Saturday, 15 June 2019

The End of NHS Homeopathy?

To be more precise, is the end of NHS homeopathy in England in sight? It's been gone from Wales and Northern Ireland for sometime. Scotland is a different matter but even there the signs are not good (except in Grampian).

Some explanation of how the NHS works is required. Few people (including some of those who work in it) understand its structure and where homeopathy might fit in.

Primary Care
This has a broad meaning - it covers any healthcare service/person that you initially use except unless you have a serious potentially life-threatening condition that requires immediate attention. In the context of this post it means General Practice.

As of March 2019, there were GP practices still prescribing homeopathic medicines - unsurprisingly, some are the same as mentioned here.

Secondary Care
Again, this has a very broad meaning. GPs are generalists as the name "general practitioner" suggests. GP surgeries don't have specialised equipment. In the NHS, GPs refer patients to other providers for more specialised treatment. This is not always about the capability of GPs. Sometimes it is about cost effectiveness and/or how services are funded. For example, some GPs use to perform minor operations but it is no longer funded.

GPs act as gatekeepers to specialised services.

Secondary care is often thought of in terms of hospital care but it does include psychiatry, psychology, occupational therapy and physiotherapy that can be outside of the hospital setting. There is such a thing as tertiary (and even quaternary) care but it will not involve homeopathy.

History of the NHS and Homeopathic Hospitals
It's sometimes assumed that prior to the formation all medicine was private. This is not so. For most, yes, it was private (possibly funded by insurance or mutual organisations) but there existed social provision by local authority and voluntary hospitals. National Insurance paid for working men's GP treatment (but not medicines).

The NHS took over the local authority and voluntary hospitals. This included the homeopathic hospital - there were five in London, Glasgow, Bristol, Liverpool and Tunbridge Wells. Despite claims to the contrary, the Labour government did not grant them any special status. Medical homeopathy, never very popular outside the moneyed classes, was already in declineAlthough in 1948 hospitals had considerable autonomy, this changed over the years. The reorganisation of 1974 reduced that considerably. Other changes meant that small hospitals could no longer function effectively as independent organisations - they became part of other NHS hospitals. There's a long history of inpatient beds closing, surgery ending, moves to smaller premises - often losing the title of "hospital" and even affiliation with a hospital.

Later reorganisations in 1990s notionally gave back some autonomy but the introduction of the internal market commissioner/provider model was the beginning of the end for the homeopathic hospitals. Commissioners increasingly did not want to pay for the services. Healthcare rationing has always existed in the NHS but there was an increasing drive to stop funding ineffective treatments. Homeopathic services tended to be commissioned by PCT/CCGs that had a local homeopathy provider and loyalty/inertia played a part in that, or the services were provided as part of a block contract and not commissioned as such.

In the end, all NHS England secondary care homeopathy provides have either shrivelled away to nothing or become voluntary/private providers.

Royal London Hospital for Integrated Medicine
Despite the grand title, the Royal London Hospital for Integrated Medicine (RHLIM) isn't really a hospital and hasn't been one for many years. Yes, it occupies part of the former Royal London Homeopathic Hospital but there are no inpatient beds, much of the building is used for other purposes.

To understand the current predicament of the RHLIM, is is necessary to understand some of its history - its version of history needs to be taken with a pinch of salt (different version here).  Prior to 1948, it was a voluntary hospital. It was independent until the NHS restructure of 1974 when it became part of the South Camden health district.  It became a Trust in 1992. It's independence did not last long. In 1999, it became part of the Parkside Health NHS Trust which was dissolved in 2002. RHLIM became part of University College London Hospital (UCLH). The building was renovated between 2002 and 2005. RHLIM had to operate out of Portakabins for a period. A grand re-opening by Prince Charles happened. In 2010, the name formally changed from the Royal London Homeopathic Hospital to the Royal London Hospital for Integrated Medicine.

But this doesn't tell you very much. The RLHIM has never been purely about homeopathy and magic pills. It carried out surgery for one thing.

