Written evidence submitted by the Society of Homeopaths (ELC0055)
Organisation
The Society of Homeopaths is the UK’s largest professional organisation registering homeopaths with 1300 members. Homeopaths registered with the Society have agreed to practise in accordance with a strict Code of Ethics and Practice, hold professional insurance and pass academic and clinical assessment before being admitted to the Register. The Society’s register has recently been accredited by the Professional Standards Authority.
Reason for submitting
Treatment by homeopaths is being effectively employed at end of life in hospices, NHS settings and privately. Patients select this treatment method and patient rated improvements in wellbeing and clinical symptoms are measured in studies. We argue that treatment by homeopaths can provide a patient centred, cost effective model which addresses the five priorities for care outlined by the Department of Health.
Summary
There is a significant trend for homeopaths to see many patients in palliative and end of life care. This document will therefore outline:
This document will highlight the potential for homeopathy as a medical system, treatment option and philosophy to address issues of specific interest to this Health Committee enquiry, namely that:
An introduction to homeopathy
Homeopathy is
“a system of therapeutics founded by Samuel Hahnemann (1755-1843), based on the Law of Similars where ‘like cures like’. Diseases are treated by highly diluted substances that cause, in healthy persons, symptoms like those of the disease to be treated. The dilutions are repeated so many times that there is less than one molecule per dose, and it is suggested that benefit is from the energetic life force of the original substance” (http//www.nim.nih.gov/cgi/mesh).
The therapeutic system of homeopathy is founded upon several principles. Most pertinent to this submission is the principle of individualisation whereby medicines are prescribed according to patient specific as opposed to disease specific symptomatology. Most controversial is the principle of potentization, whereby the medicinal effect of a homeopathic medicine can be changed and/or enhanced (and the toxic side effects diminished) (Hahnemann 1846) for which there are currently no accepted explanations for mechanism of action ( Walach 2005).
Treatment by homeopaths is available in some locations on the NHS via medically qualified homeopathic practitioners, in some hospices and privately via professional homeopaths.
Homeopathy Research
Most published trials of the efficacy of homeopathy do not reflect the central principles of homeopathy, hampering demonstration of homeopathy’s effectiveness. Nevertheless of six systematic reviews examining the RCT research literature on homeopathy, five reached the conclusion that, with important caveats, homeopathic medicines probably differ from placebo medicines (Mathie, 2014).
We suggest that the therapeutic modality of homeopathy is best characterised as a complex intervention (Relton, 2007). Treatment by homeopaths is best seen as a ‘whole systems’ approach suggesting interconnectedness, non-linear outcomes and a contextual view of human beings as inseparable from and responsive to their environments (Koithan et al., 2012). This contrasts to the biomedical model which presupposes unidimensional simple causes and individually tests single aspects. The ongoing debate about the efficacy of the individual elements and how to test them using biomedical methods is obscuring the fact that patients accessing treatment by homeopaths consistently say they feel better.
Individually tailored care
During a consultation the professional homeopath will focus on building up a complete picture of an individual’s unique make up considering all aspects of the patient’s health including diet, medical history, life events, lifestyle and personality. Homeopathic prescriptions are based on the process of matching this unique collection of symptoms as closely as possible with those of an appropriate homeopathic medicine (called a ‘remedy’). This personalised approach is known as the principle of individualisation. Homeopathy can therefore be seen as a ‘holistic’ therapy, such that homeopathic care takes into account all aspects of the patient as an individual.
Homeopathy as well placed to support multi-morbid patients requiring palliative care
Homeopaths usually see patients after they have received medical diagnoses and treatment from their doctor. Some individuals seek a homeopath because they are experiencing side effects from conventional drugs, others because they have symptoms that fail to respond to conventional medicine and others because conventional tests have failed to find the cause of their problem (Spence et al, 2005; Luff et al., 2000). Many of these patients have long-term health problems and multi-morbidities ill addressed by the biomedical model.
The potential to deal with multiple complaints using a single remedy is a core competency of homeopathic treatment and well placed to support the treatment of multi-morbid patients clinically and cost effectively (Frei, 2014). In comparison, conventional medicine prescribes separate medications for each complaint, so patients often undergo polypharmacy. This may result in drug interactions and undesirable side effects. Treating patients as whole people rather than focusing on a course of action for each disease diagnosis has been shown to provide effective amelioration of symptoms according to patients. A recent study of 43 mulitimorbid patients (at least 3 co-morbidities) given homeopathic treatment found 47% improvement after one month and 63% after two months rating each symptom’s intensity on a scale of 0-10 (Frei, 2014).
