Broken promises

The Society of Homeopaths (SoH) has withdrawn from the Professional Standards Authority (PSA) Accredited Registers (AR) scheme as discussed here.

The Problem

When the SoH withdrew from the Accreditation scheme it said among other things -

Public protection, patient safety and patient choice are paramount and built into all the Society’s processes and governance. Accountability is ensured through a balance of representation by practitioners and independent members on the Board as well as on the Society’s professional standards and education committees.

Given the history of the SoH and the various reports from the PSA this is difficult to believe. To an outsider it looks as if the SoH doesn't really understand public protection and has always put member interests first. Yes, the SoH has at times made efforts to comply with Conditions aimed at public protection but...

It's very likely that the changes the PSA imposed on the SoH will be undone. Probably quietly and it will try to keep up a facade but it seems almost inevitable that the SoH will fully revert to not giving a shit about public protection. It's probably has been in the process of doing so for quite some time.

PSA bad decisions

Arguably, the PSA should never have accredited the SoH in the first place but 2014 is a long time ago. 

The PSA should never have renewed Accreditation without Conditions in April 2019. This caused the Good Thinking Society to apply for a Judicial Review. This was withdrawn just after the PSA accredited the SoH with strict Conditions in February the following year. At the time, it looked like the SoH might have tried to meet them but things went sour very quickly.

There is an argument that the PSA should have removed the SoH's Accreditation rather than just suspending it. The suspension report was very clear that the SoH did meet not just Conditions but also many of the then current Standards. Removal of Accreditation would have been reasonable given that it was clear that the SoH could not or would not meet the Conditions and the Standards.

There is also an argument that the PSA should have removed Accreditation post suspension for the same reasons as above, and more so as time progressed. 

Accreditation Report Conditions

In February 2020, the PSA imposed the following Conditions.

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

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

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)

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.

In theory, the SoH managed to do a & b. a was in practice modified so that advice on diet, provision of supplements was permitted to a degree. It was struggling with c. The SoH had indicated its intention to renew accreditation but suspension stopped that process. The SoH made statement at the time of suspension which includes -

Since July 2020 the Society has been working towards meeting a number of conditions laid down by the Authority following an In-Year review of its accreditation. Evidence of compliance with some of the conditions was due in February 2021 but as a result of an interim internal panel review of the Society’s progress on those due in October 2020, the PSA decided its accreditation should be suspended. The Society is disappointed it was not given the full term to February 2021 to meet the conditions as it was confident it could do so and frustrated that the Authority’s panel and report made no allowance for the additional and incredibly challenging circumstances that Covid-19 presented at the same time as dealing with the new conditions. The Society has now been given a 12-month window in which to meet the PSA requirements and have its accreditation reinstated.

The in-year review added more Conditions, it did not remove pre-existing Conditions. Monitoring of SoH members websites (and social media - see below) suggests that there was no way that the SoH were going to meet Condition c. by February.

As regards to Condition d. writing guidance etc isn't exactly hard. The PSA were not asking them to enforce a new policy on adjunctive therapies straight away, they were asking the SoH how they would ensure compliance. The guidance etc must have been nearly ready in January 2021 if not completed when the PSA suspended Accreditation.

The SoH did not issue the Guidance in February 2021. One thing the guidance should have done is prohibit members from offering Homeopathic Detox Therapy, which is essentially a variation of CEASE therapy. The use of adjunctive therapies seems quite common.

In Year Review Conditions

Several months after the SoH managed to retain Accreditation back at the beginning of 2020, things started to go badly wrong for the SoH. They appointed Sue Pilkington as Professional Standards and Safeguarding Lead. Pilkington, judging by some of her (now deleted) social media posts was not only anti-vaccination but promoted thermography for breast cancer screening. The media got hold of the story (paywall but free registration allows reading of a limited number of articles per week) and also the PSA were so concerned by Pilkington's appointment they staged an in year review.

The in year review (published ) resulted in additional conditions -  

1. The Society must ensure that its recruitment processes include appropriate due diligence checks to assure itself that applicants are, and have been, in compliance with the Society’s Code of Ethics and position statements, including those relating to the use of social media. This should apply to all paid and voluntary positions within the Society including Board and staff members. The Society should also ensure that it has processes in place to assure itself that officials of the Society remain in compliance after appointment. The Society must report to the Authority on the steps it has taken to comply with this condition within three months of the date of this letter.

