Accreditation of the Society of Homeopaths

As predicted, the Professional Standards Authority (PSA) has conditionally accredited the Society of Homeopaths (SoH). The Accreditation Report is largely what was expected.

What was not expected was that the PSA issued a press release. Generally, the accreditation of a voluntary register isn't news. This can be explained by the considerable media interest that was stirred up earlier in the year.

Potentially, there are very far reaching implications for the SoH, its members and to a lesser extent UK homeopathy. Some are obvious, but others a lot more subtle. 

Media reporting
Several newspaper ran stories about the reaccreditation -

Society of Homeopaths rebuked over bogus autism remedies (The Times, 14/02/2020)
Homeopaths 'forbidden' from offering autism 'treatment' by Government watchdog (Independent, 13/02/2020)
Homeopaths banned from practising quack autism 'treatment' by Government watchdog - but NHS director wants them struck off completely (Daily Mail, 13/02/2020)

The "treatment" in question is CEASE (Complete Elimination of Autistic Spectrum Expression) therapy. Anyone who has read this blog before will understand that this is a big thing. The articles also go on to mention that the SoH has accepted that it is beyond the competence of their members to give "advice" on vaccination. There were a couple of opinions pieces too as well as a few articles in the specialist press.

There was also a very interesting segment on BBC Radio Scotland (starts around 1:25).

Whether any of the journalists read the actual Accreditation Report and not just the PSA's press release is unclear.

Reaction
The SoH's response is one of trying to put a brave face on things. Perhaps given the calls for their accreditation to be removed, they felt that even accreditation with stringent conditions was a lot better than they could have hoped for? Note the supportive noises from Cristal Sumner, CEO of the British Homeopathic Association (BHA) as well. As discussed here, anti-vaccination nonsense has the potential to strain relationships between homeopathc associations and now that the SoH is prohibiting it, there maybe more cooperation between the two and less with other bodies.

The reaction of members is muted to say the least. The comments on this SoH Faceook post tend towards it being a good thing but generally, members have said very little. Some members have expressed upset on Facebook but it's probably not a good idea. It is known that discontent with the SoH trying to deal with issues that have been raised over the past couple of years has caused some members to leave. It's not a question of whether more members will leave of reaccreditation but how many. 

Other homeopaths and their fellow (often anti-vaccination) travellers see things rather differently from the SoH. The ban on CEASE is Big Pharma trying to suppress a cure for autism. And of course the Government and the media are in the pocket of Big Pharma. It's obvious that they did not read the media reports and even more obvious they have not read the accreditation report. This post on the Arnica Facebook page gives an idea. Themes such as censorship and comparisons to Nazi persecution of the Jews and other groups crop up. 

Others saw the prohibition on CEASE as a good thing. The parents of autistic children are often targeted with bogus cures/treatments for autism. Despite noises from politicians etc, very little has been done by the authorities. The Advertising Standards Authority (ASA) did take action though and reportedly many practitioners removed CEASE claims when referral to Trading Standards was threatened.

Some critics of homeopathy were disappointed. Professor Stephen Powis (National Medical Director of NHS England and Professor of Renal Medicine at University College London) is quoted as saying - 

Taking homeopathic remedies, instead of evidence-based, effective and scientific advice – particularly on lifesaving interventions like measles vaccines – risks sending well-meaning parents down a path that puts them and their children at great risk. 

It's absolutely right that homeopaths should be banned from advertising quack remedies for autism, but frankly this is not enough and they should not be issuing medical advice, full stop.

Removal of accreditation and a ban on homeopathy were themes that cropped up a lot in comments on the media articles (supporters of homeopathy were in a minority and often didn't understand the story).

The Good Thinking Society (GTS) has not said very much because they and their lawyers are still studying potential implications for judicial review (more of which in a future post). 

But why accredit at all?
Both Powis and Sir Simon Stevens (Chief Executive of the NHS England) stated that the SoH should not be accredited under any circumstances and were widely quoted in the media at the time of the announcement of the GTS judicial review. From the Accreditation Report -

5.1 The Authority had received a letter from Simon Stevens, NHS England Chief Executive, and NHS England National Medical Director, Stephen Powis. The letter explained that ‘the NHS, the Chief Medical Officer and the National Institute for Health and Care Excellence take the evidence-based position that homeopathic remedies are not scientifically validated and recommended to treat any health conditions’. The letter stated that it was ‘difficult to see how the Society of Homeopaths can inspire public confidence when the position of both the NHS and NICE, whose statutory duty it is to protect patients and the public by ensuring treatments are effective, have a firm and evidence-based position that homeopathy should not be recommended to the public’. 

5.2 The letter acknowledged that it is not within the remit of the Authority to consider efficacy, a position which the Authority strives to make clear to the public. The Authority noted that homeopathy is legal and that members of the public choose to use this therapy. 

5.3 The Authority recognised the significant concerns raised by the letter, but considered that these concerns should be addressed in wider policy debates about the Accredited Registers, and in the research which the Authority was already undertaking into patient perceptions of the Accredited Registers. The purpose of the annual review of accreditation was to determine whether or not the Society of Homeopaths met the existing standards: the accreditation process could not be used to consider wider policy issues.

The enabling legislation, the National Health Service Reform and Health Care Professions Act 2002 is discussed here. It does not allow the PSA to consider efficacy of a therapy as a criteria for accreditation. Nor does it seem to impose a statutory duty on the PSA towards public health. 

Powis and Stevens' letter suggests that the SoH would fail to meet various of the Standards for Accredited Registers, most likely -

Standard 2: the organisation demonstrates that it is committed to protecting the public and promoting public confidence in the occupation it registers.  

