Examination of Witnesses (Questions 112-173)
PROFESSOR EDZARD
ERNST, DR
PETER FISHER,
DR ROBERT
MATHIE AND
DR JAMES
THALLON
25 NOVEMBER 2009
Chairman: We now welcome our second panel
this morning: Professor Edzard Ernst, the Director of Complementary
Medicine Group at Peninsula Medical School—welcome; Dr Peter
Fisher, the Director of Research at the Royal London Homeopathic
Hospital—welcome to you; Dr Robert Mathie, the Research
Development Adviser at the British Homeopathic Association and
Dr James Thallon, the Medical Director at the NHS West Kent. Thank
you all very, very much indeed for coming. I am going to ask Graham
Stringer to begin this set of questions.
Q112 Mr Stringer: Can I start with
the central question of the last panel: is there any evidence
that homeopathy shows any efficacy beyond the placebo effects?
Professor Ernst: I would echo
what has been said and warn people to pick cherries out of a bigger
cake; if you look at the bigger cake the bottom line is there
is no good evidence that homeopathic remedies are better than
placebos.
Dr Fisher: I diametrically disagree
and am shocked, actually, by the statements that have repeatedly
been made this morning that there is no evidence. You have, in
fact, a submission before you that actually enumerates the meta-analyses
and systematic reviews. It is actually due to my colleague, Robert
Mathie, but to summarise: there have been five, comprehensive,
global systematic reviews or meta-analyses of homeopathy which
look at the whole thing, of which four were positive. If you look
at the condition based systematic reviews and meta-analyses there
are 24, of which nine are positive, five negative and ten inconclusive
for various reasons, including the trials were not large enough
or they were heterogeneous—the trials were somewhat different
and they could not really be compared. I say it is quite clear
if you actually look at the evidence, and they are enumerated
in a document you have before you.
Dr Mathie: I think it is important
to ensure that when one looks at systematic reviews one also looks
at individual medical conditions, for which homeopathy may or
may not be effective. In terms of the placebo effect, there is
evidence from three systematic reviews and meta-analyses of homeopathy
showing a specific homeopathic medicine is efficacious compared
with a placebo. Seasonal allergic rhinitis and vertigo would be
two particular examples that I could mention in more detail, if
you wish.
Dr Thallon: I will give my view
from an NHS commissioning perspective, as that is the organisation
I represent, and we found quite clearly that, in terms of competing
priorities, evidence in favour of homeopathy is so weak as to
not make it a priority within the context of the other priorities
facing the NHS.
Q113 Mr Stringer: That is an interesting
point. Should the NHS spending on any treatments be based on evidence
of efficacy or effectiveness?
Dr Thallon: Absolutely; I think
it should be an organising principle of our provision of health
care.
Q114 Mr Stringer: I am sorry, I perhaps
was not as clear about that. What is your understanding of the
difference between efficacy and effectiveness?
Dr Thallon: I do not know if I
have one, really. What I would stick to is that we would expect
that treatments which we commission to have been tested insofar
as it is possible—insofar as there is evidence of effectiveness
(I certainly understand what that is)—I would expect them
to have passed that by a wide margin and, also, for there to have
been a demonstrable need for that treatment in order for it to
be commissioned.
Dr Mathie: Can I answer the question
about efficacy compared with effectiveness?
Q115 Mr Stringer: Yes.
Dr Mathie: It is indeed a fundamental
point. Efficacy is judged in placebo controlled trials of a very
specific medicine or intervention. So it is very specific, usually
in terms of pharmacological investigation; it is a very specific
drug and a very specific dose; it is a very specific schedule
treating a very specific type of patient, who may be limited by
gender, age and so on. So efficacy is almost a laboratory experiment,
if you like; it is testing the way in which a drug, in principle,
could have an effect. Effectiveness is something that usually
non-placebo controlled trials are designed to do, usually against
usual care, or sometimes no treatment—for example, waiting
list controls—in which the real world effect of a system
of care is judged against what is usual up to that point—a
new intervention that is compared in the real world against usual
care.
Q116 Mr Stringer: Just on the first
part of the question, do you believe that NHS spending should
be based on efficacy or effectiveness?
Dr Mathie: Both.
Dr Fisher: In simple terms the
distinction is between ideal conditions and real world conditions—efficacy
being ideal conditions and effectiveness being real world conditions.