2. The Society must provide the Authority with its policy for the escalation of complaints against registrants, which are initially handled informally, into its formal processes and its procedures for handling persistent complainants. The Society must also provide a summary of complaints received since the publication of its new position statement on 10 June 2020 (including those handled through an informal route) and outcomes to the Authority. This should be completed within three months of the date of this letter.

3. The Society must: 

a) monitor its registrants’ use of social media to ensure that they are complying with its position statements. The Society should provide quarterly reports to the Authority. 

b) review, and if necessary, update its social media policy for registrants, ensuring consistency of guidance to registrants on the content of their own websites, and their statements and actions on others’ websites and other social media. This should be completed within six months of the date of this letter.

The suspension report makes it clear that although the SoH did attempt to meet these Conditions, it fell far short of the mark.

Suspension

In addition to the pre-existing Conditions, the suspension report imposed even more Conditions on the SoH if it wished to regain Accreditation.

1. Demonstrate that it has sought as far as reasonably possible to ensure compliance of its registrants with its Code of Ethics (including Advertising Standards Authority (ASA) requirements), and position statements over a period of at least six months. As part of this the SoH must demonstrate that it has taken action to identify and address instances of non-compliance, to the satisfaction of the Authority. 

2. Ensure that it has appropriate separation in place between its functions of protecting the public and supporting professional interests. A clearer focus on public protection must be reflected and applied through its key functions, including: 

a. Governance 

b. Setting of standards 

c. Complaints handling 

d. Provision of information by the SoH to the public. 

3. Demonstrate through these arrangements and its decisions that it has a clear focus on public protection when considering matters related to the practice of homeopathy by its registrants. 

There's no obvious evidence that the SoH made any progress on any of these Conditions. If anything, from some of the things the SoH said, it looks as if everything came to a grinding halt whilst the SoH decided what to do.

The suspension report additionally said -

Whilst we would expect the SoH to consider the points raised in this and earlier reports to satisfy these requirements, it should not limit itself to these. Fully addressing the points above will require the SoH to reflect on how it can demonstrate a focus on public protection, as required to meet the Standards for Accredited Registers and in doing so it might identify further actions.

That's a big ask.

The suspension report also details the failure to meet the previous Standards. It is discussed in greater depth here.

Disciplinary Action and Resignation

The primary purpose of disciplinary action is not punishment but to protect the public. This is true for both ARs and statutory regulators (SRs) like the General Medical Council and Nursing and Midwifery Council. However, there are some critical differences between ARs and SRs.

Being struck off by an SR is essentially the end of a registrant's career (and in rare cases, loss of all or part of  their NHS pension). Not so in the case of an AR although they will be prohibited from joining another AR. If the SoH struck off a member, there isn't necessarily any obstacle to them joining an non-AR association. However, it does send the message that the member is deficient in their practice etc. 

In some cases, an SR may consider that a registrant voluntarily relinquishing their registration (thus ending their career) is sufficient protection. SR disciplinary processes are expensive. However, in serious cases the SR will not allow this.

ARs can't prevent registrants from resigning (and continue practising) but they can still procede with disciplinary processes. The primary value of this is to flag to the public questionable registrants.

In cases where a registrant has been convicted of a criminal offence, striking off can be a foregone conclusion. Depending of the nature of the offence, both ARs and SRs may suspend registration as soon as the details of the matter come to light but they tend to wait for the outcome of procedings before their final decision.

Not all unethical acts are necessarily illegal. Even if some illegality is involved the Crown Prosecution Service may decide not to prosecute.

Because of the SoH's lack of transparency, it is not known beyond a single case, if the SoH initiated disciplinary proceedings against any of his less than non-compliant members. It said that it would do this. From the Accreditation report -

The Authority noted (as stated above) that registrants who disagreed with the Society’s position had resigned their registration. Registrants who remained on the register but did not comply with the Society’s position and standards would be subject to its professional conduct procedures. The Society confirmed that registrants who had been identified as CEASE practitioners had been prioritised within its audit schedule. The Society confirmed it would re-review websites of those who had previously been required to make changes, to assure their compliance.

