Wednesday, 15 January 2020

How bad is anti-vaccination among (and for) homeopaths?

This blog has looked several times at anti-vaccination sentiment among homeopaths (here, here and here). These posts give a flavour of how extreme homeopaths can be in their opinions as well as at hinting at the how widespread anti-vaccination is. It goes without saying that CEASE therapy and homeoprohylaxis are considered anti-vaccination.

There could be severe consequences for UK homeopathy.

Some history
To understand the current situation, it is necessary to understand some of the history of UK homeopathy. Anti-vaccination sentiment is nothing new in homeopathy and neither is anti-vaccination sentiment in general although the type of individuals/organisations involved has changed as have some of the objections to vaccination.

The early history of UK homeopathy has been documented by a number of people but perhaps the most important is Peter Morrell. Some of Morrell's work is in the public domain which is very helpful but Morell is pro-homeopathy, anti-vaccination and somewhat bonkers.

Because of a shared language, there has always been a strong interchange between UK and US homeopathy. The predominant direction of that influence shifts and changes over time. However, there are profound regulatory and legal differences between the UK and the US that do to a degree act as a barrier to certain ideas.

Homeopathy is very conservative in that it places great store on the teachings of Hahnemann and other homeopaths of history. However, the language used in their books is often impenetrable to the modern reader. It can be very aphoristic, couched in terms that are obsolete and now pretty meaningless. There is also homeopathic literature devoted to what the "Great Masters" actually meant in their writings and it will come as no surprise that there are differences in interpretation, which are often at the heart of doctrinal differences between different "schools" of homeopathy.

Homeopaths quibble over whether Hahnemann himself was pro or anti-vaccination. Hahnemann was a contemporary of Edward Jenner. But James Tyler Kent certainly was anti-vaccination and is infamous for his germ theory denialism -
The microbe is not the cause of disease. We should not be carried away by these idle allopathic dreams and vain imaginations but should correct the Élan vital.
Kent was an adherent of Swedenborgianism and believed that disease had spiritual causes. This belief is still found among modern homeopaths. Swedenborgianism never caught on in the UK. James Compton Burnett was an English homeopath and was one of the first to write about "vaccinosis", a term that homeopaths still use. Bear in mind Burnett was writing in 1884 - the smallpox vaccine was commonly used and the first chlorea vaccine was only introduced in that year. There were no other vaccines. Early smallpox vaccines were not as safe as modern ones and some of the methods used in vaccination were unsanitary. Burnett's "vaccinosis" is very different to, say, Tinus Smit's notions of it before he changed his language to talk more of "vaccine injury" and "vaccine damage".

Historically, most UK homeopaths were doctors. There were few lay practitioners and often medical homeopaths were opposed to them. UK homeopathy, whether medical or lay came very close to dying out in the decades after the Second World War. It was only in the 1970s that interest started to pick up again and it was largely lead by lay homeopaths who went onto form to the Society of Homeopaths (SoH). Morrell has a fairly detailed piece on the history of UK lay homeopathy. Medical homeopathy also seems to have become more popular from the 1970s onwards. Both are now in decline.

Some of the founders of the SoH certainly do not think of homeopathy as a "complementary" therapy. They see homeopathy as an alternative to conventional medicine and are very hostile towards it. There was a tendency to see homeopathy as some sort of anti-establishment radical social movement and most medical homeopaths as part of the establishment. 

Bear in mind some of these people went on to found homeopathic colleges and if they didn't, often taught at them, wrote books and so on. It is difficult to guage what impact their thinking had on the homeopaths that they taught and to what degree that that thinking has been passed down. One thing that became very clear during research of current anti-vaccination homeopaths is that many do see themselves as part of a generalised radical movement centered on left wing politics and environmental issues although there are a minority that hold to more right-wing/libertarian positions.

The recent history of anti-vaccination isn't just about the MMR controversy and the claim that it causes autism. One of the main US anti-vaccination organisations the National Vaccine Information Center (NVIC) was formed in 1982, way before Andrew Wakefield appeared on the scene (1998). NVIC's initial focus was the DPT vaccine brought about by a TV documentary DPT: Vaccine Roulette which drew on the views of Gordon Stewart. Stewart was later strongly associated with AIDS denialism during a particularly ugly period in South African history. But prior to Stewart there was Dr John Wilson who made the claim that DPT caused brain damage (do read this by Brian Deer - it also mentions Stewart). Wilson's claims caused DPT vaccine rates to plummet and there was a huge outbreak of whooping cough in the UK during the 1970s. 

So, in addition to an instrinsic strand of anti-vaccination in homeopathy, the revival of homeopathy was taking place at a time when there were vaccine scares. It is difficult to piece together how prevalent anti-vaccination was among UK homeopaths but there are some clues. The paper The Reluctant Profession - Homoeopathy and the search for legitimacy (Cant and Sharma, 1995) is fascinating in many ways (and a very different perspective from the writing of Morrell). It tells us - 
During the last fifteen years there have also been changes in the claims that the Society has made. For instance, the Society issued a leaflet about the potential hazards associated with child vaccination, but in 1993 they decided not to print the leaflet as it was regarded as too contentious:
We had to ask whether it was in our professional interests to cover this area, some members may see this as a climb down, but we have decided not to reprint the article because basically the Department of Health told us that if we continued to promote the non vaccination stance then we would find it very hard to begin a process of state recognition and at the same time we were beginning to see it was not our function to give out this advice. (Officer of Society)
This 1995 letter from the British Journal of General Practice states -
The homoeopaths were asked whether they used or recommended orthodox immunization for children and whether they only used and recommended homoeopathic immunization. Seven of the 10 homoeopaths who were medically qualified recommended orthodox immunization but none of the 13 non-medically qualified homoeopaths did. One non-medically qualified homoeopath only used and recommended homoeopathic immunization. 
A 2002 letter in the British Medical Journal says -
We contacted 168 homoeopaths, of whom 104 (72%) responded, 27 (26%) withdrawing their answers. We contacted 63 chiropractors, of whom 22 (44%) responded, six (27%) withdrawing their responses. No general practitioners responded. The table shows that only a few professional homoeopaths and a quarter of the chiropractors advised in favour of the MMR vaccination. Almost half of the homoeopaths and nearly a fifth of the chiropractors advised against it.
Bear in mind that this is post-Wakefield.

The 2005 thesis The body, health, and healing in alternative and integrated medicine: An ethnography of homeopathy in South London is very long and quite difficult to read online. Again, a fascinating document with a somewhat different perspective than that of homeopaths themselves. It is very illuminating of the belief systems of homeopaths and their clients. There is also a great deal on anti-vaccination sentiment among both. 

From page 90 -
I asked two of the homeopaths, at the time of much press debate on the public's failure to take up the MMR vaccination for their children, why homeopaths didn't speak out in the press, giving their view of the harmfulness of vaccinations to the immune system? They told me that this message had been forbidden by their parent organisation, the Society of Homeopaths. In Cant and Sharma's analysis, this instruction had been made in order to reduce possible friction with the biomedical system and the government, during a period in which the Society moves towards hopeful government recognition of homeopathy as a profession through parliament. It was interesting to see this played out in the communications between these homeopaths and their clients. They still told them that vaccination was harmful to their children's developing immune systems, but stressed the need for each parent to make up their own mind about vaccinating or not. Had the research been done a couple of years prior, the more radical nature of the homeopath's stance against vaccination might have been more openly communicated. So when I asked the homeopaths why letters to the press defending the homeopathic position of the harmfulness of vaccines had not been sent, I was told that this view must be suppressed for political reasons. 
Plus ça change, plus c'est la même chose. Although if the SoH did forbid the message, many did not get the message or it was rapidly forgotten. 

