Singled out for special criticism were two initiatives by the Prince of Wales: the government-funded patient guide prepared by the Prince’s Foundation for Integrated Medicine, and last year’s Smallwood report which the Prince commissioned to make a financial case for increasing NHS provision of complementary and alternative medicine (CAM). The letter’s publication coincided with a date when the Prince outraged clinicians and researchers once again, this time by using his address to the World Health Organisation in Geneva to ask doctors to embrace alternative therapies in the fight against serious disease.
The NHS Trust mailing was organized by Michael Baum, Emeritus Professor of Surgery at University College London and a past HealthWatch Awardwinner. Although the campaign was not a HealthWatch initiative, among the distinguished signatories were Professor John Garrow, past chairman of the HealthWatch Committee; clinical science consultant and frequent contributor to the HealthWatch Newsletter Les Rose; and Edzard Ernst, professor of complementary medicine at the Peninsula Medical School in Exeter, last year’s winner of the HealthWatch Award.
Les Rose commented, “We immediately got support from the Royal College of General Practitioners and the Royal Society. Overall, so far we have had over 180 media items referencing the letter, and 90% of the news items focus on the key issue of evidence. Our main objective has been achieved - to get people debating the evidence.” The Royal College of General Practitioners have also responded directly to questions on CAM put to them by Rose, which we publish with permission on page 2 of this issue.
The Department of Health replied by letter to the signatories, and a personal response to this from Professor John Garrow appears on page 6 of this issue of the HealthWatch Newsletter.
The scientists’ original letter, after being leaked to the Times, made headlines all over the world. Many reports supported the scientists. For example, Dominic Lawson’s Independent column on Friday 26th May recalled a visit to a “cranial osteopath” on the advice of their younger daughter’s godmother, Diana the Princess of Wales. Lawson’s personal view of the experience, and of alternative medicine in general, may be judged by his article’s headline: “Can you tell the difference between homoeopaths and witch doctors? The answer is: witch doctors are not publicly funded within the NHS. Not so far, anyway.”
Two pages give links to the full text of the scientists’ original letter along with much of the ensuing media coverage.
At HealthWatch’s eighteenth AGM and Open Meeting this October the HealthWatch Award will be presented to Ben Goldacre, the junior doctor and Guardian contributor whose “Bad Science” column every Saturday debunks pseudoscientific nonsense in cosmetics adverts, alternative therapies, and media science stories. Aged just 30, with a First in Medicine from Oxford and a Masters in Philosophy from Kings College London, Goldacre has published academic papers on neuroscience and won prizes in medicine and writing, including Best Science Feature from the Association of British Science Writers. He appears frequently on television and radio to complain about the public misunderstanding of science.
The HealthWatch meeting, which is free and open to all, will take place on Wednesday 18th October 2006 at The Medical Society of London at 11 Chandos Street, W1G 9EB. As usual, Nick Ross will present the HealthWatch AJAHMA Student Prize to the winners of this year’s competition assessing the quality of clinical trial protocols, and the meeting will conclude with an address by Dr Goldacre followed by discussion.
Ben Goldacre’s columns can be found online at: http://www.guardian.co.uk/life/badscience/
Les
Rose has addressed some key questions on the issue of complementary medicine
and GP’s to the Royal College of General Practitioners. Here they are,
with the answers, exclusively for HealthWatch members.1. The College states that acupuncture is now ‘mainstream’. Does this mean that the College endorses its use in most or all of the indications for which benefit is claimed, or only for those for which there is robust evidence? Examples of the latter are post-operative nausea and vomiting, and some types of musculoskeletal pain.
“The College will only support those therapies where there is good evidence. When it comes to interventional new management the College would seek to support those areas where there is evidence. Obviously the use of a therapy has to be specific and not ‘blanket’. Thus medications and procedures are symptom or disease specific, not merely globally acceptable. For example the use of acupuncture for specified indication only where there is robust evidence.”
2. What is the College’s position on homoeopathy? Does the College approve the use of this modality by its members and fellows?
