Tuesday, 8 October 2019

Good Thinking Society Judicial Review

The Good Thinking Society (GTS) have been granted permission by the High Court for judicial review of the Professional Standards Authority (PSA) decision to accredit the Society of Homeopaths (SoH).

This post will repeat content very familiar to some readers. It is intended to be more stand alone than some other posts.

It isn't intended to provide a full explanation of the judicial review process. It is recommended that readers consult this from the Public Law Project. In short, judicial review is a process by which the decisions of public bodies can be challenged in Court when other means of redress have failed.

What is CEASE therapy?
CEASE stands for "Complete Elimination of Autistic Spectrum Expression". It is based on the belief that vaccines and other medicines are the primary causes of autism. It posits that homeopathic remedies made from these toxins can remove the "toxic imprints" that cause autism. It suggests that autism can be cured or at the very least improved.

Homeopathic remedies are in themselves harmless, unless contaminated. CEASE clearly advocates medical neglect of autistic children. To quote from the book Autism Beyond Despair written by the inventor of CEASE, Tinus Smits -
... All kinds of detoxification reactions may occur. The most common are eliminative reactions with an increase of reactivity (fever). Fever should not be treated with medication, as it is a healthy reaction of the organism and not a disease! It helps greatly to overcome an acute disturbance, shortens the healing process, stimulates reactivity and avoids complications. Eliminations like diarrhea, flu, expectoration, and bad-smelling and cloudy urine should also be left alone, because they are a part of the healing process.
A case of diarrhea as a cleansing reaction
I remember an autistic child who got diarrhea during the detoxification of his vaccines. The diarrhea relieved his system so much, that his autism almost disappeared instantly. After ten days the mother started to worry and went to the family doctor because I was absent at that moment. He prescribed Immodium (Loperamide) to stop the diarrhea by paralyzing the peristaltic motions of the bowels. Almost immediately the child had a setback and became autistic as before. The diarrhea was a perfect detoxification for his bowels and brain. Neither the doctor not the mother understood this, and the medication interfered with the progress of the cure.
CEASE advocates ignoring symptoms of potentially serious diseases. CEASE also states that autistic children should not be vaccinated. It also involves very high doses of vitamin C to the point where it causes diarrhoea (and then reducing the dose).

The vast majority of CEASE practitioner sare medically unqualified lay persons. The vast majority have no training in autism awareness. There are questions about whether they have had suitable training in safeguarding vulnerable children: they appeal unable to recognise that CEASE is neglect (if they did they would not practice it).

Some background
The PSA is an official body with two separate but related functions. It acts as an oversight body for the regulators of the staturorily regulated medical professions. It sets standards for regulation and monitors performance against them.

It also has a voluntary accrediation scheme for registers that admit practitioners who are not regulated medical practitioners. Registers can apply to join this scheme if they can demonstrate that they meet the Standards set by the PSA. They are assessed every year against the standards.

The Society of Homeopaths was formed in 1978. It is the largest homeopathy association in the UK (but not the richest). It currently has around 1,000 members. The majority are medically unqualified lay persons. There are some nurse/midwife members. Some are still reigistered, other are not. They are a very few doctors too. Its membership is predominantly female. Whilst it is the biggest association it is likely that more homeopaths do not belong to the SoH than do.

The SoH was originally accredited by the PSA in 2014. There were numerous objections to this but the PSA took the line that legislation prevented them from considering the efficacy of any therapies that might be offered by members of a register applying for accreditation. They considered it ultra vires. It is understood that someone did at some point indicate an intention to seek judicial review of a decision to accredit (it is not clear if it was the initial decision or a subsequent one) but no application was made.

The existence of CEASE therapy has been known for years but outside of homeopathic circles not much detail was. Seemingly no-one had picked up that it advocates the medical neglect of autistic children. The SoH were informed of concerns about members offering CEASE therapy towards the end of 2017.

Concerns were raised with the PSA that given their history, the SoH were unlikely to do anything concrete to address issues other CEASE therapy and might even ignore them. Also around this time the Advertising Standards Authority (ASA) were alerted to widespread online advertising of CEASE therapy - although this did not single out SoH members.

The PSA did renew SoH accreditation in 2018 but the announcement was made many months after the notional end of the previous accreditation period. That accreditation was conditional on the SoH developing an action plan to deal with members offering CEASE therapy. From correspondance obtained by Freedom of Information Act (FOIA) requests it would appear that there was a reluctance on the part of the SoH to act and even less to act quickly. The action plan aimed for member compliance by December 2018. The 2018 conditional accreditation was widely reported by the media. It caused major upset in the UK homeopathic community. The initial reporting coincided with the SoH's annual conference.

It is also known from FOIA requests that during the accreditation process the ASA send out an enforcement notice to all CEASE practitioners pointing out the types of marketing claims that were prohibited and that non-compliance could result in referral to Trading Standards who have the powers to prosecute.

During 2018, it became clear the SoH's action plan was not acheiving widespread compliance. Whilst some members did amend their marketing claims, some did not. Some members did remove all mention of CEASE from their websites but many simply modified the language, in particular to remove claims that vaccines cause autism and so on. Removing certain marketing claims is one thing but many link to the cease-therapy.com website where the prohibited claims are still made. Of course, removing marketing claims does not mean that practitioners were not making the claims face-to-face, on social media, via Skype, in email newsletters and so on.

