on the use of CEASE therapy by registrants, including advertising this. This must be submitted to the Panel for review and published within three months  
b. Develop mechanisms to ensure that registrants who use and advertise CEASE therapy follow the Society’s position and do not breach its Code of Ethics and Practice. An action plan outlining how this will be achieved must be submitted to the Panel within one month  
c. Review risks related to CEASE and other therapies additional to registrants’ regular scope of practice, as part of its ongoing risk assessments. This must be incorporated into the Society’s risk matrix within three months.
Condition 1.b was met some time ago. A Freedom of Information Act request obtained the "action plan". Without getting bogged down in the detail, as to be expected the SoH did complain about timescales and how the "action plan" would be implemented. To quote -

There are four key points to the the plan:
  1. The establishment and the publicising of the Society's position on aspects of CEASE therapy
  2. The collection of data showing the Society which of it[s] members advertise and practice CEASE
  3. The surveying of the advertising and website claim by members who claims they are CEASE practitioners
  4. Providing clarity on what actions the Society will take for those members who contravene its stated position.
Point 1 is pretty dull but -

Once the wording of the statement is agreed then, within one month, the Society will:
  • Place the statement on the public area of the website
  • Run a news story on the home page of the website, including a statement of whare require of members
  • Inform all members in our weekly newsletter of the Society's position on CEASE accompanies by a copy of the statement
Oh dear. That's not what the condition (b) stipulated. Misreading by the SoH is not uncommon. It seems to be a common trait in homeopathy. 

Regarding Point 2, the SoH complains that it does not know which members have had CEASE training or how many of them practice it. The SoH accepted that it needs to monitor websites etc to ensure compliance. The SoH says that Point 3 is difficult - from experience, it isn't and the correct tools can make the job a lot easier. What is much more difficult is determining whether members actually practice CEASE therapy and to what extent they actively promote medical neglect. Some may simply have had the training and never had any interaction with autistic children. It's also said that lay homeopaths can pick up trade by word of mouth, personal recommendation etc without the need to invest in a website. It's known that some of these recommendations occur in closed Facebook groups (including Arnica ones).

Point 4 is where things start to get interesting.
  • Those members whose websites are found to be in breach of guidelines are contacted by e-mail, highlighting the concerns requesting that changes are made within 30 days.
  • If the member refuses to make changes and the issues are in breach of the Society's policies and/or Code of Ethics, the matter is referred to the Society's Preliminary Investigation Panel for further investigation as per the Society's Professional Conduct Procedures.
  • Ultimately members who refuse to comply can be removed from the register.
Something that needs to be pointed out here is that the SoH has a poor history of dealing with all but the most serious breaches of their Code of Ethics. It was only under pressure that they acknowledged that CEASE therapy is a problem and even then, squirmed.

Accepting Risks
The SoH did eventually accept that CEASE therapy advocates harmful practices yet asserted that members did not engage in them. How it knew this when it also claimed that it did not know that which members engaged in CEASE therapy is moot. It appears an over optimistic assumption. The evidence collected on this blog (see this and Jennifer Hautman in particular) suggests very strongly that there are UK lay homeopaths who do engage in harmful and unethical practices. There is evidence that has not been published here yet.

At the time of writing the SoH is yet to publically announce their position statement on CEASE therapy but this bullish blogpost by CEO Mark Taylor in response to a Guardian story (which broke as the SoH were having their Annual General Meeting) is problematic. To quote -
What is the perfect antidote to spending most of a day grappling with a journalist who wants to run a simplistic and lazy attack on homeopathy in a national newspaper?
Whilst the message may have been aimed at SoH members, it appears in a public area of the SoH website and was written at a time when presumably the SoH were still coming up with their position. "simplistic and lazy attack"? Public reaction as demonstrated on this Mumsnet thread was one of "surely this is child abuse?" and "how is this legal?" Taylor is clearly very out of touch with public sentiment. Taylor goes onto say -
Websites are also meeting places, allowing members to gather news and information, learn, research and discuss – largely away from prying and hostile eyes.
Taylor is obviously discomforted by scrutiny. The SoH can not be described as transparent. It is very likely that it is poor at communicating with members.