In the late 1950's Ralph Twentyman introduced Iscador therapy (a non-homeopathic concoction made from rotten mistletoe). Twentyman was involved with Anthroposophy and other esoterica. He was involved with the Camphill movement. Many current and former RHLIM doctors profess an interest in anthroposophic medicine. Iscador is effectively banned in the NHS these days (but that's another story).

Anthony Campbell introduced acupuncture to RLHIM in 1977. Environmental medicine is a real thing but some forms of quackery use the term. Those quacks that do tend to promote ideas like electromagnetic hypersensitivityHomeopathic podiatry turns up in 1984.  Autogenic training was introduced in 1985. 1995 saw the appearance of "manual medicine" - this is often a euphemism for chiropractic. "Western" herbal medicine appears at some point. 

In 1981 the operating theatre and surgical beds were closed.  45 inpatient beds then but by 1991, only one ward remained and it closed at the weekends. Figures from 1997/98, show only 4 beds. There are no beds now. 

An "education unit" was opened at some point. Faculty of Homeopathy training events are held there. Conferences were held too. Apparently research goes on too but where the funding for this comes from is unclear.

There is a pharmacy which is also a retail pharmacy, which is unusual.
The pharmacy is also a registered retail pharmacy selling a wide range of products to the general public.
These include;

  • Books on complementary medicines
  • Flower essences
  • Herbal medicines and topical applications
  • Homeopathic kits
  • Men’s organic skin care range
  • Mother and baby natural skin care
  • Natural and organic skin care and beauty products
  • Natural hair care
  • Nutritional supplements
  • Organic herbal teas
  • Organic self tan and sun care products
  • Over 3000 homeopathic medicines
  • Self-help books

The retail service is open Monday to Friday between 09:00 and 17:30.
Our pharmacists are able to provide professional advice on using complementarymedicines for minor ailments.
A telephone mail order and advisory service is available to everyone for more information call 020 3448 2600.
There is a bit of a problem here. Whilst a hospital pharmacy can supply all manner of things to patients, a retail pharmacy is very restricted in what it can supply to members of the public without a prescription. Unless the pharmacy manufactures the remedies themselves, only those products registered with the MHRA will be available for purchase. UCLH have been made aware of this and have given assurances that no unregistered products will be available for retail sale. The staff of the pharmacy are employed by UCLH. 

To think that ULCH took over the RHLIM out of altruism would be foolish. UCLH has space problems for one thing. Most of the RHLIM is used for other purposes. There's a ULCH phlebotomy suite. Some of it is rented out. The British Medical Acupuncture Association have a (private) teaching clinic. Great Ormond Street Hospital (GOSH) run the Zebra and Hare outpatient clinics from there - it is very close to GOSH. 

The building is Victorian. It wasn't built to modern hospital standards. There are limits to what uses these kinds of building can be put to. Some other hospitals have sold off their old sites/buildings for redevelopment. Others with larger sites have put up new clinical buildings and turned old facilities into offices and the like. The building is in a prime location and very valuable. It might not be politic to sell it because of Royal patronage. 

In the dim and distant past, GPs could refer NHS patients to the RLHIM for any reason but not all GPs wanted to. Advice from the British Homeopathic Associations (BHA) and the Friends of the RLHIM was to change to a GP that was more sympathetic to homeopathy! Changes to the NHS meant that a GP's decision not to refer could be raised with local NHS bodies but there was no way to force a GP to refer. Changes to the way that NHS treatment is funded meant that PCT/CCGs could decide to fund homeopathy, place restrictions on access or totally defund it.

But "patient choice!" homeopathy supporters cry. The NHS Constitution isn't particularly helpful but there is guidance that explains what patient choice means in practical terms.
If you need to be referred as an outpatient to see a consultant or specialist you may choose the organisation that provides your NHS care and treatment (an outpatient appointment means you will not be admitted to a ward). You may choose whenever you are referred for the first time for an appointment for a physical or mental health condition. 
You may choose any organisation that provides clinically appropriate care for your condition that has been appointed by the NHS to provide that service.