Yes, they should be based on decisions particularly about real
world effectiveness, because in the real world issues like long-term
use, the co-morbidity of people who have got multiple illnesses,
side-effects, and so on, are much more prominent than they are
in the short term, very rigorous efficacy studies. You may think
the distinction is academic but actually I can quote you numerous
examples where looking at the two different types of evidence
leads to different conclusions; treatments which appear to be
efficacious in small-scale but rigorous trials may not actually
be effective in the real world because of adverse effects or whatever.
Professor Ernst: I would agree
that good decisions are based on both. Efficacy tests whether
treatment works under ideal conditions; for instance, a hypertensive
agent may well be effective under ideal conditions and then will
not work in the real world because people experience side-effects,
etc, etc. Good decisions need to be both based on efficacy and
effectiveness. I would add, however, that without efficacy effectiveness
can be quite meaningless, and there are trials that are designed
in such a way that, for instance, could test standard care plus
homeopathy versus standard care alone. If you understand what
homeopathy entails, the empathetic encounter of one hour of empathy
and understanding towards the patient, it is predictable that
such a trial will generate a positive result simply because of
its non-specific effect—its placebo effects—and therefore
because it is predictable (and we have shown that this is predictable)
such a trial should not be done because you know the result before
the trial, and arguably such a trial is even unethical.
Q117 Mr Boswell: Can I come in on
this, and I think it is primarily for Dr Fisher. I wonder if you
would like to comment on the tolerance of homeopathic remedies
over a relatively long period of administration. I think it is
sort of implicit in the distinction you were drawing between the
necessary metrics for efficiency and effectiveness. Clearly, if
there are problems with long-term medication of, say, hypertension,
as Professor Ernst has mentioned, it might be helpful to the Committee
to know whether that is a factor which, at least, would colour
the advice which pharmacists would be giving to people.
Dr Fisher: Sure. It is normally
assumed that homeopathy is completely safe—at least direct,
in terms of the distinction between direct safeness and indirect
safeness.
Q118 Mr Boswell: There is no direct
harm derived from taking—
Dr Fisher: Actually, that is not
quite true. We did survey the literature, we asked the MHRA, we
asked the USFDA, we asked the companies and, actually, if you
look at placebo-controlled trials of homeopathy you do find a
slightly increased incidence of adverse effects in the active
arm compared to the placebo arm, but there is no evidence of serious
or life-threatening adverse effects. There is evidence that active
homeopathy can cause certain problems, and that comes from a systematic
review of the world literature.
Q119 Mr Stringer: Can you be more
specific about that?
Dr Fisher: There are a number
of reports. For instance, there was a trial done in Italy on homeopathic
medicine for prevention of flu where quite a lot of people who
actually got the homeopathic medicine got flu-like symptoms but
did not actually get flu. That was more frequent in the group
that got the active homeopathy than the ones who got the placebo.
It was quite a large study—800 patients studied—and
that is the largest, single report of adverse effects with homeopathy.
Again, the MHRA has a number of yellow cards; the FDA has reports
of adverse effects—generally mild and transient—but
there do appear to be some.
Professor Ernst: I think what
Peter just referred to, at least partly he referred to, is called
"homeopathic aggravation"; homeopaths believe that if
they find the ideal optimal remedy then there will be or can be
an aggravation in about 20 per cent of patients that is expected.
Peter also knows, because he has in his journal published our
systematic review of testing with these aggravations, we looked
at all the clinical trials and counted such events and we found
no statistically significant difference between the aggravations
reported in the placebo arms as compared to the homeopathic treated
arms. So the story of homeopathic aggravations may well be a myth.
Q120 Mr Stringer: Thank you. Dr Thallon,
is it ethical for the NHS to prescribe placebos? Should the NHS
prescribe placebos?
Dr Thallon: I struggle with the
notion that it is ethical to prescribe placebos. I am not saying
that it does not happen; I think that a number of the ways in
which people behave or prescribe could be described as prescribing
placebos but, in principle, if you prescribe a drug which you
know to have no clinical efficacy on a basis which is essentially
dishonest with a patient, I personally feel that that is unethical
behaviour.
Q121 Mr Stringer: Is the natural
conclusion from that that the NHS should not spend money on a
placebo?
Dr Thallon: I would very much
think that is a logical conclusion. To me, this is all about following
the evidence to its logical conclusion.