The question started to be raised in 2018, given the unwillingness/inability of the SoH to achieve compliance, whether they should be accredited by the PSA in 2019. It also became clear that if the PSA did, the decision could be challenged via judicial review.

Again, announcement of accreditation did not happen on time but before any announcement was made the ASA went public regarding the enforcement action and it revealed referrals had been made to Trading Standards. Again, this caused much upset in the UK homeopathic community and curiously, happened just as the SoH annual conference started.

At one point on Twitter and also in board papers, the PSA did imply that they were aware that CEASE could be considered discriminatory.

The PSA 2019 accreditation of the SoH appeared very quietly some time in April 2019. The PSA accredited the SoH with no conditions.

On 29/06/2019, the GTS announced that they had applied for judicial review.

Accreditation Process
It is necessary to understand a little about how the PSA accreditation process works. Registers are expect to signal their intent to renew months in advance of the expiry of accreditation term. The public and other stakeholders are invited to comment on the register. It's not an invitation to talk about the efficacy of a therapy or the service recieved from a member of a register. The PSA may also monitor communications issued by the register during the year, media reporting and so on. It is expected of certain stakeholders that if they have major concerns about a register that they raise them immediately rather than wait for the invitation period. 

The register is expected to submit by the end of the tenth month of the accreditation period (November 2019 in the case of the SoH) -
- A completed and signed renewal application form 
- Any supporting documentation 
- An updated Risk Matrix 
- Responses to feedback shared by stakeholders through our Share Your Experience process 
- Registrant numbers to allow us to calculate the annual renewal fee.
Why is the 2019 accreditation is problematic?
To begin with the 2018 accreditation was condititional and there is a lack of clarity about what was expected from the SoH beyond an "action plan" and what the consequences would be if the SoH did not fulfill the terms of it. To repeat the Conditions -
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.
There is demonstrable evidence that with (b), whilst the SoH may have developed "mechanisms", they were not effective. 

The accreditation report mentions CEASE extensively. It is clear that the PSA understands that CEASE is problematic in a number of ways, it was certainly aware that some SoH were still making problematic claims (and likely practicing it) but yet it saw fit to renewal accreditation unconditionally. Yes, it made a number of recommendations re CEASE but they are not binding. Recommentations are - "Actions that would improve practice and benefit the operation of the register, but do not need to be completed for compliance with the Standards to be maintained. Implementation of recommendations will be reviewed at annual renewal." 

Also, to quote from the PSA -
The Accreditation team will present the report to the Moderator to make a decision. Outcomes may be:  
- Accredited  
- Accredited with Recommendations  
- Referral to targeted review  
- Direct referral to an Accreditation Panel 
Outcomes of an Accreditation Panel may be: 
 - Accredited with Recommendations 
 - Accredited subject to certain Conditions that you must satisfy to retain accreditation 
- Suspension dependent on appropriate action 
- Removal of accreditation.
The accredition decision was made by a single Moderator. A Moderator can not impose Conditions. Only an Accreditation Panel can do that and the Moderator chose not to refer.

GTS grounds for application
This blog isn't privy to what was submitted but some of evidence the GTS and their legal team likely used is in the public domain. The arguments made are not very different from those suggested on this blog. The exact detail is unknown but the main thrust is very clear. To quote from the GTS -
Good Thinking argued that the effect of PSA accreditation is to sanction treatments performed by members of the accredited organisation, such as the Society of Homeopaths, and that the PSA must carefully consider whether such treatments are harmful as part of its deliberations.  Additionally, Good Thinking argued that in reaccrediting the Society of Homeopaths the PSA failed in its legal duty to consider the potential effects of its decision on disabled people, such as the autistic children at whom CEASE therapy is aimed.  It was also argued that the decision to reaccredit given what the PSA knew about CEASE therapy was irrational.  The Judge granted permission on all grounds.
Bindmans, GTS's solictors repeat the same statement here.

From the permission itself -
  1. The Claimant has raised an arguable case to the effect that in taking an accreditation decision, the Defendant must make an assessment of the likely impact of doing so in particular on users of health care and other members of the public. There is an issue between the parties as regards the nature of, and the limits of, the Defendant's role and remit in making accreditation decisions. The Defendant says that the impact of accreditation is to impose standards of organisation and governance on bodies, but the Claimant says that it goes beyond that because the effect of accreditation is indirectly to sanction treatments performed by members of the accredited organisation. This then gives rise to issues regarding the inquiries required of the Defendant and whether the inquiries made were sufficient.
  2. It is acknowledged that the Claimant says that this is not a public law issue, but one of whether the Claimant would have formed a different view from that of the Defendant. That might be the conclusion at the end of the case, but it is at least arguable that the difference was about the Defendant failing to pay adequate regard to relevant considerations required of a person accrediting. The effect contended for was that the Defendant did not ask itself the right question or make sufficient inquiries or conscientiously consider the facts. There are also arguments about whether the Defendant breached the public sector equality duty and/or acted irrationally.
It is important to remember that the granting of permission is not a judgement. The legal meaning of "arguable" is different from the everyday one. It is suggestive of argument having merits which need to be explored rather than the reverse.