There are plenty of examples of problem websites and social media accounts. Both the SoH and PSA have been supplied with lists of them at various points. The SoH could have ended up initiating disciplinary proceeding against a large number of members and even having to expel the worst offenders. 

It is also known that formal complaints were made and concerns raised about certain members and not all of these were about advertising. Some were about unsafe practice, behaviour well outside scope of practice and dishonesty. These are serious issues.

Some of those who have left the SoH are highly problematic. It is unknown whether disciplinary proceedings were started against any of them or even threatened. In some cases, it could be argued that pursuing disciplinary action would be in the public interest.

End of Story?

Should the withdrawal of the SoH be the end of the story as far as the PSA are concerned? 

The PSA certainly will have to have dealings with the SoH and individual members over the continued use of the PSA Accredited Registers logo etc inspite of the prohibition on its use. But there is something else.

It's clear that some SoH members undermine public health and not just because of anti-vaccination. An organisation that tolerates this undermines public health by inaction. The SoH is big on inaction.

When an AR withdraws from the Scheme, the PSA does not produce a final report. In the case of the SoH, if it had, it is unlikely that it would add very much over the suspension report. One of the things that some would like to know is whether the SoH took any positive measures to comply with Conditions. It has been suggested to the PSA that is in the public interest to know this. 

No oversight and legislation

One of the arguments that mostly homeopaths made when there were calls to remove the SoH's accreditation would lead to a lack of oversight. The PSA's role is not strictly one of oversight but rather quality assurance. These mostly homeopaths generally tried to pretend that widespread non-compliance with the SoH's positions, Code of Ethics, etc wasn't a problem and even that they said something other than was written. The latter could be due to SoH communications to members that downplayed public protection.

Whilst there is increasing take up of the AR scheme in certain sectors, such as psychological therapies, except for the International Federation of Aromatherapists, there have been no new applications from CAM organisation since the initial wave.

There is an argument that the accreditation/quality assurance model is a poor fit for many CAM organisations. It's not just the nature of the therapies and practitioners that are problems, the organisations themselves are often unequipped to act as a professional register. The new Standards are likely to bring this to a head.

It is clear that the majority of CAM practitioners do not belong to an AR and their organisations (if they belong to one) are not going to apply for AR status.

This blog has argued before that legislation is the best option for controlling the risks associated with CAM. The behaviour of some CAM practitioners regarding COVID-19 strengthens the argument. There has been discussion of legislation to control the spreading of health disinformation around COVID-19.

Society of Homeopaths surrender Accreditation

The Society of Homeopaths (SoH) recently announced that it has withdrawn for the Professional Standards Authority (PSA) Accredited Register (AR) scheme.

This is not unexpected. It taken quite a while though.

Slow process

As far back as 2018 (and possibly earlier), the SoH board were considering whether AR status was worth it as board minutes reveal. As this blog pointed out last year, withdrawal has increasingly looked the least worst option for the SoH going forward. That is even more true now given recent events such as the PSA suspending the SoH's accreditation (discussed here).

It's possible that the SoH board are just very slow at making decisions. Over the years, the SoH has become increasingly less transparent. It no longer makes board minutes public (and has hidden a lot of them that were public in the past). It hasn't made its annual report public for several years. However, the SoH did state at the time of suspension -

The Society and its members have been working hard and put tremendous effort into addressing the concerns of the Authority. We will take time to consider the full report carefully and in due course will be seeking clarification from the Authority on those parts of the report that are unclear, at odds with the Society’s own experience, or contain new guidance.

The SoH did contribute to the PSA consultation in February 2021. It is a somewhat odd document but the news item that mentions the contribution is dated 12/05/2021 and it says -

As a leading healthcare organisation representing professional homeopaths, the Society of Homeopaths contributed to the consultation process following 5 years accreditation of their register. The Society register is currently under suspension and the Board and a dedicated working group in consultation with members is undertaking an internal review of the PSA accreditation programme.

Four months after suspension, the SoH still hadn't made a decision but the consultation contribution states -

The Society held a member consultation on PSA Accreditation in 2020 to gain a greater understanding of members’ views and their experience of the impact of the programme. Narrative responses were offered to enable the Board of Directors and staff to gain a greater understanding of members’ views and their experience of PSA accreditation. To the quantitative question ‘how important do you think PSA (or external) accreditation is?’, members rated it most important for the future of professional homeopaths in the UK (3.5 out of 5), and that it had least impact on the public (3.1 out of 5) and patients (2.8 out of 5). This is an indication of the low public profile of the PSA, while showing, significantly, that most Society members consider PSA accreditation important for the future of the profession. 

