Memorandum submitted by the West Kent NHS
Evidence Check 2 Homeopathy
1. Background to Homeopathy Commissioning Review
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 This decision was challenged via judicial review and subsequently rescinded while the PCT conducted a full Equality Impact Assessment (EIA), which took place between December and June 2008.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 evidence base
· Production of a consultation document and related questionnaire - sent to a random sample of 1000 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
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 of homeopathy.
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
commissioning data indicates that in total 52% of all GP practices across
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.
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
2.3 Value for money
2.3.1 The financial value of homeopathy is small - c. £200k 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 other services.
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
than 1% of the PCT population use homeopathy services, with the majority
focused in Tunbridge Wells. Service use
is not spread equally throughout
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.
2.5.4 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 Change
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:
· Renegotiate the tariff
· Introduce a homeopathy exclusions policy
· 'Multi-faceted' option (incorporating a number of other options)
4. Mitigating Actions
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 homeopathy treatment
· 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. Individual Treatment Panel
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. Declaration of Interest
7.1 NHS West Kent operates a policy not to fund routine homeopathy treatment.
Dr James Thallon
Medical Director, NHS