Q122 Mr Stringer: Does anybody else
want to comment?
Dr Mathie: Can I clarify, I think,
the key point that has not yet been raised this morning, and that
is that there are significant numbers of homeopathic medicines
that are not diluted to the point where the molecular content
is uncertain.
Q123 Mr Stringer: I am sorry, can
you say that again?
Dr Mathie: There are a substantial
number of homeopathic medicines where there is molecular content.
There seems to be an assumption that they are, to quote from an
earlier commentator, "just sugar pills"; in fact, many
are not just sugar pills and many of those have been investigated
in randomised controlled trials, and some of those have shown
clinical effectiveness beyond placebo, and some of those, in turn,
have shown clinically relevant and meaningful effects of homeopathic
medicines compared with placebo. So there are trials out there
which are of good quality and of good design, with good sample
sizes where positive evidence is available, and it is not cherry
picking.
Q124 Chairman: Would you give us
one example and get Dr Thallon to say whether it is NHS prescribed?
Dr Mathie: Vertigo. There is a
product made in Germany—regrettably it is not available
for use in the UK—called Vertigoheel and there is systematic
review of the original randomised controlled trials showing that
that product is efficacious beyond a placebo effect.
Q125 Mr Stringer: Professor Ernst?
Professor Ernst: I had my hand
up to answer your question on whether the NHS should prescribe
placebo or allow placebos. First, about Vertigoheel, this is not
even a homeopathic product; this is homotoxicological, which strictly
speaking is not homeopathic. This may be too technical. I would
argue—
Mr Stringer: It sounds very interesting,
actually.
Chairman: We can cope with technical
data; we are okay with that. We are called the Science Committee.
Q126 Dr Harris: Do not raise expectations!
Professor Ernst: If one defines
homeopathy as curing like with like, the homotoxicological treatments
are not homeopathic—that is the point I was trying to make.
Back to the placebo question. I would argue it is unnecessary,
unreliable and unethical to prescribe placebos through the NHS;
unnecessary because if you do it well then an active treatment
will also generate a placebo effect. If I give my patient an aspirin
for his or her headache and I do it with empathy, time and understanding
this patient will benefit from the pharmacological effect of the
aspirin and she will also benefit from the placebo effect through
the encounter with her clinician. It is unreliable and there is
lots of data to show that placebo effects are notoriously unreliable;
somebody who responds today may not respond tomorrow; responses
are not large in effect size and they are not usually long-lasting.
Foremost, it is unethical. That is my third point.
Q127 Mr Stringer: You get to the
same conclusion as Dr Thallon that, therefore, the NHS should
not spend money on placebos?
Professor Ernst: Correct, yes.
Dr Fisher: If I could just comment,
firstly, on Vertigoheel; it is actually registered as a homeopathic
product in Germany and prepared according to the HAB, the Homeopathische
Arzneibuch, which is the German Homeopathic Pharmacopoeia. To
come back to the other question of placebo effects, I believe
I am the only person called today who actually practises homeopathy.
I am a rather atypical homeopath in the sense that I am a doctor;
I am also an accredited rheumatologist—I could prescribe
all those nasty toxic drugs that my friends and colleagues prescribe
and freely acknowledge are less safe than they might wish. I practise
homeopathy because I think it works, and I believe the evidence
supports me in that. I would not practise it for two minutes if
I thought I was conning the patients. We just need to be clear
about placebo effects, because sometimes a lot of concepts get
muddled up. There are non-specific effects, sometimes also called
context effects, and that means that every good doctor should
talk to their patient, explain to their patient, give their patient
good advice on diet and lifestyle and do all of that before even
thinking of reaching for the prescription pad. However, having
done that—and I have absolutely no shame about maximising
my non-specific effects (I think every good doctor should do it)—I
would not use homeopathy for two minutes if I thought it was only
a placebo. I think the strongest evidence that it is not a placebo
comes from an area that has not even been mentioned this morning,
which is basic science. There is now a burgeoning area of basic
science—there are models which you can do in a test tube—which
show effects with high dilutions which have been replicated by
multiple laboratories, multi-centre groups. I believe there are
seven such models now, by the last count; the best known one is
inhibition of basophil degranulation by high dilutions of histamine
(basophils is a model of the immune response); there is another
one concerning aspirin and blood-clotting and another one concerning
metamorphoses of tadpoles to frogs. These have been replicated
by independent groups or multi-centre groups. The frog one was
done originally in Austria and recently repeated in Brazil.