The SoH also conducts member surveys, the results of which are generally not publicly available. It's unknown what kind of questions are, level of engagement etc are are. However, a now hidden student survey from 2019 has this -

Both paint a picture of both existing and student members placing value on accreditation.

Of course, suspension of accreditation changed things and the SoH may have thought it important to consult with members again. From experience in the real world, consultations can take a long time especially if communications are poor and engagement low. It can be necessary to improve and repeat the communications multiple times, extend deadlines in the hope of increased engagement. It can take a long time.

The SoH may have wanted to wait until the outcome of the strategic review of the AR scheme to make a decision. It is known that the PSA issued at least one draft of the new Standards. The SoH should have been aware of what the new Standards were going to look like, barring minor tweaks, before they made their announcement.

Why has the SoH withdrawn?

The SoH did make a statement but -

After a number of consultations with the Authority, it has become clear to the Society that the new fee structure for the Accredited Registers Programme disadvantages smaller organisations in favour of larger bodies, and the fee increase proposed by the Authority to the Society, aside from lacking clarity for the future, effectively prices us out of the scheme. Further changes to the Authority’s standards and criteria are also still to be confirmed. The Board has therefore made the decision to withdraw from the Authority’s voluntary accreditation scheme.

It is important to remember that the Department of Health and Social Care has stopped providing funding for the AR scheme. The intention was always been that the scheme would become self funding. Fee increases this year were inevitable.

What the SoH says doesn't make much sense.

The new fee structure impacts far more on larger registers. It doesn't take a mathematical genius to work out that the current £10,000 plus £5.70 per member (with a maximum cap of £60,000) is going to affect them more when the previous fees were  £10,414 base fee and a per registrant fee of £0.10. In fact, very small registers with 72 or fewer members would end up paying less.

The PSA always reserved the right to charge an AR for extra work that they might have to carry out - £650 per manday - but the guidance is much more explicit about when they might charge. It is unknown whether the PSA has ever charged the SoH additional fees. 

It's impossible to tell from published accounts how much attempting to meet the AR Standards and various Conditions has cost the SoH in the past. For some ARs, meeting the standards is relatively easy if somewhat onerous in terms of administrative overheads.

The SoH does have financial issues. Membership numbers are declining and so is the SoH's income. It was running at a loss for a few years although it managed a small surplus in the last reported year. It's not going to go bust in a hurry but most of its assets are tied up in an office building.

The appointment of new CEO Corine Stuart may be a signal that the SoH want to concentrate on membership numbers. Her SoH bio is very revealing but contain an odd statement -

They say that in the midst of difficulty lies opportunity, and with that being so, and with more and more of us looking for alternative, natural and gentler ways of healing the mind and body, Corinne believes the time is now for each of us to help usher in a new golden age for homeopathy.In many cases it is difficult to determine why individual members have left but it is known that some were upset by the increasing restrictions on what they could claim in their marketing. 

Her Linkedin profile makes for very interesting reading. 

Commercially astute strategic planner with a consistent track record of delivering outstanding results for membership organisations. Turnaround specialist with deep expertise in membership growth and customer loyalty • Able to identify new markets and secure profitable revenue streams • Excellent communicator with the ability to engage multiple stakeholders and raise the profile of an organisation • Track record of delivering value-led service improvements • Ability to inspire and influence diverse teams • Experienced in governance and performance reviews

Some of it management jargon, expertise in membership growth would be of interest to the SoH. The profile reveals Stuart worked for the Countryside Alliance. Many SoH members would have a problem with the Countrsyide Alliance's pro hunting stance.

SoH membership numbers have been in decline for quite a few years. Membership numbers do fluctuate doing the year but is probably around the 870 mark at the moment. 

The numbers of newly graduated homeopaths joining the SoH has declined. It's strongly suspected that the number of students studying homeopathy has dropped considerably but without actual data, this is difficult to prove. The above mentioned student survey suggests that in 2019, there were around 360 student members. Homeopathy courses run for up to five years. Data suggests that not all of these student members become full members but it is possible that some do not graduate or choose to practice. How many students members graduate but do not go onto full membership is impossible to determine.