Strange as it may seem, the enabling legislation (the Health and Social Care Act 2012) of PSA with regards to accredited registers does not explicitly state that it has a statutory duty towards public health and safety beyond what is in . Nor is the PSA directly responsible to any legal entity that has such a statutory duty. There is more of a statutory duty on the PSA with regards to staturorily regulated professions but bodies such as the General Medical Council have considerable (quasi) legal powers themselves. Many in the regulated professions are also employed by NHS bodies that have statutory duties to public health and safety.

Regardless of the lack of a clear statutory duty, the PSA states as one of its objectives -
1. Increasing the influence of the Authority’s work to improve regulation and registration and promote the health, safety and wellbeing of patients, service-users and other members of the public.
"Influence" is a very vague term but one tool that the PSA has is place conditions on an accreditation to improve areas in which a register falls short on protecting the public. It has the powers to refuse, suspend or remove accreditation.

The PSA describes the overall benefits of accreditation as -
Whether you are a member of public looking for a health practitioner, an employer recruiting staff or a commissioner buying services, Accredited Registers can help you choose with confidence. 
When you choose to see a health and care practitioner you want to know that you are in safe hands. Using someone on an Accredited Register gives you peace of mind, knowing that:
  • Practitioners on an Accredited Register are part of a government-backed scheme to protect the public
  • The organisation holding an Accredited Register has been rigorously assessed by us and awarded our quality mark
  • We make sure you are given clear and accurate information to help you choose a practitioner to meet your needs
  • We make sure Accredited Registers handle complaints fairly and robustly
  • If a practitioner is struck off an Accredited Register they are not allowed to join another one in the same occupation (or another in a different occupation if removed for misconduct), so you and others can avoid poor practice
  • Accredited Registers are recognised and supported by key stakeholders in the UK.
Practitioners who are committed to high standards choose to join an Accredited Register. Responsible employers and commissioners choose practitioners on Accredited Registers. 
We recommend the public only see practitioners on an Accredited Register (or a Statutory Register). Look out for our quality mark which is displayed by practitioners on Accredited Registers.
"You know you are in safe hands" and "Practitioners on an Accredited Register are part of a government-backed scheme to protect the public" are very suggestive statements.

CEASE does advocate medical neglect of autistic children. It can hardly be said to be safe.

The question of whether accreditation of a register indirectly sanctions treatments offered by members is not straightforward. Certainly some SoH members believe that it does - claims that they are accredited by PSA (rather than belonging to an accredited register) have been seen. Likewise similar claims have been made by homeopathic colleges. It is understood that the PSA aren't happy about these claims and will seek to have them removed if made aware. Unlike some other registers, the SoH's focus is on a single therapy - homeopathy. It does not support or endorse the use of other therapies by members. Public awareness of the accredited registers scheme is low and understanding of its niceties likely very much lower. Would a member of the public upon encountering a website of an SoH member believe that the PSA sanctions homeopathy?

The SoH position on CEASE (and vaccination and homeoprophylaxis) is muddled. It says -
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
So it endorses those elements of CEASE that don't contradict NHS guidance? NHS guidance on homeopathy is vague but says -
Some people who use homeopathy may see an improvement in their health condition as the result of a phenomenon known as the placebo effect. 

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.
The more bizarre elements of CEASE simply aren't covered by NHS guidance. Does the SoH, for example, endorse the prohibition on microwaving of food? There are problems with rejecting parts of a therapy but accepting others - Smits would have said this is not CEASE therapy. To quote a Dutch homeopath -
Tinus has high expectations of himself, but also of his colleagues. He has a strong Hahnemanian attitude, saying: make it like I do, but do it exactly like me, otherwise you will not the same results. Perhaps this is exactly the quality you to achieve what he has done, the ability to open up new horizons.
Does the PSA by accrediting the SoH endorse the elements of CEASE that the SoH does not prohibit? It would likely say not.

Is Judicial Review Avoidable?
Possibly and there are good reasons to do so.

Judicial review is expensive. There are ways to limit the cost but the loosing party can end up facing having to pay the other side's legal costs in addition to their own. For example, the British Homeopathic Association ending up having to pay £120,000 pounds in their failed judicial review of NHS England's decision to issue guidance to the effective that GPs should not prescribe homeopathy on the NHS. 

Whilst the PSA is a considerably larger and better funded organisation than the GTS, the accredited registers scheme is intended to be self funding. It isn't yet and the PSA are given a subsidy by the Department of Health and Social Care (DHSC) to keep the scheme running. It is likely that the costs to the PSA in dealing with the SoH are already higher most other registers. Depending how the PSA budget for legal costs, the judicial review could have the effect on making self funding an even more distant prospect, which is unlikely to please the DHSC. Other registers would also be effectively subsidising the SoH. They might not be happy about this.

The GTS are using crowdfunding to cover (some of) their initial legal costs. It is possible that they might not secure enough to proceed any further. Sometimes public authorities will gamble on this and the complainant's fear that they will lose and have to cover the public authority's legal costs. 

