Evidence Check 2: Homeopathy - Science and Technology Committee Contents

Examination of Witnesses (Questions 112-173)


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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