The SoH has tried to recruit members who have not gone through SoH accredited courses. It's also tried to entice those that did but didn't join the SoH in. Likewise, it's tried to lure back members who have left. From what can be seen, it's not been very successful.

Members leave the SoH for all sorts of reasons. Whilst there is no available demographic data, it is suspected that retirement is a big reason. Some members may stop practicing for other reasons such getting a job, focussing on other therapies, having to be a full-time carer for a relative and so on.

Some leavers may continue to practice. Whilst it is true that some members left the SoH due to disatisfaction with increased restrictions on what they could do and what they could, there are other more mundane reasons.

SoH membership is expensive compared to that of other homeopathy associations. Likewise it is  expensive compared to other more general CAM associations that admit homeopaths. The SoH offering doesn't seem to offer any substantitive benefits over those of any other association. Maybe some members came to the realisation that membership was poor value for money.

It is difficult to guage what impact lockdown might have had on member incomes and possibly for some the current SoH fees have become too much to bear. 

Tougher Standards

Although a future post will look at the new Standards, Guidance and Evidence Framework, in greater detail, the new Standards introduced a "public interest test". 

We will decide whether it is likely to be in the best interests of patients, service users and the public to accredit a register, with consideration of the types of activities practised by its registrants. This will include, but not be limited to, consideration of the following:

• Evidence that the activities carried out by registrants are likely to be beneficial.
• Evidence that any harms or risks likely to arise from the activities are justifiable and appropriately mitigated by the register’s requirements for registration.
• Commitment to ensuring that the treatments and services are offered in a way that does not make unproven claims or in any other way mislead the public.

To meet Standard One, we will need to be assured that any harms or risks likely to arise from the activities can be mitigated by the register’s requirements for registrants, and that they do not outweigh the likely benefits to patients, service users and the public. If Standard One is met, then these mitigations will be further tested during assessment of Standards Two to Eight before accreditation is granted. For more information, see Supplementary guidance – Standard One. 

The supplementary guidance for Standard One makes for very interesting reading.

It's probably more of a "public protection" test than a public interest one. 

Reaction

The mainstream media in the UK are largely pre-occupied with the COVID pandemic. The suspension of accreditation saw almost no coverage but the withdrawal has -

• Has homeopathy lost its last strand of credibility? (Daily Telegraph, 17/08/2021)
• Victory for campaigners as homeopaths quit healthcare watchdog (Times, 16/08/2021)
• The Times view on the Society of Homeopaths withdrawing from the watchdog’s list of healthcare providers: Beyond the Fringe (Times, 16/08/2021)

Unfortunately, these are all behind a paywall but you can register for free to read a limited number of articles per week. 

As per usual, the media don't always get the details exactly right. The timing of events, cause and effect and so on. They don't explain how important the changes to the Standards are and their broader implications but that can be the nature of newspaper articles. It is also worth noting these articles were published several weeks after the SoH's announcement of withdrawal on 23/07/2021.

In some ways the SoH should count itself lucky that there hasn't been more media interest. Things could have been a lot worse. Because of timings, if the SoH had not withdrawn, the PSA could have started the process to expel the SoH. Expulsion would have attracted a lot more media interest. 

Specialist media did not seem to pay any attention to the SoH withdrawal and more surprisingly to the new Standards.

The Good Thinking Society (GTS) made an announcement which as you might expect is a lot more nuanced that mainstream media reporting and recognises the importance of the new Standards. The timeline in that announcement is specially useful in understanding how events played out even if can be argued that the chain of events started much earlier.

GTS project director Micheal Marshall popped up on various podcasts - 

• Skeptics with a K: Episode #309 (19/08/2021)
• The Skeptic Zone #670 (08/08/2021)

Marshall also wrote a piece for The Skeptic that discusses the SoH's withdrawal among other regulatory issues. It also mentions this blog. 

There has been very little in the way of public reaction by members or their supporters. It's possible that there has been been some sort of instruction by members not too. It's possible that members and supporters have moved towards discussing issues in non-public forums, Facebook groups, etc. Or maybe the members simply don't care? Em Colley isn't a member of the SoH, rather the Alliance of Registered Homeopaths. Her blogposts (here and here) certainly suggests she does not understand accreditation. This isn't unusual. Many SoH members don't.