Q128 Mr Stringer: Just a final question
to the whole panel. Should money that is spent on homeopathic
consultations be redirected to elsewhere in the NHS?
Dr Thallon: We very much take
that view. We would not swap it from one treatment directly to
another, but clearly if the business of PCTs is about prioritisation
then the treatment which the balance of scientific opinion says
is of either virtually no efficacy or effectiveness or none we
would prioritise at a far lower level than other treatments we
wish to commission.
Dr Mathie: For me it begs the
question that there is a need for cost-effectiveness evaluation
of homeopathy. There is almost none, at this stage, and the whole
question about the cost and the impact of homeopathic consultation
could be tested in appropriate studies. The other problem, I think,
is that where does the patient go if he or she does not go to
the homeopathic practitioner? I am talking about in, typically,
a medical practitioner of homeopathy. They will go elsewhere in
the NHS and they may not get the rounded approach to treatment
of the person which is what homeopathy is characterised by. So
this is not a straightforward point.
Q129 Mr Stringer: Dr Fisher?
Dr Fisher: What was the question—I
am sorry?
Q130 Mr Stringer: The question was
should the money that is spent on homeopathic consultations be
redirected within the NHS?
Dr Fisher: I think the evidence,
such as it is (for instance there is good evidence from France
and Germany) is that you get more bang for your bucks with homeopathy.
If you integrate homeopathy you get better outcomes and it does
not cost any more. So I do not think it should be redirected;
you get more bang for your bucks.
Q131 Mr Stringer: Professor Ernst?
Professor Ernst: If the NHS's
commitment to evidence-based medicine is more than lip service
then, surely, money has to be spent for treatments that are evidence-based,
and homeopathy is not.
Q132 Dr Harris: Dr Fisher, you mentioned
that there were some adverse effects found in homeopathic treatments.
How many homeopathic treatments over the 200 years that it has
been in existence have been withdrawn from the market due to safety
fears because of these adverse effects, as one sees in conventional
medicine?
Dr Fisher: Not many but some have
been. The most recent one was something called Malaria-officinalis
which was most regrettably (and I opposed it) used by some non-medical
homeopaths allegedly to prevent malaria.
Q133 Dr Harris: It had side-effects,
did it?
Dr Fisher: No, it was withdrawn
because of safety concerns.
Q134 Dr Harris: On the basis of adverse
effects?
Dr Fisher: No, nothing has been
withdrawn.
Q135 Dr Harris: That is interesting.
When Graham Stringer was asking the questions he started with
you, Professor Ernst, so you did not get a chance to respond to
the assertion made by the witnesses on your left that systematic
reviews overwhelmingly showed effectiveness of homeopathy.—five
out of six, I think, was the expression used.
Dr Fisher: Four out of five.
Dr Mathie: I do not think we used
the word "overwhelming".
Q136 Dr Harris: Four out of five
seems to be a majority. Would you comment on that? Have there
only been five systematic reviews and do they show that positive
result, in your opinion?
Professor Ernst: I have supplied
you with a list of systematic reviews as published a few years
ago, and in that list there are already, I think, almost two dozen.
Q137 Dr Harris: Two dozen?
Professor Ernst: None in that
list, which was after a very prominent systematic review and meta-analysis
by Klaus Linde was published in The Lancet, including the
ones we analyse in The Lancet data including Linde re-analysing
his own data, none of these systematic reviews were positive.
Q138 Dr Harris: Why do you think
that homeopaths say that systematic reviews are positive if it
seems to you that they are not positive? Both sides cannot be
right.
Professor Ernst: I know of some
reviews which are not systematic. I know of a Swiss health technology
assessment which is not what I understand by a systematic review
because it includes everything such as case series observational
studies, non-controlled studies, non-randomised studies, and so
forth. When you do that indeed the majority of publications is
positive, but in a systematic review, typically, you define your
entry criteria and we usually define them as randomised clinical
trials—if possible, randomised placebo controlled clinical
trials and in homeopathy that is possible—and the vast majority
of these systematic reviews do not confirm that homeopathic remedies
are more than placebos.
