Tuesday, 24 May 2011

#NHSreform, it's emphasis on 'patient choice' and testing unproven remedies

It's been a while (alright, it's been ages) since I blogged on anything vaguely bad-science related or scientific here, for which I apologise given that it was my original (self-appointed) remit to do so. Well, here goes...
Simon Singh raises an interesting question via Twitter - Why waste limited research funds on proven pseudoscience? The proven pseudoscience in question here is homeopathy, and Simon's enquiry stems from an Early Day Motion (EDM) tabled by every skeptic's favourite MP David Tredinnick. Tredinnick's Motion calls for public funding to facilitate research into this important area to ascertain the effectiveness of homeopathy. The Motion has since been amended by the intrepid Liberal Democrat MP for Cambridge Julian Huppert - Amendment 1820A1 in the previous link comprehensively refutes Mr. Tredinnick's premise and I hold out hope that more MPs will emerge as signatories to Julian's amendment than the 13 (to date) that support the Bulls$*t from Bosworth...

As it happens the funding of research into alternative therapies, homeopathy amongst them, was raised recently when I spoke at a political event (no wait, don't go...!) where I discussed the Government's reforms to the NHS - I was sharing the platform (or rather patio as we were in a beautiful garden in Hackney) with Liberal Democrat Health Minister Paul Burstow MP.

I've written about the political side of the discussion over on Liberal Democrat Voice, but it was in the Question and Answer session that followed our discussion that alternative therapies, and research into their efficacy, was raised.

We were asked about whether there was any enthusiasm to run publicly-funded, properly controlled clinical trials into alternative therapies, given that in his talk Paul had intimated that with greater choice and freedom for commissioning General Practitioners (GPs), they would be more flexibility to prescribe a variety of interventions that 'the patient felt would help them recover.'

Turns out the questioner was posing an interesting variation on the theme of 'should we pay to find out whether sugar pills/sticking needles into meridians etc works, and should they be available on the NHS,' intimating that if critics of alternative therapies were so certain that things that have been used for aeons don't work, why not fund large-scale high-quality trials to sort the wheat from the chaff - to show what works and what doesn't?

Paul responded by reassuring us that whilst GP commissioners would be free to procure whatever services they saw fit, they would still face guidelines from NICE and the MHRA on what they could offer the patient - he also suggested that if healthcare was to become more outcomes-focussed, then there would be more scope for prescribing interventions that patients themselves reported as being beneficial.

This has been the standard Government line for some time now, which leaves much room for interpretation to say the least. What if a patient reports they feel better following a nice foot massage? Or by having hands waved over them? Perhaps patients would like to have wax candles stuck in various orifices? If they say it makes them feel better, who are we to argue? Roll-up, roll-up, for the great Alt-Med giveaway - Department of Health funding for anyone who can convince a patient with a self-limiting condition to fill in a questionnaire favourably...

Flippant jokes aside, the question about publicly funding research into homeopathy needs answering - or rather, the answers that exist need to be articulated more forcefully. I'd recommend reading Andy Lewis' take on such matters, who's written extensively about testing alternative therapies in patients - particularly with regards the ethical problems involved.

My answer to our interlocutor was two-fold. Firstly I said that in times of plenty, we would love to study as many therapies as possible as extensively as we could, so that the best treatment options were available to patients - indeed that's how evidence-based medicine proceeds - but that such studies must, above all else, pass elementary criteria for plausibility, prior evidence of efficacy (perhaps in animal studies), and be demonstrably safe - not only in themselves, but taken within the context of discouraging the use of established treatments. As many (if not most) so-called alternative therapies fall at these hurdles, it's hard to justify stufying them further at public expense.

Of course, I said, at a time when public funds are constrained - with the NHS facing its toughest financial settlement since its inception - it is deeply unethical to divert scarce funding to enquiries into questionable practices. Secondly, I suggested that contrary to opinion - expressed most strongly amongst proponents of quackery - that because there's little or no profit to to be made from alternative therapies, Big Pharma refuses to do good clinical studies and that therefore the government should do so instead. This simply isn't true on two fronts - the Alt Med industry is worth hundreds of millions of dollars a year and can be very profitable, and some good evidence does exist regarding the use of such therapies as homeopathy, aromatherapy, acupuncture and so on - it's just that when the studies are of good quality, they inevitably give an answer that quacktitioners would rather not hear.

Indeed the gentleman interested in studies of alternative therapies was surprised to hear that enough evidence as to their efficacy exists to allow systematic meta-analyses - mostly by the Cochrane Collaboration, and mostly showing that Alt Med therapies simply don't work better than placebo. This suggests to me that although the scientific method has been used to investigate whether homeopathy and its like are effective, the results haven't trickled down into the vernacular.

In sum, then, I think I managed to argue against public funding of research into 'proven psuedoscience,' partly because it's already been shown to be rubbish and partly because further studies would be expensive and unethical.

I could go on for ever - I could emphasise that for journalists and bloggers to adequately inform the public about the lack of efficacy and outright dangers of some alternative medicine we need to have our libel laws radically reformed so we can write without fear of being silenced; I could lament the seemingly forcible retirement of the inestimable Professor Edzard Ernst, he who has dedicated an entire career to systematically evaluating the evidence for or against alternative therapies; I could even harp on about the tyranny of choice, whereby when confronted by a smorgarsboard of options we often fail to choose wisely based on what's good for us...

But I think it's best to leave the last word to musical genius Tim Minchin and his exposition of alternative medicine in the form of his beat poem Storm - where he rightly says, "You know what they call “alternative medicine”That’s been proved to work? Medicine.”


Anonymous said...

"Why waste limited research funds on proven pseudoscience?"

Quite - particularly as the degree of dilution used in homeopathic 'remedies' is such that it would be impossible to quantify any 'dose' (chances are the diluted substance contains no molecules of the original) and hence relate any possible benefit to dosage.

David Colquhoun said...

These discussion always seem to omit the fact the in the USA, the National Institutes of Health has spent more than a billion dollars on investigating all sorts of alternative medicine. For all thaty money it has failed to produce a single useful treatment.