The section "The Vaccine Support Group" starts on page 225.
Jenny started The Vaccination Support Group 3 years ago. The impetus to start the group came from her clients. At the time she was running sessions for mothers to lear about homeopathic first-aid to use on their children. The people attending had a lot of issues around vaccination, wanting to make decisions but not knowing where to get the information. Jenny recruited her friend from homeopathic college, Eve an ex-midwife, to help her start a vaccination group. The group meets one evening every month for a couple of hours in Jenny's house or the house of one of the group members, Sally. Jenny has a list of topics for discussion and negotiated with the group their preferred topics for a particular session. The women who attend the group are mostly mothers of babies and small children, although quite often homeopath friends of Jenny and Eve's attend, or other alternative therapists, to find out more about the vaccination debate to support their clients. The evenings cover childhood vaccines, the research on their side effects, and information about homeopathic strategies to boost immune systems and treat symptoms should mothers choose not to vaccinate.
It is clear that Jenny is Liz Bevan-Jones and Eve is Yvonne Stone. Both still actively promote anti-vaccine information and are involved with Arnica Group. They authored the No Nonsense Vaccine Handbook. Stone has been mentioned on this blog.

There is more but the above should be sufficient to give a flavour.

Current Situation - anti-vaccination movement
Anti-vaccinationists in the UK are nowhere near as organised, well-funded or influential as they are in the US. There is not political support for anti-vaccination in the UK. Not are there big donors. What groups there are tend to be either focused on "vaccine injury" that want to obtain compensation, legal action, etc or based on a more generalised anxiety about vaccines who are supportive of the former. UK anti-vaccination groups tend to be less aggressive in their claims. Whilst UK individuals can be just as nasty as US ones, it's much less frequent.

Some US arguments apply less or even not at all to the UK. For example, although mandatory vaccination is discussed, it is unlikely to happen in the UK. There is a view that if vaccination rates have fallen to the point where mandatory vaccination is the solution then public health education has failed. Decisions about mandatory vaccination in the UK would be made at a national level, whereas in the US they are made at the State level.

The fellow travellers are different in the US too. It should be noted that Church of Scientology front groups have become involved in lobbying. And of course there is the health freedom movement which is more of a lobby group that serves the interests of certain manufacturers and their lawyers than a grass roots consumer movement. Neither have much influence in the UK. 

The politics of US anti-vaccinationists can be very different too. Right wing libertarianism is rare in the UK but not in the US. Even the appeal to the "natural" is more commonly couched in terms of an alternative to the Big Pharma conspiracy to poison the population than being linked to concerns about the environment.

The UK population is prossibly less prone to conspiracy theories than the US and there are likely differences in the popularity of various conspiracy theories between the two. Cultural, economic and political differences militate towards that. This Guardian story is interesting because it compares UK Leave/Remain supporters with US Trump/Clintion supporters. It mentions anti-vaccination and curiously Leave supporters are more likely to believe in anti-vaccination conspiracy theories. This is curious given that the majority of anti-vaccination homeopaths looked at, if they expressed an opinion, were Remainers. Conversely, the populist right have picked up on anti-vaccination in other countries such as Italy.

There have not been any really big media stories since Wakefield that anti-vaccinationists have successfully used or that gained traction with the UK media. It might be thought that stories like the H1N1 vaccine Pandemrix increasing the risk of nacrolepsy in a certain age group might have been picked up on in a big way but they weren't. Whilst there is some resistance to flu vaccination, Pandemrix isn't mentioned. Flumist seems to be the main focus along with the supposed lack of efficacy for flu vaccines in general. There is also opposition to HPV vaccination the motivations for which are complicated. However, the claim that MMR causes autism is still central to most anti-vaccinationists.

Wakefield's initial claim was that autism was somehow linked to changes in the gut caused by measles RNA in the MMR vaccine, his imaginary autistic enterocolitis. This idea has largely lost favour with anti-vaccinationists although the related imaginary leaky gut syndrome still has adherents, including homeopaths (and others) who claim to treat autism with restrictive diets. More common is the claim that vaccines contain mercury which causes autism. Most vaccines no longer contain thiomersal, no link has been found between the levels used in vaccines and any condition. But some anti-vaccinationists still trot this out. Some anti-vaccinations have abandoned this line in favour of the claim that is aluminium in vaccines that cause autism. This comes from the discredited work of Christopher Exley.

It doesn't matter to anti-vaccinationists that no link between vaccination and autism has been found. It doesn't matter that putative mechanisms of action are discredited. Their counter-factual beliefs are resistant to rational argument. Challenging those beliefs often leads to entrenchment of their position.

Society of Homeopaths
Anti-vaccination poses a huge threat to the SoH and may tear it apart.

A previous post talks about a sampling exercise. This was expanded to look at all SoH members with websites. The percentage of SoH of members with their own websites who expressed anti-vaccine sentiment on their website or on linked to social media was 32%.

A further piece of analysis was also done. In February 2019 the PSA and SoH were supplied with a list members offering CEASE therapy and the related Homeopathic Detox Therapy. This list was used as the basis of an analysis that looked at Facebook accounts, whether or they were linked to by the member's website. The results were mixed.

People use the internet in different ways. Not everyone distrusts as Facebook as much as they should and some use it extensively. Some consmers may find homeopaths via Facebook rather than Google or using a third party directory. Facebook is probably the primary route for anti-vaccination misinformation transmission.

There were a small number of members who very frequently shared/posted anti-vaccination misinformation on Facebook. One posted over 110 items in less than 11 months, sometimes posting multiple items in a day. Those members shared some truly awful posts including -


It is difficult to say whether the dismissive attitude towards unnecessary deaths, disability or just suffering caused by vaccine preventative diseases in far away countries is one of racism or parochialism. Whether anti-vaccinationists played any role in the Samoa measles outbreak is currently unclear but their activities have been linked to outbreaks in the US

The sharing of extreme US anti-vaccine material cropped up a lot. The claims made go far beyond "vaccines cause autism". Claims that vaccines kill more people than the diseases they prevent, that HPV is not a cause of cervical cancer. Incredibly bizarre conspiracy theories.

Faculty of Homeopathy
The Faculty of Homeopathy (FoH) describes itself as -
Founded in 1844 and incorporated by Parliament in 1950 the Faculty of Homeopathy supports registered medical professionals with their homeopathic practice. We are the only homeopathic organisation to be recognised by professional bodies such as the General Medical Council (GMC) and we have nine course providers, including four overseas.
This isn't strictly true as they have members who are not registered medical professionals. Also, the General Medical Council (GMC) doesn't recognise homeopathy as a specialty, it recognises that FoH as a revalidation body, which is rather different.

The FoH is legally exempt from publishing accounts. It hasn't made the number of members public for some years. Because of the way its search facility works, it's difficult to determine how many members it does have, but there are estimated 150 on its register in UK and Ireland. There are lower levels of membership but the expectation is that unsupervised homeopathy doesn't go on.

Not all regulated medical practitioners who practice homeopathy are members of the FoH. The FoH only admit those who have completed their approved training courses. Some practitioners have chosen to do lay homeopathy training courses. There are some medical practitioners who are members of the FoH and another homeopathic association but it seems like that they gained membership of the latter by a different route than simply having completed a certain training course. 

FoH members are far less likely to have their own online presence. As a result, it is far more difficult to determine whether they hold anti-vaccination views. It's understood that anti-vaccination views are not uncommon in Anthroposophy, but they are not universal and anthroposophic doctors have their own organisation (partly because the training is different) but some FoH mention that they are interested in anthroposophic medicine. 