Q139 Dr Harris: Dr Mathie, do you
accept that the overwhelming view of independent researchers,
who do not make money from conventional medicines competing with
you or make money from practice or selling or manufacturing of
homeopathic medicine—do you accept, even though you may
disagree with them, that the overwhelming majority of people who
have looked at this from an independent perspective say that the
evidence base is poor for efficacy of homeopathy when looking
at good quality systematic reviews?
Dr Mathie: Given that most people
in that category probably have not investigated the research literature
in sufficient depth to really form a well-judged opinion, my answer
would be yes.
Q140 Dr Harris: Because they are
ignorant, essentially? I do not mean that in a pejorative way;
they just have not done the job well enough—all these people
like Professor Ernst, who is a Professor in this field. They are
just inadequate in their research?
Dr Mathie: Not at all. What I
would say is that there are those with whom I have endeavoured
to collaborate and do have collaborations with who are mainstream
academic researchers—for example, in atopic eczema at the
University of Nottingham—who are seriously engaged by the
idea of conducting randomised controlled trials in homeopathy
because atopic eczema is not well treated conventionally and they
see an effectiveness gap there, and it is worth trying and worth
testing in an objective, open-minded fashion. There are many people
in the country who are prepared to engage in homeopathic research
and it is those types of people that I am very eager to collaborate
with.
Q141 Dr Harris: However, systematic
reviews take a lot of time; you have to look through thousands
of papers—
Dr Mathie: Of course they do.
Q142 Dr Harris: You have to check
them and the entry criteria. You have to be quite dedicated to
do these systematic reviews and to review systematic reviews.
The majority of those people, without an axe to grind, say that
they do not show an effect. Does that worry you?
Dr Mathie: It does. However, reviews
are designed to distil the literature out into a single paper
or two, compared with maybe a dozen randomised controlled trials.
Can I just address the question about the discrepancy of opinion
regarding the results of systematic reviews. May I just quote
a recent paper by Dr Klaus Linde himself in a paper published
just a few months ago. He says: "With small and heterogeneous
datasets, the most likely situation in complementary and alternative
medicine—these decisions [about the validity of trials and
which trials are contained within systematic reviews] can lead
to quite different findings. A powerful example of how different
approaches, summarising the available evidence, can lead to very
different conclusions are the two large meta-analyses on homeopathy
published in The Lancet 1997 and 2005"—and we
know which ones he is talking about there—"although
the basic datasets [themselves] yielded similar findings";
it is the interpretation that differs depending on one's perspective.
Q143 Dr Harris: Feel free to send
that into us. That is probably the easiest thing.
Dr Mathie: I can hand it to you
if you would like.
Q144 Dr Harris: I just want to deal
with this ideal world/real world thing. If you cannot find an
effect, if you cannot demonstrate efficacy in an ideal world where
everything is set up to identify that effect, it is hard to see
that an effect you see in the real world—dirty clinical
practice if you like—is based on the cited efficacy. It
might be due to confounding factors.
Dr Mathie: I understand your question.
Q145 Dr Harris: It is not the other
way round, is it?
Dr Mathie: However, it is based
on a false premise, if I may say so, because in fact there is
efficacy research there. There are published efficacy studies.
There are something like 37 of them, if I remember offhand, where
there is positive evidence. There are another 50 in which there
is inconclusive or perhaps negative evidence. What I would make
a plea for is that the efficacy studies that do exist—and
I could name them all and I can send the details to you because
they exist out there—should transform gradually over time
with active research into effectiveness research where those homeopathic
medicines that are shown to be effective are used within the armamentarium
of the homeopathic process because, after all, what has not become
fully clear this morning is that homeopathy is a system of care.
There are 3,000 homeopathic medicines in the pharmacopoeia. We
need to understand the efficacy of each, ideally, but let us do
it gradually with those specific medicines where they are frequently
used and have been researched in efficacy research and can become
gradually evidence-based contributions to homeopathy as a system
of care.
Q146 Dr Harris: Dr Thallon, you have
sent in evidence setting out how you did your review, and I do
not think it is worth you repeating that because it is in the
written evidence which will be published if we do a report on
this, as I suspect we will. Why do you think it is right that
what you did should have to be replicated many times in every
commissioning organisation or is there something in the water,
or not in the water in West Kent, that makes your findings different
from something that might be done in Manchester?
