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The Society of Homeopaths (SoH) has withdrawn from the Professional Standards Authority (PSA) Accredited Registers (AR) scheme as discussed here.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 This was withdrawn just after the PSA accredited the SoH with strict Conditions in February the following year.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.