The FoH's official position is that it supports vaccination. As discussed in a previous post, it is suspected that a statement from 4Homeopathy was actually written by the British Homeopathic Association (BHA) which is so closely linked to the FoH to pretty much be the same organisation but Gary Smyth, President of the FoH, said in the FoH house magazine -
Dr Smyth said: “As has happened too many times in the past, we are being tarred with the same brush as some other practitioners who take an anti-vaccination stance, so it’s important that we make it clear that we are certainly not anti-vaccination. It is frustrating that our detractors know exactly the right buttons to press to generate division among homeopaths and also to get front-page headlines.”
It is known that there are FoH members who are anti-vaccination. Jayne Donegan is the most obvious example. The FoH have long known about Donegan but have never dealt with her. Problematic in a different way was the reporting of Ainsworths producing a booklet that on the face of it promotes homeoprophylaxis. Anthony Pinkus is behind Ainsworths. It's not clear if he had any hand in writing the booklet (he has written others) but Pinkus is Pharmacy Dean of the FoH. Yubraj Sharma is a problem. Christine Suppelt too. There are also concerns that some veterinary surgeons are suggesting homeoprophylaxis to clients even if they don't mention it publicly.

The General Medical Council (GMC) are looking into Donegan's case. This will likely take a long time. 

Alliance of Registered Homeopaths
The Alliance of Registered Homeopaths (ARH) is the second largest homeopathy association in the UK with around 530 members. It was formed in 2001.  It's about half the size of the SoH. It differs from the SoH in a number of key ways. Firstly, it recognises additional courses that the SoH doesn't and entry via other routes is easier. The leadership of the ARH is essentially static - it has had the same directors for a number of years and how one becomes a director of the ARH is unclear. That leadership is very distrustful of conventional medicine and cares very little for what external authorities might think of it and its members. It doesn't even try to pretend professionalism in the way that the SoH does. Inaction seems its default position. As an organisation, it rarely says anything publicly although some of its members are extremely vocal.

The ARH has no obvious position on vaccination unlike the SoH and FoH. It is more than happy to publish anti-vaccination (which imply vaccines cause autism etc) and homeoprohylaxis articles in its magazine. 

One difference between the SoH and the ARH is that the Professional Standards Authority (PSA) require the SoH to keep their register up to date. The ARH is under no such obligation. Its register contains quite a lot of errors and omissions.

Researching anti-vaccination among ARH members certainly gave the impression they were more likey to stress homeopathy as alternative to medical treatment, that esoteric beliefs, especially related to neo-shamanism and the Goddess movement were more common than with SoH members. Identification with social and political movements was less stressed and sometimes environmental concerns were linked to esoteric belief.

To begin with the same methodology as with SoH members - that is to say member websites that were listed on the register were examined. If those websites belonged to a clinic or where in a foreign language they were excluded. Social media accounts linked to from the member website were also examined. Any anti-vaccination sentiment or direct links to anti-vaccination websites etc were noted. The results were slightly surprising. Only arond 26% of those members expressed anti-vaccination views.

When looking at member's websites that were either not recorded in the register or wrongly recorded and likewise searched for social accounts, a different picture emerges. Of those members that had any online presence that was their own, 44% expressed anti-vaccination views. 

The ARH has some very problematic members. Trevor Gunn was discussed here and Cathy Lemmon here. Melissa Wakeling appeared in a Daily Mail story offering homeoprophylaxis - and is involved with Free and Healthy Children International (FHCi) discussed here. Lorraine Whitby was caught out by the Daily Telegraph. The Advertising Standards Authority (ASA) recently made it public that members Carolyn Stevens (mentioned here) and Paula Lattimer have been referred to Trading Standards who have the powers to prosecute. There are others not (yet) referred to Trading Standards who still make the "Complete Elimination of Autistic Spectrum Expression" claim such as Mary Harper. And of course ARH Communications Director Steve Scrutton spews anti-vaccination and anti-medicine nonsense on his blog.

There is good reason to believe that the ARH will do nothing to rein in the dubious claims of members. It never has before and given the prevalence of anti-vaccination, it probably can't. Whether it would actually support the likes of Stevens and Lattimer if they faced prosecution is unknown. That would involve doing something.

The ARH hasn't had any real dealings with the media. It is likely not to respond to enquiries, "no comment" or at most offer up some empty words. Notionally, 4Homeopathy can provide help in dealing with the media but...

Homeopathic Medical Association
The Homeopathic Medical Association (HMA) looks like the third largest homeopathy association in the UK. It was formed in 1985 but there is very little on the internet about its history. It is even lower profile than the ARH. It used to be involved with 4Homeopathy but at some point withdrew.

The HMA does not have a stated position on vaccination. However it published a petition from Natural News regarding the infamous anti-vaccinationist Sheri Tenpenny on its website. There isn't a lot on its website. It is almost as if the HMA stopped functioned some time ago. The last published new item is from 2015. The website doesn't appear to have been updated in a long time. Its Facebook page hasn't been updated since 2014. There is a 2017 conference brochure but it is not clear if it took place.  Unless the organisation operates purely by post, email or on a members only part of the website, it looks largely moribund. Companies House records reveal it had one employee in prior to 2019 accounts but none now. 

It has 257 members but many of them are Japanese. Both the SoH and the ARH have a few Japanese members, but the HMA has 137 of them. Only around 105 are UK based. This is very odd. Again, using the same methodology as in the intial SoH analysis, there were only 32 member websites. Of these, only 7 contained anti-vaccination statements or linked to social media with such statements. This is around 22%.

Keith Smith was caught out by the Daily Telegraph in the same undercover operation as Lorraine Whitby and Alan Freestone. 
Keith Smith in Eastbourne warned the reporters not to listen to "unqualified workers in the National Health Service, and politicians," and instead "go to the top" – to authors like Trevor Gunn, a homeopath whose books include "Vaccines: This book could remove your fear of childhood illness". 
He declined to comment on this story.
It is telling that Smith references Gunn who is extremely anti-vaccination.

The Federation of Holistic Therapists (FHT) like the SoH is accredited by the PSA. It has a number of homeopath members but the FHT effectively has two registers - one accredited by the PSA, one not. The numbers are so small it isn't worth doing any analysis. The same is true for a number of non-PSA accredited registers such as the Complementary Medicine Association and the Complementary Therapists Association

Of course, some of the worst anti-vaccination homeopaths don't belong to any association. Their position is extremely exposed.

It's clear that anti-vaccination poses a serious threat to the SoH but it is a threat to UK homeopathy in general, particularly in the area of cooperation between associations in the promotion of homeopathy to the public.

Quite clearly, anti-vaccination among lay homeopaths poses real problems for the FoH. Although they are a minority of homeopaths, they have considerably more power than other associations. Partly this stems from their status as medical professionals, partly because they have Royal patronage and other links to the establishment but also because of money (or rather the BHA's money). The FoH/BHA are suspected to provide a lot of the funding and some of the manpower for 4Homeopathy. It should be noted that it is generally FoH members that turn up in national media interviews, although lay homeopaths sometimes turn up in local specialist media. Donegan and Pinkus aside, it is lay homeopaths that get caught by the media.

Media interviews with FoH members are tedious to watch/listen to but could be very different in the present climate if an interviewer brings up the subject of anti-vaccination. Of course, the FoH are pro-vaccination and the interviewee is likely to trot that out. Some FoH members are obviously anti-vaccination and the FoH have known about them for a long time and done nothing. An interviewer may not know that and not ask the right questions. It depends how good the researchers are. But that there are homeopaths who are anti-vaccination is pretty widely understood by some in the media now. The interviewee could respond that they aren't their members and that's where the trouble could start.

There have been antipathies between medical and lay homeopaths in the past and old wounds could be reopened. In short, medical homeopaths regard lay homeopaths as potentially dangerous amateurs. Lay homeopaths regard medical homeopaths as not true homepaths. There have been accusations that medical homeopaths seek to control lay homeopathy. 