Dr Thallon: We are in a particular
circumstance because there is a homeopathic hospital within our
geographical locality and that is why we had to go to the lengths
we did in order to prove the case, because other commissioning
organisations who spend a bit of money on homeopathy did not have
the facility within their borders that meant that the resistance
to the commissioning decision was likely to be as intense as it
was for us. I think our process in terms of its quality and the
way that it is done with scrutiny is a good roadmap for other
organisations to adopt, and we would be very happy to act as a
guide to other commissioning organisations that wish to follow
this path. Personally, I feel that if effectiveness in clinical
treatment and evidence-based medicine is going to be an organising
principle of the NHS, then to do this in every locality would
be a diversion of otherwise scarce resources, and if it were possible
to learn from our experience then we would be very happy to give
that learning out.
Q147 Dr Harris: Have you considered
either circulating it yourself, would you have objections to other
people circulating it, or do you think it would save time and
money if the Department of Health circulated your work?
Dr Thallon: I certainly do not
think the issue of the decommissioning of non-evidence based practice
should be beneath the Department of Health to help commissioning
organisations with. Yes, I would have thought there could well
be a role for the Department of Health in helping other organisations
get to the point we have got to should they choose to do so.
Q148 Dr Harris: The Department of
Health has not issued any guidance and has not asked NICE to look
at this. That may be a reluctance by the Department of Health
to give any advice or instructions or guidelines or policies to
commissioners, but my experience locally is that commissioners
are overwhelmed with guidance and advice and executive letters
and circulars from the Department of Health.
Dr Thallon: Not overwhelmed but
there is plenty of it.
Q149 Dr Harris: As an individual
doctor who has the views you have, having looking at it, why do
you think the Department of Health and ministers are not dealing
with this?
Dr Thallon: I think this would
have to be a personal rather than an organisational view.
Q150 Dr Harris: Of course.
Dr Thallon: I think the politics
of homeopathy and what homeopathy is are difficult because homeopathy,
to an extent, appears to my mind to go beyond the debate purely
about the science, because I feel that we have taken a view about
where the balance of the scientific community's opinion is on
homeopathy and to me and my colleagues it is pretty clear. Clearly
there is something that perpetuates the notion that homeopathy
is important which goes beyond purely the scientific debate because
to my mind—and it can never be settled because you never
know what might happen—the balance of the current research
at the moment suggests to us, essentially scientifically trained
but lay people, that the issue of the effectiveness of homeopathy
is not in question.
Q151 Dr Harris: My last question
is to Dr Fisher. In your written submission to us, which I read,
and in your answer, you talked about the basic science that shows
a basis for the function of how homeopathy might work. I think
it is fair to say that some of it is radical stuff. Why do you
think that there has been no Nobel Prize given to the people who
have made these astonishing discoveries of the potential for the
memory of water and a physiological impact of some homeopathy
remedies where the dilution is such that it is accepted that there
is unlikely to be a single molecule left?
Dr Fisher: It may yet happen.
I think we are at a very early stage. The research has burgeoned
in the last few years and it needs more work. We are talking about
a sociological phenomenon within the scientific community and
of course new ideas often encounter strong resistance. I think
that is what is going on. People say loosely that it challenges
the basic laws of physics; it does not. It may yet happen.
Q152 Dr Harris: On that basis then
why is it that when you have a solution of water that used to
have some homeopathic substance in it but it has been diluted
that the water is said to retain that memory but does not remember
all the poo, you could call it, that has been in it, because all
water has bits of our effluent.
Dr Fisher: I am surprised you
did not mention Oliver Cromwell's bladder. In this context it
is traditional to mention Oliver Cromwell's bladder because apparently
somebody once calculated that in each glass of water you drink
it is statistically probable that one of those molecules once
passed through Oliver Cromwell's bladder.
Q153 Dr Harris: The point I am making
is that you have a higher chance of having that molecule but you
do not believe the molecule is necessary, so why is it that the
specific effect is from the homeopathic element that has been
in it and not someone's ammonia that has been in it?
Dr Fisher: It is quite straightforward.
The point is that we use highly purified water and highly purified
ethanol there. There is no such thing as absolutely pure water
but this is highly purified, it is double-distilled and deionised.
Q154 Dr Harris: It has not even got
sugar in it?