You may also choose which clinical team will be in charge of your treatment within your chosen organisation. For a physical health condition, you will be seen by the consultant or by a clinician who works in the consultant’s team. For a mental health condition, you will be seen by the consultant or named health care professional who leads the mental health team or by another health care professional in the team.
An explanatory footnote -
If an organisation has been ‘appointed by the NHS’, this means that it has been commissioned by a Clinical Commissioning Group or by NHS England to provide that NHS service.
Clinical appropriateness? A treatment with no evidence of efficacy would not be appropriate. Some services are commissioned by NHS England but RHLIM homeopathy services would not be one. In terms of services commissioned by CCGs? There are core services that all CCGs commission, so yes, in theory a patient could go to any organisation that provided it but if a CCG does not commission a service it doesn't matter if another does hence the postcode lottery for certain services. When a CCG does commission an unusual service, it will be from local organisations. 

In the past, GP referrals were done by letter but now online - NHS e-Referrals (e-R - formerly Choose and Book). Patients are able to log in and choose a provider. It is possible to configure all sorts of restrictions. 

This is where things start to get messy and complicated. Michael Marshall of the Good Thinking Society (GTS) and the Merseyside Skeptics Society discusses them in this podcast (from 42:15 - well worth a listen). The GTS have campaigned against NHS homeopathy for many years. 

London CCGs do not explicitly commission services from RHLIM. There are block contracts with UCLH. What Marshall uncovered was that RHLIM were treating patients referred to them with homeopathy (and other therapies) despite various London CCGs having a policy that required explicit prior approval for such treatments. The RHLIM believed this was permissible due to a vaguely worded agreement with predecessor organisations. This is extraordinary. Other things came out too - such as a lack of record keeping. 

But how could this go on? Part of the answer is the British Homeopathic Association (BHA) and Friends of the RLHIM were providing guidance on how to game e-R. It's not possible to select "homeopathy", instead a clinic offering a certain "service" is selected. And these can be very broad brush like "women's services". 

It must also be the case that there was a lack of governance on the part of UCLH management. To be fair to UCLH, RLHIM is responsible for probably <1% of activity and certainly doesn't generate any contract income itself. Nor does RHLIM have much of a public profile (most reporting is negative) - it's not doing any sexy science. 

The current situation is that treatment with homeopathy will under no circumstances be funded as explained here - which outlines the North London CCGs exceptional funding policy. However this document whilst it explains that patients will have to pay for homeopathic remedies also states -
Please note that other than payment for your non-NHS funded homeopathic remedies and Iscador for any patients as part of their routine care, all your NHS appointments and other treatments provided by the RLHIM are NHS-funded and unaffected by this change. For queries related to your RLHIM outpatient appointments, please contact the RLHIM Booking Team on 020 3448 2000.
It is possible that this information has not been updated (correctly). There should be no NHS appointments for homeopathy, regardless of who pays for the remedies. Private prescriptions being written as part of an NHS funded appointment? Iscador is not homeopathic but that it was being prescribed on the NHS is concerning.

It's not clear whether RHLIM is still providing NHS appointments without prior approval. An FOIA request be will made.

The future of the RLHIM as an entity looks bleak and not just because of loss of funding. The North London Sustainability and Transformation Plan is looking to reduce the number of centres offering certain services. As RLHIM duplicates services and is small, it is particularly vulnerable. NHS recruitment problems also place pressure on core services - it makes little sense to staff non-core services. The building is already used for non-RLHIM activities and its proximity to GOSH and distance from other UCLH sites suggests the building should be transferred to GOSH (although rules get in the way).

Income from private patients is a significant source of revenue for some hospitals. However, the nature of homeopathy is such that it does not need to be provided in a hospital setting with all the attendant fixed costs. RLHIM would unlikely be price competitive. It should be noted that some doctors at RLHIM do offer private services outside of RLHIM (Helmut Roniger for one) although they do use working at RLHIM as part of their marketing. A model where rooms are rented out to private practitioners is also unlikely to be competitive. 