The organisation will need to demonstrate that its purpose and directives are focused on public protection. Additionally, the organisation will need to show that in carrying out its voluntary register functions public interest is paramount and that professional interests do not dominate or unintentionally subvert that interest. 

Evidence of this might include board or committee discussions where issues have been debated and conflicts of interest identified or the ethical interests of parties weighed in the balance; decisions made about admittance to the register where the documented rationale shows due consideration of public protection; outcomes of complaints; particularities of governance arrangements. 

And 

Standard 7: governance  

The organisation:

7a) Ensures that the governance of its voluntary register functions is directed toward protecting the public and promoting public confidence in the occupation it registers. 4 

This standard is linked to Standard 2. Where organisations have functions other than voluntary registration (for example, a professional or representative body) they will need to explain how their governance arrangements enable them to achieve this outcome, demonstrate that it is effective in causing that to happen in practice and explain how they assure themselves that it is. Forms of assurance might include reports to the board or relevant committee focusing on outcomes achieved, case audits, external or peer review.

Footnore 4 explains - 

By ‘promoting confidence in the occupation’ we mean maintaining among members of the public a well-founded confidence in the integrity and trustworthiness of registrants on an accredited register.

The PSA has only once removed Accreditation and that was from Treatments You Can Trust (TYCT). Its failures are very obvious and it is looks as if TYCT made no real attempt to rectify its failings and in some cases went backwards. Removing its Accreditation would have been a very clear cut decision.

Removing the SoH's Accreditation would have been more difficult because its failings are nowhere near as dramatic. Also, that last year the SoH was accredited without conditions makes it more difficult. The failings were there back then but not considered enough of a problem for the PSA to do anything. The PSA could concede that they made a mistake but they have been reluctant to do so so far. The PSA can only remove accreditation if, in its judgement, a Register stands no chance of meeting the Standards. Not giving a Register a chance to try to meet the Standards might be considered unfair.

If the PSA had removed accreditation, the SoH would almost certainly have appealed. If that appeal failed, it could apply for judicial review. It would have suceeded on fairness grounds unless other reasons were overwhelming.

It is possible that the SoH has changed in a meaningful way. The Accreditation Report makes much of the efforts of the SoH to change but to an outsider it looks as if the efforts are relatively recent. At times the SoH have certainly come across as not taking the Standards very seriously, perhaps this has changed? At other times it certainly appeared to put its own and members' interests before protecting the public.

What does "Accredited with Conditions" mean?
It means that the SoH almost meets the Standards. It has a couple of deficiencies that are possible to rectify. 

Conditions are things that the SoH must do in the set time scales to be deemed to meet the Standards. If they do not, the PSA can remove their accreditation. To quote -

1. The Society of Homeopaths must: 

a. make its position statements clear that registrants must not practise or advertise adjunctive therapies that are incompatible with Society registration. Specific reference must be made to the Society’s position forbidding the practice of CEASE, and dietary/nutritional supplements. This must be submitted to the Authority for review and published within three months. (paragraph 2.13) 

b. make its position statements clear that registrants’ scope of practice does not allow registrants, whether acting in a professional or public capacity, to provide advice on vaccination or offer or provide homeopathy as an alternative to vaccination for the prevention of serious infectious diseases. Registrants should direct service users to NHS and other public health sources, for example, their GP or public health departments. Revised statements must be submitted to the Authority for review and published within three months. (paragraph 2.19) 

c. provide quarterly reports of its monitoring to ensure that within the following 12 months all registrant websites comply with its updated position statements (as referred to in part a above) (paragraph 5.10) 

d. complete and make available to the public its guidance on adjunctive/supplementary therapies and inform the Authority how it will promote compliance with that guidance. (paragraph 2.24)

CEASE Therapy
The SoH has finally prohibited CEASE therapy but even that it didn't get quite right - 

2.9 The Society confirmed to the Authority, in its responses to the Authority’s queries, that it intended its updated position on CEASE to mean that registrants were not permitted to practise CEASE or otherwise promote it. 

2.10 The Authority considered whether this new position statement effectively communicated to the public the Society’s revised approach to CEASE. The Authority noted that the statement referenced CEASE but that it was broadly worded. The Authority noted that the broad position on named protocols could enable the statement to effectively cover practices with elements similar to CEASE, such as Homeopathic Detox Therapy or Human Chemistry (which are discussed in more detail below) as well as any similar practices which may develop over time. 

The language used in the position statement is unclear and can easily be read as falling short of prohibition. It also does not make clear what the SoH will do if members continue to promote CEASE and other protocols.

The Accreditation Report does not directly mention the potentially discriminatory nature of CEASE but it does quote a concern raised -

5.4 The Authority had received concerns about the efficacy of homeopathy and suggesting registrants could not diagnose or treat any condition. The concern argued that the practice of CEASE therapy was ‘harmful to and discriminates against autistic children’ irrespective of controls on advertising and marketing the therapy. As noted in Standard 2 above, the Society has updated its position on CEASE and the Authority has issued a Condition to the Society to make further changes to its position statements.

The PSA later say -

 Equality duty under the Equality Act 2010  

14.1 The Authority had regard to its duty under the Equality Act 2010 whenconsidering the application for renewal of accreditation. This included its dutyto have due regard to the need to: (a) eliminate discrimination, harassment,victimisation and any other conduct prohibited by or under the Equality Act2010; (b) advance equality of opportunity between persons who share arelevant protected characteristic; and (c) foster good relations betweenpersons who share a relevant protected characteristic and persons who donot share it. 

