Memorandum submitted by the NHS West Kent
1. Background to Homeopathy Commissioning
1.1 The West Kent PCT Board made a decision
to withdraw routine NHS funding of homeopathy at its meeting on
27 September 2007. This decision was challenged via judicial
review and subsequently rescinded while the PCT conducted a full
Equality Impact Assessment (EIA), which took place between December
and June 2008.
1.2 The full EIA found that whilst homeopathy
has no proven clinical effectiveness there may be an impact on
a small cohort of patients with complex long-term conditions and/or
life-limiting illness who no longer find relief in conventional
medicines and who perceive benefit from their experience of homeopathy.
1.3 The review included public consultation
and was conducted between April and July 2007.
1.4 The original public consultation process
was challenged in the courts and found to be sufficient. The consultation
was not about whether homeopathy works but rather whether the
NHS, in light of competing priorities, should fund it. A Homeopathy
Consultation Advisory Group (HCAG) consisting of representatives
of the PCT, GPs/Practice Based Commissioners, West Kent Patient
& Public Involvement Forum, Kent County Council's NHS Overview
& Scrutiny Committee, Maidstone & Tunbridge Wells NHS
Trust (Homeopathic Practitioners and Management), and the TWHH
League of Friends was established to oversee the process. The
PCT's Director of Civic Engagement chaired the group.
1.5 The HCAG agreed a series of options,
which formed the basis of public consultation between 23 April
and 2 July 2007.
1.6 The consultation process included:
A systematic review of the high quality
Production of a consultation document
and related questionnairesent to a random sample of 1,000 of
the PCT's registered patient population in addition to those who
requested it directly or received a copy through their personal
connection with homeopathy and/or the TWHH
A series of public meetings
An audit of all GPs in West Kent
2. EVIDENCE BASE
2.1 Clinical effectiveness
2.1.1 The PCT commissioned an independent
review of studies meeting the criteria for evidence based medicine.
The review found no clear evidence to support or oppose the commissioning
2.1.2 The PEC concluded that there is limited
evidence in favour of homeopathy; the PCTs resources should be
directed towards treatments that have a greater evidence-base.
2.2 Population needs
2.2.1 PCT commissioning data indicates that
in total 52% of all GP practices across West Kent refer patients
to secondary homeopathic services.
2.2.2 The PCT conducted an audit of all
GPs, which showed that in those practices that use homeopathy,
less than 1% of the registered population are referred.
2.2.3 Almost all referrals for homeopathy
are at the request of the patient rather than as a result of a
clinical decision to refer.
2.2.4 There is no information available
about the proportion of people with the conditions most commonly
referred to homeopathy that use the service, or what the outcomes
of their treatment is, to enable a clinical needs analysis.
2.2.5 The PEC's view was that in light of
the many competing demands on PCT budgets and the range of treatments
that cannot currently be routinely funded, homeopathy is not a
priority for the general population of West Kent.
2.3 Value for money
2.3.1 The financial value of homeopathy
is smallc. £200,000 per annum, however, since
clinical effectiveness is not proven it is not possible to conduct
a cost effectiveness analysis.
2.3.2 In terms of cost-benefit, results
of the GP audit, TWHH's own audit and personal anecdote from service
users suggest that homeopathy may provide help for some individuals
and/or conditions where conventional medicine is perceived to
have failed or created unacceptable side effects. In some cases
this is additionally reported to have resulted in a reduction
in the use of conventional healthcare resources.
2.3.3 Levels of satisfaction amongst those
who use the TWHH are high according to the hospital's own audit.
2.3.4 Data is not available to quantify
relative health gain to individuals for each pound spent on homeopathy,
nor is it possible to conclude whether greater health gain could
be achieved for those individuals by spending the same money on
2.3.5 The PEC's view was that homeopathy
is often an "option of last resort", which may mask
the need to deal with difficult problems in a different way, and
that patients can be treated effectively through other mechanisms,
for example pain management programmes. They are concerned about
the high rate of ongoing/follow up visits, which may indicate
some dependence on homeopathy.
2.3.6 The PEC also recognised, however,
that homeopathy offered as part of a multi-faceted and primary
care based approach for treating people with complex problems
may add benefit, if fully integrated within a multi-professional
approach; this would not require a secondary care service.
2.4 Impact on other services
2.4.1 Results of the GP audit suggest that
on average about half of people referred for homeopathy simultaneously
access conventional treatment for the same condition.
2.4.2 About 40% of the GPs who had referred
someone for homeopathy said that they would probably refer to
other forms of treatment if homeopathy were withdrawn.
2.4.3 Some service users report a significant
reduction in their use of conventional services as a result of
their experience of homeopathy, and this is backed up anecdotally
by some GPs.
2.4.4 The PEC's conclusion was that whilst
additional services may be required they might also be more effective
overall than homeopathy and support a wider group of patients
than those who would use homeopathy.
2.4.5 The services that GPs suggest might
be impacted if homeopathy were withdrawn are, for example, allergy
specialists and dermatologists, GPs and psychological services,
but this is not quantified.
2.5 Public demand
2.5.1 Less than 1% of the PCT population
use homeopathy services, with the majority focused in Tunbridge
Wells. Service use is not spread equally throughout West Kent.
2.5.2 Despite extensive national and local
publicity about West Kent PCT's review of the commissioning of
homeopathy services, only 22 letters and e-mails and 197 feedback
forms were received during the consultation period, and only 63 people
in total attended one of five public meetings.
2.5.3 Across the UK and in other parts of
Europe, funding for homeopathy is being withdrawn in light of
2.5.4 The PEC's view was that funding of
homeopathy should be considered in context of all the priorities
of the PCT and as such is not a priority. They believed that the
fact of having a NHS funded Homeopathic Service within PCT boundaries
means homeopathy receives undue weight in the public's mind compared
to other services and treatments that are under funded or cannot
currently be provided on the NHS.
3. OPTIONS FOR
3.1 The consultation document identified
three possible options for change, which were discussed and agreed
with the HCAG, as follows:
Referrals to the Individual Exceptional
Treatment Panel for decision
Fixed number of visits for homeopathy
Withdraw routine funding of homeopathy
3.2 As a result of the consultation a number
of additional options were suggested. The HCAG considered all
of them and finally added three further options:
Introduce a homeopathy exclusions policy
"Multi-faceted" option (incorporating
a number of other options)
4.1 Actions to mitigate the potential impact
on existing service users were approved at the time of the Board
decision. These included:
Establish an Individual Case Review Service
for those people who wished to continue homeopathy treatment
Agree exceptionality criteria for use
by the Individual Treatment Panel when deciding on requests for
Conduct a review of services available
for people with complex multiple long-term conditions for whom
conventional medicines may no longer be effective, including the
provision of self-care support
4.2 In January 2009 the NHS West Kent
Board received an update on the process of implementation of the
agreed EIA mitigating factors and approved a set of decision making
criteria in relation to exceptionality for use by the Individual
Treatment Panel (ITP) from April 2009.
5.1 From April 2009 new referrals for
homeopathic treatment are required to go via the ITP.
5.2 Guidelines for exceptionality in the
case of referral for homeopathy treatment were developed in conjunction
with the Clinical Leadership Board and approved by the PCT Board
in July 2008.
6.1 The weight of evidence collected as
part of the initial review indicates that homeopathy services
are not a clinical priority when compared with the many competing
priorities of the PCT.
7.1 NHS West Kent operates a policy not
to fund routine homeopathy treatment.
Dr James Thallon
Medical Director, NHS West Kent