When Newsnight carried out undercover investigations in 2006, it caused all sorts of havoc. The late Peter Fisher spoke out against lay homeopaths offering malaria "prevention" in the report -
I'm very angry about it because people are going to get malaria - there is absolutely no reason to think that homeopathy works to prevent malaria and you won't find that in any textbook or journal of homeopathy so people will get malaria, people may even die of malaria if they follow this advice.
The FoH will have to start distancing itself from lay homeopaths or at least those that continue with anti-vaccination unless it wants to find itself tarred with the brush (it should deal with its anti-vaccination members). It could pull the funding/resources from 4Homeopathy. The Find a Homeopath website is registered to Karin Mont, Chair of the ARH. Not that the ARH makes any mention of 4Homeopathy and it's not clear if it has any real involvement with it. If there is prosecution of ARH members, depending on how the ARH deal with it, that would be the end of whatever involvement it has with 4Homeopathy. 

And mere "distancing" may not be enough. It could come to denouncement. Condemning extremists who don't belong to any organisation is easier than denouncing those that do because that is an implicit criticism of the organisation. 

Smyth is only partially right when he said "our detractors know exactly the right buttons to press to generate division among homeopaths". Those divisions already existed and there more than a few of them. UK homeopathy tries to pretend they aren't there or downplays them in the name of "stronger together". Perhaps, the FoH could continue to cooperate with the SoH and its accredited colleges if they managed to deal with their anti-vaccination members. The price might be higher than that. The SoH might have to condemn anti-vaccination, it might have to publicly support vaccination rather than just say giving "advice" about anti-vaccination is beyond the competence of members.

That would still leave other divisions, including those that revolve around the competence of lay homeopaths to treat anything.

Existential Threats
In the short term, UK homeopathy associations may be in for a rough ride but homeopathy and homeopaths are not going to disappear. They maybe more marginalised than before, the market may shrink but homeopaths will likely keep on doing whatever it is that they actually do.

There have been moves in the past towards statutory regulation of homeopathy and other forms of CAM. It did happen with chiropractic and osteopathy in the UK but nothing else. Government enthusiasm waxes and wanes. Of course, the obstacles to statutory regulation of homeopathy are such that it could never happen but previously governments have said things to the effect of sort yourselves out or we will legislate. Legislation doesn't have to involve statutory recognition of homeopathy or any other form of CAM. As discussed here, it can prohibit medically unqualified persons from performing certain activities. An absolute prohibition on homeopathy would very difficult but, for example, preventing lay homepaths (and other medically unqualified lay persons) from treating children would not be. 

Playacting at medicine is bad. Spreading anti-vaccination propaganda is bad. If there are hundreds of lay persons doing both in the UK and it does not stop, Government may eventually react. The worst case scenario is that there is a localised outbreak of a vaccine preventable disease in an area where anti-vaccination homeopaths operate. 

UPDATE: 29/01/2020
Homeopathy International (HINT) saw fit to make a statement on vaccination. It is bizarre to say the least. 
The position of Homeopathy International (HINT) on vaccination and informed consent is simple and straightforward and is in line with the current legal situation in the UK. People must be free to make decisions about their health and their children’s health, and they must have all the information required to reach their decisions.
HINT is pro children and pro informed consent, in full agreement with UK law. It is not “anti vaxx”, a phrase increasingly used to demean the undecided. 
Several of HINT's steering committee are anti-vaccination. And no, "anti vaxx" is not used to describe the undecided, it is used to describe those who spread anti-vaccine propaganda etc.

HINT makes much of informed consent and Montgomery v Lanarkshire Health Board. Montgomery revolves around the non-disclosure of risks and HINT attempts to argue that the risks of vaccination are not spelled out to patients and that the risks are underplayed or even suppressed. The irony is that non-disclosure is almost universal in homeopathy. Also, it can be argued very strongly that the provision of misinformation (eg vaccines cause autism) is negligent. 
HINT agrees with the current UK legal position. Unless adults and the parents of young children are made fully aware of all material risks, they cannot give valid consent to any procedure. HINT expects all professionals who are asked for information about vaccination by adults and the parents of children, to be in possession of sufficient information to enable them to point those people in the direction of available and reliable information, so that adults and parents can make their own decisions. 
Healthcare professionals who are asked for information about vaccination may find that adults and parents of children may need to read or research widely. 
Reliable information? 
HINT is aware, as are other observers of the vaccination question, that some adults and parents wish to look further for information, as is their right. HINT considers that when healthcare professionals are sought out for information, those professionals must exercise their duty to listen carefully, and to give financially disinterested and up to date information, within the limits set by their knowledge. The perception of ambivalence and uncertainty in the NHS that some people experience is perhaps understandable.
"Limits set by their knowledge"? This is different from the SoH line that advising on vaccination is beyond the competence of lay homeopaths. The Dunning-Kruger effect and other cognitive biases mean that lay homeopaths are often incapable of recognising the limits of their knowledge and evaluating information. 

HINT fails to distinguish between information, misinformation and conspiracy theories.
Information about vaccination in the public media is influenced by the nature of the vaccine industry and controlled by a few large corporations. Corporate law requires them to put shareholder benefit before all else. To maximise shareholder return, in a vaccine marketplace worth nearly $50 Billion annually, those corporations employ huge advertising budgets. The public media depend on advertising income, and not surprisingly, feel obliged to reflect the views of their important advertisers. This seriously distorts the balance of information provided to readers and viewers.
Really? Vaccines are prescription only in the UK. The Human Medicines Regulation 2012 prohibits the advertising of prescription only medicines.  However, it does allow public health campaigns. Information about vaccination is far from controlled by large corporations.
The United States and New Zealand are the only two countries that allow direct-to-consumer advertising of prescription medicines. This belief is very common among UK homeopaths and anti-vaccinationists. It's also very wrong.

HINT has one member who is clearly anti-vaccination. Although HINT does not be seem to be actively recruiting members, they may see an opportunity to if the SoH clamps down on anti-vaccination.

Wednesday, 8 January 2020

What next for the Society of Homeopaths?

"We will not apologise for our existence and grovel before allopaths and homoeopathic doctors. There should be complete support from government for lay homoeopaths."

2019 was not a good year for UK homeopathy. Neither was 2018. 2020 is unlikely to get any better. It's probably going to get worse, especially for the Society of Homeopaths (SoH). It could easily drag out beyond that.

The date for the Good Thinking Society (GTS) judicial review of the Professional Standards Authority's (PSA) decision to accredit the SoH in 2019 has not been set yet. For what can be determined the 2020 accreditation process is underway. It's not clear which will reach an outcome first.

Recent posts have tended to concentrate on the implications of the judicial review but that it hasn't happen yet means that potentially re-running the 2019 process is not going to happen. This post will concentrate on the 2020 accreditation.

Core Issue
Whilst CEASE therapy and homeoprophylaxis are issues for the SoH, it is the prevalence of and sometimes extreme anti-vaccination sentiment among members that is the big threat to accreditation. Analysis suggests at least a third of members hold such views. Spreading anti-vaccination misinformation is not helpful to public health efforts. It would be very difficult to the PSA to accredit the SoH given that they have been informed of both the prevalence and severity of such views. The PSA has an implicit duty to public health. Things became very much harder with the intervention of Sir Simon Stevens and Professor Stephen Powis.

Accreditation Process
The details of the accreditation process have been discussed before but will be recapped. 

From what is known of SoH board meeting dates, the Board should have made a decision to carry onwith accreditation in September, if not before. The SoH were criticised by the PSA for not communicating what was discussed in board meetings in the past and for a while did fairly promptly publish them. This seems to have stopped. There is no indication of whether accreditation was discussed at the September meeting. This meeting was the last one that former CEO Mark Taylor was involved with. Taylor has said some odd things.

The PSA gather information during the year. They say they monitor external communications of registers, monitor news and conduct sampling exercises of registers but how much they actually do is probably limited. They don't have huge resources. However, they were fully aware of the media reporting. It is also known that they do from time to time read this blog. The PSA expect that serious concerns about registers should be raised with them.

