NHS Homeopathy #3 - Analysis GP Prescribing data

A previous post discussed the now closed Items which should not be routinely prescribed in primary care: A Consultation on guidance for CCGs, the petition created by supporters of homeopathy and how wrong the supporters of homeopathy were about the Consultation.

It also discussed some of the workings of the NHS.

Decline in Prescribing
One thing that it very clear from even the most cursory analysis of NHS England GP prescribing data is that the prescribing of homeopathic medicines has declined enormously. This article from the Nightingale Collaboration clearly demonstrates this. There seem little point in duplicating its content - please do read it.

What the article does not explain is why there has been such a dramatic decline. Unfortunately, this is an impossible question to answer. It is possible to speculate on potential reasons and they fall into a number categories -

1. Decreased Patient Demand - It has been suggested that to some degree prescribing of homeopathic medicines is patient driven ie patients specifically ask for them. The numbers of patients asking could have declined. This could be due to demographic change or it could be due to changes in public attitudes. Although there seems to have been a drop in the number of lay homeopaths in recent years, this is not a good proxy for patient demand for homeopathy.
2. Typical GP Behaviour - There's an acronym that used to appear on GP notes - TEETH - "tried everything else, try homeopathy". How widespread this attitude was in the past is unclear. Typical GP attitudes may have changed. The prescribing of placebo is seen by some as unethical. In recent years opponents of homeopathy within the medical profession have become increasingly vocal. As discussed in the previous post, CCGs have increasingly recommended not prescribing homeopathic medicines but it is difficult to guage what impact this has had directly - also the decline started way before the re-organisation that created CCGs. It is know that there were locally argeed forumlaries in some areas prior to this but they are difficult to get hold of.
3. True Believers - GPs who are enthusiasts for homeopathy are not exactly common. Various numbers have been suggested for the number of GPs with "training" in homeopathy but it is impossible to determine how many. It may well be the case that there are fewer of them now. If the historical high levels were associated mainly with prescribing by "true believers", as they leave the NHS GP practice (retire or move into private practice) and fewer younger GPs are becoming "true believers", this could well account for the decline in prescribing. It is worth pointing out that no NHS GP could get away with 100% prescribing of homeopathic medicines. That's only possible in the private sector and even it would carry considerable risks. Although CCGs have no power to prevent such a thing, peer pressure and patient disatisfaction would make it impossible. Even "true believers" may have changed their behaviour as a result.
4. Economics - As mentioned in the previous post, it makes economic sense for many patients and NHS England that GPs suggest to patients which homeopathic medicine to buy themselves rather than write a prescription. Changes in prescription charges vs cost of homeopathic medicines could drive GPs to increasing to suggest rather that prescribe. It is also the case that GP perception of increased financial pressures on NHS England could drive such a change. If this were the case the ratio of prescriptions for patients exempt from charges should have changed over time,

Even if were possible to obtain data to confirm or refute these speculations, it would not be an easy or cheap process. Given that the cost of GP prescribing of homeopathic medicines is so small and still seems to be decline there seems little point in doing so. It could cost NHS England more to do the analysis that the actual cost of the products!

Demographic Analysis

Along side the Items which should not be routinely prescribed in primary care: A Consultation on guidance for CCGs, NHS England also published an equality analysis. Much of it is irrelevant to homeopathic medicines but contains some key demographic details.

In 2016, there were 1541 (63.2%) prescriptions dispensed to female patients and 889 (36.8%) to male patients. It is not number of unique patients, so it is not possible to derive an average number of prescriptions, prescription items or cost per patient. That would have provided an insight into the type of conditions (acute vs chronic) being prescribed for.

In terms of age bands - 

Age Band	Number of Prescriptions	Percentage of Total
Under 18	359	14.71%
18 to 30	273	11.19%
31 to 44	386	15.82%
45 to 64	635	26.02%
65 and over	787	32.25%
Total	2440

It is worth noting that those under 16, between 16 and 18 in full time education and those over 60 are automatically exempt from prescription charges.

It would be useful to have had this information over time but...

In depth (but quick and dirty) GP Prescribing data Analysis
It is possible to download NHS England GP prescribing data. Data is released on a monthly basis. Unfortunately, the files generated are very law. Typically, they contain 4 million rows of data. It would a mammoth task to download the available historical data and the data would have to imported into a proper database. This would be beyond the casual user.