A ruling in favour of the GTS is unlikely to have much impact on the overall credibility of the PSA and accredited registers scheme (although it may raise questions about certain registers). It could be severely deterimental to the SoH. Reputational damage is one thing but it could give more power to those disatisfied with the SoH deferring to external regulators etc, assuming they do not leave. Whether an adverse ruling would have an effect on UK homeopathy as a whole is debateable. 

Whether the GTS would abandon judicial review if the SoH, say, declared that it would prohibit members from offering CEASE etc, would discipline any member found doing so and made a firm commitment to carry through is unknown. Ditto if the SoH said that it had decided that PSA accreditation was no longer tenable. The SoH are very unlikely to do either. Both would be damaging.

There also good reasons why judicial review should go ahead. One less obvious reason is that there is little or nothing in the way of relevant case law. Various public authorities do have accreditation schemes. The extent to which public sector equality duty (PSED) should be considered in accrediting organisations/individuals is unclear. This article talks about PSED in a procurement context. Of course, with accreditation, registers are effectively buying a service from the PSA rather than the other way around but even so...

A word about evidence
The PSA have in the past refused FOIA requests relating to the SoH. One of these refusals was appealed and ended up with Information Commissioner's Office (ICO). The ICO upheld the refusal. 

There are limits to what FOIA requests can obtain. The ICO's ruling is quite helpful in understanding why the PSA refused the request and - 
21. The PSA further stated the qualified person has closely evaluated all of the information and has reached the reasonable conclusion that this ‘would’ inhibit the free and frank provision of advice and the exchange of views for the purposes of deliberation and that it ‘would’ prejudice the effective conduct of public affairs. After reaching this decision the qualified person, as well as the relevant team members closely considered the arguments for and against releasing the information and reached the conclusion that the public interest in transparency is, in this case, outweighed by the public interest in the Accreditation programme being successfully maintained for the purposes of public protection. 
And later -
25. The PSA explained that as this is an ongoing process, without the trust of the organisations involved it would be unable to fulfil its statutory functions in relation to accreditation. The Accreditation team have received feedback from a number of registers that are involved in the accreditation process or considering applying, that they would be unwilling to provide information that they consider to be sensitive as part of the application process if they believed that it would be released into the public domain. The BACP (another accredited register) has advised the PSA that they would consider it to be a ‘breach of confidentiality’, highlighting the wider impact on the programme. 
26. It further confirmed that this conclusion had been reached after considering responses received from other accredited registers, which they stated they would not have applied for the scheme and disclosed the information had they believed it would be disclosed under the FOI, and indications from other organisation that they would not provide full and frank information in future should it be released.
What will be presented to the Court will not be subject to these limitations. 

Judicial Review
A judicial review is different from most other Court proceedings (especially as depicted in film and TV). The Public Law Project explanation is very clear so quoted here -
Usually within 35 days of the decision to grant permission the defendant must file and serve its detailed grounds of resistance, setting out in more detail the basis on which it is defending the claim. That must include any written evidence it wants to rely on. The case is then set down for hearing before a judge in the Administrative Court. The time estimate for the hearing will normally be agreed by the lawyers for all the parties. 
The full hearing is very formal. It involves lawyers from both sides making arguments about the lawfulness of the decision, act or failure to act which you have challenged. It is very unlikely you will have to give oral evidence, and you may not even need to attend the hearing, unless you would like to do so for your own interest. 
At the end of the hearing the judge can give judgment there and then, but that is unusual. The judge usually “reserves” the judgment, which means that the judgment will be given later, usually a few weeks after the hearing has taken place.
There's no back and forth between the lawyers. Witnesses are rarely called and cross examination is very rare. Arguments are largely set out in writing and both sides them before the hearing. There is a possibility for interested parties (in this case the SoH) to speak. 

Looking again at the permission -
Consideration should be given as to whether the scope of relief is too broad referring to a declaration of about accreditation generally. Further, there is a question as to whether the declaration as regards the Decision is about the interested Party generally or as regards the Interested Party relating to CEASE therapy. These are matters as to which greater definition is required as to the scope of the challenge. This appears to be the intention of the Grounds of Claim, whereas as currently drafted, the relief may be broader than is required.
Relief here mean the legal remedy sought. The GTS are asking that the decision to accredit the SoH is overturned on the basis of irrationality. For practical purposes, the scope of relief has little differences to the likely arguments. The jist of the skeleton arguments are clear but what might the more developed arguments be? It is possible to speculate...

Developing the arguments - PSA
So what grounds might the PSA's lawyers set out in its defence? They will point out that legislation does not allow them to take into account the efficacy of the therapies offered by a register. They are likely to stress the PSA's role in accrediting voluntary registers is limited to setting Standards relating to how registers carry out their functions and how they are run. It is not a regulator of regulators, it is an assurer of bodies that practitioners voluntarily join. Those bodies are under no compulsion to apply for accreditation.

The onus is on registers to do what is required to meet the Standards. The PSA specifies what the Standards are and whilst it produces guidance on how to meet them it is not its role to dictate exactly how a register should go about this. 

An example might help. The PSA does not have powers to investigate complaints about members of a specific register. It would direct the complainant to the register. If the complainant was unhappy with how the register dealt with their complaint? The PSA has no powers to deal with that either. However, it would consider whether the register was meeting the Standards in the manner it deals with complaints in a more general context.

