Thursday, 25 June 2020

Society of Homeopaths - update on Accreditation with Conditions

The situation with the Society of Homeopaths (SoH) and their Accreditation by the Professional Standards Authority (PSA) is somewhat unclear. That Accreditation had a Condition placed on it and there was a three month deadline for parts of that Condition to be met.

Condition
The following Condition of Accreditation was issued to be implemented by the timeframe as specified, or by the following annual review of accreditation:  
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)
Slightly later that might have been expected, the PSA made an anouncement.  
The Authority renewed accreditation for the Society of Homeopaths in February 2020, with conditions attached. Two of the conditions were required to have been met by May 2020. 
These conditions have been met. For more information, please refer to the panel decision and to the Society’s website.
So parts a) and b) have been satisfied? 

Position Statement
It is relatively short so is reproduced in full.
The Society of Homeopaths is committed to choice in healthcare, enabling the public to make informed decisions to achieve and maintain good health. Our registered homeopaths work holistically, offering support to each individual, guided by their specific symptom picture. 
As Homeopaths do not claim prevention or complete cure of any named disease, the Society does not permit RSHoms to practise or promote protocols such as CEASE therapy which are dedicated to specific named conditions. 
The Society expects professionalism in every aspect of homeopathy practice with clarity for the public regarding the expertise of its registered homeopaths. RSHoms will expect patients to maintain a relationship with their GP and other healthcare professionals involved in their care. 
Our Registered Homeopaths will work within their individual Scope of Practice and act appropriately as healthcare professionals in all aspects of their work, adhering to the Society’s Code of Ethics and Scope of Practice. This applies within the consultation as well as professional communications. 
RSHoms may only claim expertise in a specialist area or offer an adjunctive therapy if they can provide evidence that they are suitably qualified and insured to do so. RSHoms may give general health advice, such as for nutritional supplements, providing the advice complies with relevant official guidelines.
Members with qualifications in additional therapies will ensure that the patient is always informed about the treatment modality being offered and consent has been obtained. 
The Society does not permit RSHoms to offer homeoprophylaxis, provide advice on, or participate in a patient’s decisions regarding vaccination. RSHoms should direct patients to their GP or public health departments.
Advice for the Public on vaccination 
Homeopaths are not able to offer advice on vaccination. 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. 
May 2020
So, yes, it has made public the prohibition on CEASE therapy but it was prohibited because the PSA would not have accredited the SoH if members were permitted to carry on offering it than because of claims of cure or prevention. If the PSA had, the Good Thinking Society would have carried on with their Judicial Review which they would have won. It would be a blatent breach of its Public Sector Equality Duty.  

The wording of the prohibition "practice or promote protocols... ...which are dedicated to specific named conditions" is odd. This is different from "must not practise or advertise adjunctive therapies that are incompatible with Society registration". So any distinct protocol for a named condition is prohibited but others are not?

Consider the case of Homeopathic Detox Therapy (HDT) which is basically the same thing as CEASE therapy and the Accreditation report makes note of this. This interview with its supposed inventor Ton Jansen reveals that much broader claims are made than just "vaccines cause autism" and homeopathic remedies made from vaccines can "cure" autism. To quote -
Well, there are many cases I have successfully cured, including children with diabetes and autism, cancer patients, Crohn disease, glaucoma, multiple sclerosis, etc. As I mentioned, when you know what to do, there are no incurable diseases. My experience is that well indicated homeopathic remedies work well, but not long lasting. After a proper course of HDT they work perfectly. So I am very happy that I discovered this workaround path.
Some SoH members who formerly openly offered CEASE therapy now offer HDT instead. Question is whether HDT is also prohibited by the SoH? If it isn't, what is the reasoning for this given that CEASE therapy is? The risks are very much the same.

What happened to the prohibition on dietary/nutritional supplements? Rather than a prohibition, the SoH indicate that as long as "relevant official guidelines" are stuck to, there isn't a problem. That the PSA say part a) of the Condition has been met suggests that some sort of discussion went on. This blog has always maintained that the big problem with CEASE therapy is that it advocates neglect of autistic children. Media reporting has had a stronger focus on the high doses of vitamins and minerals. Looking back at what both the SoH and PSA have said over time, they have responded more to that than the issue of neglect. It's something tangible. The Position Statement effectively prohibits doses higher than recommended daily intake. So no more advising vitamin c megadoses and so on. A total prohibition would be difficult and would not make much sense (although there are questions about multi-level marketing and commission-based sales made by some members).