Fortunately, the OpenPrescribing initiative has done that hard work all ready. It provides a simple to use tool to explore the data in a number of ways. It can drill down from CCG level to GP practice level. Also, it's possible to download the data to to manipulate in ways that they tool can't do, although it is tricky to deal with. This has been done. The resulting analysis is very interesting and seems to disprove some of the contentions of UK homeopathy groups as well as misreporting by the media.

As OpenPrescribing plan to publish a more academic analysis, this analysis will be somewhat cursory.

Some of the terms used require some explanation. Prescription is obvious. Items is the effectively the number of medicines ordered on a prescription. It is surprising that more than one homeopathic medicine is sometimes prescribed - this goes against the tenets of classical homeopathy. Actual cost is the cost to NHS England to re-imburse community pharmacies for the cost of medicines. It does not include the £1.25 per item dispensing fee or the potential £20 "specials" fee. It's not possible to determine the value of these fees but they could be considerable. 

Looking at CCG level, for the period 2012-07 to 2016-06 (neatly 5 years), those CCGs with more than 1% of the total spend are -

Total Result	£556,994.37	Percentage
NHS BRISTOL CCG	£93,603.72	16.81%
NHS GLOUCESTERSHIRE CCG	£58,854.62	10.57%
NHS WEST KENT CCG	£44,747.14	8.03%
NHS LIVERPOOL CCG	£34,222.06	6.14%
NHS HIGH WEALD LEWES HAVENS CCG	£33,764.88	6.06%
NHS HERTS VALLEYS CCG	£14,570.72	2.62%
NHS NORTHERN, EASTERN AND WESTERN DEVON CCG	£12,801.84	2.30%
NHS SHEFFIELD CCG	£10,649.43	1.91%
NHS DORSET CCG	£10,269.83	1.84%
NHS SOMERSET CCG	£9,846.58	1.77%
NHS SOUTH WORCESTERSHIRE CCG	£9,681.01	1.74%
NHS HARINGEY CCG	£8,896.19	1.60%
NHS CANTERBURY AND COASTAL CCG	£7,460.52	1.34%
NHS LEWISHAM CCG	£7,455.12	1.34%
NHS KERNOW CCG	£6,773.46	1.22%
NHS WILTSHIRE CCG	£6,618.03	1.19%
NHS SHROPSHIRE CCG	£6,457.52	1.16%

The OpenPrescribing tool did not like all of those CCGs selected - CCGs up to Lewisham were input. Unfortunately, when drilling down to Practice level, OpenPrescribing data downloads do not provide CCG. Not that this matters.

Below is a list of those Practices within the selected list of CCGs. Only those with spend over £3k in the period are are shown.

HELIOS MEDICAL CENTRE	£66,513.14
ST.LUKE'S MEDICAL CENTRE	£47,630.25
BELMONT SURGERY	£30,750.81
BLACKTHORN	£30,653.53
ISLINGTON HOUSE MEDICAL CENTRE	£19,331.93
BEDMINSTER FAMILY PRACTICE	£12,799.56
THE JENNER PRACTICE	£6,327.80
THE VILLAGE MEDICAL CTRE	£6,069.44
TENBURY SURGERY	£5,895.32
MARKYATE SURGERY	£5,646.89
SOUTHMEAD & HENBURY FAMILY PRACTICE	£5,336.61
RICHMOND MEDICAL CENTRE	£5,189.62
FRIARY HOUSE SURGERY	£4,909.97
BRIDGE HOUSE MEDICAL PRACTICE	£4,519.90
KINGS LANGLEY SURGERY	£4,186.88
OLD SCHOOL SURGERY	£4,137.42
DOVERCOURT GROUP PRACTICE	£3,711.17
DR M FLYNN'S PRACTICE	£3,536.52
CHARTHAM SURGERY	£3,155.67

Helios Medical Centre makes up for 12% of total spend in the period, which is extraordinary. It falls under Bristol CCG whose local formulary does not include homeopathic medicines. Bristol CCG will be well aware of the prescribing via reporting. Although the data does not drill down to which GP is prescribing, the staff list suggests that Dr Frank Mulder and Dr Joan Platford could be responsible for the majority of the prescriptions. Both have links to Anthrosophy and anthroposophic medicine. There would appear to be no or little change in the value of prescriptions over time.