Looking at the Condition that was placed on the SoH, the PSA specified that the SoH needed to come up with an action plan but it did not specify what that action plan should be. Nor did it specify what the outcomes of that action plan should be. 

There is an assumption that if a register meets the Standards then its members will, for practical purposes, be generally safe in their practices. Things can go wrong for all manner of reasons that can not be blamed on a register. 

One argument that might be made is that for many practical purposes a Recommendation will achieve the same effect as a Condition. This assumes that a register takes accreditation seriously and has a desire to improve. 

The PSA would have made their decision to accredit the SoH on the basis of evidence made available to them at the time by a register. There is an expectation that registers will be open and frank in their submissions, that they will not hold back information that might be prejudicial. The PSA may request specific additional information from a register but it has no statutory powers to demand such information. It is dependent on registers being cooperative.  It could, in theory, refuse or place restrictions on accreditation if requested information was not supplied but this seems unlikely.

Here is a bland statement from the accreditation report -
14.1 The Authority had regard to its duty under the Equality Act 2010 when considering the application for renewal of accreditation.
What deliberations the PSA made in deciding that it meets the

Developing the arguments - GTS
What more detailed arguments might the GTS' lawyers make? It must again be stressed this blog is no more privy to the discussions between the GTS and their lawyers than any other member of the public. This does mean that it is possible to speculate without prejudicing any legal action. The only possible advantage that this blog has over another member of the public is familiarity with information that it already in the public domain.

There are multiple arguments that could be advanced. The problem for a lay person (and even a lawyer who is not a specialist in public law) is determining their relative relevance and strengths. There is a distinct difference between, say, writing polemic blog posts about why the PSA were wrong to accredit the SoH or some SoH members are bad people and getting a Court to rule on the irrationality of the PSA's decision.

The GTS say their goals are to -
  • If successful, the challenge could see the accreditation decision ‘quashed’ (annulled) by the court and the PSA ordered to take into account the harms associated with CEASE therapy in considering any reaccreditation application from the Society of Homeopaths
  • Good Thinking hopes that this will result in the Society of Homeopaths being required by the PSA to take action to protect autistic children from harmful therapies, or lose their accredited status
It isn't neccessary to deploy lots of arguments to achieve these.

Whilst the exact legal duty of the PSA towards public safety is unclear, there is no doubt that it has a moral duty. It is also clear from various statements that it was Government's intention that it should have such a duty. Likewise statements from the PSA itself seem to indicate that it feels that it does. Whereas the framing of the legislation may be such that consideration of the efficacy of a particularly therapy would be ultra vires, there is nothing in legislation that prevents the PSA considering the safety of a therapy. 

That there have been no reports of harm caused by CEASE therapy is irrelevant. The absolute risk of harm may be low but its impacts could be disasterous. That in Court cases where harm has resulted for medical neglect involving CAM treatment by medically unqualified lay persons, the blame is generally placed on parents is also irrelevant. The Standards state that a register that meets them -
3a) Has a thorough understanding of the risks presented by their occupation(s) to service users and the public – and where appropriate, takes effective action to mitigate them.  
3b) Is vigilant in identifying, monitoring, reviewing and acting upon risks associated with the practice of its registrants and actively uses this information in carrying out its voluntary register functions. Evidence provided should demonstrate how the organisation seeks, gathers and handles information, and provide examples of having acted to prevent or mitigate risk. The Professional Standards Authority will decide whether this Standard is met with reference to guidance provided in the Accreditation Guide (2016).
Note the emphasis on risk and "effective action". It stands to reason that the PSA does in its evaluation of whether a register meets this standard make its own evaluation of risk to some extent. 

It can be strongly argued that the very phrase "Complete Elimination of Autistic Spectrum Expression" is discriminatory. Whatever the reasoning behind the choice of words, it could be read as suggesting that autism is something undesireable that should be got rid of. Autistic people vary considerably in their needs and their abilities. The politics surrounding autism are very complicated but for some autistic people, autism is very much part of their identity. The phrase can be read as invalidating that identity. The reactions of autistic adults to the phrase without prior knowledge of the therapy are illuminating. All were negative but some found it very menacing. Comparisons to eugenics and even the Nazi Aktion T4 euthanasia programme were made. 

CEASE does single out autistic children as a group. That practitioners claim that it can be used for other conditions is a red herring. The advocacy of neglect could be read not just as discriminatory but also as victimisation, albeit more passive that some forms.

The PSA understand that CEASE is discriminatory. By accrediting the SoH they are in breach of PSED.

It boils down to this. Given what the PSA knew about -
  • the risks associated with CEASE therapy
  • the questionable efforts of the SoH to mitigate the risks
  • the discriminatory nature of CEASE therapy
  • the prevalence of CEASE therapy among SoH members
was it rational for the PSA Moderator to (unconditionally) accredit the SoH? Would a reasonable person reach a different conclusion from the Moderator?

Re-run of Accreditation Process
If the GTS are successful in overturning the PSA's decision, the PSA will have to re-run the accreditation but in such a way as to correct the deficiencies identified. This does not necessarily mean that the re-run accreditation will have a different result but it will have to be done differently. It would seem sensible that it would be carried out by an Accreditation Panel. 