“When it comes to homoeopathy the College is not convinced that there is sufficiently robust evidence to support its general use. Indeed the National Electronic Library for CAM (NELCAM) seems to suggest there is little evidence for its efficacy. Thus currently the College would not generally support its use. If the evidence base changes we would, of course, be happy to reconsider.”
3. The College’s statement is presumably intended for a lay audience. Therefore it needs to define what evidence is. I have spent many hours in media interviews this week, and this is probably the clearest issue arising. Will the College state clearly that only evidence from properly designed and conducted studies can be admitted when making treatment decisions? Anecdotal evidence can be indicative of the need for further research, but can never be decisive. It would be of enormous benefit to public health if this could be made clear.
“I would support the concept that evidence means evidence from a research perspective and does not include anecdotal evidence. The interesting thing is, of course, that there is the ‘art’ of medicine as well as the ‘science’ of medicine and we have to mix the two - as per the answer to question 2. However, to advocate the use of a therapy we have to have robust scientific evidence for its use. Generally this means randomized controlled trials which is the standard for clinical effectiveness studies of controversial drugs.”
If members would like to receive occasional information about our activities between newsletters, they should inform the HealthWatch Secretary by sending an e-mail to kenneth.bodman@btinternet.com and he will arrange this. A recent example would be the opportunity to receive a copy of the letter to health authorities concerning the need to have only proven treatments available on the NHS. There will not be many such alerts and members can cancel the arrangement at any time.
Andrew Herxheimer has written to inform us of an error in issue 61 of the HealthWatch Newsletter, concerning a news item on page 2 which had begun by saying that a meta-analysis had found no evidence that the hormone melatonin is effective in treating secondary sleep disorders or preventing jet lag. “I’m afraid the first sentence of your item about melatonin is mistaken,” writes Herxheimer. “The meta-analysis by Buscemi et al [1] did not examine whether melatonin is effective in ‘preventing jet lag’, only whether it improves sleep in jet lag. It found no evidence of improved sleep. There is however good evidence that melatonin helps to reduce jet lag [2].
“The British Medical Journal asked me for an editorial [3] about the Buscemi review, which explains the point. Both appeared in the print version of the BMJ of Feb 18.”
Lawyers acting on behalf of the World Chiropractic Alliance are reported to have issued a warning to a bus company in Connecticut, USA. The buses have been displaying advertisements featuring the words, “Injured by a chiropractor?” in large text, followed by a telephone number and web site. The ads were placed by the Chiropractic Stroke Victims Awareness Group. Stroke from chiropractic neck manipulation can result when an artery to the brain ruptures or becomes blocked as a result of being stretched. The odds of such a serious complication are estimated to be anywhere between one in 5,000 and one in 10 million manipulations.
http://www.chirobase.org/08Legal/bus_ad.html
Mental Health charities have called for better regulation of over-the-counter herbal medicines sold to treat depression. Depression Alliance Cymru, an Welsh independent charity run by and for people affected by depression, together with the Centre for Mental Health, warned about St John’s Wort and Passiflora, saying that, “The active ingredients in these preparations are not alternatives to antidepressants, they are antidepressants. St John’s Wort contains an SSRI (from the same family of drugs as Prozac); Passiflora contains a Mono-Amine Oxidase Inhibitor (a family of drugs that are rarely prescribed because they have dangerous interactions with common foods such as bread, cheese and red wine). Using the raw plant rather than the active substance means that there is no way of controlling dosage.” St John’s Wort has been banned from over-the-counter sale in Ireland but is freely available in the UK.
or more information see: http://www.centreformentalhealth.org/agree/docs/news.html
The
week beginning Monday 22nd of May began cold and drizzly as if to warn me not
to bother getting out of bed. The week ended with me thinking that the omens
had been in part correct but had failed to include a sufficiently surrealistic
component. That Monday every National Health Service trust responsible for commissioning
both primary and secondary health care was sent a letter signed by me and 12
other scientists more distinguished than myself.These included seven Fellows of the Royal Society, one Nobel Laureate and Europe’s first and only Professor of Complementary and Alternative Medicine (CAM). In this letter we warned of the creeping acceptance of alternative medicine in the NHS, picking out for special attention homoeopathy, otherwise known as “The Harry Potter School of Medicine”. This is of course no joke as, within the last couple of years, the Royal London Homoeopathic hospital was refurbished by the University College Hospitals Trusts (UCHT) at a cost, I hear, of about £20,000,000.