St. Luke's Medical Centre no longer exists. It was forced to close due inability to recruit staff. It closed back in July 2015. If it had not, its spend would have easily exceeded Helios. Although it did close, it re-opened in another guise St. Lukes Therapy Centre. Stroud is a hotbed of Anthroposophy and so is the Centre. Whilst it is true that many practices are having difficulties recruiting GPs, there is a question of whether GPs would be comfortable working with anthroposophic enthusiasts.

The Belmont Surgery is now Wadhurst Medical Group. Its staff list turns up Dr. Andrew Sikorski. Sikorsi's LinkedIn profile shows him to be an integrative medical consultant. He is a GP, not a Consultant according to the GMC register. Skorski's "treatments" include Psionic Therapy whatever that is. Sikorski is quite well known for his pro-homeopathy comments in various places on the internet. The value of prescriptions for homeopathic medicines has fallen over time though. Back in 2012 andd 2013, values of over £1,000 per month were routinely seen. In 2017, £100 would be more typical. The reasons for the decline are unclear.

The Blackthorn Medical Centre has links to the Blackthorn Trust which offers anthroposophic medicine. This page on the practice website states that the Trust certainly was funded by the NHS at one point. Whether this is still the case is another matter. The staff list when compared to this newletter from the Blackthorn Trust suggests that both Dr Martin Gerhards and Dr Saskia Renkema are involved in anthroposophic medicine. The newsletter also sheds some light on prior funding of the Blackthorn Trust by the NHS. Similar to the Wadhurst Medical Group, there seems to have been a decline the value of prescriptions. 

Islington House Medical Centre is in Liverpool.It is unusual in that it was set up in 1937 and would appear to have been in the hands of the same family since then. The prescribing patterns seem very strange. Back in 2012 and 2013, typical prescribing value was roughly £180. This has declined In 2017, there were months when there was no prescribing of homeopathic medicines. But then there are these outliers -

date	name	items	actual_cost	Average item
2016-05-01	ISLINGTON HOUSE MEDICAL CENTRE	17	2821.52	165.97
2016-06-01	ISLINGTON HOUSE MEDICAL CENTRE	12	3003.42	250.29
2016-09-01	ISLINGTON HOUSE MEDICAL CENTRE	4	2709.86	677.47
2016-12-01	ISLINGTON HOUSE MEDICAL CENTRE	4	2709.74	677.44

There is no immediate explanation for this. There is no known homeopathic medicine that costs £165 a go, let alone £677. Miscoding could be one explanation. Liverpool CCG will be approached to see if they can shed any light on this.

Bedminster Family Practice used to list homeopathy as one of the services provided. Dr Nick Wilson ran a clinic according to older documents. However, it is no longer listed on their Clinics and Services page. The prescribing history is similar to Islingthon House in that spend was generally a low, showing decline but certain months were outliers, but more so.

date	name	items	actual_cost	Average item
2015-08-01	BEDMINSTER FAMILY PRACTICE	4	1,120.94	280.24
2016-01-01	BEDMINSTER FAMILY PRACTICE	6	1,591.95	265.33
2016-03-01	BEDMINSTER FAMILY PRACTICE	2	543.50	271.75
2016-04-01	BEDMINSTER FAMILY PRACTICE	2	998.89	499.45
2016-08-01	BEDMINSTER FAMILY PRACTICE	2	566.70	283.35
2016-09-01	BEDMINSTER FAMILY PRACTICE	5	1,689.73	337.95
2017-01-01	BEDMINSTER FAMILY PRACTICE	4	1,949.37	487.34
2017-03-01	BEDMINSTER FAMILY PRACTICE	2	594.40	297.20
2017-04-01	BEDMINSTER FAMILY PRACTICE	2	1,090.08	545.04
2017-05-01	BEDMINSTER FAMILY PRACTICE	2	594.25	297.12
2017-09-01	BEDMINSTER FAMILY PRACTICE	3	1,852.42	617.47

Again, there are questions about the average value of the items prescribed. Bristol CCG will be contacted.