Even if the GTS are unsuccessful, unless the SoH choose not to apply for accreditation for 2020, the PSA are likely to be very mindful of CEASE therapy and other factors. The accreditation decision is likely to come under far more scrutiny that any previous one and it is possible that there 

Compared to 2019 accreditation, the PSA are in posession of considerably more evidence. They are also aware that there is key evidence that may be available for the asking. For example, whilst CEASE is obviously a bad thing, the exact details of CEASE training are unknown. It is known that at least one training session also included homeoprophylaxis. Some homeopaths on their websites have mentioned it includes information on the Jarisch–Herxheimer reaction. Given that is the result of endotoxins being released by pathogens when treated with antibiotics, whatever is being seen isn't that and must be caused by something else. There are questions about what other potentially dangerous wrong things it contains.

This blogpost from Les Rose contains something chilling. It is about an open day held by the Salisbury Homeopathy College (SHC). 
We then had a wrap-up session with Annie, whose task presumably was to get us to commit to a four-year part-time course. There was the usual discount for signing up on the day. This was supposed to be an opportunity to ask questions, but Annie was so fired up that it was hard to get a word in edgeways. I was going to mention CEASE therapy anyway, but she got in first and divulged that they teach it on the course. Some of the tutors are qualified CEASE therapists, including Joanna. This is interesting in view of the storm that The Society of Homeopaths is sailing into right now. Briefly, the PSA has placed the SoH on notice to discipline members who practise it, on pain of losing its accreditation. The team in Salisbury must be aware of this, but they didn’t mention it.
And -
I tried to press Annie on vaccination, but she was careful not to come out as 100% against it. She does advise patients on homeopathic alternatives for travel, but generally leaves it to them to have the jabs if they want, and “sort it out when they get back”, ie a homeopathic `detox’. She is clearly convinced that vaccines can be harmful, but won’t deny that they have some benefits.
SHC are accredited by the SoH. If the SHC is still teaching CEASE, this raises all sorts of questions about their accreditation by the SoH. It means that any graduate of SHC will be need to be monitored by the SoH. It also means the SHC hold CEASE training materials.

The prevalence of anti-vaccination sentiment is a real problem for the SoH. Roughly 30% of members with websites are openly anti-vaccination in one way or another. Troublingly, this also includes some of its directors which may explain why it has done very little. Some members are very extreme. Some colleges also host talks by anti-vaccination speakers which are considered "professional development".

But is isn't just about the headline grabbing issues. There are board questions as to whether the SoH meets some of the Standards. Reading the SoH website it is difficult not to come away with the impression that it is more interested in itself and its members than it is in protecting the public. It seems to have become less open, more defensive, secretive even. It is known from FOIA requests that the SoH has a history of seeking delay, putting obstacles in the way of reaching agreement, implementing action plans etc. Some of this may have been down to ex-CEO Mark Taylor but the board must also shoulder some responsiblity.

Friday, 4 October 2019

All things must pass

Mark Taylor, CEO of the Society of Homeopaths (SoH) has retired after five years in post. Over those five years, he has overseen all sorts of shenanigans, a marked decline in membership numbers as well as making a series of very odd statements. True to form, Taylor signed off with a strange blogpost.

It is worth looking because it gives an opportunity to discuss some aspects of the SoH, particularly governance and its strategic direction. Taylor starts off with -
The Society’s current strategic plan contains the following vision: 
      To see homeopathy firmly established within British healthcare

I am standing down after nearly five years as Chief Executive and I have been asked what I think needs to happen for us to come close to this lofty aim. So, free from the constraints of corporate responsibility, here are my personal suggestions:
1. Let’s stop blaming the detractors
Detractors are not turning patients away. They are demoralising, irritating and they cause trouble for us with the authorities and in the press but there is no evidence that the millions of people favourably disposed to homeopathy are influenced by the lies and bile produced by the small number of detractors. Let’s just ignore them, depriving them of the oxygen of publicity.
Taylor is right in that the stated strategic goal is a "lofty aim". It isn't something that the SoH can do, even in cooperation with others. It might as set a strategic goal of holding a Homeopathy Awareness Week on Mars by 2025 run by British homeopaths. Failure is inevitable and automatic.

One problem with believing your own propaganda is the cruel reality that the imagined support for your position is much less than you believe. Comparison with fringe political groups is appropriate. It is all very well for leaders of these groups to talk about "massive support" but how many people turn up to the meetings/marches? There have been pro-homeopathy demonstrations but they've had very low turnouts.

The "millions of people favourably disposed to homeopathy" line and variations are often repeated but it is a matter of faith rather than a matter of fact. There isn't any decent information on the prevalence of pro-homeopathy beliefs in the UK but it is known that there has been a considerable decline in the number of homeopaths who belong to the various associations.

Whatever spin Taylor et al want to put on it, from the perspective of the homeopathy associations, homeopathy is in decline. 