As chance would have it, that very day the National Institute of Clinical Excellence (NICE) gave conditional approval for the use of aromatase inhibitors (AIs) for postmenopausal women with hormone response tumours. I was particularly delighted by this news as I had personally led much of the clinical research in this area over the last seven or eight years and reported the first positive results at a breast cancer conference in the USA in 2001. The Americans had adopted this treatment in 2003 but our NHS patients have had to wait another three years. During this time the money spent on homoeopathy in UCHT, which also happens to be my own NHS trust, could easily have covered the costs not only for the AIs but also herceptin, thus saving many lives through the practice of good evidence based medicine (EBM).
By Tuesday our letter had found its way to the Times. By some remarkable coincidence that day was also scheduled for his Royal Highness the Prince of Wales to address the assembly of the World Health Organization, on the merits of CAM.
My schedule that day looked something like this:
Skip breakfast
07.45 BBC Birmingham
08.00 BBC4 Today
08.30 BBC5
09.30 Start clinic with constant interruptions.
12.00 Operating theatre
Skip lunch
14.00 More patients
15.15 BBC world service
16.30 ITN news 20-minute interview in pouring rain
17.30 Sky news live
18.00 Pick up message from husband of patient of mine who has just been diagnosed with liver metastases.
19.00 Quick dinner
20.00 Meet said husband for a malt whiskey or three for consolation and shoulder to cry on.
On Wednesday the backlash began, as we were named as heartless scientists, closed minded bigots and Jurassic doctors. On the last point I was amused to note that in the Prince’s speech he urged the audience to respect ancient wisdom. Perhaps our aggregate wisdom of about 700 years wasn’t ancient enough?
Thursday I was back in my clinic. My first patient was a lovely Chinese lady in her mid forties. Three years ago she had been treated for breast cancer with breast conserving surgery, radiotherapy and tamoxifen. Cancer had now recurred close to the original site. Her original surgeon wanted to carry out a mastectomy but I had been able to salvage her breast. This was her first post-operative visit. She was delighted with her treatment but “confessed”, rather sheepishly, to taking traditional Chinese medicine alongside tamoxifen for three years. She described it as magic mushrooms that boost the immune system and I have since learnt that they are indeed a mushroom extract known as Ganoderma sporo-pollen and Ganoderma spore bioactive lipids. If anyone out there can let me know if this stuff can compete for the oestrogen receptor or interfere with the action of the enzymes that convert tamoxifen to 4-Hydroxy-N-Desmethyltamoxifen, the active metabolite, I will be eternally grateful.
That evening I was to speak at a fancy dinner raising money for cancer research. I found myself sitting next to Uri Geller, the other “entertainer” for the evening. After my talk, as a gesture of appreciation, he took the dessertspoon out of my hand and stroked it gently. The spoon bent to 90 degrees on its own volition and I was left thinking that maybe Harry Potter did have something to offer.
Finally on Friday afternoon I took myself off to the British Museum to view the exhibition of Michelangelo’s drawings. This is a wonderful journey into the transcendental. The centrepieces of the exhibition were his preparatory drawings for his master-work on the ceiling of the Sistine Chapel. What I had never realized before was that every image on that ceiling had been planned with exquisite care as a scaled-down drawing. These drawings were then scaled up using a matrix technique into full size cartoons, all but one of which have since been lost. The outlines on these cartoons were then transferred onto the wet plaster of segments of the roof for fresco painting by piercing the sheet with thousands of pin holes along the key lines and then rubbing in charcoal. The highlight of the exhibition for me was the interactive display whereby you could build up a fresco by selecting and transposing photographic segments from the original drawings that fitted in place like a jigsaw. This was evidence-based art (EBA) at its best. It doesn’t save lives but it sure as hell saved my sanity.