One GP practice of interest is not in this list. One of the partners at Plas Meddyg Surgery is Dr Ralf Schmalhorst is a member of the Council of the Faculty of Homeopathy. One of the reasons the practice is not on the list is that the spend is trivial. However this may be explained by Dr Schmalhorst offering homeopathy on a private basis.

Conclusions
It is very difficult to draw any firm conclusions from the data and investigations except that -

• GPs who are interested in Anthroposophical Medicine are amongst the highest prescribers of homeopathy
• There are some very strange high item value

Email from the BBC

A complaint was made to the BBC regarding BBC Radio Oxford's David Prever show as broadcast on 17 October 2017. The offending show is no longer available but basically the segment discussed homeopathy giving undue coverage to pro-homeopathy opinion resulting in false balance.

The BBC have recently been accused for false balance in giving too much prominence to the views of Lord Lawson on climate change.

Below is part of the response -

I was naturally sorry to hear you were unhappy with the programme segment and concerned to learn that you felt the item was troubling, so I've carefully reviewed the show in question and have also discussed all your concerns personally and at length with the radio station's Editor in Oxford, and other senior editorial personnel within BBC News. With your feedback in mind, we do feel that you have a point here in that whilst the programme's production team clearly attempted to ensure a balance by hearing from both sides, actually they hadn't fully understood the risk of potentially straying into the area of 'false balance' which you mention here. I would assure you, though, that the first guest did very clearly explain to listeners how the new website's data shows the extent to which a medical practice embraces the principles of evidence-based medicine, and he made very clear that there’s no evidence for the effectiveness of homeopathy as a medical treatment. 

The presenter then sought thoughts from listeners as to whether they had had any homeopathic treatments and if so whether they felt they had worked or not for them, after which we then heard from a second guest who also explained why homeopathy can’t work in that it's not evidence-based. Following this we heard from a third guest who talked about her own experiences and why she personally believes it can work, which in this context we acknowledge could have inadvertently suggested to listeners that there isn't a majority medical and scientific consensus on the matter. We of course regret this occurrence, and are very grateful indeed to you for bringing the issue to our attention with your detailed points. As a direct result of your feedback, the station's Editor has personally spoken to the entire team there to ensure that going forward there is a full and thorough understanding on the crucially important issue of 'false balance' for topics such as this and the pitfalls which can arise if not handled carefully, thus making sure that when subjects like this are covered the balance is appropriate and proportionate as you rightly say. This is clearly an important area, and I can assure you that this has been a very valuable learning experience for the team and I would like to again express my thanks to you for your very valuable feedback as this has allowed us to review the output, to reply to you with an explanation and an apology, and most importantly to take specific action as a direct result of your complaint to ensure this isn't repeated in the future if such matters are revisited. I do hope that you will agree from my reply here that this matter has been taken incredibly seriously by both my team and the senior management team at BBC Radio Oxford, and that you are assured that your points have been fully understood, discussed at the highest level, and immediately acted upon to address the issue and to prevent a recurrence.  

NHS Homeopathy #2 - More on GP Prescribing

A previous post discussed the NHS England Items which should not be routinely prescribed in primary care: A Consultation on guidance for CCGs. The intention was that this second post on NHS homeopathy would look at GP prescribing data in some detail in. However delays in obtaining the relevant data and certain events have conspired against this.

Some groups and individuals who support homeopathy have responded to the Government response to the petition started by Cristal Sumner CEO of the British Homeopathic Association (BHA). Also, the BHA have started a crowd funding campaign to apply for permission for a judicial review.

Responses to the Government Response
It would appear that the responses of the various UK homeopathy organisations are almost identical. This is not surprising as UK homeopathy tends to coordinate its PR somewhat better than it did in the past in the guise of a group known as 4Homeopathy. To quote from one post -

In essence, the government hasn’t replied to the evidence brought forward in favour of homeopathic and other complementary treatments. Their response blames the rising costs of all prescriptions, citing the need to cut medicines considered of low clinical value. Despite all evidence provided proving the benefits of homeopathy, the statement concludes that: 

“… We are not aware of any evidence that demonstrates the therapeutic effectiveness of homeopathic products.”

The problem here is that the evidence that homeopathy groups and individuals would have submitted would not prove homeopathy to have any benefit beyond placebo. Government, or more specifically the Department of Health, has replied. If UK homeopathy is expecting a point by point refutation of the "evidence" they supplied, it is deluded.