In month 8 - September most likely -
The Accreditation team will populate an annual review form based on the information collected throughout the year and send this to the Accredited Register in month eight. The Accreditation team will ask the Accredited Register to confirm their intention to apply for renewal and will arrange a meeting with  those who will be completing the form. This meeting can be face to face, via telephone or videoconference. 
At the meeting, the Accreditation team will provide clarity to the Accredited Register on the information that they need to supply within the form and as supporting documents. This should prevent the submission of information already held by the team. The Accredited Register will then be responsible for completing the form and providing any updates that the Accreditation team is not aware of.
 Evidence require includes -
a. Information on addressing outstanding Conditions, Instructions or Learning Points (will become Conditions and Recommendations in due course)  
b. An overview of the past year, separated into developments, challenges and achievements  
c. An update on the number of registrants on the register, including registrants added and removed  
d. A financial update  
e. An update on complaints against registrants – this should include numbers received, how they were handled, brief details of any themes identified and links to any public outcomes  
f. An update on complaints against the organisation – this should include numbers received, themes and a summary of outcomes. Complaints against the organisation refers to any complaints received, including where a complaint has been escalated where the complainant or registrant is not happy with the outcome  
g. An updated risk register  
h. Board minutes (if not available online)  
i. Annual reports produced by boards and / or committees (if not available online)  
j. Any changes that would alter the impact assessment.
The PSA started canvassing for "Share Your Experience" from the public and key stakeholders in late September. It ran until late October. So it is clear that the SoH did signal their intention to seek accreditation. This is the process that Stevens and Powis's response was part of. It is known that there were other submissions too and and it suspected that the SoH acted on some.
The Accredited Register will be required to submit its completed annual review form and supporting documents by month ten of accreditation.
Which should have been November 2019. It forms part of the formal application for accreditation. At this point, a register would be required to pay a non-refundable fee. In the case of the SoH, it will be around £10,350. It is expected that it is paid in full although alternative payment schemes might be negotiated. If the accreditation process is complex and time consuming, the PSA reserve the right to charge the register -
Supplementary fees
The Authority reserves the right to charge additional fees on top of the fees described above, according to variables that reflect additional complexity and that require additional resources to assess the application. Variations include, for example, the need for additional research to learn about different disciplines, receiving high volumes of information from the Share your experience invitation which requires extra work by the Accreditation team, the need to consider variations in education and training, the need for additional site visits, increased case sampling, additional reviews of the application, or where the impact assessment is complicated. This will be considered on a case by case basis. 
Any extra days required will be charged at £650 per day; calculated in half day units. Organisations are advised to discuss their application and the implications of costs with the Accreditation team before submitting their application. 
In prior years, Mark Taylor certainly made the accreditation process more difficult and time consuming than it had to be. It would not be a surprise if the extra fees were introduced to deter that kind of behaviour.

The Accreditation Team will then produce a draft report that will be shared with the register for them to check for accuracy. It is not clear when this happens. Although the SoH's accreditation cycle runs from January, last year's accreditation report wasn't published until April. Whether there was a delay at this stage or later stages (or multiple delays) is unclear. It can not be assumed that this draft report has been produced yet.

Once that stage is competed, a summary report is sent to a Moderator. The Accreditation Team and the Moderator will have a meeting. The Moderator can decide to unconditionally accredit a register, which is what happened last year, but the Moderator will very likely refer the decision to a full Accreditation Panel, which is made up of three senior staff members.

Outcomes of the Accreditation Panel are discussed further below.

The 2019 accreditation report contains 11 Recommendations. Whilst a register does not have to implement them, there is an expectation that they should at some point. They will need to provide the PSA with of what progress they have made.
  1. The Society’s published information and tools should ensure that registrants treating patients and service users with mental health problems are able to make appropriate referrals where necessary. (paragraph 3.10)
  2. The Society should consider and report to the Authority on whether restricting advertising of CEASE to its acronym is meaningful and not misleading to the public. As part of this the Society should consider if use of the CEASE acronym should be banned by the Society for its registrants. (paragraph 5.14)
  3. The Society should seek an appropriate external peer review of information presented on its website relating to the evidence base for homeopathy. (paragraph 6.5)
  4. The Society should review use of the distinction between the use of ‘should’ and ‘must’ within its Code of Ethics and amend where necessary. (paragraph 8.5)
  5. The Society should consider publicly reporting on the number of complaints that are resolved outside its formal complaints process, including the number received and their outcomes. (paragraph 11.8)
  6. The Society should make clear in its policies that it can investigate a concern from someone whose previous complaint was found to be vexatious under its policy. (paragraph 11.12)
  7. The Society should consider whether further action is needed to ensure that decision makers within its complaints processes are appropriately trained and act in accordance with its rules. (paragraph 12.2)
  8. The Society should consider further mechanisms to allow witnesses in complaints hearings to participate without unnecessary contact with other parties, for example using screens or videoconferencing. (paragraph 12.4)
  9. The Society should review the tone and content of its communications to those involved in its complaints processes to ensure that public confidence in the Society and its processes are maintained. (paragraph 12.6)
  10. The Society should make clear within its policies and procedures that it can consider concerns about registrants occurring outside of their practice and investigate as necessary to determine potential breaches of its codes. (paragraph 12.11)
  11. The Society should consider potential risks to service users from adjunctive therapies practised by its registrants as it becomes aware of them. The Society should consider mitigating these, and whether the practices are compatible with registration. (paragraph 12.15)
Some of these are easy to deal with. Others are not. Recommendation stops short of suggesting that members should be banned from offering CEASE. It merely suggests the prohibition of the acronym. The SoH have come close to this via its revised Position Statements but it is still going on. It is not clear if the SoH will sanction members who breach the position. The September board meeting may have addressed CEASE issues but as no report has been published, who knows? Supposedly -
An invitation only meeting would be held in September to discuss the issues around CEASE. LW would chair and SH would attend. Invitees would all be RSHoms, some CEASE practitioners and some not. Any recommendations or options from this meeting would go to the Board. Some of the issues would be wrapped up in the Scope of Practice Review that was currently being undertaken.
LW = Linda Wicks who was revealed by the Daily Mail as anti-vaccination. SH = Selina Hatherley who wrote this bizarre post that uses a lot of words to say very little. Hatherley claims to be able to diagnose allergies and food intolerances with a skin conductance machine.

Recommendation 10 interacts with anti-vaccination activities outside of the actual practice of members. To quote from the report -
12.8 A concern was raised about registrants, alleging they had written books that made statements that did not reflect NHS recommendations, for example by arguing against vaccinating children. The team noted that the book named in the blog was listed on the Society’s updated Resources page and asked the Society if the book was in line with its standards. The Society responded that it had since removed the book and other resources posted as it was not sufficiently familiar with them to promote them to its registrants. The Society emphasised that it 'supports informed decision-making, parents should be advised to include their GP in any decision relating to vaccination’.  
12.9 The team asked if concerns regarding statements made in a book could be investigated in the same manner as any other. The Society advised it would have to meet its normal complaint criteria about services provided by registrants. The team noted previous Panel decisions regarding concerns raised indirectly, that it ‘would expect a register to consider a complaint under their procedures and to consider whether there is any action they should reasonably take to enable them to assess whether they do have concerns and to assure themselves that it is reasonable not to take action notwithstanding that an allegation is broadly or vaguely stated rather than specific.’ The team suggested that in this case for example, it could have checked whether there was a concern that could be handled under Section 2.2b or 2.9 of the complaints procedure.  
12.10 A concern was also raised about a registrant’s involvement in a university research project, and their ‘treatment of vulnerable children’ and ‘supply of unlicensed medicines in breach of the Human Medicines Regulations 2012’. The Society had responded that the complaint did not fall within its complaints process and that enough evidence was not provided to progress the complaint. The Authority suggested that the Society might have made an enquiry of the University to consider whether any action was necessary, in linewith the above. 
12.11 The Authority stated that a register should be able to consider concerns about registrants occurring outside of their clinical practice, particularly where those activities were relevant to clinical issues, as would be the case with a book dealing with such a subject. Registers should be able to seek further information to satisfy itself about whether its codes may have been breached. The Authority issued a Recommendation for the Society to make this clear within its policies and procedures. (Recommendation 10)
The SoH may be trying to deal with Recommendation 11. The "scope of practice" review mentioned above may have considered this, assuming that it delivered anything. But as discussed here, it could be a very widespread problem and the SoH should now be aware of some of the "adjunctive therapies". 