Portland Centre for Integrated Medicine
There once was a Bristol Homeopathic Hospital (BHH). Its history is not well documented online. This history has to be taken with a pinch of salt for reasons that will become clear. This history isn't very helpful either.The original hospital building was sold in 1994. At some point NHS reorganisation meant that it became part of what is now University Hospitals Bristol NHS Foundation Trust (UHB - and it was formerly United Hospitals Bristol). This is only slightly helpful and this doesn't add much. Data retention policies vary and it is likely that some of this information no longer exists. What is known is that there were inpatient beds at the BHH in 1986 but it is not known what they were used for. If they were used for homeopathic treatment, they are long gone.

This archived webpage from 2008 has a picture of what was the home of the BHH for while. 

The entrance to the Homeopathic Hospital
Rather small for "purpose-built hospital opened in 1994 next to Cotham House"? That archived webpage also tells us -

The homeopathic service offers a general service for children and adults with a wide range of chronic illnesses and a Complementary Cancer Care Service where patients are seen within 4-8 weeks of referral where possible.
And -
Homeopathy is useful in the management of:
  • Rheumatology
  • Allergic conditions
  • Asthma
  • Eczema and other dermatology conditions
  • Menstrual and Menopausal problems
  • Digestive and Bowel Problems
  • Stress and Mood disorders
If any General Practitioners or Hospital Consultants are uncertain about the usefulness of homeopathic medication for a particular patient, please telephone Dr Elizabeth Thompson, Lead Clinican to discuss the clinical details.

The clinical lead for many years was Elizabeth Thompson. Thompson is a consultant at UHB. Her specialty is palliative care. In some places she is described as running the "Integrative Cancer Care Service". The UHB website shows no sign of it. Again, from the archived webpage, a staff list -

DoctorTitleReferral information
Dr Elizabeth ThompsonConsultant Homeopathic Physician, Lead ClinicianReferrals for all morbidities including urgent oncology related referrals
Dr Roy WelfordAssociate SpecialistReferrals for all morbidities
Dr Gillian HowAssociate SpecialistReferrals for all morbidities
Dr Julie GeraghtyAssociate SpecialistReferrals for all morbidities
Dr Helen BeaumontAssociate SpecialistReferrals for all morbidities
Dr Trevor ThompsonClinical  AssistantReferrals for all morbidities
Dr Michael HandfordClinical  AssistantReferrals for all morbidities
Dr Moira HamiltonClinical  AssistantReferrals for all morbidities including urgent oncology related referrals
Dr Andrew MorrisClinical  AssistantReferrals for all morbidities
Dr Willa MuirClinical  AssistantReferrals for all morbidities
Dr Lee BurtonClinical AssistantReferrals for all morbidities

Urgent oncology referrals is somewhat worrying but likely an overstatement and it is clear that it was adjunctive (it likely involved Iscador). Anecdotally, these clinicians were difficult to manage. Some of the names appear elsewhere.

This UHB business plan from 2008 contains talks about "competition" and promoting its specialist services but...
A specific area of risk in this market is the provision of NHS homeopathy, which continues to benefit from public demand but which is increasingly seen as a low priority by PCT commissioners. A local marketing plan is in place to sustain referrals until the long-term prognosis for the service is clear. 
It isn't known what level of activity there was but that UHB was actively marketing homeopathy in the region is odd. 

A Freedom of Information request from 2010 tells us that there were 4293 appointments for 713 unique patients at a cost of  £569,843. This about £800 per patient.

A UHB Governers meeting says -
Homeopathic Services - George Wynne-Willson raised the question of the future of the Homeopathic Hospital in light of the research into the effectiveness of homeopathic treatment. Robert Woolley explained that Trust is required to provide certain mandatory services according to our contract schedule, this includes homeopathic services. It would be for the commissioners to choose to decommission the service, not the Trust.
Wynne-Willson is an elected governor for the Bristol area. He appears to be involved in the voluntary sector. Woolley is the current Chief Executive of UHB (although only acting at the time). His response is incorrect as homeopathy has never been a mandatory service. UHB was under no obligation to provide the service.