There were also bizarre reactions from the likes of Steve Scrutton but they are of no consequence beyond a possible comedic value.

Messages were also disseminated by 4Homeopathy et al to "keep up the pressure" on NHS England. To quote -

We all need to maintain the pressure during this critical time, to make decision-makers aware of the issues and inconsistencies which plague the consultation and its process. 

MPs need to be aware that NHS England is basing its decisions on a fundamentally flawed report which is not peer-reviewed evidence. Please write to your MP to make them aware of the issues and your concerns. To help create a letter we have provided some helpful information. Read through the points in our template letter, and please write in your own style to help ensure it is opened and read. 

Over 20,000 people have signed the parliamentary petition—Stop NHS England from removing herbal and homeopathic medicines—letting the government know that homeopathy should not have been part of the consultation. Keep sharing so we can have a stronger voice in representing patients and the public.

Although this does not mention it, there is an assumption that if the petition reaches 100,000 signatures, it will be debated in Parliament. The reality is that it may be debated. However, as discussed in the previous post, the petition is factually incorrect. A debate around a petition that states NHS England is attempting to ban GP prescribing herbal and homeopathic medicines when it doesn't have the powers to do so would not really be a debate.

And most recently, this -

The NHS is slowly dismantling our healthcare choices without proper and lawful consultation. 

Two days ago, the British Homeopathic Association (BHA) commenced its legal challenge, asking for a judicial review of the NHS England consultation, Items which should not be routinely prescribed in primary care. 

We have, from the outset, believed this consultation to be flawed, on a number of levels. Not only was the timing of the consultation suspect, homeopathy experts and practitioners were not consulted for the drafting of the proposal itself. But, most of all, it is obvious that this consultation never represented a genuine attempt to engage consultees – which is strongly suggestive of a pre-determined decision, one not to be overturned regardless of the outcome. 

We invite you to visit the British Homeopathic Association’s website to read the full reasoning behind the drive for this judicial review, but also to help support part of the legal costs they will face to get this judicial review.

Putting aside the matter of the judicial review, there are fundamental problems with the above. Nowhere is it made clear on what grounds the consultation is considered unlawful. Nor is any reason given why the timing is "suspect". Anyone with experience of being involved with NHS public consultations will understand that in most cases the decision is predetermined. Public consultation can be regarded as rubber stamping exercise.

Consultation Revisited
Before looking at the BHA's attempt to gain a judicial review, it is necessary to have some context. Returning to the consultation it states -

The commissioning guidance, upon which we are consulting, will be addressed to CCGs to support them to fulfil their duties around appropriate use of prescribing resources. It is proposed that the guidance will be statutory guidance issued under S14Z8 of the NHS Act. We expect CCGs to take the proposed guidance if and when issued into account in formulating local polices, and for prescribers to reflect local policies in their prescribing practice. The proposed guidance does not remove the clinical discretion of the prescriber in accordance with their professional duties.

Statutory guidance is a concept that is rarely explained very well. Essentially, some bodies are empowered by law to issue guidance that must legally be taken into due consideration by the persons/other bodies under the control of the first body. This does not mean that the guidance must be implemented but it necessary to demonstrate that due consideration has taken and the reasons why the guidance has not be implemented must be made clear. In most cases, statutory guidance is implemented. In the case of NHS England, it is not clear what sanctions are available in the case of non-compliance.

It is worth pointing out that the majority of CCGs are already largely compliant with any statutory guidance that may be enacted through local prescribing policies and formularies. It is also clear that there is an expectation on the part of NHS England that prescribers with abide by the guidance. Most GPs already do to some extent and will likely comply without issue.

It is important to note that NHS England says the guidance will not remove clinical discretion.

Rules for Public Consultation
An excellent presentation can be found on the Healthwatch website. It contains lots of references for the interested reader.

Government guidance can be found here. The principles are fairly self explanatory. 

GP Contract
As mentioned in the previous post, GPs are not directly employed by NHS England. They are contractors - generally CCGs contract with GP practices rather than individuals. The GP Contract is a contract in terms of law. The current GP Contract can be found here. Unfortunately, it is various parts and difficult to navigate. It is actually easier to look at the standard contract from 2016/17.

It is a long document and much of it is not relevant to this post. Section 14 deals with prescribing and dispensing. 