Homeopathy as well placed to support patients cost-effectively
Homeopathy is often accessed within the NHS as one of a basket of Complementary and Alternative Medicines (CAMs). In 2001 between 5% and 11% of practices nationally were providing CAM therapies to support patient groups and 18% - 50% of GPs felt that complementary therapies had the potential to contribute to the care of these patients (Thomas, 2001 & 2005). Homeopathy was most frequently used for cancer care; emotional problems, care of the elderly, acute minor ailments; minor trauma; children’s injuries; and symptom relief.
However the report found that the proportion of practice-based CAM services funded by the NHS fell from 75% of practice-based CAMs provision funded by the NHS in 1995; to 58% in 2001. It is hypothesised that it has since fallen more. This despite the fact that most health economic studies associate homeopathy with reducing direct, indirect and intangible healthcare costs whilst increasing Quality of Life and reducing disease severity (eg Witt et al., 2005 &2008). One UK study suggests a saving of £190 million if 4% of GPs use homeopathy (Roberts, 2008).
A financially straitened NHS is struggling to cope with an aging population with chronic disease. New ways have been called for to diminish the financial burden by investigating the appropriateness, cost-effectiveness and efficacy of various medical systems (Council of the EU, 2013). Homeopathic treatment is a medical system well placed to achieve this.
Homeopathy is valued by patients
Qualitative research demonstrates high satisfaction with complementary therapies (including homeopathy) among patients receiving treatment funded within the NHS. Semi-structured interviews using a critical incident approach (n=49) in 8 sites across England providing complementary therapy services within primary care concluded that they were experienced as ameliorating and curing conditions, including chronic problems. Practitioners were perceived as being caring and patients valued the development of a therapeutic relationship within which they were encouraged to take an active part in looking after their health. Positive experiences of complementary therapy use were contrasted with either a failure of orthodox medicine or a dislike of the orthodox treatments available to them. Very few negative aspects were reported (Luff, 2000).
Surveys also suggest high satisfaction with treatment by homeopaths. A recently published paper by Van Wassenhoven and colleagues (2014) surveyed 919 adults receiving homeopathic treatment in six European countries and Brazil to explore their reasons for consultations, expectations and satisfaction with homeopathy. Perceived health-related quality of life improvement between baseline and six months was β = 0.339, t = 6.441, p = 0.000 with difference ranging from 3.87 to 10.41 depending on diagnosis. Patients suffering from stress, anxiety, depression (mean change 10.408, CI 5.730), skin affections (8.897, CI 3.754) and psychological complaints (7.327, CI 2.404) rated improvements highest. The satisfaction of patients was linked to the perceived competence of the homeopath, perceived improvement of the main complaints and the time dedicated to them by the homeopath.
In the UK, a six-year outcome study at the Bristol Homeopathic Hospital (Spence et al., 2005) analysed 23,000 outpatient consultations from 1997 to 2003. Over 70% of follow-up patients reported clinical improvement following homeopathic treatment. Over half had suffered from their complaint for over 3 years and 77.2% had already used conventional medication. During follow-up 52.8% of patients stopped conventional treatment: 61.8% because of unsatisfactory results; 20.1% because of concern about side-effects; 13.9% because they considered the therapy too aggressive; 13.2% because of too many side-effects and 9% because of the suggestion by the homeopath.
The safety of homeopathy
The concerns regarding the side effects and aggressiveness of conventional treatment highlighted above tend to be predominant reasons why patients turn to treatment by homeopaths because the safety of homeopathy is considered to be another core competency.
Seven reviews of the evidence of the safety of homeopathy indicate that homeopathic medicines may cause mild to moderate transient side-effects, but not strong or persisting side-effects (Bornhöft et al., 2006, Dantas & Rampes, 2000, ECCH, 2009, Grabia & Ernst, 2003, Woodward, 2005). No interactions with conventional drugs have been reported. A potential reported risk involves delay in referral for necessary conventional examination and/or treatment (Posadzki, 2012). However, evidence indicates that such cases are rare (ECCH, 2009) and the concern is not applicable when services are accessed within NHS settings.
Homeopathy in end of life and palliative care
The literature on the effectiveness of homeopathic treatment in end of life and palliative care comes from cancer settings. Below we present a selection of published surveys, case series and service evaluations from the UK where possible. No RCTs were found, presumably due to ethical concerns and patient choice being inbuilt into service provision. Evidence is from PROMS (patient reported outcome measures).