Denying the "oxygen of publicity" to "detractors" is a curious notion. How would Taylor propose this is done? The SoH and the UK homeopathy community (the word is used advisedly) do not control access to the media or the public. 
2. Classical or not makes no difference
Two weeks into this job I found out there was not one sort of homeopathy but many. Most patients still have no idea and most don’t care. We can either accept that there is so much more that unites us than divides us or we can confuse our patients and delight our enemies by seeing how many homeopathic angels we can get to dance on the head of a pin.
Many older white males would disagree with Taylor. The history of homeopathy is littered with bitter disputes over homeopathic doctrine and who is "the true inheritor of Hahnemann". Hahnemann himself was scathing of homeopaths that he judged as doing things wrong. Although the SoH accepts members who practice all sorts of strange variations of homeopathy (not to mention other stranger therapies), there is still a perception that it favours classical homeopathy as opposed to, say, radionics.

Taylor is right in that the public don't care about doctrinal differences. UK consumer awareness of the nature of homeopathy is low and if US research is anything to go by, the more they know, the less likely they are to use homeopathy (and by extension homeopaths).
3. The future of homeopathy is in the hands of homeopaths
History, evidence and millions of patients worldwide show that there is nothing wrong with homeopathy. Homeopaths are the best advocates. We must devote more time and resources to helping them build their practices and match their homeopathic knowledge with an equal understanding of marketing, administration, sales, networking, IT and advocacy.
Homeopaths are the best advocates? But they need to understand advocacy? There seems to be a contradictory there. However much the SoH try to empower homeopaths, if the market isn't there, it isn't there. 
4. Science and research are not the only answer
Let us be clear, evidence and research are very important and the more material we have to support homeopathy the better. But it is not the only way to defend homeopathy, indeed it is not the best way. There is no silver bullet; the establishment will never be convinced by the evidence. Use it by all means but the concept of patient choice is much stronger and resonates with a significantly wider group of people. How can it be right to persecute something that costs the state nothing, is non-toxic and is respected and utilised by millions of people?
It depends what the question is. Patient choice on the NHS is necessarily limited by financial constraints and there is a duty on NHS bodies to ensure that money is well spent. It's always been the case if you can afford, there is plenty of choice.

Who is this "establishment"? It's obvious that the SoH craves the approval of this vague entity. And what is this persecution he speaks of?
5. Homeopaths together are stronger
If you wanted a structure guaranteed to be ineffective and weak in making the case for homeopathy, I suggest we stick to what we have. We need one body, one register, one vision and one voice. History and vested interests need to be cast aside.
History? Originally, there was just the one register - the Society of Homeopaths. The history of the various UK lay homeopathy associations (and other associations that accept homeopaths) is not well documented. There was an attempt back in the mid 2000s to set up a central register via something called the Council of Organisations Registering Homeopaths (CORH). Some money was provided by The Prince's Foundation for Integrated Health. A newletter can be found here. This ended in acrimony that seemed to be mostly between the SoH and the Alliance of Registered Homeopaths (ARH). Many of the same people involved are still around. Many of them don't play nicely with other children let alone each other.

For practical reasons alone, creating a single register would be difficult and expensive. There are also questions as to what its role should be. Arguably, promotion of homeopathy should not be part of its role. 

In reality, having certain homeopaths on your register is just asking for trouble. Not just because they represent reputational damage waiting to happen but also because some of them are divisive by nature.
6. 4Homeopathy is not enough
The thinking behind 4Homeopathy is great (though it would not be needed if 5 (above) was implemented but it is not enough. We need to be part of a much wider and influential CAM pressure group. Only then would we get the ear of Ministers and the attention of the press.
4Homeopathy is largely ineffective. It is distracted by non-UK issues. It becomes involved in very fringe issues and expends a lot of energy on them. That post mentions the "Release the First Report" business. That report was recently released and unsurprisingly it doesn't demonstrate that homeopathy works. Even less surprising is that the media were completely uninterested in what homeopaths had to say about it. To quote from NHMRC's CEO Anne Kelso
I am also aware and concerned that a significant amount of misinformation has built up about the content of this 2012 draft report. I am releasing the report now in an annotated form to address this misinformation.
4Homeopathy and Homeopathy Research Institute (HRI) must bear responsibility for much of that misinformation.

Board minutes reveal attempts to link up with other CAM organisation but nothing seems to have come of them. Perhaps the involvement of Scientologist Martin Weightman was offputting? Or maybe Barry Tanner was a bit too much for them? Other CAM professions can are equally as riven by divisions as homeopathy - they have multiple associations that don't work together well, often with an acrimonious history.

For various reasons, not all CAM associations are equal. Larger associations and those with larger financial resources would be likely to dominate any pressure group but some CAM therapies are more negatively perceived than others. Would the chiropractic associations want to share a platform with angelic therapists? 
7. Never lose the passion
All the above is not a plea for convention and orthodoxy, it is a plea for effectiveness and growth. We can do this without losing the range of unique characteristics that define and enhance homeopathy – sustainability, holism and inclusivity. But most of all, the passion.
I do not imagine that everybody will agree with all my points but that is what it looks like from an outsider who has been, fascinated and energised by the homeopathy sector.
Very strange.

