Member News
By Richard Parsons - 5th August 2010
The Department of Health (DoH) response to a report from the Commons science and technology committee on homeopathic services provides quite a neat illustration of the tensions inherent in public services and perhaps in parts of the government's reform agenda.
The trade–offs between national standards and 'postcode lotteries' are already well known, but there are also other issues which are also worthy of attention.
Evidence
On the issue of homeopathic care, it seems, there are contradictory demands from the public (perhaps 'campaigners' would be a better word), with the government unwilling to take sides.
The DoH notes just that: "Complementary and alternative medicine, including homeopathy, has a long tradition, and very vocal proponents and opponents".
Usually when there are competing opinions, the government's role is to take a view on which one it favours and set out its reasons for doing so.
But in this case the government responds with perhaps the oddest sentence I've ever read in an official document.
"We remain committed to ensuring that the appropriate use of sound evidence is embedded in policy–making."
How odd is it that "sound evidence" is qualified by use of the word "appropriate"?
That seems to suggest either that use of sound evidence could sometimes be inappropriate or that 'non–sound evidence' should also be a factor in some decisions.
Choice
The government does, however, clarify the grounds on which it might justify relying on unsound evidence.
"There naturally will be an assumption that if the NHS is offering homeopathic treatments then they will be efficacious, whereas the overriding reason for NHS provision is that homeopathy is available to provide patient choice."
So patients should be free to make bad choices seems to be the suggestion here.
Which raises the question of what is meant and intended by choice in public services.
A choice over hospitals and doctors and waiting times is not the same as choice between sensible policies and irrational policies.
Effectiveness
But the DoH suggests it is ok to use homeopathy as long as it is for treating a non–serious illness where it doesn't matter if the treatment makes no difference and the money is wasted.
"The main public health risk that can arise from homeopathic medicinal products is their inappropriate use in serious conditions. The National Rules Scheme is based on the premise that public health protection is better served where it is clear that the use of these products should be restricted to minor self–limiting conditions."
So patient choice is important. And patients can make poor decisions if they really wish to.
But they can only make poor decisions in situations where it makes no difference to them.
This seems and odd framework for public policy.
Paradox
This framework, however, gets more complex still.
As the DoH notes, for an informed choice to be made it is "vitally important that the scientific evidence base for homeopathy [ie. that there is none] is clearly explained and available" to the patient.
But, as the Commons committee noted, this leads to a paradox:
"For patient choice to be real choice, patients must be adequately informed to understand the implications of treatments. For homeopathy this would certainly require an explanation that homeopathy is a placebo.
"When this is not done, patient choice is meaningless. When it is done, the effectiveness of the placebo – that is, homeopathy – may be diminished."
So now a patient can make a poor choice in situations that make no difference, but the very process through which they choose is designed to ensure that there is no positive effect.
If the patient was just given the homeopathic treatment without choosing it and having it fully explained, there may be a chance that it would have some positive placebo effect.
Postcode lottery
The devolution of decision-making adds a further layer of complexity.
The DoH clearly addresses the 'postcode lottery' issue, stating that it prefers decisions about homeopathy to be made locally.
"The Department sets out policy guidance and recommendations, and asks that the local NHS implements that policy in the way that is most appropriate for their local communities. Primary Care Trusts are responsible for commissioning high quality services, within allocated resources, to meet local patient needs.
"Given the geographical, socioeconomic and cultural diversity in England, that involves a whole range of considerations including, but not limited to, efficacy."
So perhaps some patients can be allowed to make bad choices which are deliberately rendered ineffective if their local clinicians agree, while others in different parts of the country are not.
That seems like a 'postcode lottery', but not quite in the usual sense of the phrase.
Judgements
As if there weren't enough factors to balance already, theses local bodies are also expected to "take account of safety, clinical and cost effectiveness, and the availability of suitably qualified and regulated practitioners".
And this leads on to the issue of professional judgement.
"Most importantly perhaps, the relationship between a clinician and a patient is one that is built on trust and understanding. Clinicians are bound by a strong moral code but also by the guidance from the General Medical Council – rather than by instructions from the Department."
There is the additional requirement that patients should be "able to make informed choices about their treatments" but that a clinician should be "able to prescribe the treatment they feel most appropriate in particular circumstances, within the regulatory and guidance frameworks by which they are bound".
So does a patient choose or does a clinician prescribe? Which is more important, the patient with the choice or the doctor with the money?
Other factors
Other factors are also part of the decision-making process.
There is tradition and the way things have always been done.
"Homeopathy has a long tradition in Europe and is a recognised and widely used system of medicine across the EU."
And there are European regulations, which state that "patients should be allowed access to the medicinal products of their choice, provided all precautions are taken to ensure the quality and safety of the said products".
Lessons
I wouldn't suggest that all of these tensions are new.
Doctors have always had to balance, for example, what they think is the best course of treatment with the patient's own preferences.
And homeopathy might be something of an atypical example of choice in public services.
But if citizens are to become more engaged with the services they choose, I do think the framework within which they are constrained needs to be straightforward and clear.
With regards to the NHS and homeopathy at least, that doesn't seem to be the case.
This article first appeared on the eDemocracy Blog
Have your say...
Please enter your comments below.