The potential outcomes of the accreditation process are -
  • Renew accreditation
  • Renew accreditation with Conditions 
  • Adjourned The Panel essentially decides that more information/clarification is required from the register. It can also adjourn if it believes that there are specific actions that required in order to meet standards. 
  • Accreditation suspended The Panel believes that the register does not meet the Standards. It will give the registers 2 weeks to supply evidence that it does meet the standards. The Panel may decide that the register and its members can not use the PSA quality mark. SoH might find member compliance difficult. This outcome can also be appealed.
  • Accreditation removed Appeal is possible but must be lodged within 2 weeks,
Only the full Accreditation Panel can reach all of these outcome decisions, Moderators only the first.

The Accreditation Team will also produce a report regardless of outcome, which will be published once approved by the Accreditation Panel.

The PSA do not seem to charge for the appeal process (although they say they work on a cost recovery basis) but if the SoH decided to appeal a decision they would need to pay for specialist legal advice (and may have already taken some). Permitted grounds for appeal are that the PSA -
  • Acted outside or beyond its powers
  • Did not follow proper procedure
  • Acted irrationally
Simply not liking an outcome is not sufficient grounds for appeal. To an extent, those grounds mirror those for judicial review but it is senior members of the PSA involved with the appeal rather than a court. The PSA may involve specialist and/or legal advisors. If they do, the SoH might feel they have to do the same. Depending on the timing and outcome of the GTS judicial review, it may have been established that the PSA acting irrationally in accrediting the SoH in 2019 by the time an appeal might be made.

Given the attention on the accreditation process, it is difficult to imagine the PSA not following its own procedures. A challenge on acting beyond its powers? It would be difficult to frame in that the powers of the PSA are very clear cut.  It is expected that the PSA will document the rationale for its decision in such a way to avoid accusation of irrationality. 

If the appeal is rejected or the outcome is not what the SoH wants it could apply for judicial review. This would be an expensive option. The SoH probably can't afford it.

In a communication sent to members, Emily said: “The Society Board has discussed recent events and taken some time to align our leadership on the direction the Society must travel. The discussions were deep and far ranging but unanimous agreement was formed on the importance of professional standards. 
“With this as my mandate, I will bring together a revised Society strategy which will ensure that professional standards are at the heart of all we do. Included in this strategic work will be opportunities for members to have their say.”
This is largely management-speak. Whilst Emily Buttrum, CEO of the SoH may have a mandate from the Board, where is the mandate from members? Buttrum's statement implies that professional standards were not previously at the heart of all the SoH and its members do. Giving members opportunities to "have their say" is one thing but it's not clear if members have ever been asked if PSA accreditation was something that they wanted.

In the past, they were asked about statutory regulation
Consultation regarding the application itself is continuing. A survey of Society members in 2006 showed that 65 per cent of respondents supported statutory regulation. A further survey in November 2009 indicated that 81 per cent of those who responded were in favour of statutory regulation, although numbers participating were disappointing. Members will have an opportunity to ask questions and express their views at the AGM in April. Feedback from members is welcome at any time: please address your comments to:
Statutory regulation is a different kettle of fish. It has to be pointed that the SoH were told in no uncertain terms by the Department of Health in the early 2000s that anti-vaccination would be an obstacle to recognition. Whilst members did modify their language, anti-vaccination didn't go away.

The SoH has an annual member survey, highlights of the 2019 can be found here. It is possible that questions were asked about accreditation but not reported. Questions may have been asked in previous years. Even if they were, the response rate won't not indicate a mandate. Also, a survey may be the wrong place to ask this sort of question.

The SoH has made much of the benefits of accredition (which don't seem to have materialised) but it is very quiet about the downsides.

Board Elections etc
The SoH board is made up of 6 homeopath and 3 lay directors. Homeopath directors are elected and serve a three year term (resignation asided). They can stand for another term but once the second term is completed, they must wait a year before standing again. Lay directors are appointed by the board for a three year term. They can be re-appointed by the board for a second term. Two homeopath members have reached the end of a three year term and need to decide whether to stand again. Linda Wicks should resign but may try to brazen it out. Two of the lay directors are reaching the end of a second three year term and have to go. Recent media coverage will not help the SoH in attracting replacements.

The election process for homeopath directors starts with nominations. They must be members of the SoH and be nominated by two other members. Last year, the nomination process started on 12/12/2018 and closed on 25/01/2019. It is possible that because the 2020 Annual Conference is a month later than 2019, the process will start later. Possibly other events have gotten in the way or the SoH may not have made it public (which runs the risk of some members not being aware of it). Last year, postal voting for directors was underway in February and candidates made videos, wrote blurbs etc that appeared on the members only section of the SoH website. They also responded to questions there including "If the Society’s work to retain accredited register status with the Professional Standards Authority (PSA) has been worthwhile." What was said in the blurbs etc, what answers were given is unknown. Voting closed on 05/03/2019. Results were announced on 15/03/2019 with 23% response rate (which was the highest response since 2015). The SoH's AGM was on 23/03/2019 and the new directors would have been quizzed during that.

Because of the low turnout, it is difficult to argue that directors have a strong mandate from members to do anything, even if they have a spiel that involves doing something. It seems unlikely that the director elections would be about whether to continue with PSA acreditation or not. Or any other contentious issue for that matter. Even if these were big issues and there was a clear choice between the position of candidates, unless there was a much bigger turnout, it would not be a mandate either.

Depending he timing of the results of the PSA accreditation and possibly the judicial review, adverse outcomes could well have an impact on voting.

Annual Conference and AGM
The past two conferences coincided with negative media reporting. Whether the reporting had any effect on the mood of members is unknown. There could be very bad news before the Conference. Imagine if the SoH has lost PSA accreditation or very severe conditions have been imposed. Imagine that there has been extensive media reporting. Attendees may not be very happy.

There is a tendency for homeopaths to blame malign external forces for their misfortunes. Some attendees may be in a state of denial re anti-vaccination causing problems. As far as is known, SoH conferences don't feature drunken punch-ups but if things go badly prior to the Conference, there could be animosity.

Apparently, CEO Emily Buttrum and the Chair of the SoH will be available to meet individual members for questions. Who the Chair of the SoH will be then is an interesting question. Linda Wicks currently occupies the post but for her to remain might sent out a bad signal.

It's not known how many attend the SoH Conference. The 2020 Conference will be held in London. Unsurprisingly, there are a good few members in London or easy reach of it but travel and accomodation can be expensive for those further away. The theme of the Conference this year is All About Men. Given that homeopaths and their clients are predominantly female, this might prove less than popular. It is interesting to note that all the speakers are male. Maybe the thinking is that men are an untapped market for homeopathy? 

The Annual General Meeting is scheduled for 2 hours as part of the Conference. It is free for members to attend (the rest of it isn't). Members are expected to tell the SoH they are attending, so that they can be copied in on minutes of the AGM etc. Its main business is the presentation of the Annual Review (see 2018 as an example) but in past years there has been "general discussion" before that. In 2019, the SoH did canvass members to Quiz the Board. What came out of this is unclear as the minutes of the AGM do not seem to have been made public yet. 