Only one study was found regarding care of children, a survey interviewing 96 parents of children who had died of cancer in Melbourne, Australia between 1996 and 2004 (Heath, 2012). 30% of parents reported using some form of CAM during the end-of-life period, the most common therapies being organic foods, faith healing, and homeopathy. 78% felt CAM use had benefited their child significantly.
A complementary therapies service at Whipps Cross University Hospital (Barts Health Trust ) for patients with cancer and palliative care “works collaboratively with patients to give them back some control over managing their health” (Briscoe, 2014). A range of therapies are offered which includes homoeopathy. A service evaluation using The Measure Your Concerns and Wellbeing Questionnaire (MYCaW) indicated that patients using homeopathy perceived 21.5% global improvements (symptoms and wellbeing). Therapies are also offered to carers. The project receives charitable funding and treatment costs are “substantially lower than average costs of other treatments in the NHS”.
A Case series of 100 consecutive cancer patients at the Bristol NHS homeopathic hospital (Thompson, 2012) explored the homeopathic approach to symptom control and its impact on mood disturbance and quality of life. Patients completed the Hospital Anxiety and Depression Scale (HADS) and the European Organization for Research and Treatment in Cancer - Quality of Life Questionnaire - Core 30 (EORTC QLQ-30) at initial consultation and four to six consultations later. Thirty-nine patients had metastatic disease. Nine patients were refusing conventional cancer treatments. The most common symptoms were pain, fatigue and hot flushes. Symptom scores for fatigue and hot flushes improved significantly over the study period but not pain scores. Side effects included a transient worsening of symptoms in a few cases, which settled on stopping the remedy. Patient satisfaction was high, 75% rated the approach as helpful or very helpful for their symptoms.
At the Cavendish Centre for Cancer Care in Sheffield, homeopathy is provided as one of a range of CAM treatments as part of the centre’s ethos to “provide an opportunity for patients to tell their story, make sense of the illness experience, construct meaning from it and set realistic expectations for the chosen intervention” (Peace, 2002). From a case series of 157 patients, 88% reported improvement in their main concern according to the Measure Your Own Medical Outcome Profile (MYMOP).
In a small study (N=15) recently published (Poole, 2014) fifteen survivors of any type of cancer received treatment by homeopaths for three months. Their total, physical and emotional wellbeing scores all improved significantly according to the Functional Assessment of Chronic Illness Therapy for Cancer(FACIT-G) outcome measure.
In a study at 3 integrative cancer centres (the Haven (x2) and the Penny Brohn Cancer Care centre) 782 consecutively recruited patients who completed MYCaW showed a clinically significant improvement at the end of treatment of 2.06 (for concern 1) and 1.74 (for concern 2) points on a seven-point scale for a selection of CAM therapies that included homeopathy. Almost half of the participants nominated psychological and emotional concerns, and others requested help with general well-being, physical problems and the side effects of orthodox treatments. (Seers et al. 2009).
Effective integration of homeopathy with other services
Homeopathy is often provided amongst a basket of other CAM therapies. Whipps Cross offers it alongside aromatherapy, massage, reflexology and shiatsu. The Haven offers it alongside mindfulness, massage, acupuncture, aromatherapy, shiatsu, craniosacral therapy and others. The rationale for such therapies is provision of patient centred care, greater autonomy and choice. Complementary therapies appear to be a valuable adjunct for people at end of life care.
Homeopathic and conventional approaches can be used alongside one another to give the most appropriate care to each individual patient and no drug interactions have been reported.
Conclusion
From the evidence presented above it appears that the provision of homeopathy is valued by patients and is clinically helpful, providing a unique take on palliation of the multi-morbidity and chronic disease which tend to characterise end of life. As an individualised therapy it is well placed to support a person centred approach to management of symptoms. Where trials inclusive of homeopathic principles are performed, they demonstrate effectiveness.
One of the questions of interest to this enquiry is whether the right services are being commissioned to provide quality end of life care. We argue that a holistic, person centred approach is more appropriate than the current biomedical unitary approach. Atul Gawande in this year’s Reith lectures states that “we have had a 50 year experiment with medicalising mortality - I think that has failed” (http://www.bbc.co.uk/programmes/b04tjdlj). We have presented evidence that treatment by homeopaths is effective, cost effective and valued by patients.
We suggest that increased provision of homeopathy within the NHS would offer cost effective provision, greater patient choice and higher quality of life care at this vulnerable juncture, valuing patient’s wishes, addressing their discomforts and providing them with autonomy as they approach end of life.
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15 December 2014