Michael Baum
Emeritus Professor of Oncology
University College Hospital, London
So said Cherrill Hicks at the press launch on 9th May of the new refurbished version of the web site http://www.BestTreatments.co.uk, of which she is editor. The other members of the platform party were Dr Brian Fisher, a GP who has an internet kiosk in his surgery and said his patients found it “empowering” to know so much about their condition, and Dr Jason Roach, the editor of the online “Clinical Evidence” from which all this comprehensive and reliable information comes.
It is a beautifully constructed website that I found very easy to use. From the homepage you can select any of about 140 conditions, and another 40 topics are to be published in 2006 (but coccydynia is not mentioned). There are also helpful sections about many operations or tests, such as “Having a defibrillator fitted”. A patient can select a version of the text intended for “Patients” or look at the one for “Doctors” to check that the lay version really is equivalent to what the doctor also was told. For those who are library-wise there are proper bibliographic references to the evidence on which the advice is given. I have book-marked the site as a “favourite place”, since it is an easy route to the treatment of most common conditions.
Great stress was laid on the independence and reliability of the evidence cited, based on the advice of “the world's leading doctors”. It is not sponsored by drug or other companies or the Department of Health, so it is impartial, and when it does not know it says so. At this a cynical journalist enquired if it was funded entirely by philanthropy? Not quite: the Department of Health had no influence on the editorial content, but paid BMJ Publishing for the material to be available free in the UK. Other users had to pay for the franchise.
Is the advice comprehensive and reliable? Probably no expert in a particular field would give full marks to the advice on his topic. Obviously it is an impossible task to keep everything up to date on such a huge database, although as I understand the material is reviewed at least once a year it is probably as reliable as can be achieved in practice.
One of the sections I found disappointing concerned complementary treatments - specifically St John’s wort, acupuncture and cranial osteopathy were listed among the topics covered. The structure of the website is designed to take the visitor from a selected condition to the choice of treatments: it is not designed to operate in reverse, for example, to answer the question: “What is homeopathy good for?” There is a search facility, so you can ask for a search on “homeopathy” or “homoeopathy”, and in both cases the reply is “No relevant articles found”, so maybe you can deduce that there is no evidence that it is a treatment useful for any of the conditions covered.
If you search for “acupuncture” you are rewarded by 26 entries relating to short-term back pain, long-term back pain, slipped disc, morning sickness, smoking, tennis elbow, tinnitus, painful periods and rheumatoid arthritis. Concerning short-term back pain, slipped disc, smoking, tennis elbow, tinnitus, painful periods and rheumatoid arthritis however, either there was no good evidence of efficacy, or the evidence was that it was ineffective. This leaves only long-term back pain and morning sickness in which the evidence of efficacy is worth examining. The entries relating to the effect of acupuncture in these two conditions is copied below:
We found two summaries of research (called systematic reviews) looking at acupuncture for people with long-term back pain. They examined the results of 12 small studies. One review found that acupuncture helped improve how well people felt. However, it also found that pretend acupuncture (for a placebo) worked as well as real acupuncture in reducing people’s pain. So, we can’t be sure that people felt less pain because of the acupuncture. It may be that people felt better because they felt good about the treatment. The other review found that the studies it looked at weren’t good enough to tell us for certain how well acupuncture worked.
Because the women who had the placebo acupuncture felt better, too, we can’t be sure whether the acupuncture itself made the women feel better, or whether they felt better because they saw a healer and had some treatment.
The other study, which included 55 women, found that having acupuncture made
no difference to women’s symptoms.
I would expect better than this from “the world’s leading doctors”.
At HealthWatch we believe that Randomised Controlled Trials (RCT) are useful
because you compare the effect on people having a treatment with those having
placebo (ie everything but the treatment). If the results in the two groups
are not different that tells us the treatment is not effective. Doesn’t
it? So why are these leading doctors “not sure”?