14.2 Specifically, the Authority had due regard to the position of children; peoplewith a disability, including autism; people with mental health problems; andalso other users of healthcare, as set out in the annexed Equality ImpactAssessment. The Authority issued Conditions of Accreditation andRecommendations to address risks to those with protected characteristics.

The Impact Assessment is not online. It will be interesting to find out what it says.

There are members still openly offering CEASE and similar. Even if they aren't, some may still practice it and risk that being caught out by undercover reporters etc. Because of what CEASE represents, the SoH would be foolish to think that withdrawal of marketing claims is the end of the matter.

Vaccination
Although matters with CEASE seem to be drawing to some sort of conclusion, this is certainly not the case with anti-vaccination. Anti-vaccination is a very serious issue for the SoH and UK homeopathy.

2.14 The Authority also considered the Society’s new position statement relating to vaccination and contrasted it to the previous version: ‘The Society does not endorse the use of homeopathic medicines as an alternative to vaccination for the prevention of serious infectious diseases. RSHoms must not offer homeoprophylaxis, provide advice on, or actively participate in a patient’s decisions regarding vaccination. 

‘Homeopaths are not able to offer advice on vaccination and the Society recommends that members of the public seek the advice of their GP and/or relevant Department of Health guidelines concerning vaccination and protection against disease when travelling’ 

2.15 The previous version stated: 

‘The Society … does not endorse the use of homeopathic medicines as an alternative to vaccination for the prevention of serious infectious diseases’ and; ‘The Society supports informed decision making in regard to vaccination. We recommend that patients seek advice from their GP, as well as organisations that specialise in providing information about this complex issue, so they can make an informed choice for themselves and their children.’ 

2.16 The Society highlighted collaboration with other organisations working in homeopathy and complementary medicine to produce a public statement on homeopathy and vaccination, stating that ‘questions about vaccination from the public to a registered homeopath should be deferred to those medically trained to answer them, such as GPs’. 

2.17 The Authority considered that CEASE, and other practices such as ‘Homeopathic Detox Therapy (HDT)’ or ‘Human Chemistry’, aimed to ‘cleanse’ the patient of toxic substances. The Authority noted that proponents of ‘antivaccination’ had claimed that vaccines may contain harmful components that could be treated through those protocols and asked the Society for its position. 

2.18 The Society stated that it considered that its new position statements regarding generic protocols and on vaccination addressed these matters. The Society confirmed that discussing arguments (such as that vaccinations contain ‘toxins’) to promote anti-vaccination sentiments, which might influence a patient’s decision to vaccinate, could be in breach of its position statements and wider standards. 

2.19 The Authority noted that the updated position statement confirmed that registrants ‘must not offer homeoprophylaxis, provide advice on, or actively participate in a patient’s decisions regarding vaccination’ but that the phrase ‘the Society does not endorse the use of homeopathic medicine as an alternative to vaccination for the prevention of serious infectious diseases’ was not sufficiently strongly worded, as the Society should make clear that its registrants must not use or offer homeopathic medicines for this purpose. The Authority considered that as it had queried the Society’s use of the term ‘endorse’ regarding CEASE therapy and required the Society to make its expectations clearer, the same Condition should be applied to its policy on vaccinations. The Society’s position statements should make it clear that registrants’ scope of practice does not allow registrants, whether acting in a professional or public capacity, to provide advice on vaccination or offer or provide homeopathy as an alternative to vaccination for the prevention of serious infectious diseases. Registrants should direct service users to appropriate sources, for example, their GP. This must be submitted to the Authority for review and published within three months. (Condition 1b)

Note that again there are issues over language. It does not directly address the issue of involvement with anti-vaccination groups such as Arnica but presumably it would be acting in a public capacity if that involvement were anything but passive. Giving talks, distributing "information" and actively posting "advice" on Arnica group pages certainly would not be passive. The SoH must consider whether membership of anti-vaccination groups is compatible with SoH membership whether the PSA has instructed them or not. 

The previous Accreditation Report states - 

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. 

The book in question is No Nonsense Vaccination Handbook written by (still) SoH members Liz Bevan-Jones and Yvonne Stone. Stone did have an excerpt of the book on website. It's been deleted but can be found here. The extract suggests that Stone promotes homeoprophylaxis even if she does not offer it herself, she gives advice against anti-fever medication and so on. It is impossible not to come to the conclusion that Stone is anti-vaccination. Stone doesn't seem to have got the message from the SoH that advice on vaccination is prohibited. On this page -

VACCINATIONS 

One of the first things to consider is Vaccination 

View the current UK Vaccination Schedule 

If you want to make an informed decision then you can search for sites on the internet. The No Nonsence Vaccine Handbook is available in all homeopathic pharmacies and homeopathic book shops. 

And below is a "Contact me" button. Actually, the book is no longer available in homeopathic pharmacies. The General Pharmaceutical Council (GPhC) stated in an email -

... From this, we did not identify a need for action other than in relation to Helios offering for sale on its pharmacy website a number of books which could appear to endorse practices which place the health, safety and wellbeing of members of the public at risk.  The content and key messages of this literature appeared to run directly contrary to government/NHS guidance, including for example those which endorse CEASE therapy and the non-vaccination of children. 

We advised Helios that the sale of such literature was not compatible with our standards for both registered pharmacy premises and pharmacist.  This is because the purpose of the standards is to ensure pharmacies and pharmacy professionals deliver safe and effective care to patients and the public, and that patients and the public have confidence in pharmacy as a whole. Helios immediately reflected on our points and have removed the items from sale.