Dr Fisher: At that stage no, so
the impurities are a concentration of parts per million or parts
per billion. You then add something at a concentration of parts
one in ten or one in 100 and shake it. .
Q155 Dr Harris: The shaking is important?
Dr Fisher: The shaking is important.
Q156 Dr Harris: I would have thought
it would have less memory if you shook it. I can understand if
you left it alone it might form a memory.
Dr Fisher: This has been looked
at and the answer is that it does not induce the same structural
effects. You are inducing structural effects which may involve
silica and which may involve dissolved oxygen molecules—it
is not quite certain—but you can show that this water is
different from water that is just shaken without the stuff being
in it.
Q157 Dr Harris: How much do you have
to shake it?
Dr Fisher: That has not been fully
investigated.
Q158 Dr Harris: A random amount of shaking?
Dr Fisher: You have to shake it
vigorously but exactly how much you have to shake it, no. If you
just gently stir it, it does not work.
Q159 Dr Harris: Does the MHRA check
how much it has been shaken before it approves it for treatment?
Dr Fisher: You would have to ask
the MHRA, I do not know.
Q160 Chairman: Dr Harris, I am going
to leave the shaking at that point. Professor Ernst, you just
wanted to have a last word on that.
Professor Ernst: Just a quick
comment. Even if the water is different it leaves totally unanswered
the question of how it exerts any health effects in human bodies.
The water in my kitchen sink is also different from distilled
water yet it is unhealthy and not healthy.
Chairman: Okay, we will ponder on that.
Dr Iddon?
Q161 Dr Iddon: This year the Department
of Health announced that it was going to run some pilot studies
on personal health budgets allowing people to spend public money,
to a degree, on whatever they desire to spend it on, including
homeopathy. Bearing in mind that the National Health Service is
always short of money—this has already been referred to—is
it right, do you think, gentlemen, that people should be able
to take money away from perhaps more deserving areas in the NHS
and spend it on homeopathy if that is what the patient desires?
Professor Ernst: This is presumably
from the ill-conceived notion that patient choice has to dominate
in health care. I am an ex-clinician and I know about the importance
of patient choice, but patient choice that is not guided by evidence
is not choice but arbitrariness, and therefore I am not in favour
of it.
Dr Fisher: I strongly support
patient choice and clearly where patients do get the opportunity
to choose they very often do choose homeopathy and other forms
of complementary medicine.
Q162 Dr Iddon: And it is right that
that should be with public money rather than their own money?
Dr Fisher: Yes, I think so. There
needs to be a balance but, yes, successive Governments have been
committed to patient choice and rightly so, in my view.
Dr Mathie: The British Homeopathic
Association strongly supports patient choice for treatments that
are evidence-based and would propose the development of much greater
research in order to secure that evidence base.
Dr Thallon: Personally I support
the issue that clinical effectiveness should be an organising
principle of the NHS. It is conceivable that personal health budgets
may cause some inefficient use of NHS resources, however, there
are limits and the NHS is not purely governed by clinical effectiveness.
There are issues of patient consent and it is public money at
the end of the day. It may well be right for people to have an
element of choice in what they spend their money upon. However,
I think there are issues around whether or not they should be
able to choose a treatment which is clearly lacking in evidence.
What would happen once that treatment had been used, found to
be ineffective and they were forced to return to the NHS; what
would the attitude of the NHS be at that point?
Q163 Dr Iddon: I think I can only
put this question to these three gentlemen and it is this: if
a patient came to you for homeopathic treatment and you felt that
you might put that patient at risk by treating them in such a
way, would homeopaths have the courage to refer them to a traditional
clinician because with a homeopath the patient might be at risk
with the homeopathic treatment as against the traditional treatment?
Professor Ernst: I find it impossible
to generalise across homeopaths. There are good homeopaths, in
the sense that they are responsible and try their best to look
after patients, and there are homeopaths who are less well equipped
to do that and indeed less well-trained, and I would argue that
doctor homeopaths, by and large, are better equipped to do that.
There are too many different types of homeopaths for me to be
able to answer that question.
Q164 Dr Iddon: I know it is difficult
to generalise, I accept that point but do you think homeopaths
are adequately qualified to recognise by a clinical diagnosis
a serious medical condition?
Professor Ernst: Doctor homeopaths
should be because they have studied medicine. Anybody who has
not studied medicine is unlikely to be well-equipped for all difficult
situations.