Even more strange is the claim that cranial osteopathy is a treatment considered in http://www.BestTreatments.co.uk. Search for “cranial osteopathy” yields one entry relating to colic in babies. It says that there is no evidence that cranial osteopathy is useful for colic in babies, but warns that it may be dangerous. (This is in marked contrast to the Foundation for Integrated Health’s publication “Complementary Healthcare: a guide for patients” in which it is listed among the “16 most widely used complementary therapies.”) It seems that evidence of efficacy does not correlate well with frequency of use in complementary medicine.
John Garrow
Emeritus Professor of Human Nutrition
University of London
“In answer to John’s question about the site’s reliability: all the material we publish on BestTreatments is regularly reviewed by clinical experts and is also subject to regular checks from our in-house team of doctors. Each of our topics is reviewed and updated annually, but we also publish more urgent updates - such as a major new study on the risks of a particular intervention, or new advice from the regulatory authorities - within days.
“In answer to his comments about complementary treatments: acupuncture as an intervention for both back pain and morning sickness has been categorised as needing further study. This means there is not enough good quality research to conclude whether acupuncture works for these conditions or not. However, I accept John’s point on our reporting of the research and intend to amend our material accordingly. Further research has been published on acupuncture as a treatment for chronic back pain and this topic is due to be updated very soon.
“Finally, it’s not clear from John’s comment if he is critical of BestTreatments for including cranial osteopathy. We think it’s particularly important to include the evidence on popular complementary treatments, so that people can make an informed choice.”
For example, in a sequence in which acupuncture was used instead of a general anaesthetic during open heart surgery in China, it has been claimed that the narrative exaggerated the role of the acupuncture, and underplayed the role of powerful sedatives and large doses of local anaesthetic that were used during the surgery.
A televised experiment showing magnetic resonance scan images (MRI) of the brains of patients undergoing acupuncture was reported in national newspapes under headlines such as “Acupuncture does combat pain, study finds”. Yet Professor George Lewith of Westminster University, leading acupuncture researcher on the team devising the BBC experiment, later said, “The interpretation of the science in this particular programme was not good and was inappropriately sensationalised by the production team.”
Edzard Ernst, professor of complementary medicine at Exeter University and a consultant for the series, complained about the programme on faith healing, which he felt was creating a false impression. “The journalists were at a complete loss to understand the difference between an anecdote and real evidence,” he told the Guardian. The BBC refutes the allegations and is understood to be considering commissioning a second series. Dr Jack Tinker, dean emeritus of the Royal Society of Medicine who was, along with Professor Ernst, scientific consultant for the series, is said to remain happy with the tone and content of the films.
Nevertheless the programme on herbalism has already been exploited by vendors of unproven treatments, for example the herb sutherlandia is being promoted as a new weapon in the fight against HIV and Aids using direct references to the BBC programme; and Professor Ernst claims to have received letters from members of the public who want to be operated on by acupuncture anaesthesia.
Guardian, 25 March 2006
British Medical Journal 2006; 332: 981 (22 April)
Until recently, the Department of Health footed the bill for NHS doctors in England to receive the publication but has now decided not to renew its contract with Which?, giving the publishers only hours’ notice before the latest contract expired at the end of March.
Ike Iheanacho, DTB’s editor, claims the publication actually saves the NHS money, citing as an example its recent advice against the use of two very expensive anti-cancer drugs (bevacizumab and cetuximab) outside clinical trials because of the lack of evidence on cost-effectiveness. “If this advice were followed,” he says, “and led to each PCT stopping just one inappropriate prescription of each drug, the NHS could save around £9 million. Without DTB, this kind of independent, robust and cost-saving guidance will disappear, making life much easier for the pharmaceutical industry and ultimately, costing the NHS more.” The value of the DTB contract has been fixed at £1.4 million a year over a 6-year period. This is against an NHS drug budget of around £8 billion a year and a pharmaceutical industry annual promotional spend of £1.65 billion.
For more information see http://www.which.net/press/releases/ dtb/060503_hewitt_nr.html
Deborah Ross, writing in the Independent magazine recently, amused a number of readers enough to send the HealthWatch Newsletter editor copies of her “If you ask me” column.