The SoH's Articles of Association make for very dull reading. It is extremely unlikely that SoH Board would put forward a resolution about accreditation. But -
At any General Meeting, Members representing at least 5% of members eligible to vote, may bring a resolution to the Meeting. 
So 50+ members who felt strongly enough could force a vote on accreditation? Or is 5% of members present? The legal details are very boring. The SoH is a limited company by guarantee without shares. It has members, not shareholders. The resolution would have to submitted to the SoH and they would send a communication to all members. Members don't have to be present at the AGM, they can vote by post or by proxy. Things are different if a poll on a resolution is required. Only members present and proxies can vote. If a resolution for a postal poll was put forward...

What could happen?
The loss of accreditation would be humiliating. The SoH crave approval from the "establishment". Its "vision" is something along the lines of homeopathy being firmly established in British healthcare. However the SoH might try to spin it, loss of accreditation would be a rejection by authority. Perhaps they believe that official approval is key to expanding homeopathy beyond a tiny and contracting core market of oddball consumers? 

How humiliating depends on exactly what the PSA say in their report and the extent to which the media pick up the story. If the PSA removed accreditation on the basis of, say, the SoH has anti-vaccination members who pose a risk to public health and SoH are not trusted to deal with it, that would be a big story. If it's couched in less direct terms, well, maybe a small group of fringe practitioners having a little known rubber stamp losing that rubber stamp isn't that much of a big deal. The PSA are likely to be extremely measured in what they say because of scrutiny.

Unless there is something terrible that totally dominates the media, the likelihood is that there will be extensive negative coverage. Some outlets have considerable background material they could use for more in-depth pieces. If anti-vaccination is the main reason for loss of accreditation, some stories might cite more extreme members as examples. They might cite the prevalence of anti-vaccination.

What impact reporting might have on public perception of the SoH and homeopathy in general isn't clear. Use of homeopathy in the UK is low compared some other countries. Those who use homeopaths are unlikely to stop using them as a result of negative media coverage. But would it make those who might be tempted by homeopathy more reluctant? 

Timing of the accreditation decision vs that of the GTS judicial review could be a factor. If the juducial review happens first and goes against the PSA, it would be incredibly difficult for the PSA to do anything other than remove accreditation. If the removal of accreditation happens first, this would be a vindication of the GTS's position. It might make a ruling against the PSA more likely - it could be read as a tacit admission that the PSA got the 2019 accreditation wrong.

Would it have any immediate impact on members? The PSA website does have a Check Your Practitioner. Selecting "homeopath" gives the option of the SoH and the Federation of Holistic Therapists (FHT). It links to their registers. The PSA very likely know how many times the links are clicked on. Both the SoH and FHT likely know how many times their registers are accessed and may track the referring website. Whether members of either register get any clients via this route is unknown. Much is made of the advice given to GPs etc that they should preferentially refer patients to members of Accredited Registers other those CAM etc practitioners who are not. Again, how many clients end up with homeopaths via this route is unknown. In either case it is unlikely to be many. There is also the question of whether Accredited Register status has any bearing on client selection of a homeopath either via the Find A Homeopath website or any other search/directory. Some homeopaths say that the bulk of their business comes through word of mouth. It seems unlikely that SoH members would experience much, if any, downturn in business if accreditation was removed.

The loss of accreditation means that neither the SoH or its members can use the PSA quality mark. How long the PSA will give them to remove the mark before taking action is another matter but experience suggests that some members aren't very good at amending their websites in a timely fashion. Incorrectly claiming to be accredited is an offence under the Consumer Protection from Unfair Trading Regulations 2008. It's very unlikely that it would come to legal action but the PSA might well send strongly worded letters to the SoH and certain members.

Adjournment, suspending accreditation and conditional accreditation all effectively set conditions that if not met, lead to removal of accreditation. What differs is the signal that the different outcomes sent out. Adjournment seems unlikely, but suspension is a possibility. However, the timescales for adjournment and suspension make it very unlikely that the SoH could meet any conditions. It is not clear if the PSA will charge a register for the extra work that these may cause them.

The question with Renew Accreditation with Conditions is whether the SoH could meet conditions in a specified timeframe. It could find itself under tremendous pressure to do an awful lot in a very short period. If it can not, it will lose accreditation. The PSA might not expect problems to be totally sorted out but it probably would want to see very serious steps taken to begin the process and some concrete progress to be made.

The PSA would almost certainly want to SoH to deal with anti-vaccination. It is unlikely to tell the SoH exactly how to do this because of its role - it isn't a regulator. With CEASE in 2018, the PSA asked the SoH to come up with an "action plan" which the PSA agreed to. The 2019 Recommendations aren't very directive either. 

What might satisfy the PSA? Perhaps a prohibition of discussion of vaccination - whether on websites, social media, public talks or direct to potential clients. No more anti-vaccination books or articles. No more links to anti-vaccination websites. All existing publicly accessible anti-vaccination content will have to go. There will be no more involvement with Arnica Group etc. No more crowdfunding for Andrew Wakefield. No sharing of online petitions. Because of the apparent lack of member language comprehension skills, the SoH would need to be very clear about what it considers unacceptable and make it public. 

But where do members get these ideas from? It is known that some tutors are homeopathic colleges are anti-vaccination. It is known that some, including SoH member Ralph Jeutter teach homeoprophylaxis. It is know that CEASE therapy was taught at some colleges, at least one accredited by the SoH. Some colleges host talks by anti-vaccination speakers. The SoH might need to consider whether they can accredit colleges that harbour anti-vaccinationists, regardless of whether they are SoH members or not. 

The SoH may well end up having to routinely monitor the activities of several hundred members. It is unlikely to have the resources to do this. From experience, it is time consuming to say the least. They might have to employ additional staff that they can ill afford or divert resources from other functions. Automation can reduce the amount of work required but would require investment and does have limits. Automation can reduce the amount of material to be looked at but a human still has to determine whether content is compliant or not.

Arguably, Renew Accreditation with Conditions could have worse results than Accreditation Removed. The latter would be a clean break even if humilating. The former would prolong the pain and if the SoH doesn't meet the conditions, it would be even more humiliating. They were given a chance to put things right and failed. Also, it would represent two rather than one event for the media to pick up on.

Depending on the nature of the conditions, it may be possible for a third party to monitor compliance. It may be possible to detect failure before any deadlines. In the worst case scenario, it may be possible to point the finger at individuals to blame for that failure. The media will like that but it could also cause division between members.

The SoH could try to second guess what conditions might be imposed and start dealing with the associated issues before accreditation decision is made. Possibly the change to its Positions Statements and the emphasis are attempts to do that but they may be a reaction to media coverage. It would be gambling that Renew Accreditation with Conditions is more likely than Accreditation Removed. Any action taken may be in vain and maybe in devisive. 

Something that is not clear is whether a register that loses accreditation can re-apply for accreditation at a later date. There doesn't seem to be anything to bar this. However, the SoH would have to sort out its problems before even thinking of re-applying, not just come up with an "action plan". 

Accreditation without conditions seems unlikely but that's what was thought re the 2019 accreditation.

Loss of Members and Income
These are biggest threats to the SoH. 

It is known that SoH's membership numbers peaked many years ago. There was a period of decline but it has hovered around the 1,000 mark for a few years. There is some uncertainty about the exact figures as it is suspected that the SoH did not count student members in their figures but do so now. 

The SoH is not in fantastic financial shape can ill afford to lose members. A lot of its money is tied up in its freehold offices. It has some cash reserves and an overdraft facility but the majority of its income comes from membership fees and costs have outstripped these. Its Conference sometimes generates a small profit but nothing to write home about. It ran at a deficit in 2017 and 2018. The 2019 accounts are not available yet but it would be unsurprising it they show a deficit unless the SoH has managed to severely reduce its costs. Membership numbers have not tangibly increased so income will be pretty static.