There is another story that could also be told.

Victory?

Is the withdrawal of the SoH from the PSA AR scheme a victory? If so, who for?

Assuming that the SoH withdrew because they knew they could never meet the new Standards, then any "victory" is more about the creation of the new Standards. Different stakeholders had different priorities for what they wanted from the review of the AR scheme but for some stakeholders, the introduction of the public interest test is is a win. SoH withdrawal is collateral damage. The new Standards weren't created to specifically penalise the SoH, although their antics may well have informed some of the thinking behind the public interest test and certainly were picked up on in some submissions to the PSA's consultation on Standards etc.

However,  withdrawal means that the SoH doesn't have to undergo radical (and expensive) change to meet Standards. It also means that it can ignore certain problems with certain members. Problems like militant anti-vaccination members and those spreading misinformation regarding COVID. Not that it wanted to deal with them in the past.

It is withdrawal a victory for the extremists? Impossible to certain. It's easy to identify very vocal SoH members with strong opinions, some of those opinions are widely held by SoH members even if not as strongly expressed or even openly. 

Impacts

In the short term, for the SoH, individual members and their existing clients, there will be little to no immediate impact. If there were any possible major non-media generated impacts, they would have happened after suspension of accreditation. From observation, there did not seem to be any but this is very likely due to accreditation not delivering any real benefits to the SoH or its members.

Suspension required SoH members to remove the PSA AR logo (and by extension claims to be part of an AR) from marketing. There are still a number of non-compliant members. Withdrawal and the announcement of the new Standards may make this more of a pressing issue. Ultimately, the PSA could mount legal action against those non-compliant members.

There is the question of whether negative media reporting has any impact on public perceptions of homeopathy. Difficult to say. It isn't going to have any effect on entrenched opinions. 

In the medium to longer term, the SoH's primary concern is going to be membership numbers, both increasing the number of graduating students and increasing retention. It isn't clear what impact withdrawal will have on this.

There is an alternative AR that homeopaths can join if they feel accreditation is important - the Federation of Holistic Therapists (FHT). The FHT is very different to the SoH in how it is set up and operates - full discussion is beyond the scope of this post - but crucially membership is a lot cheaper. There are already some SoH members who are also FHT members but they joined before suspension.  Whether the FHT can maintain AR status under the new Standards is another matter.

It's also possible that the Complementary and Natural Healthcare Council (CNHC) could open registration to homeopaths. The reasons why they don't register them are historical and no longer apply. As with the FHT, its unclear whether they will retain accreditation.

Withdrawal may stop certain members from leaving, attract back those some of those who left the SoH because of dislike of increased restrictions on marketing and practice. The SoH were never very good at enforcing those restrictions but on the face of it, they still exist. Whilst they may stop enforcing them entirely, it may well be that only removal of the restrictions is enough for some.

Removing those restrictions could result in very negative media coverage. It is easy to imagine stories along the lines of the SoH effectively admitting that anti-vaccination is OK by them. If not enforcing the restrictions results in anti-vaccination claims increasingly creeping back on member websites, social media etc, the same kind of risk exists.

Some SoH members may well be in favour of the SoH taking an openly anti-vaccination stance, like back in the good old days when they joined etc, doing so would be magnitudes worse than the impacts of removing restrictions.

But what about the SoH as an organisation, particularly its leadership? The Board's homeopath element (six out of nine directors) has been pretty static for some time (see Companies House data). That's unlikely to change. For one thing, directors who do wrong things don't resign. 

The Board is largely responsible for the difficulties the SoH has faced over the last 4 years. Of course, wilfully non-compliant members played a part but that the SoH failed to deal with them is a failure of leadership. It placed member interests before public protection. In hindsight, the decision to apply for AR status was a huge mistake. The SoH were told years before that by the then Department of Health that anti-vaccination was a problem.

Public criticism of the SoH by members is virtually non-existent. Because the SoH has become less transparent, it's unknown if members bring up issues in Annual General Meetings etc. It seems very unlikely that the SoH will be held to account by its members. Most of them probably don't care, some will think the SoH and its Board haven't done anything wrong. If the example of some extreme anti-vaccination members is anything to go by, those with strong opinions will simply leave.