She wrote, “It is often curiously hard to get any kind of alternative practitioner, whatever their particular school, to accept alternative methods of payment like, for example, an old shoe…I don’t know why alternative people have to be so conventional in this respect, or why their ancient Chinese way of going about things must always be complemented by the most up-to-date Western billing systems…”
You
will remember as a child being told to eat up your carrots as a means of being
able to see in the dark. Recently the Drug and Therapeutics Bulletin (published
by Which?) has looked into the promotion of nutritional supplements, some of
which make claims that they are good for the health of the eyes.The debate concerns a problem that is going to confront our increasingly aged population: that of macular degeneration. It is the commonest cause of blindness in the Western world in individuals over 60. Around 17,000 people become blind or partially sighted as a result of macular degeneration in the UK each year.
The macula is the central area of the retina and is responsible for detailed
vision, specifically for reading and writing. Deposits, which can be seen as
yellow spots on the retina, develop and this results in progressive loss of
central vision over a five to ten year period. In some cases this can result
in severe loss of vision. In a survey of 5,000 people in America, 30% of patients
over the age of 75 had signs of age related macular degeneration.
The symptoms of macular degeneration are distortion of straight lines or edges,
which may be noticed when you are looking at wall tiles, windows or doorways.
There can also be missing central vision. Words may appear broken with letters
missing when trying to read. The onset can be reasonably sudden and if this
occurs it is sensible, without delay, to contact your Optician, GP or nearest
hospital’s Eye Department. Cataract by contrast has slower onset and gives
misty vision.
Laser therapy can slow the progress of the disease in a very small number of patients but will not restore lost vision. New drugs have recently been licensed in the UK which are injected into the eye and which help a few more patients (but do not benefit everybody affected by the disease). These drugs have not yet been approved by NICE.
Precisely why macular degeneration occurs is not known but there is a greater chance of it developing in cigarette smokers or in those with a raised cholesterol level. There is a theoretical benefit in giving anti-oxidant vitamins, but there is no firm evidence that this is an advantage.
A major study, ‘The Age Related Eye Disease Study’ (AREDS), was
completed four years ago in America on over 4,000 patients with a median age
of 69 years. All patients had good vision in at least one eye at the start of
the study and were followed for over 6 years. The patients were divided into
four groups. Group 1 were patients who were free of any macular abnormalities
ranging up to Group 4 where patients had significant lesions or advanced disease
in one eye. The study was a double masked trial using zinc and anti-oxidant
vitamins (in various combinations) or a placebo.
The results of the study showed that in the patients who had no disease at the
start, not enough of them had developed the disease to make any useful statistical
comparison. Only in the most affected patients (Group 4) was there any significant
benefit in the treatment of using either zinc or anti-oxidant vitamins plus
zinc to reduce the progression of advanced disease and loss of vision.
A number of other studies have been carried out but none have produced significantly positive results to enable a firm recommendation on the use of supplements.
From the evidence currently available there is an indication for the use of
a specific combination of zinc and anti-oxidant vitamins only in patients who
already have advanced macular degeneration in one eye and this regime should
be clearly recommended by an eye specialist. For those patients who are smokers
or those with smoking histories, they will be advised to take a specific preparation
which does not include beta carotene.
There are a number of nutritional supplements which claim to improve eye health
and these are available for purchase from pharmacies, health food shops and
also available on the Internet. But for people with no symptoms of the disease
there is absolutely no indication for taking any nutritional supplements. It
is preferable to have a balanced diet which is rich in anti-oxidant vitamins.
In summary the advice for our ageing population is:
The following websites could also be helpful:
The Royal College of Ophthalmologists http://www.rcophth.ac.uk
The Macular Degeneration Society http://www.maculardisease.org
Keith Isaacson
Consultant Orthodontist
The North Hampshire Hospital, Basingstoke
Certain nutritional supplements claiming to improve eye health may be in breach of UK medicines legislation, warned the Drug and Therapeutics Bulletin on 3rd February. Editor Dr Ike Iheanacho said, “We are concerned about promotional claims for some nutritional supplements aimed at people worried about macular degeneration. In particular, we have reported the claim that ‘Viteyes’ can ‘slow macular degeneration’ to the Medicines and Healthcare Products Regulatory Agency (MHRA).”