The SoH had previously agreed with the PSA that it would conduct an audit of a sample (30) of member websites biannually. The audit essentially checks that websites comply with the CAP Code. The SoH wanted to deal with a number CEASE therapy websites as part of this. The PSA were insistent that this would take far too long (2+ years) and would potentially leave the public (especially children) at risk. Notionally, the audit of members offering CEASE therapy will be complete by the end of 2018.

But these audits are problematic. The SoH appear to be taking the line that is permissable for members to make reference for named conditions (except for notifiable conditions). This would appear to be based on the notion that the Advertising Standards Authority somehow recognise PSA accreditation of the SoH as meaning that members are somehow "suitably qualified" (something given credence by this CAP statement). This is problematic as legally, such claims are not permitted (see here) for homeopathic products - and thus by extension by homeopathic practitioners. This places the SoH at odds with its own Code of Ethics that makes Blue Guide compliance mandatory. These audits only concern themselves with breach of a somewhat convenient interpretation of voluntary advertising regulations rather than legal compliance. Looking at member website that mention CEASE therapy is not just about marketing claims, it's very much about visible event of risky behaviour and non-compliance with mandatory guidelines on practice - a very different thing. (It's also bizarre that the ASA might permit advertising from a SoH member but rule against identical advertising from a non-member with equivalent "qualifications".)

Position Statement
The FOIA return did not include any detail on likely back and forth between the SoH and PSA (this is being awaited). It is expected that the SoH would aim for the least damaging wording. It appears on a webpage with other position statements (on homeoprophylaxis - bogus homeopathic preventatives - and vaccination. This page and its antecedants have been more or less visible over time. The statement on CEASE therapy merits dissection -
The Society of Homeopaths appreciates that its registered members use different methodologies and adjunctive approaches and embraces diversity within the homeopathic community. We consider diversity to be healthy and appropriate to the demands of an informed public.
Embraces diversity? Anyone familiar with the history of homeopathy will know that a lot of it consists of arrogant men claiming they do homeopathy right and everyone else is doing it wrong. Adjunctive approaches? Many homeopaths do not see homeopathy as adjunctive (complementary) - they see it as an alternative to conventional medicine and CEASE therapy as per Smits is very anti-conventional medicine. If the statement relates to the use of nutritional supplements etc in CEASE therapy, there's the issue of lack of training in nutritional science (as opposed to bogus "nutritional therapy").
CEASE is a therapy designed by Dr Tinus Smits in the Netherlands. A number of Society members have been trained in CEASE and make reference to it in their marketing. While this is acceptable, members should be aware the title, meaning ‘Complete Elimination of Autistic Spectrum Expression’ is misleading. RSHoms must not suggest that they are capable of a complete cure of autism as this would be unethical and in breach of the Code of Ethics.
No. In terms of what the law says, it is not just "cure" that is the problem, it is the (implied or explicit) claim to treat autism. It is possible that the SoH will provide more detailed guidance to to members but, again, given the history of the SoH, they may not.
The Society does not endorse any aspects of CEASE therapy contrary to NHS guidance and nor should RSHoms. In particular on vaccination, homeopathic prophylaxis, and the use of dietary supplements. It is beyond standard homeopathic practice to provide advice on the use of supplements and therefore any guidance given should be in line with the NHS Guidelines
Does the business of NHS guidance on supplements apply more broadly? What about other NHS guidance? This guidance states that "Currently, NICE doesn't recommend that homeopathy should be used in the treatment of any health condition." and "If you choose health treatments that provide only a placebo effect, you may miss out on other treatments that have been proven to be more effective." Does that apply?
The Society expects its members to comply with its Code of Ethics and statements on vaccination and homeopathic prophylaxis at all times, and any breaches may be treated as disciplinary matters. In order to ensure patient safety and In line with our guidelines, we will check the websites and marketing of all our members on a regular basis to ensure they are adhering to this statement.
The SoH are unlikely to be the only people checking on websites and marketing.

Best Practice
Yes, the position statement falls far short of what would be considered best practice in health and social care settings. There's no mention of safeguarding, autism awareness or competency for example. It must be pointed out that the PSA was not aware of them at the time that conditional reaccreditation occured. It can also be argued that the PSA is not in the position to impose best practice - it is really up to registers to adopt it - the PSA are more concerned with standards that relate to how registers are run.