Taylor's Reign
Taylor stated with the SoH in February 2015. From that SoH news item -
Mark has extensive experience of not for profit organisations and joins the Society from VocalEyes a charity that helps to provide access to the arts for the blind and partially sighted people, where he was interim chief executive from August 2014. Prior to that Mark was director at the Museum Association (MA) for 24 years. 
He brings a knowledge and understanding of membership organisations including publishing, communications, training, event management and a range of membership services. He is widely experienced in lobbying, advocacy and campaigning on behalf of sectors and professions. 
Mark Taylor says “The Society is in good shape with a board focussed on the long term and a settled and talented set of staff. But, even in my preliminary discussions, I can see that membership services and the image of homeopathy are priorities.”
Taylor isn't a homeopath. In essence, he is a professional administrator. The SoH did experiment with a CEO role in the past but between 2010 and 2015 did not have one. Likely requirements of Professional Standards Authority (PSA) Accredited Registers scheme lead to the appointment of Taylor. Taylor was not involved in the initial accreditation. 

To be fair to the SoH, it at least seems to be going through the motions of being a more professional organisation that it was prior to PSA accreditation and Taylor joining. It still has issues in coming to terms with external requirements but even there some small progress has been made. 

The composition of the SoH Board has changed over time - there are now more non-homeopath members. Compare the board from 2013 -
with as of September 2019 -
Homeopath directors are elected by members. Their term is 3 years. They can serve a maximum of two consecutive terms before having to step down. They must wait at least one year before seeking re-election. Independent directors are appointed by the Board but the same strictures about maximum of two consecutive terms apply. The SoH are going to appoint an additional two independent directors so that the balance is 50/50. Independent directors can vote in Board meetings.

In 2009, the SoH had 1483 members. In 2014, the SoH claimed to have "over 1200" members. It now has barely over 1000 members (and dipped under 1000 in 2018). The SoH has tried to boost numbers in a number of ways. It introduced reduced membership fees for new members for the first two years for new members. It made concerted efforts to attract back members who had left. It made the route for entry for those without qualifications from its recognised courses easier along with encouraging homeopaths from outside of the UK to join. It made increased efforts to recruit student members. And so on. At best, these have slowed the decline in membership. At worst they've cost money/reduced income for zero effect.

Obviously numbers are dropping because the SoH is losing more members than it is recruiting. A very rough estimate of recruitment by year has been made. It looks as recruitment numbers peaked some time in the early 2000s (and possibly a bit before). The SoH was getting over 200 new members a year then. Since 2011, the numbers have hovered around the 50 mark. It is possible that the SoH suddenly became less successful at recruiting new members but if it did, the other homeopathy associations were also affected by the same issue. Joining any association would have had to become much less attractive. It's reasonable to assume that new number of newly qualified homeopaths has dropped considerably.

Members are likely leaving the SoH for three reasons -
  • Retirement - quite simply, they have reached an age where they don't want to work anymore.
  • Business failure - whilst for some homeopathy is just a part time hobby and they have a secure income from other sources, this is not the case for others. The biographies of many homeopaths suggests they gave up a career to do homeopathy and they have the option of going back to that. Not everyone is cut out for self employment and the uncertainities that go along with it. 
  • Disatisfaction with the SoH - which could be various.
Obviously, the SoH can do nothing about the first. As for the second, the SoH can't magic up a market when none exists but it is doing things like this. It is known that some homeopaths are very upset with the SoH not standing up to officialdom etc. Some have left as a result and more may do so.

Like 4Homeopathy, the SoH has supported a number of homeopathy related campaigns presumably in guise of "promoting" homeopathy that are not UK related and certainly don't impact on their members. Changes to US enforcement policies re claims for over the counter homeopathic remedies have no impact on their members (unless they manufacture the products). Whether or not GPs are allowed to prescribe homeopathic remedies on the NHS doesn't impact on the vast majority of members or their clients. Indeed, they would represent competition.

There have been a number of media stories which not favourable to the SoH. There have also been a number of stories not directly connected to the SoH that they have commented on. Just reading a few of these should give a flavour.

New CEO Emily Buttrum
The role of a chief executive officer varies but in the case of the SoH the role is likely to involve day-to-day management as well as a bit of being the public face of the SoH. Emily Buttrum's appointment is unlikely to result in any changes in direction for the SoH - that is for the board to decide.

From what she says on her consultancy website, her last operational role was Commercial Director at South London and Maudsley NHS Foundation Trust. Typically, this kind of role involves a lot of writing of project funding bids and involvements with contracts.

Buttrum officially started her role of 01/10/2019 although it would not be a surprise if she had informally attended key SoH meetings before then. On 03/03/2019, news broke of the Good Thinking Society (GTS)  succesful application for judicial review of the Professional Standards Authority (PSA) decision to accredit the SoH. This will be discussed at greater length in a future post but...

The Plot Thickens
There are some key dates to consider. Permission was granted on 13/09/2019 which was a Friday. It is believed that the SoH isn't open on Mondays (although staff may read emails). The SoH would have been aware on 17/09/2019 at the latest.

The SoH had a board meeting on 23/09/2019. It is very likely that the permission was discussed. The report of that meeting is unlikely to appear until November.

The SoH may have believed that the media would not have been interested. Even if they did, it would have been foolish not to have some sort of plan in place. It is interesting to note that the SoH did not respond to media requests for interviews etc. This may represent a change in strategy. 

At the time of writing, they have not made an statement on their website. To be fair, the SoH can take a little while to respond to events. They will need to offer some sort of reassurance to members soon if they haven't already (possibly by email or their online newsletter).