Professor
Garrow shares his personal view on the Department of Health’s reply to
the recent scientists’ letter, of which he was a signatory, which expressed
concern over the use of “alternative” medicine in the NHSOn 19th May 2006 a group of physicians and scientists concerned with medical research sent a letter to the Chief Executives of National Health Service Trusts in the UK. The full text of the letter is available on the Internet1, but the essential points are as follows: “At a time when the NHS is under intense pressure, patients, the public and the NHS are best served by using the available funds for treatments that are based on solid evidence.
“Furthermore, as someone in a position of accountability for resource distribution, you will be familiar with just how publicly emotive the decisions concerning which therapies to provide under the NHS can be; our ability to explain and justify to patients the selection of treatments, and to account for expenditure on them more widely, is compromised if we abandon our reference to evidence. We are sensitive to the needs of patients for complementary care to enhance well-being and for spiritual support to deal with the fear of death at a time of critical illness, all of which can be supported, through services already available within the NHS, without resorting to false claims.”
In view of this situation the recipients of the letter were urged to ensure that patients in their Trusts did not receive misleading information about the effectiveness of “alternative” medicines, and they should ask the Department of Health (DoH) for evidence-based information about the effectiveness of these treatments. These are reasonable and constructive suggestions.
The response from a spokesman for the DoH was prompt, brief and - in my view - totally missed the point. It is to be hoped that, on mature consideration, the Department will see that it will not benefit the NHS to follow the dismissive tone of their spokesman. Successive sentences of his reply will be considered here. The first was:
“It is up to individual clinicians and Trusts to decide whether they think a complementary and alternative medicine (CAM) is the best treatment for a patient.”
This statement is plainly untrue, and if it were true it would be an amazing departure from the stated policy of the DoH to support evidence-based medicine. The function of the National Institute for Clinical Excellence (NICE) is to examine the evidence for the effectiveness, safety and value-for-money of treatments, and on the basis of this examination to advise if the treatment should be made available on the NHS. It therefore cannot be up to an individual clinician, or Trust, to use public funds to pay for any treatment (whether conventional or CAM) if this use has not been approved by NICE, and the same rule should apply to CAM therapies.
The second sentence I find equally amazing:
“We know it is important that as more people turn to these therapies a solid evidence base is developed.”
This implies a curiously inverted logic. Usually we expect that work to develop a solid evidence base for the use of a therapy is the first step and, if this first hurdle is cleared, the therapy is made widely available. The alternative thinking is that if many people “turn to a therapy” that is a signal for the DoH to fund research to see if it is effective. What if the research does not provide a solid evidence base? Will people then be turned away from the therapy to limit the waste of NHS money on a therapy that does not work? Indeed, if evidence of efficacy was a requirement for NHS funding this would avoid both the waste of money and the error of giving NHS patients the wrong treatment.
Given that the test of efficacy should be obtained as soon as possible, if not actually before the treatment was made available, one might expect the plan of research would at least be expeditious, but this hope is soon destroyed:
“That’s why we have provided nearly £3 million to develop CAM researchers to help build research capacity. We have also provided £324,000 for three research projects looking at the role of complementary therapies in the care of patients with cancer.”
In 2000 the House of Lords Select Committee recommended that public money should be made available to test the efficacy, safety and value-for-money of the more promising CAM therapies. This money was made available in 2004, but was used “to develop CAM researchers to help build research capacity.” Presumably the logic of this was to teach CAM therapists about research methods so they can find out if their therapy works. This logic fails for two reasons. First, it will take many years to train these novice researchers, and experienced researchers who could do the task immediately were available, but not funded. Second, CAM therapists are not the ideal people to investigate the efficacy of CAM therapies, since they have a built-in bias towards finding them effective.
The final paragraph of the DoH response seeks to justify the use of public funds to provide patient guides to the 16 most popular CAM therapies.