At some point, it might need to sell its offices but the property market is very quiet and in some areas property prices have fallen. It could purchase a smaller office or it could rent one. It could have staff work from home and hot desk more. It might have to make staff redundant.

The reason that this post makes so much about "mandate" is because at some point the SoH has to make decision about whether it wants some kind of official approval or whether it wants membership numbers and income.

One unanswerable question is whether any members would leave the SoH if accreditation was lost. If PSA accreditation is important to them, the Federation of Holistic Therapists (FHT) accept homeopaths with certain qualifications. The Complementary and Natural Heathcare Council (CNHC) do not currently accept homeopaths, but there is nothing to stop them doing so. The reasons that they don't are historical rather than practical. There was a big falling out between the homeopathy associations and the CNHC. Members could join the FHT without leaving the SoH but that might be too much expense for some. There is an expectation that if a member of an accredited register practices more than one therapy, if their primary register does not accredit their secondary therapy then if there is another accredited registers that does, they should belong to it too.

Would pro-accreditation members be upset by the loss of accreditation? If accreditation was lost on the basis of anti-vaccination, would they blame the Board for not having dealt with it? Would they blame anti-vaccination members and their non-compliance? Difficult to say. 

student survey suggests that PSA accreditation is important to some. Without it, the SoH may be less attractive to new homeopaths. At the moment, maybe old members leaving and new members joining are roughly in equilibrium. A hit on recruitment would not be felt straight away. 

As the opening quote suggests, there are homeopaths who do not like being told what to do. It's very clear that there are some members who do not care if their activities cause the SoH to lose accreditation (that assumes that they are bright enough to grasp that). Some think that the SoH Code of Ethics and Position Statements don't apply to them. Some publicly say they are compliant but certainly aren't face-to-face or on media that they don't think is looked at.

If the PSA impose conditions, the SoH is going to have to do something unless it has given up on accreditation. It can issue all the Position Statements and communications it wants but it some problem members will not comply voluntarily. Some might leave at this stage - there is an undercurrent of disatisfaction with the SoH as it is. Who knows how many? However, given the history of the SoH saying one thing and then doing nothing, problem members may think that nothing is going to happen to them. The threat of disciplinary action may have no effect on them until the process actually starts and once it starts, it doesn't matter if the member leaves or not. It will continue. 

The disciplinary process is not quick. It involves various time consuming stages and potentially lots of people. If the SoH needs to involve lawyers, the process can be expensive. It should also be pointed out that the PSA will take a dim view if the SoH did not stick to its procedures. Arguably, breaches of the SoH's Position Statements are much more clear cut than compliants brought by clients over deficiencies in treatment etc. There isn't a need to interview anyone, look at  client records and so forth. The SoH doesn't publish particularly detailed outcomes of disciplinary hearings. The nature of accusations is not revealed for example. However, it will be clear to some why the member is being disciplined.

Once the first disciplinaries start, it will be clear that the SoH is prepared to act. It will certainly cause upset. There will be much wailing and gnashing of teeth. Some problem homeopaths will turn red and start shouting a lot. Some might leave at this point before they are disciplined themselves. It is possible that members disciplined will appeal which just adds to the complexity, time and potentially cost.

Possibly the worst case scenario is Accreditation with Conditions and failing to meet the conditions. Some problem members might leave, but then later pro-accreditation members might leave. Maybe some of the problem members would come back? It might well depend on how annoyed those problem members were with the SoH. 

Schism is a possibility. Rather than move to a different association (or no association at all), leavers could decide to set up their own register. The Alliance of Registered Homeopaths (ARH) was supposedly set up by SoH dissidents. Although Homeopathy International (HINT) only seem to have a handful of members, it does represent a certain strand of extremism. 

One possibility is that the majority of SoH members simply don't care either way about accreditation. It doesn't matter to them what happens, they will keep on being members until they retire etc. They like the idea of being in an association but don't get terribly involved with it. They don't get the internal politics or the external pressures on the SoH. But is there really a silent majority?

The SoH does not come across as an organisation that makes hard headed financial decisions. Even if were, it lacks the information to be confident about any decision re ensuring financial sustainability. True, its ability to influence external factors is necessarily limited but it seems to lack understanding of factors that it can deal with despite its inward focus.

Accreditation retained
If the SoH does some how manage to retain accreditation, fulfills any imposed conditions, it is not the end of the story. It will have to start thinking about 2021 accreditation almost immediately after that. It might be thought that if the SoH can get through the 2020 process, things will get easier. Not so. It could very much harder.

The SoH will have to accept that its place is not one of being "firmly established within British healthcare" but instead very fringe. Whatever official approval it might have is contingent on limiting what it and its members say and do. Lay homeopathy partly exists in its current form due to benign indifference on the part of regulators and the authorities. But the past few years have demonstrated that regulators etc aren't always indifferent.

CEASE, homeoprophylaxis and anti-vaccination are not the only problems with SoH members. The SoH may find itself under pressure to restrict members in terms of the conditions they claim to "help with". They could find themselves under pressure to not treat certain vulnerable groups such as children and others who lack capacity to give informed consent.

Put another way, there would be pressure to define a scope of practice. There would be pressure to define the limits of competence of members. 

Best Guess
My gut feel at the moment is that the PSA will Renew Accreditation with Conditions. 

UPDATE: 11/01/2020
The SoH have finally got round to announcing the Board Election process. There will be three posts up for election this year. Maggie Dixon is stepping down a year early. Linda Wicks does not appear to be stepping down though although there is still time for this.

UPDATE: 22/01/2020
A couple of things have happened recently that aren't going to help the SoH.

Firstly, a market research company ran a poll on whether the SoH should retain PSA accreditation. The results of the poll don't mean very much and are unlikely to have any impact on the PSA's eventual decision. What is more interesting is how clueless homeopaths and their supporters are. Anna Watson, founder of Arnica Group shared it on the group's Facebook page. Facebook very helpfully tells us that people should read WHO's information on the importance of vaccination before joining the group. What it doesn't warn of it is the awful medical "advice" that is given on that page, some by SoH members. It seems some of the group members thought that the poll was a petition. It's not. It seems some of the members struggled to understand what it was about. Arnica Group were not the only ones to share the "petition". CAM4Animals (discussed here) did as well. It's not a good look being supported by anti-vaccinationists who blindly share things on social media without understanding that they are part of the problem. The SoH did post something on Facebook stating that the poll had nothing to do with the SoH or the PSA.

Secondly, Dr Miriam Stoppard had a piece in the Daily Mirror that pointed out that anti-vaccination homeopaths are a risk to public health. Perhaps some homeopaths are getting more savvy in how they respond to media stories - they tend not to respond now. Except for one, Emma Colley (mentioned here). Her blog post is a prime example of whataboutery and getting things very wrong -
10 – Despite being a homeopath for over 12 years, and met many international and national homeopaths through conferences, teaching days and work, I know of no one who is ‘pushing’ anything. This article is merely using an agenda, to try and associate homeopaths and vaccination, which are clearly 2 separate topics. If you need to, the 4Homeopathy position on this is here.
15 – I would suggest that any organisation or person who is spreading anti-homeopathy myths is particularly dangerous right now – there are so many drugs out there with so many side effects and so much potential in this gentle, natural medicine. There are people in need of help – not just from more suppressive drug regimes.
16 – I would also suggest that no one is suggesting a homeopathic vaccine. This article is recycled nonsense in my point of view. I hope some of the links and comments above have been of interest.
Colley suggests a lot of things. Evidence suggests something else and yes there is clear evidence of some UK homeopaths offering homeoprophylaxis. Colley isn't a member of the SoH. It's not clear if she is still involved with 4Homeopathy. Question is, how typical is she of how homeopaths think?