The book is still available from other outlets though. It was written before the prohibition on "advice" but it is likely that Bevan-Jone and Stone writing another edition would be incompatible with SoH membership. It is likely that direct sales by themselves or any other SoH member would be an issue as would be re-printing.

The prohibition on "advice" is likely to apply to any members writing for publications that are aimed at the public, or appearances on broadcast media.

Given the prevalence of anti-vaccination sentiment among SoH members (at least a third), this is going to difficult to deal with. It is a huge cultural shift and some members may not be able to stomach it. It will likely take a long time. Again, removing claims from marketing is not enough and there is the danger of being caught out by undercover investigation.

Scope of Practice
There is anecdotal evidence that suggests lay homeopathy is not very lucrative. It is understandable that some homeopaths may diversify into other therapies. The business of SoH members offering other therapies was discussed here. 

2.23 The Society advised that it ratified a formal Scope of Practice in September 2019. The Scope sets out what all registered members of the Society of Homeopaths can do, and what registrants may be able to offer as a result of achieving qualifications in other areas. Where they are outside of the main scope of homeopathy, registrants must make clear to the public they are separate practices and provide relevant evidence of qualifications held for those practices. The Scope of Practice would be formally issued to registrants and published online in January 2020. The Authority will follow this up with the Society in due course to ensure it has been done. 

2.24 The Society advised that its newly revised Scope of Practice will be supported by guidance on Professional Homeopathy Promotion ‘which will outline how members of the Society can communicate their adjunctive therapies alongside their homeopathic practice and what evidence of certification they are required to demonstrate. This piece of work will take place in the first half of 2020 following the review and update of the Society risk register.’ 

2.25 As part of the Condition issued the Authority required the Society to complete and make available to the public its guidance on adjunctive/supplementary therapies and advise the Authority how it will promote compliance with that guidance. (Condition 1d) 

2.26 The Authority considered that the Society’s updated standards and guidance should be able to be understood by patients and service users as well as registrants. The Society should communicate its updated position statements and guidance and consider how it will ensure that members of the public are aware they can contact the Society should they require further information (Recommendation 1)

The SoH were not exactly keen to do this.

3.3 At the previous annual review, the Authority had notified the Society that concerns had been raised about Society registrants offering therapies such as the ‘Asyra bio-energetic screening system’ and ‘Vega Machine’. The Society had previously advised that it did not review or regulate additional therapies offered by members and would refer to registration bodies covering a broader range of therapies. The Society stated that it considered that such devices were diagnostic tests and not therapies. 

3.4 The Authority noted that as devices such as the above informed registrants’ homeopathic practices the Society could investigate related allegations. The Authority had issued a Recommendation for the Society to consider what risks any adjunctive therapies or practices it becomes aware of may pose to the public, what controls may be needed to protect the public, and whether the practices are compatible with registration.

The Scope of Practice document is not publicly accessible. Little is known about its exact contents but - 

8.3 The Society developed its Scope of Practice Statement for registrants, setting its definitions for the title homeopath and the practice of homeopathy. The Scope was developed with the assistance of a registrant working group. The policy sets out that registrants’ scope is defined by professional standards set out in the National Occupational Standards, Core Criteria for Homeopathy Practice, and Code of Ethics, alongside CPD, supervision and compliance with relevant regulations and guidelines. The policy recognises registrants are well placed to support public health ‘by encouraging their patients to make a range of lifestyle changes’ for example support with giving up smoking and weight control. The Scope explicitly states: 

‘Registered members of the Society of Homeopaths who use additional therapies will ensure that the patient is always clear about any different or additional treatment modalities being used, and that the treatment options have been agreed. Such additional therapies, which are distinct from homeopathy, are only practised by members who can demonstrate the capability, competence and insurance required to do so.’

National Occupational Standards (NOS) are discussed in this blogpost and mention of the Core Criteria for Homeopathy is mentioned. Unfortunately, the SoH have chosen to hide it from the public but a version of the document can be found here. The SoH's Code of Ethics has changed over the years but not hugely so.

Members are "well placed to support public health"? If so, they are also well placed to undermine public health with useless and even harmful "advice". Anti-vaccination is the obvious examples but SoH members have been known to promote thermography over mammography for breast cancer screening.

Defining "homeopath" and "homeopathy" is unlikely to be very detailed. If it were, it might well exclude some members from the definitions. There is a division in homeopathy - the "classical" (as per Hahnemann) and the "practical", which is highly variable and eclectic. It can incorporate practices such as dowsing and radionic remedy makers for example. It sees them as part of homeopathy rather adjuctive. There is potential for division. Also definitions can be somewhat circular - homeopathy might be defined as what homeopaths do and homeopaths are people do homeopathy. The SoH has always been more aligned towards "classical" homeopathy.

Evaluating member capability and competence in very fringe therapies is difficult to say the least. Normally, qualifications are the proxy used. The SoH is probably not able to evaluate a myriad of qualifications. It might choose to recognise certain qualifications because they are recognised by another accredited register, because they meet National Occupational Standards or they are accredited/validated by a reputable body. This may effectively prevent some members practicing more fringe therapies. There are no recognised qualifications. One thing the SoH can't do is depend on, say, a self-evaluation framework. 

A related area that is not mentioned is the sale of products that are unrelated to homeopathy, especially connected to multi-level marketing (MLM). Some SoH members are involved with Mannatech, some with doTerra. Others seem to sell Neals Yard Remedies (NYR will be the subject of a future post). The ethics of some MLM schemes are dubious to say the least. Again, it suggests that homeopathy is not terribly lucrative. There are also manufacturer run courses. Some of the herbal product manufacturers do them but they are really aimed at retail staff rather than practitioners.