“Patients rightly expect to have clear information about the range of treatments that are available to them, including complementary therapies. Patient guides, such as that produced by the Foundation of Integrated Health, are an important way of making sure this information is easily accessible to patients and ultimately help them to make the right treatment choices.”
This is neither logical, nor consistent with what has already been stated. The letter to which it was a response complained that evidence of efficacy was being disregarded when choosing therapies for public funding. The response does not mention evidence of efficacy (neither do the publications that are here endorsed - they are an advertisement for the therapies that are available) so it is not a reply to the letter. The purpose was to “make sure this information is easily accessible to patients and ultimately help them to make the right treatment choices.” This is a shift from the position indicated by the first sentence of the response: now it is the patient (not clinicians, nor Trusts, nor NICE) who finally make the choice of treatment. But the logic here is circular: the CAM treatments in the FIH guide are the “most widely used”, so they are the patients’ choice, hence they should be publicly funded. If evidence of efficacy is to be trumped by evidence of popularity, and the more the DoH promotes CAM therapies the more will be the evidence of popularity, then a New Age Popularity-based Medicine will triumph. It seems this is the real danger. So we must hope that the NHS will pay more heed to the dictates of reason and provide treatments that have good evidence of efficacy.
John Garrow
Emeritus Professor of Human Nutrition
University of London
The full text of the doctors’ letter to NHS Trusts of 19th May 2006 can be found on The Times web site on: http://www.timesonline.co.uk/
The
geneticist Steve Jones has said that he has given up trying to speak to creationists,
because there is no point in discussions with those who don’t want to
hear, and whose response to evidence is to deny it. HealthWatch is not directly
concerned with creationism, but denial of evidence is important to us.On the 23rd of May Prince Charles gave a speech to members of the World Health Assembly in Geneva, Switzerland, yet again trying to sell his message of “integrated medicine” to the world. He sees it combining the best of conventional and complementary medicine, an idea that I have previously described as analogous to combining astronomy and astrology.
Possibly in an attempt to pre-empt Prince Charles, some eminent doctors and scientists sent a letter to all the NHS Trusts asking them to think very carefully before spending their stretched resources on unproven complementary therapies. It probably drew more attention than was deserved to the Prince’s speech. As I write, three weeks after the speech and the publication of the letter in the media, repercussions rumble on. They are dispiriting in the Steve Jones way. It is a word fight between two groups of people each unable or unwilling to see the other's point of view. Actually, that is a simplification. I can see the point of view of the man whose e-mail was read out on Radio 4’s PM programme. For him, complementary therapies had cured his angina, and also his eczema. For me, as a rationalist who realises the weakness of anecdote and the strength (and some weaknesses) of proper evidence, the complementary therapy (or at least, the therapists) made him feel better, but his angina and eczema would have gone away anyway.
The newspapers have been full of similar letters and articles. Professor Edzard Ernst, the current HealthWatch award winner, leading researcher into complementary therapies and one of the signatories of the letter to Trusts, can publish all the carefully collated reviews he likes; all it needs is one letter from a mother who “protected” her children with homoeopathy instead of immunisation and that is “balance”. For too many people, it is more than balance; it is negation.
There are few phrases more dispiriting to supporters of evidence-based-medicine (EBM) than, “therapies known for thousands of years”, “we have so much anecdotal evidence”, “there is so much we don't yet understand” and “lots of conventional medicines haven’t been properly tested”. These phrases are the true signs of the “closed minds” that critics of complementary therapies are so often accused of having. They are the comfort blankets of the ignorant.
But it is not their fault. The real fault lies in the denigration of science in education. Science is difficult and expensive. In the present climate, it is easy to see why schools and universities prefer to teach arts. Future generations must be able to understand what is, and what is not, proper evidence - whether it is favouring the use of a drug or interpreting the age of rocks.
Whether a government largely composed of lawyers with their eyes to the main chance can themselves understand this is open to question.
Neville Goodman
Consultant Anaesthetist
Southmeads Hospital, Bristol