This document from 2014 from Bristol CCG reveals that the future of UHB homeopathy provision was under consideration. It contains a report from the South West Commissioning Support Unit (SWCSU - which has been subsumed into the South, Central and West Commissioning Support Unit).
SWCSU met with the homeopathic service and came up with a pragmatic compromise policy that would reduce homeopathic activity by a further 30-50%. This was considered by CPRG, who supported a ‘do not commission’ policy from a clinical perspective only. They requested that the full briefing paper was considered by CCG, which details the various commissioning options to the CCG Boards, so that the CCGs can make a decision on the commissioning of homeopathy. CPRG were cognisant of the fact that CCGs may for other reasons wish to adopt a different position than their recommendation which is not to routinely fund any homeopathy. The CPRG made their point quite strongly that as a clinical forum they would not support any commissioning of homeopathy due to the weak evidence.
CPRG = Clinical Policy Review Group.
The provider is currently University Hospitals Bristol Foundation Trust who is keen for any policy to be adopted at a much later date, after they have moved this service to a social enterprise model. The service providers would like no change until at least October 2015 in order to guarantee their income to keep their business model viable. A lack of decision leaves us with a fully commissioned position rather than any limitations at all. If there is not a decision to limit activity with the compromise solution or to decommission the service, the default position will be that BNSSG continue to commission homeopathy with no restrictions.
These figures are on a different basis from figures shown further below. New outpatients can be used as a proxy for unique patients as a referral generated a maximum of nine appointments - assuming patients are not referred multiple times. 

New outpatients appointments353283
Follow-up appointments13001545
Total Cost194,354.00210,796.00
Cost per new outpatient550.58744.86

The drop in referrals can be explained by -

Recent CCG commissioning changes include a local commissioning policy, which has probably been the cause of a recent reduction in referrals.

UHB subcontracted homeopathy contract to the Portland Centre for Integrated Medicine (PCIM) in October 2015.  PCIM is a Community Interest Company (CIC) which is not unusual. When NHS bodies outsource, it's not just commercial entities that submit tenders. This article explains how some CICs are providing NHS services. CICs are private companies though and not accountable in the same way that the NHS is. For example, they are exempt from the Freedom of Information Act.

"Centre" tends to imply a building of some sort. There isn't one. It rents rooms at Litfield House Medical Centre - whose main business seems to be renting out rooms for private medicine. 

This document from March 2016 explains some of the detail of PCIM's formation including -
Currently all approved referrals from GPs or local secondary care clinicians are passed to the single, local NHS homeopathy service. This service is commissioned by the BNSSG CCGs from University Hospitals Bristol (UHB). Features of the local NHS homeopathy service include:
  • Outpatient service only [i.e. no beds] 
  • Appointments for both adults and children
  • Clinician-led, including doctors and occupational therapists
  • Patients are offered a first appointment and then no more than four follow-up appointments. Around a third of patients do not use all five appointments. In certain circumstances, such as long-term cancer, a further four appointments are available. 
Until recently the service was wholly part of University Hospitals Bristol. By mutual agreement, the lead consultant Dr Elizabeth Thompson developed a plan to offer a wider integrative medicine service [e.g. acupuncture], with homeopathy as part of this, and for the whole to become a social enterprise. As the business model relied on a large proportion of NHS referrals, aspects of 'due diligence' and the 2014 review of homeopathy held back this plan for a while. 
The plan came to fruition in 2015, and the service is now provided by the Portland Centre for Integrative Medicine (PCIM), an employee-owned social enterprise. The service runs from premises in Clifton. It is effectively a 'sub-contractor' of University Hospitals Bristol. The PCIM is in a transition phase in its relationship with University Hospitals Bristol. This has enabled both the 'due diligence' and employment aspects to so far be managed thus:

  • PCIM are responsible for the operating costs of running their services, which is offset by the outpatient tariff received for appointments. This is paid monthly as 1/12 of predicted annual income. 
  • Administrative and clinical staff remain University Hospitals Bristol staff, and are seconded to PCIM. For technical reasons, this is until March 31st 2016. 
In summary, patients receive NHS funded appointments, in much the same way that other local services are run by non NHS organisations, such as the Community Interest Companies running community health services in each of the local CCGs. The aspiration of PCIM to offer a broader range of integrative medicine services is mentioned later in this paper.
That document also makes it clear that decommissioning homeopathy was an option and -
The Governing Body is asked to agree that:
  • A public engagement exercise on the future commissioning of Homeopathy is completed and
  • Consider a joint public engagement exercise with North Somerset and South Gloucestershire CCGs
  • North Somerset and South Gloucestershire CCGs are also considering this decision, and if all agree to this recommendation it is suggested that one public engagement exercise is undertaken across all three CCGs. 
  • Consider the resource requirement for a public engagement exercise
This Somerset CCG document from June 2017 tells us  -
David explained that the CCG had been identified as a national outlier in the commissioning of homeopathy. The CCG has a contract with University Hospital Bristol (UHB) for this service and the UHB sub-contracts it to the Portland Centre. In 2016/17 the CCG spent ∼£30K on homeopathy; this was out of a total NHS annual contract value at that time with the Portland Centre of £211,000. The Portland Centre is in Bristol but also holds a NHS homeopathy clinic in Street.  
Of the 29 first new outpatient attendees in the eleven months to February 2017, 24 were initiated by consultants at UHB and not local GPs. There were 182 follow-up appointments in the eleven months’ period.  
David advised that applications should be submitted to the Independent Funding Review Panel from the patient’s GP, consultant or clinician for prior approval of these treatments but this has not been happening. The current policy in use is the Bristol CCG’s policy and the CCG has now written its own policy which states referrals will only be approved where there is evidence that the treatment requested is effective and the patient has the potential to benefit from the proposed treatment. 
Bristol, North Somerset and South Gloucestershire (BNSSG) CCGs (it's a "cluster") board papers has this table - 

There is something odd about these figures. That "Total number of sets of appointments funded" is likely number of appointments funded and that they are exact multiples suggests a calculated rather than an actual number of appointments. The cost per patient although it falls is much higher that the £800 in 2010. 

There is another source of information on PCIM activity - Companies House. The accounts don't make a lot of sense in that payments seem to be made by UBH and then PCIM pays them money back but four of the medical team are seconded from University Hospitals Bristol NHS Foundation Trust; the provider directly employs one doctor on a part time basis and two temporary administrative staff.

BNSSG launched public consultations on treatments they wanted to stop funding/change eligibility for in July 2017. Homeopathy was only one of those. But there was a problem. The consultation was announced very late and it only ran for 6 weeks. This turned out to be a mistake. Someone declared their intention to challenge the public consultation by Judicial Review - there were sufficient grounds. 

Because of this BNSSG re-ran some of the consultations in 2018 (although they have publicly said that they wanted to wait for the NHS England consultation). To be clear, the NHS England consultation was about primary care prescribing and the BSSNG consultation was on commissioning of secondary care services.

Of course, the homeopathic trade associations and their supporters did mount a campaign but it was pretty half hearted and of course, the British Homeopathic Association had already committed to a judicial review of NHS England's decision. Not that more BHA involvement would have made any difference to the outcome - which was the decommissioning of homeopathy.

PCIM's response was predictable. It contains the following -
PCIM has about 1500 registered patients who access NHS medical homeopathy. As ever this change in service provision most impacts those who might not know about or who can’t afford to pay for holistic approaches. 
Patients register with a GP, they attend a secondary care clinic. As the figures above show, there is no way that PCIM had 1,500 patients at any point in time. This is a total number of patients seen over an unspecified period.

PCIM has re-branded itself as the National Centre for Integrative Medicine (NCIM). It still operates out of Litfield House. It runs some clinics at The Practice Rooms in Bath. They also say they run clinics at the Vine Surgery in Street. Some of the clinics are free or low cost. These are funded by the BHA but it's not a lot of money. As well as medical homeopathy it also offers other therapies provided by lay persons.

NCIM offers various training as well.

It's unclear whether it will survive.