Social Media
This is very telling.

5.15 The Authority had received concerns regarding a sample of registrants’ public social media posts, that appeared to discourage vaccination and drew this to the Society’s attention. The Authority considered an initial response from the Society which appeared to apply different standards between registrants’ professional, and personal behaviours on social media. The response suggested the possibility that outside of their homeopathic practice, registrants may act contrary to the Society’s standards without risk of disciplinary action. 

5.16 The Authority did not agree with the Society’s position that personal beliefs, stated in public spaces, could be distinguished from registrants’ professional practice. The Authority noted many practitioners were self-employed or  otherwise represented their own practices on social media, and that promoting ‘anti-vaccination’ messages may conflict with the Society’s position statements. The Authority asked if the Society had considered issuing its policy on the use of social media (further to existing statements regarding treatment of cancer) in its position statements (or other guidance) or within its Code of Ethics. 

5.17 The Society, having further reviewed the social media pages provided, considered they were part of the registrants’ practice due to the content and nature of the materials ‘posted’. The Society stated it accepted that if registrants’ personal social media pages are publicly accessible, members of the public looking for information about homeopaths or homeopathy may be informed or influenced by what they read there. 

5.18 The Society affirmed that the use of social media blurred boundaries between registrants’ personal and professional lives. The Society stated it would develop guidance on the use of social media by registrants and its Board. The Society would draw from existing examples of best practice and engage its membership in development of the guidance. Once issued the Society would check registrants’ engagement with the guidance and include social media pages where possible within its regular audit of registrants. 

Bear in mind that Linda Wicks, Chair of the SoH was caught out posting anti-vaccination material on Facebook, which is alluded to in the Accreditation Report.

7.3 The Authority considered news articles that had alleged Society Board members held views contrary to the Society’s positions on vaccination, as demonstrated by personal social media posts. The Society responded that the concerns had been addressed under its regular complaints processes and that Board members had removed such content. This matter was discussed with the Board and contributed to the development of the Society’s new position statements. The Society confirmed that Board members must act in compliance with the Society’s standards and position statements. 

7.4 The Panel noted the positive impact of demonstrating that Society Board members were held to the same standards as its registrants.

Obviously posting anti-vaccination misinformation on Facebook etc didn't carry any disciplinary consequences then but does it now?

It is long established that social media can often be considered marketing and subject to advertising regulation and consumer protection legislation. It is worrying that it seems to have taken several exchanges for the PSA to get the SoH to understand this.

The issues associated with the use of social media by medical professionals are well understood. Various regulatory and professional bodies have produced guidance over the years and there has also been legal and academic discussion. Likewise, there is ethical guidance for medical professions on personal beliefs, for example this from the General Medical Council. It must pointing out that the practice of a Doctor being informed by their own personal beliefs is very different from a SoH member's practice of homeopathy because homeopathy is effectively an unevidenced estoric belief system. That will be very difficult for the SoH to accept. 

Monitoring Compliance
Monitoring is one thing but there are questions about what the SoH and its members might think compliance looks like. For example, the SoH have in the past said to the PSA that members' websites were compliant with a previous position statement when to a more disinterested observer they probably weren't. The PSA did some checking at the time and found at least one non-compliant website. It is clear that in the past the SoH has taken a very narrow and highly reactive approach to compliance. It's also not clear if it had any effect -

5.11 The Authority noted the work the Society has undertaken with registrants to change their advertising but was concerned that there was currently no evidence as to whether this had influenced the practice of registrants. The team asked the Society to further discuss how it has, or will, assure itself that its work and position statements in relation to CEASE, and other areas, are resulting in a change in registrants’ practice in addition to changes to advertising.

It seems likely that the ASA enforcement action had more impact than any of the SoH's actions.

"Culture of compliance" is corporate management speak and its meaning differs depending on who you ask. Even so, it is a useful concept - are members of the SoH someone culturally opposed to voluntary compliance? Some likely are but surely not the majority? Something is very wrong if the SoH finds itself in a position where it has to engage in a compliance audit of the websites of all its members. 

The scope of monitoring mentioned in the Condition may be limited to members' own websites but if the SoH were proactive, they would monitor social media of at least some of their more problematic members. Even restricted to problem member websites, it is a lot of work.

Can the SoH meet the Conditions?
The real answer is it depends on what level of progress in meeting the Conditions would be acceptable to the PSA (and potentially the Courts). The SoH has a lot to do and it may struggle to deliver even part of it in the proscribed time scales. The PSA can amend the time scales if minded to. Three months might seem like a long time but it isn't and the clock is ticking.

It might be thought that issusing statements, coming up with policies is easy. In reality, the SoH may struggle to reach consensus positions, especially when something has been effectively imposed on them ie having a social media policy. The longer it takes to formulate these positions and policies, the later some of the other things that need to be done will start. Dragging more people into the process will not not necessarily help. If anything, it can slow down arriving at consensus and making decisions.

Something that the SoH need to be careful of is thinking that there is more of a negotiation to be had with the PSA. It may have made this error in the past. It also really needs to get the policies/statements that the PSA has to agree to right first thing. It has to get the language right.