However, as was made clear in this discussion of National Occupational Standards and the previously mentioned discussion of the reacrreditation, the SoH's Code of Ethics does place duties on the SoH and its members. There is a certain irony that by aping the forms of regulated healthcare professions in an attempt to gain credibility, the SoH has lost credibility by failing to live up to them. 

Even if the SoH do not adopt (all) best practice principles, there is nothing to stop individual members doing so. For example, the National Autistic Society offer online autism awareness training at the very reasonable price of £36 per module. The SoH should recognise this as Continuing Professional Development (CPD). The NAS even offer a safeguarding module. Of course, there are other training providers. There are also CPD courses in self-evaluation that are well suited to some working in health and social care. And so on. It is worth pointing out that these courses are often cheaper than CEASE therapy et al training.

In short, CEASE therapy is not safe. By extension homeopathy as a whole is not as safe as it is made out to be. The SoH have been forced to admit this.

The SoH often shows one face regulators et al, another to members. It is obvious that as a body it craves "official" recognition and so forth. But it is losing members, it is running at a deficit and whilst it has sufficient financial reservers to weather recruitment problems, reduction in income and increased costs for a few years, there are questions over its long term viability. The face that the SoH presents to the public is partly governed by a joint strategy by various homeopathic trade associations (via the 4Homeopathy group). Much is made of the safety and lack of side-effects of homeopathy. The SoH makes a great deal out of PSA accreditation but it is likely that consumer awareness of the PSA is very low and it is unlikely to make a difference to consumer behaviour.

It's odd that the SoH makes so much out of PSA accreditation to differentiate themselves from trade associations yet uses the Findahomeopath website - which includes other non-accredited registers. Yes, the SoH have it's own little page that mentions accreditation etc but the search facility makes no mention of this. If the SoH really believed that accreditation somehow embues members with superiority, why both with the website? It's is noted that the SoH has at times expressed disappointment that the PSA doesn't do more to promote accredited registers. This is a misunderstanding of the PSA's function. It is an exexcutive body of Government whose primary responsibility is the oversight of regulators of the legally recognised professions - not a commercial organisation that exists to promote the interests of accredited registers whose members are not legally recognised in anyway.

Given this, the PSA forcing the SoH to make a statement on CEASE therapy is humiliating but such is the price of retaining accreditation. It must be particularly humiliating for Mark Taylor. Whilst doubtless the Society will attempt put a positive spin on things, the media (who are very likely to pick up the story) will not. Social media has not really picked this up but this is partly because other media stories regarding CEASE therapy have grabbed popular attention in particularly this Canadian story and to quote -
B.C.'s top doctor says there are "huge potential harms" connected to a homeopathic treatment based on the unfounded claim that vaccines cause most cases of autism. 
Three registered B.C. naturopaths are the subject of a complaint to the College of Naturopathic Physicians because of the treatment, known as CEASE therapy — "complete elimination of autism spectrum expression." 
Provincial health officer Dr. Bonnie Henry told CBC News she was concerned to learn that CEASE is being offered in B.C. 
"It's certainly not based on science. It's based on a belief system," Henry said. "My big concern is that it really misleads parents into believing that immunizations are a cause of their child's autism."
That someone almost equivalent to Professor Dame Sally Davies speaks out against CEASE therapy is telling.

The SoH has been slowly losing members over time and the vast majority of its income is from membership fees. The SoH has engaged in a number of initiatives to stabilise/increase membership and thus revenue but has not had much success. These initiatives cost money. The SoH also commissioned a new website. It is currently running a deficit. Whilst it may have sufficient reserves to run at a deficit for several years with current membership levels, its financial future is by no means secure.

The SoH likely hopes that all members offering CEASE therapy will voluntarily comply with its position statement. Some may - especially if they have had few/no takers for CEASE - but some others? The SoH may well face dissent from certain members (including some mentioned here). The SoH if it wishes to be re-accredited in the future can not afford to indulge dissenters. It can not afford any delaying tactics, challenges to the position statement and its enforcement. If dissenters do not comply, the SoH will have to take disciplinary action. This will consume resources and potentially cost money - especially if lawyers become involved. If a member is expelled by the SoH, they do have a right of appeal. Again, this consumes resources and it is more likely that lawyers could become involved. It is worth pointing out that large numbers of complaints/disciplinary proceedings can 

The PSA are likely to take a keen interest in any disciplinary proceedings as are critics of homeopathy. If the SoH don't deal with things effectively, accreditation is at risk.

