On Monday night, the 20th October 2008, I will attend a debate at University College London at 7.00 pm. The motion is: ‘This House believes homeopathy should not be available on the NHS’ The debate is free and open to all and this is how you get there.

Speaking against the motion: Dr Peter Fisher – doctor, specialist physician,chief consultant at the Royal London Homeopathic Hospital and homeopathic physician to the Royal Family.

Speaking for the motion: Simon Singh – author, journalist and TV producer

But fear not for the intrepid Singh! It is he who has home ground advantage for UCL is the spiritual home (okay really sorry to use that word to describe disciples of Scientism – but you know what I mean) of four of the authors of a famous/notorious letter attacking the provision of homeopathy on the NHS, Professor David Colquhoun, Professor Lewis Wolpert, Professor Michael Baum and Professor Peter Dawson.

I have referred to this letter before in these pages and accused it of trying to thwart the wishes of Britain’s GPs. Homeopathy is only available on the NHS if your GP refers you to an NHS homeopathic clinic. But Coquhoun, Wolpert, Baum, Ernst and co. (see below) did not address this letter to GPs; they wrote to Patient Care Trusts (PCTs) essentially appealing to them to prevent GPs in their areas from sending patients to NHS hospitals. Although some would describe such an action as patronising and condescending to GPs, they were quite successful with some PCTs banning GPs from referring patients for homeopathy! GPs are quite at liberty to send patients for all sorts of unproved orthodox interventions of course. Anyone reading these notes knows that huge swathes of conventional medicine are far from being evidence based. I’ve used a pie chart from the BMJ’s Handbook of Clinical Medicine many times to illustrate this.

Their letter was an open one so I thought it opportune to re-publish it here and annotate it.

We are a group of physicians and scientists who are concerned about ways in which unproven or disproved treatments are being encouraged for general use in the NHS. We would ask you to review practices in your own trust, and to join us in representing our concerns to the Department of Health because we want patients to benefit from the best treatments available.

As a physician myself, I wholeheartedly concur with this opening statement. We need to have a way of accurately assessing whether a treatment is proven or unproven. May I suggest this immaculately constructed diagram that appears in the British Medical Journal’s Handbook of Clinical Evidence as a guide to making such assessments.

This will enable us to categorize any form of medical intervention in terms of how well it has been proven. I feel confident that learned physicians such as yourselves will agree that assessing any intervention ‘alternative’ or ‘orthodox’ needs just such an objective assessment of its proven efficacy.

There are two particular developments to which we would like to draw your attention. First, there is now overt promotion of homeopathy in parts of the NHS (including the NHS Direct website). It is an implausible treatment for which over a dozen systematic reviews have failed to produce convincing evidence of effectiveness. Despite this, a recently-published patient guide, promoting use of homeopathy without making the lack of proven efficacy clear to patients, is being made available through government funding. Further suggestions about benefits of homeopathy in the treatment of asthma have been made in the ‘Smallwood Report’ and in another publication by the Department of Health designed to give primary care groups “a basic source of reference on complementary and alternative therapies.” A Cochrane review of all relevant studies, however, failed to confirm any benefits for asthma treatment.

Fellow physicians, I do not think it becoming of us to focus on or attack any one form of intervention in isolation as this may invite criticisms of inherent bias. It is incumbent upon us to agree on standards of proven efficacy and then objectively rate each intervention. The BMJ’s pie cited above, could be used until the appearance of a better objective methodology of assessment. May I respectfully suggest that our opinions (necessarily subjective) of what is ‘implausible’ are somewhat less important than objective assessment.

Secondly, as you may know, there has been a concerted campaign to promote complementary and alternative medicine as a component of healthcare provision. Treatments covered by this definition include some which have not been tested as pharmaceutical products, but which are known to cause adverse effects, and others that have no demonstrable benefits. While medical practice must remain open to new discoveries for which there is convincing evidence, including any branded as ‘alternative’, it would be highly irresponsible to embrace any medicine as though it were a matter of principle.

I absolutely agree that adverse effects of any medical intervention are a major concern for us all. Thus surely any form of treatment that is included in the repertoire of NHS doctors should not only be given its rightful place in the pie diagram but also be included in another diagram constructed to show all documented risks and side effects. In this way physicians and patients will be able to make accurate efficacy versus risk assessments on any treatment in any condition. Obviously the same criteria should be used objectively for all forms of interventions otherwise we risk being seen as biased in favour of treatments that we subjectively consider ‘plausible’.