Trying to engage with over 900 members (although that figure may decline with time) will be time consuming. It would appear that email, pronouncements on their website, etc have not been effective for the SoH. They have be forced to ring some members and actually talk to them. It is also the case that members seem to less engaged with the SoH. The Board elections discussed in a previous post did not take place because only three members were nominated for three vacancies. No-one else put themselves forward. And all of the nominees are previous Board members. At least two of them must shoulder considerable responsibility for the predicament that the SoH finds itself in. It is difficult to know whether this is the result of apathy on the part of members who might previously sought election or somewhat. 

It will become apparant very quickly if the SoH are making any progress in certain areas. They will not be the only ones monitoring the activities of SoH members.

But meeting those Conditions may come at a cost.

Recommendations
Recommendations are things that the PSA thinks a Register should do. What isn't clear is whether a Register must consider them, even if it doesn't implement them. Certainly not considering Recommendations might give the impression of not listening to the PSA.

This year's Recommendations are - 

1. The Society should communicate its updated position statements and guidance and consider how it will ensure that members of the public are aware they can contact the Society should they require further information. (paragraph 2.26) 

2. The Society should consider including a statement within its annual declarations to ensure registrants are made aware of all documentation comprising the Society’s professional standards. (paragraph 3.12) 

3. The Society should provide its social media guidance to the Authority and advise how it will promote compliance with that guidance (paragraph 5.20) 

4. The Society should commission an appropriate external review, conducted by a person who does not practise homeopathy, of the information presented on its website relating to the evidence base for homeopathy, to ensure that the information is not misleading and complies with ASA guidance (paragraph 6.5)  

5. The Society should provide an update on the review of its CPD e-learning module on advertising, and its engagement by registrants, at the following annual review of accreditation. (paragraph 7.12) 

6. The Society should consider how it can ensure that its CPD modules reflect and emphasise its position statements. (paragraph 7.13) 

7. The Society should review distinctions between the use of ‘should’, ‘must’ and ‘will’ within its Code of Ethics and amend where necessary. (paragraph 8.8) 

8. The Society should consider publishing information about its approach to informal resolution and how it will escalate concerns that are not resolved in a timely manner. (paragraph 11.11)

Some of these should be relatively easy. Some are more difficult but should flow from implementing the Conditions. Some of them are manifestations of more general concerns.

Communications
Issues with communication are a consistent theme in this year's accreditation report and also prior ones. It's very clear that the SoH struggles on a number of fronts but they are not alone in this. Many organisations struggle to communicate effectively with the public and their customers. Putting aside marketing, 

The big problem with the SoH is lack of clarity combined at times with very indirect language. Note the Accreditation Reports discussion of the weakly worded Position Statement that "does not endorse" CEASE when what was supposedly intended was a prohibition. The PSA also make note that the word "should" is used when really "must" is required.

Homeopathy is full of aphoristic jargon that bears little relationship to real world meanings of words. The supposed explanation of how homeopathy "works" is couched in metaphysical terms. It is a form of vitalism. But if you read individual homeopath's explanations the language can be "helping the body's natural tendency to heal itself". The explanations can be full of strange but meaningless metaphors. In a way, it should come as no surprise that an organisation predominantly composed of homeopaths struggles with clarity of language. It may also be the case that homeopathy attracts, for want of a better phrase, "woolly thinkers". 

Another problem that the SoH is understanding which particular audience a communication is aimed at and which platform is the best way to reach that audience. The SoH has three key audiences -

• Members of the public interested in homeopathy potentially seeking treatment
• SoH members
• Prospective members

The SoH has a number of ways to communicate but perhaps it has made bad choices in the past in terms of which route it has used in the past. Mark Taylor was a big one for making bullish statements to rally homeopaths and their supporters but whether some of those pronouncements should have been made publicly on the SoH website is another matter. It is understood that any organisation would want to put a positive spin on things in communications but when there is a disconnect behind what is publicly stated and what is known to be true, it can cause problems.

The SoH previously made content that was accessible "members only". It did so again around December 2019 onwards as well as deleting some content. Why isn't totally clear but it may be a reaction to critics of the SoH finding reasons for concern in that content. Some on the links in this blog are broken as a result. What it hoped to achieve by this is more difficult to say. Most of the content can still be obtained in one way or another. It doesn't look good from a transparency angle. Also, some very problematic content has not been removed/hidden.

Something else of concern is that the PSA do not seem to have recieved certain materials that Registers are expected to submit as part of the accredited process.

There is a different scenario with new policies etc. For example, whilst the SoH has committeed to making its Scope of Practice public, it may wait until it is sure that its members have taken the Scope of Practice onboard. It may take members some time to adapt to the new Scope of  Practice. 

Marketing
Whatever the SoH do, member marketing is always going to be an issue. The antipathy towards the ASA is still there among some. The central problem is that the claims for homeopathy can not be substantiated.

The SoH itself tries to do two things. Market homeopathy to the public and market itself to prospective members. The latter isn't a problem but the former?

6.2 The Society publishes information about the knowledge base for homeopathy on its website. It links to information about clinical trials, observational studies and systematic reviews undertaken. 

6.3 The Authority had previously considered that wording on the Society’s webpage for ‘the evidence base for homeopathy’ may give the impression that homeopathy was scientifically proven. At the previous annual review the Authority issued a Recommendation that the Society should seek an appropriate external peer review of information presented on its website relating to the evidence base for homeopathy. 

6.4 The Society advised it had contracted a Research Consultant to review the information presented regarding the knowledge base of homeopathy on the public section of the Society’s website. This work will begin in early 2020. 