The Contractor must comply with any directions given by the Secretary of State for the purposes of section 88 of the 2006 Act as to the drugs, medicines or other substances which may or may not be ordered for patients in the provision of medical services under the Contract.

The Act in question is the National Health Service Act 2006. The relevant parts of section 88 state -

(1) A general medical services contract must contain provision requiring the contractor or contractors to comply with any directions given by the Secretary of State for the purposes of this section as to the drugs, medicines or other substances which may or may not be ordered for patients in the provision of medical services under the contract. 

(2) A direction under this section must, subject to subsection (3), be given by regulations.

The regulations mentioned start from National Health Service (General Medical Services Contracts) (Prescription of Drugs etc.) Regulations 2004. In theory, the Regulations should be updated every year or so but were last done so in 2014. The Regulations represent the blacklisting/greylisting of medicines.

Non-compliance with the GP Contract can result in termination of the Contract or the withholding of monies. However, the process involved is cumbersome. It is not immediately clear if there are processes and systems in place that prevent the prescribing of medicines that are blacklisted. It would make sense if GP and community pharmacy IT systems prevent the prescribing/ordering of such medicines.

Local CCG prescribing policy and formulary enforcement
As stated in the previous post, CCGs do not seem to have any real sanctions against GPs who breach local prescribing policies. This article from the British Medical Association (BMA) spells this out in very clear terms even though it deals with excessive prescribing.


All the above makes clear the nature of the Consultation,the invalidity of petition raised by the BHA and the various "campaigning" communications.

Judicial Review
In essence, a judicial review is when a court is asked to rule whether the actions of a public body that result from powers granted to them by legislation are lawful. Judicial reviews often involve examining the decisions made by public bodies and whether the decisions are lawful. Often the process by which a decision is made is examined.

The Ministry of Justice has published the very useful Pre-Action Protocol for Judicial Review which unsurprisingly outlines the steps that should take place before an application is made for a judicial review. As it points out, the courts take the view that judicial review is a last resort and that alternative means of dispute resolution should be explored.

Before a judicial review takes place, it is necessary to apply to the High Court for leave to persue judicial review. The Court will not automatically grant leave. A number of factors may be taken into account -

• Whether alternative dispute resolution has been exhausted
• Whether the application has been made in time (typically a 3 month deadline)
• Whether the applicant has sufficient legitimate interest (standing)
• Whether the application concerns public law, rather than tort or contract law

If the Court feels strongly enough, leave may exceptionally be granted even if not all of these conditions are met.

Assuming that leave is granted for a judicial review, the Court will take into account various factors. 

• Illegality (which can involve the Human Rights Act)
• Irrationality (Unreasonableness)
• Fairness
• Procedural impropriety (statutory procedures have not been followed)
• Legitimate expectation (basically where the complainant has been lead to believe that certain steps would take place and have not)

If the Court finds in favour of the complainant, there are a number of options available.

• Quashing order (basically overturning a decision made by a public body)
• Prohibiting order (prohibiting a public body from acting on a decision)
• Mandatory order (ordering a public body to act when the decision was one of inaction)
• Declaration (basically stating what the legal position of the parties are without making any order)
• Injunction
• Damages (rare)
• Do nothing

The Public Law Project has produced a guide that is much easier to read that the Wikipedia article.

Costs

The costs of applying for leave for a judicial review are those of employing solictors and a barrister as well as a fee of £60 to the courts. These costs are non-recoverable. The legal fees will vary - it depends on how much work is involved.

If judicial review is granted, a court fee of £215 is payable. Again, the legal costs are difficult to ascertain but figures of £30,000 upwards have been mentioned. Something else that needs to be considered is that the losing party may be ordered to pay the costs of the opponent. In the case of a complainant losing to a public body, the costs could be considerable. Although things like Protective Costs Orders exist that can limit costs, these are only granted in genuine public interest cases.

Crowdfunding of a judicial review raises the question if costs are awarded, if and how they are returned to the funders.

 Aims of the BHA
One question that needs to be considered is whether the BHA has standing enough to warrant their application for a judicial review.Their about us says -

The principal objects of the charity are to promote and develop the study and practice of homeopathy and to advance education and research in the theory and practice of homeopathy provided that the useful results of such research shall be published.