At a time when the NHS is under intense pressure, patients, the public and the NHS are best served by using the available funds for treatments that are based on solid evidence. Furthermore, as someone in a position of accountability for resource distribution, you will be familiar with just how publicly emotive the decisions concerning which therapies to provide under the NHS can be; our ability to explain and justify to patients the selection of treatments, and to account for expenditure on them more widely, is compromised if we abandon our reference to evidence. We are sensitive to the needs of patients for complementary care to enhance well-being and for spiritual support to deal with the fear of death at a time of critical illness, all of which can be supported through services already available within the NHS without resorting to false claims.

I agree that funds should only be automatically available for treatments based on ‘solid evidence’. I take it that you would agree that only the sector of the BMJ’s pie representing the 13% of orthodox interventions that have been proved to be beneficial, qualify for automatic funding by the NHS. It is vital that funding for anything lying outside this segment be decided by objective assessment on a level playing field and not ‘plausibility’ which is highly subjective. Some may suggest that the medically uneducated general public should have a say about which – if any – of the treatments (both orthodox and alternative that do not have ‘solid evidence’ behind them) should be funded by their taxes. This would be consistent with the current zeitgeist where the people are promised ‘choice’ in their lives. So perhaps we could have a ‘People’s Choice’ segment of the pie representing funding. Or perhaps the power of decision should always remain with physicians who are better qualified to speak about the health and taxes of the people than they are themselves.

May I also respectfully suggest that the term ‘spiritual support’ is unbecoming of gentlemen of your standing in the medico-scientific community, has none of Popper’s falsifiability and therefore should be considered somewhat less than scientific. Therefore it is my humble opinion that it should not be used in discussions of this kind. Even if (in a bad case scenario for medical science), ‘spiritual support’ was shown to be evidence based medicine, surely we physicians are at least as capable of administering it as uneducated ‘alternative’ or ‘complementary’ practitioners?

These are not trivial matters. We urge you to take an early opportunity to review practice in your own trust with a view to ensuring that patients do not receive misleading information about the effectiveness of alternative medicines. We would also ask you to write to the Department of Health requesting evidence-based information for trusts and for patients with respect to alternative medicine.

Gentlemen physicians, I could not agree more that these matters are not trivial. But may I respectfully request more respect for our colleagues on the coalface of primary medical care – our NHS general practitioners. I accept that until we have constructed a new pie showing which treatments not in the crucial 13% segment of the BMJ pie, should be funded for various reasons such as patient demand (however irrational that can be at times) we leave such decisions to our hardworking GPs and not to non-medically qualified people in administration who may not find it easy to make objective assessments about complicated but profound medical issues. In addition our noblest efforts on behalf of the public risk being seen as patronizing and condescending by our tireless GPs who will soon be consulting on weekends.

Primum non nocere.

Your colleague,
Dr Brian Kaplan

Finally for the record, these are the doctors that signed the open letter to Patient Care Trusts (PCTs – which comprise mainly non-medical people) in order to persuaded them to thwart GPs in their areas from referring patients to NHS homeopathic physicians.

Yours sincerely

* Professor Michael Baum, Emeritus Professor of Surgery, University College London
* Professor Frances Ashcroft FRS, University Laboratory of Physiology, Oxford
* Professor Sir Colin Berry, Emeritus Professor of Pathology, Queen Mary, London
* Professor Gustav Born FRS, Emeritus Professor of Pharmacology, Kings College London
* Professor Sir James Black FRS, Kings College London
* Professor David Colquhoun FRS, University College London
* Professor Peter Dawson. Clinical Director of Imaging, University College London
* Professor Edzard Ernst, Peninsula Medical School, Exeter
* Professor John Garrow, Emeritus Professor of Human Nutrition, London
* Professor Sir Keith Peters FRS, President, The Academy of Medical Sciences
* Mr Leslie Rose, Consultant Clinical Scientist
* Professor Raymond Tallis, Emeritus Professor of Geriatric Medicine, University of Manchester
* Professor Lewis Wolpert CBE FRS. University College London