There is supposedly an agreement between the homeopathic trade associations that if a member is expelled from one, they can not join another. This would also have the effect of them no longer being listed on the Findahomeopath website (the value of a listing is moot). There are some other trade associations that have broader scope than just homeopathy that might admit them but not PSA accredited ones.

Dissenting members could simply resign and go join another trade association. Indeed, the Alliance of Registered Homeopaths (ARH) was originally formed by dissenters from the SoH.

Whatever happens, the SoH is faced with a loss of members with no real prospect of increasing membership. It is impossible to estimate numbers. The SoH may be forced to raise membership fees but as Mark Taylor said in his bullish statement about some members of the SoH -
They are often sole traders, struggling to make a living and don’t have the luxury or the budgets to travel and pay for corporate-style ‘networking’.
If this is true (and homeopaths are prone to exaggeration), such members are likely very sensitive to cost increases. The SoH might alternatively or additionally look to cut costs. This could include reducing staff costs. It might involve relocation.

As has been pointed out in numerous previous posts, the SoH are well aware of the illegality of lay homeopaths supplying unlicensed medicines. The "detox" remedies used in CEASE therapy are unlicensed medicines. The Medicines and Healthcare Product Regulatory Agency (MHRA) has the power to completely stop the supply of these remedies if it so wished. This would effectively kill CEASE therapy in the UK. The MHRA forbade the open advertising of these remedies some time ago. Other international medicines regulators have forbidden the supply of these remedies or are in the process of investigating them.

All potential UK suppliers have been written to pointing out the nature of CEASE therapy, the illegality of supply to UK lay homeopaths and the MHRA instruction not to advertise. Not that this communication has any legal force but it does place any UK supplier in an ethically difficult position - if they did not already know what the remedies were used for they now do and they will know that CEASE therapy is neglect and a safeguarding issue.

One key question is whether the SoH can do enough to be re-accredited next year? It's committed itself to doing a number of things in order to meet the conditions of this year's re-accreditation. Reading between the lines, re-accreditation may prove difficult if it fails to achieve those.

Reading between the lines, the re-accreditation of the SoH has been a learning experience for the PSA. It is likely that the business of CEASE therapy has brought the safeguarding risks associated with Complementary and Alternative Medicine (CAM) to their attention. What applies to CEASE therapy is also likely to apply to other practices of SoH members.

In essence, if the SoH wish to retain PSA accreditation in the future, they may well have to place more restrictions on what members can say and do. Whatever the SoH and its members might like to think, there is likely a de facto scope of practice for lay homeopathy. What that might look like would be better dealt with a separate post but it would likely result in the loss of even more members.

What applies to the SoH also applies to other accredited registers. Some registers such as the Complementary and Natural Healthcare Council and Federation of Holistic Therapists are just as vulnerable as the SoH.

UPDATE 01/06/2018
After a delay of a week, the SoH finally did publish a news item regarding CEASE therapy. It is unfortunate to say the least.
The Society has published a position statement on CEASE within the Patients section of the website. CEASE was developed in the Netherlands by the late Dr Tinus Smits and is a powerful homeopathic protocol for deeply treating and clearing toxicity in the body. 
Commenting, the Chief Executive of the Society, Mark Taylor, said ‘ this statement is the result of a long process of negotiation and debate with the Professional Standards Authority and involving a number of prominent CEASE practitioners. It contains nothing that is really new. Members may offer CEASE therapy providing they avoid making misleading claims or make recommendations that breach NHS Guidelines’.
The irony of the news item making a misleading claim may be lost on the SoH. The SoH have never been particularly good at public relations but Taylor's comment is indicative of a failure to grasp issues of competence and safeguarding. Why on earth would the SoH be involving those who offer CEASE therapy? They are the problem - they are the people who lack the competence to treat autistic children, advocate a bogus therapy and do not seem to grasp safeguarding issues. It's the sort of thing that the media could make a great deal out of.

It is assumed that the news item was timed to coincide with the email newsletter that the SoH sends members every Friday. What it says is unknown but it is of concern.

On the other hand, it seems like a few SoH members are dropping mention of CEASE therapy and/or autism. Of course, marketing claims are not necessarily indicative of the actual risks posed to children by a practitioner, but even so. Perhaps some members are more acutely aware of the potential impacts of negative publicity?

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