Part a) is probably satisified but the wording is clumsy, likely subject to misintrepration by members and may have some unintended conseqences. HDT is a problem though and it possible that more prohibited therapies will emerge over time.

The SoH did manage to make it clear that homeoprophylaxis and offering "advice" on vaccination is prohibited. But there is still plenty of directing the public to sources of misinformation on vaccination on members' own websites, let alone social media.

Part b) again, is probably satisfied. Member compliance is not part of part b).

The SoH probably do not understand the consequences of some of the other things that the Position Statement says. "General health advice" is, well, very general. "Relevant official guidelines" means what exactly? This could be read as prohibiting members from making any health related statement that contradicts NHS guidance. One practical implication is that it prohibits conspiracy theory type misinformation from members' websites.

"Specialist area" is a difficulty as well, particularly determining what is a "suitable qualification". The SoH is only concerned about the courses (and their providers) that allow entry to membership. It doesn't recognise any other courses. The general effect of this is that members can not refer to themselves as "specialists" or having "specialisms". Over time the use of the phrase "special interest in" has become more prevalent. It is likely that "expert" is also a problem.

The issue of recognition of courses is also an issue for "adjunctive therapies". Part d) has a deadline that for practical purposes is end of 2020 - beginning of 2021.

The unclear wording of the Position Statement has implications for Part c) that will play out over time.


Scope of Practice
The Position Statement links to a Scope of Practice document. The Accreditation report says re part d) of the Condition -
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)
The Scope of Practice document is dated February 2020 (and apparently formulated by September 2019) and there were some communications but whether or not all members would have read it is another batter. The delay between its communication to members and communication to the public should have give members sufficient time to comply with it.

It doesn't start very well. 
This statement paper aims to define the Scope of Practice for homeopaths registered with the Society by setting out:  
§ General parameters applicable to all registered members.§ An outline for each member to develop their individual Scope of Practice. 
It has been compiled through a process of collaboration between a working group consisting of the Society’s Professional Standards Manager, two Directors and four registered members and incorporating feedback from the Society’s Board and Professional Standards Committee.
To be blunt, it fails to define much at all. Possibly earlier drafts did, otherwise it looks as if the SoH put a lot of effort into creating very little. It might be the case that it was impossible to agree anything more clearly worded.

A point-by-point dissection of it would make for tedious reading but one strong criticism is that the Position Statement clearly places restrictions on practice (even if they are unclear, certainly don't go far enough and there are probably more to come) but the Scope of Practice makes no mention of those restrictions. There is a clear arc of increasing restrictions on practice over time as the SoH is forced to react to external forces judging that some members' practices are way outside of any putative Scope of Practice or any notion of the limits of competence.

Of course, there is something to be said for maintaining a list of therapies that are incompatible with Society registration separate to but referenced by the Scope of Practice. Same could be be said for qualifications for adjunctive therapies deemed acceptable by the SoH. There would be no need to update the Scope of Practice document itself every five minutes.

Professionalism and prescription
The Reluctant Profession - Homoeopathy and the search for legitimacy (Cant and Sharma, 1995) is a fascinating paper but is behind a paywall. The abstract says -
This paper examines a group of lay homoeopaths, represented by the Society of Homoeopathy, and traces the changes that have been made to their organisation, training and knowledge as they attempt to enhance their legitimacy in the eyes of the public, government and orthodox medical profession. The group has acquired a number of `professional' properties, but in so doing have reduced levels of freedom, marginalised factions within the group and failed to gain greater authority in the healthcare market. The homoeopaths themselves thus recognise that there are costs as well as benefits associated with their professional project and so they have undertaken many of the changes reluctantly.
More than 20 years later, the SoH are in roughly the same position.

The Scope of Practice document resembles to some extent Scope of Practice for regulated professions such as physiotherapy and occupational therapy. There are fundamental differences between these professions and homeopathy. Perhaps the most important is that they went through the professionalisation process a long time ago whereas lay homeopathy has at most taken a few tiny steps. Although private practice does exist, many physios and OTs are employed, their first roles are in the NHS and they may well benefit from structured development.

Many SoH members seem to have language comprehension problems. It is clear that some struggle with understanding the de facto limits of homeopathy and their own competence.

If the SoH wishes to retain SoH Accreditation and carry on down the road to greater professionalism, it will need to become more prescriptive. It is going to end up prohibiting members from more and more types of activity. It needs to consolidate Scope of Practice, not loosen it to the point of being meaningless.

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