Dr Fisher: I can only speak on
behalf of the Faculty of Homeopathy which is a statutory body
which only admits members of registered health professions, so
that includes doctors but also veterinarians, dentists, pharmacists
and so on, and for them the answer to your questions is absolutely
yes; they are equipped to make a diagnosis and indeed to recognise
the domain of professional competence. It is normal for a pharmacist,
for instance, to give advice over the counter in the shop and
also to say, "You need to go to see a doctor about that."
Of course the answer is yes, they are equipped and they would
refer on when required.
Dr Mathie: Unequivocally yes.
Q165 Dr Harris: One quick question
to Dr Mathie. You are an adviser to the British Homeopathic Association.
You do not register homeopaths?
Dr Mathie: No, the Faculty of
Homeopathy does that. We are a charity and I work as a research
development adviser for the charity. And I am not a homeopathic
practitioner, by the way.
Q166 Dr Harris: I want to ask you
if you are able to answer this and if you are not, I am sorry,
but, presumably, if there is a register—and I know it is
an unofficial register and it is not government-regulated—that
means homeopaths who stray outside what they should do ethically
and beyond their competence are subject to being struck off essentially
or disciplined?
Dr Mathie: Yes.
Q167 Dr Harris: I am just wondering
why it is that we have not heard, and maybe I have just not heard
correctly, that the 10 or 11 homeopaths that are willing to prescribe
prophylactic homeopathic anti-malarials, in the absence of advice
about conventional anti-malarials and bed nets for avoiding being
bitten, which is essential, fundamental, first year medical student
advice you give to a traveller going to a malaria area, whether
any action was taken against them by their regulatory bodies?
Have you or Dr Fisher heard through your experience that either
this practice is rife or that the penalty is that you cannot advertise
as being a Member of the Faculty?
Dr Fisher: It did not involve
any member of the Faculty. The Faculty of Homeopathy was incorporated
by Act of Parliament and it only admits registered health professionals
and none of its members were involved in that particular case.
Q168 Dr Harris: So it is the Society
of Homeopaths I am maybe thinking of?
Dr Mathie: To answer your question
more completely, the Faculty of Homeopathy is very clear in its
statement to its member practitioners that prophylactic homeopathy
is not recommended, and that includes of course malaria. We would
not support the use of prophylactic homeopathy for malaria.
Q169 Dr Harris: But should the Society
of Homeopaths deregister someone who prescribes them? These things
are on the market, are they not? I do not understand why they
are on the market if even you think they should not be used. It
does not make sense to me.
Dr Mathie: It is not for me to
suggest the behaviour of the Society of Homeopaths.
Q170 Chairman: But you are suggesting,
Dr Mathie, that everybody practising homeopathy should be appropriately
registered?
Dr Mathie: Of course they should
be and there is an aim to do just that.
Q171 Dr Harris: I really cannot understand
this. You say you should not give homeopathic anti-malarials and
yet they are on the market. Have you urged or has the Faculty
urged or has the BHA, whom you advise scientifically, urged manufacturers
to stop manufacturing these things that people might buy?
Dr Mathie: Not quite so explicitly
but we are unequivocally against the practice.
Dr Fisher: I am not aware that
homeopathic anti-malarials are on the market, but certain people
are using existing homeopathic medicines and claiming they will
prevent malaria. To my knowledge, they are certainly not legally
on the market labelled "this will prevent malaria".
Q172 Dr Harris: What was your reaction
to the Society of Homeopaths symposium which argued that AIDS
could be treated homoeopathically? Were you embarrassed by that?
Dr Fisher: I was not at it and
I do not know what happened. Certainly in our hospital, for instance,
we have a complementary cancer treatment service which uses homeopathy,
among other things, and we have recently, indeed, completed a
Cochrane review on homeopathy for the management of the adverse
effects of cancer.
Q173 Dr Harris: But can you say that
you think there is a role for homeopathy in the treatment of AIDS?
Dr Fisher: I have certainly treated
people who have AIDS, not for the primary condition but for the
complications and problems they have with the disease or with
the treatment of it, but I would never claim to be able to cure
AIDS.
Dr Mathie: And nor would we.
Chairman: I am sorry, Dr Harris, I am
going to finish on that note. Can I thank you all very much indeed
for joining us this morning for what has been an incredibly useful
session.
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