6.5 The Authority considered that the Authority’s Recommendation may not have been clear, particularly with the use of the term ‘external’. The Authority advised that an appropriate external consultant did not need to be a registrant or homeopath in order to review the material presented, and that any homeopath may be considered to have a conflict of interest. Instead the focus should be on the clarity of information about the evidence base for homeopathy and the need for the public to have access to accurate and clear information about homeopathy. The Authority decided to reissue the Recommendation: The Society should seek an appropriate external review of information presented on its website relating to the evidence base for homeopathy. This review should be conducted by a person who does not practise homeopathy. (Recommendation 4)

It is difficult to see how this can work out well for the SoH. If the "research consultant" delivers something the SoH doesn't like, it can choose to ignore them and also the Recommendation. It would not look good. 

Risk Management
This blog has long made the point that the proactive identification of current and risks has been a long standing weakness of the SoH. Whilst it is unreasonable to expect a small, quite amateur membership organisation to have to the same level of risk management competence as, say, a large commercial organisation that engages in numerous high risk activities, nonetheless, the basics of risk management aren't exactly hard. It must be remembered that the SoH's risk matrix is confidential. The PSA get to see it, the SoH Board gets to see it but no-one else does.

It is obviously trying - 

3.1 The Society’s new Chief Executive advised that a complete review of its risk matrix would be undertaken in 2020. The Society’s present matrix was updated to state ‘there have been no professional conduct complaints or enquiries by patients’ regarding risks related to anti-vaccination, homeoprophylaxis, or CEASE therapy. 

3.2 Following the proposed review of its risk matrix, the Society advised that its Professional Standards Committee would give greater consideration to forecasting potential risks, and ensuring these are recorded. The Committee would consider specific risks, to inform operational plans and assist in better risk forecasting. The Society’s Board would receive and review such risk assessments to identify opportunities to improve its overall governance.

Also -

3.29 The Authority noted the emphasis placed on the identification and management of risk during the assessment period and the Society’s plans to develop its risk management processes further. The Authority noted that the Society had implemented new controls for risks including its updated position statements (discussed under Standard 2) and its work to ensure compliance with these (discussed under Standard 5). The Authority noted the Condition issued around the position statements and monitoring of compliance, discussed under Standards 2 and 5, but concluded that the Society’s risk management processes were sufficient, and that this Standard continued to be met.

It's easy to point to examples of when the SoH did not anticipate to a particular risk or failed to respond to in a timely manner but something else that has obviously been missing too is an ability to estimate the prevalance of risks posed by members' activities and beliefs. It isn't always a few "bad apples".

This is interesting in terms of the SoH not understanding how to formulate risk statements. 

2.21 The Society noted that some practitioners were ‘not comfortable with [the] increasing degree of regulation’ apparent from recent policy directives (relating to its actions on CEASE therapy and similar) and identified a risk that ‘more homeopaths are opting to practise without formal registration’ accordingly. Although the Authority recognised that a goal of the Accredited Register programme was to bring practitioners within the regulatory assurance of an accredited register, the fact that some practitioners might leave a register rather than accept the requirements was not a reason to reduce necessary safeguards.

The risk is more properly that members will leave the SoH and the major impact will be on income. And so on.

Education
There are all sorts of implications for training providers and trainers.

9.2 The Society highlighted that all its accredited course providers are subject to a site visit every year and their curriculum provision is reviewed every other year. 

9.3 The Authority received a concern that a training provider had advertised that CEASE Therapy was included within its ‘Licentiate in Homeopathy’ course, which provides eligibility for registration with the Society. The Authority asked the Society about how the Society’s accreditation of training providers aligned with its position statements and other relevant standards. The Society responded that the provider was checked in line with its requirements, and it did not include CEASE therapy within its curriculum. The Society advised that: 

‘As part of communicating the new position statements the Society has engaged with all of the colleges and will continue to ensure that throughout 2020 that each college is aligned to our new position statements. The Education subcommittee receives reports from each of the colleges throughout the 4-year accreditation cycle. Course content will be a focus for liaison visits in 2020.’

What the PSA say is wrong in that the concerns were about CEASE being promoted face to face during a college open day rather than advertising. It is telling that at least one person named seems to have given up SoH membership and embarked on a very esoteric route. 

There is a lot more in the Accreditation Report on how SoH accredited providers are going to have to align course content to SoH position statements etc. They might have to stop training certain things eg homeoprophylaxis. On a more abstract note, germ-theory denialism might be a problem too. Increased SoH control/oversight of curicula may cause some upset. "Academic freedom!" some might cry. Although evidence is patchy it would appears that it has happened before. 

There are questions about the value of SoH accreditation to training providers though. Given that having a qualification fron a non-accredited training provider is not a bar to SoH membership and that that route of joining has been made less onerous, is SoH accreditation a compelling reason for students to pick one training provider over another?

It may become more difficult for training providers to use trainers who are known to be anti-vaccination. Some people really don't like to be told what they can and can not say. Teaching, training and possibly supervision are almost certainly acting in a professional or public capacity. SoH members who train or supervise will need to be as mindful of the SoH's Position Statements and Scope of Practice as they are in their marketing, their practice and dealing with the public.

Training providers rarely own their own premises. They hire rooms and often have long standing contracts. The Centre for Homeopathic Education got into deep trouble with Regents College over the screening of the film VAXXED. There was media reporting of this. The SoH's reaction? It has deleted it recently but it said -

The Society of Homeopaths has defended the Centre for Homeopathic Education’s (CHE) right to host a film that encourages debate on freedom of choice in healthcare. 

 An outcry from press and skeptics greeted CHE’s recent showing of the film Vaxxed to an invited audience.  It was followed by a debate on vaccination with a panel of 5 experts including doctors, one of whom was Andrew Wakefield. Responding to the outcry, the venue for the film, Regents College, cancelled all future bookings by CHE.   