 The entry at the Charity Commission states their activities are -

TO ENSURE THAT HOMEOPATHY IS AVAILABLE TO ALL BY FUNDRAISING AND CAMPAIGNING FOR: (1) PUBLIC INFORMATION AND AWARENESS, (2) ACCESS TO HOMEOPATHIC SERVICES, (3) PROFESSIONAL EDUCATION AND TRAINING, (4) RESEARCH

It is unclear whether a court would regard the BHA as having standing.

Previous Application for Judicial Review
The BHA did seek judicial review of the Lothian Health Board decision to decommission homeopathic clinic services. Or rather, they did so through a proxy. Andy Lewis wrote about this at some length so there is little point in repeating his analysis here.

The application for judicial review was dismissed. It is worth repeating a statement from the judge -

In any event, even if I had concluded that the Board had failed to comply with its PSED [public sector equality duty], I would have refused to reduce the decision under review. It is plain that the Board, as it was entitled to do, accepted the view that there was no scientific evidence for the efficacy of homeopathy and that funding for it was a waste of the limited funds at its disposal. In these circumstances the countervailing factor in this case was so powerful, indeed overwhelming, that no decision other than the one taken by the Board was conceivable. A different decision, namely, to continue spending money on a service whose efficacy was not established, would have been unreasonable.

It is difficult to say whether this sets a precedent.

The BHA Application for Judicial Review

The BHA state on their website -

The judicial review seeks, among other things, a declaration that NHS England has acted unlawfully in relation to its proposals, its failure to consult on them properly and to listen to patients! If successful, we can protect the right of patients to choose to be treated with homeopathy on the NHS and the right of the public to properly have input on the services that their National Health Service provides.

The crowdfunding page adds - 

We have commenced an application for judicial review on the basis that consultation was fundamentally flawed from the outset in that the proposal was not formulated with input from any homeopathy experts or practitioners; it was not a genuine attempt to engage consultees (a decision having been ostensibly predetermined) and did not provide consultees with adequate information on which to provide a considered and informed response.

Again, it is not clear on what grounds the BHA believe the consultation to be unlawful. 

There are questions regarding the existence and credibility of homeopathy "experts". It could be read as implying that BHA believe that NHS England is somehow incapable of evaluating evidence. It is not uncommon for homeopathy supporters to state that only those "qualified" in homeopathy are able to make judgements on its merits. This was dealt with in this post.

It is clear that scientific and medical consensus is that homeopathic medicines have an effect that is consistent with placebo and no greater. The National Institute for Health and Care Excellence (NICE) makes it clear that homeopathy is not recommded and that health professionals should make this clear to patients.

In terms of practitioners, although the data analysis has yet to be completed, it seems likely that the number of NHS England GPs who routinely prescribe homeopathic medicines is very low - a few tens. NHS England is under no obligation to consult with "practitioners" who i) are medically qualified and work in the private sector or ii) lay homeopaths or iii) homeopathy advocacy groups that do not directly represent either NHS practitioners or NHS patients. 

The number of patients prescribed homeopathic medicines by these tens of GPs is unknown. Whilst the number of prescriptions is known, it is unknown how many of these are repeat prescriptions. 

As the outcome of the consultation is not yet know the application can only be on the basis of process. It certainly the case that the consultation period was long enough. The consultation was widely publicised, especially by homeopathy supporters. Questions about whether enough engagement with patients etc was carried out are moot given the publicity.

The BHA's previous attempt at an application for judicial review focused on questions of health inequality. NHS England has addressed this here.

Bizarre
Without wishing to prejudge what the High Court determines, it seems very unlikely that leave for a judicial review will be granted. Even if it were, it is difficult to understand exactly what the BHA hope to achieve. It would be easy for NHS England simply to remove the sections of the Consultation that relate to homeopathic and herbal medicines. Not that it would change very much - CCGs would still be able to have local prescribing policies against such medicines.

The danger for the BHA and UK homeopathy in general is that any hearing could end up as placing the efficacy and validity of homeopathic medicines on trial. It could easily set a precedent that impacts on any further attempts by NHS England and/or CCGs to limit prescribing or comissioning of services.

The reputational damage that a hearing could cause for the BHA is impossible to estimate. If the mainstream media wereinterested, it could be considerable.