As SoH Chief Executive Mark Taylor points out – neither the Society nor CHE are anti vaccination.  ‘We stand for freedom of choice and diversity and as part of that we should encourage people to make up their own minds. It seems that others don’t believe people should be allowed that right’ 

This weekend’s courses went ahead as planned and CHE have been swamped by support from other organisations, homeopaths and members of the public. There is no suggestion that their partnership with Middlesex University might be under threat. 

Marcus Fernandez, Principal of CHE said  ‘We believe in open debate and freedom of speech. Everything, including conventional medicine or otherwise, should be open to discussion in a true democratic society so as to enable the patient or carer to make an informed choice’

Middlesex University's website says that the BSc Honours Homeopathy is being phased out. CHE no longer list it as an option on their course list. The SoH statement is a gross misrepresentation of the film and it is understood that the "debate" was no such thing and that the experts were not experts in any sense of the word. Whether showing the film now would be compatible with SoH accreditation is questionable.

Some training providers have hosted talks by anti-vaccinationists less well known than Andrew Wakefield, such as Jayne Donegan and convicted benefits fraudster Trevor Gunn. 


Complaint Handling and Discipline
The SoH says it doesn't get many complaints.

11.2 The Society reported it had received four complaints against registrants in the past year of accreditation. One complaint was not taken forward by the complainant and one involved a practitioner who did not belong to the Society. The Society advised that advice had been provided to that complainant about alternate sources of assistance. The other two were resolved through mediation, facilitated by the Professional Conduct Officer.

That low number may come as a surprise. But -

11.6 Concerns had previously been raised that where the Society resolved a complaint informally, acknowledgement of receipt would be provided to the complainant, but not the outcome. The Society had fulfilled the Authority’s Instruction to provide clearer information to complainants on the actions it would take when complaints were resolved outside of the formal complaints process. At the previous annual review, the Authority issued a Recommendation for the Society to consider publishing the number of complaints resolved outside of its formal complaints process, including the number received, and their outcomes, within its own annual report. This could assist the Society to demonstrate transparency and inspire confidence that concerns are addressed seriously, even if they did not result in formal investigations. The Society advised it would publish the number of complaints it had resolved informally within its next annual review.

Until very recently, the SoH would only accept formal complaints in writing. This has changed now but it may have put some off from complaining. Also, it is known that some don't make complaints because they don't believe the SoH will do anything. 

One reason for raising concerns informally is that formal complaint processes can be lengthy and cumbersome. From the SoH perspective, they divert resources from other areas and potentially can incur cost. For certain matters, the formal complaint process is overkill.

However, if a matter is not resolved informally, the SoH should escalate the matter to a more formal status -

11.8 The Authority noted the Society’s approach of attempting to resolve concerns informally before applying its formal disciplinary procedures (which also includes a separate ‘local resolution’ procedure). The Authority noted examples discussed under Standard 5 where the Society had contacted registrants regarding website content and had been given ‘last-chances’ to act before escalating to the formal procedures. 

11.9 The Authority considered a risk that different standards and expectations may be applied through informal resolution. The Authority asked if the Society had set processes, such as a maximum number of attempts to contact a registrant, or if repeated contact on similar issues could suggest that its standards were not met. 

11.10 The Society responded that it accounted for differences in registrants’ circumstances when resolving such concerns but advised there was a limit to the number of attempts it would make to contact registrants, and that deadlines would be provided. Registrants who did not engage with the Society would be referred to its Professional Conduct Committee. The Society provided an example of compliance with a deadline set. 

11.11 The Authority noted the benefits of informal resolution, but considered that information provided by the Society, such as its ‘Expressing Concerns, Resolving Complaints’, related to formal handling of complaints. The Authority issued a Recommendation for the Society to consider publishing information about the approach it will take to informal resolution, the types of concerns that may be eligible, and how it will escalate concerns that are not resolved. (Recommendation 8)

There is a concern that some members when faced with the possibility of investigation and disciplinary action will leave the SoH rather than take the "last-chance" to comply. With formal complaints, even if the member resigns, the investigation will continue. 

Longer term
It has been said before on this blog that if the SoH can meet the Conditions, it will not be the end of the story.

The SoH may be trying to get better at anticipating risks rather than reacting to things once they've happened but it may have missed some obvious ones due to the mindset of the Board etc. Some behaviours among homeopaths are so deeply ingrained among homeopaths they do not recognise the problems with them. Things that would be totally unacceptable in other spheres. 

More negative media reporting would not help either. The GTS judicial review, whatever its outcome is likely to generate some. Perhaps the timing isn't as potentially damaging as it could be. The outcome of the judicial review may have some effect on the Accredited Registers scheme that goes beyond its possible implications for the SoH.

The PSA will be running a public consultation on the Standards for Accredited Registers in the near future. It is unlikely to result in major changes to the Standards. Legislation prevents consideration of efficacy but risk is another matter. There are some problems common to more than a few registers and at the very least the PSA will probably issue more detailed guidance on what is required to meet certain of the Standards. Any changes to the Standards are likely to make them more difficult for certain Registers to meet. 

In responding to Stevens and Powis, the PSA veer away from directly addressing their concerns. It's a "wider policy debate". Is that going to happen? At some point there will have to be a review of whether the Accredited Registration scheme is delivering what it is supposed to but there is no sign of it happening soon.

By the time the SoH start thinking about applying for Accreditation again, things may have moved on considerably and it will need to ask itself whether potential costs outweigh the supposed benefits.