Wednesday, 20 December 2017

NHS Homeopathy #4 - Outcome of Consultation

Previous blogposts (here, here and here) have discussed the NHS England Items which should not be routinely prescribed in primary care: A Consultation on guidance for CCGs in some depth. Not only have they discussed that NHS England does not have the legal power to prevent GPs from prescribing homeopathic medicine, they also discussed how reporting of and reaction to the Consultation is often wildly wrong.

Responses to Consultation
The report of findings from the Consultation can be found here. It is a long document and most of it does not relate to homeopathy. The Consultation asked whether respondants agreed with two statements (as well as invititing further comment) -
  • Advise CCGs that prescribers in primary care should not initiate Homeopathy for any new patient
  • Advise CCGs to support prescribers in deprescribing Homeopathy in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change
Of those that expressed an opinion to the first statement, only 46% agreed. With the second statement, only 50% agreed.




As the various homeopathy bodies mounted an astroturfing campaign, these figures must be taken with a pinch of salt. The clinician numbers look wrong to be begin with. It seems unlikely that there are circa 150 clinicians who support GP prescribing of homeopathic medicines. It could well be that lay homeopaths said they were "clinicians" in their response. Likewise, it could also be the case that clients of lay homeopaths have described themselves as "patients".Given that only 2440 items were prescribed in 2016 and that many would have been repeats, it is difficult to believe that 875 figure. If correct, it represents an incredible level of patient engagement.

There is further analysis but it merely confirms that supporters of homeopathy are more likely to be older and female. Nana medicine.

The verbatim comments quoted are in line with expectations. One CCG stated -
“These should be blacklisted to enable a consistent and equitable approach across the country on these medicines of very limited clinical value.”
The British Medical Association (BMA) stated -
[Homeopathy is] better dealt with by inclusion in the blacklist of drugs unavailable on the NHS.
So, some respondants are clearly aware of the limitations of NHS England's powers to prevent prescription.

Submissions #1 - Homeopathy Research Institute
The Homeopathic Research Institute (HRI) submitted this document. HRI is a charity set up by one Alex Tournier. One of the research "projects" it funds is the Water Research Laboratory strangely run by Alex Tournier. From the statement -

It is apparent from the list of member organisations provided (CD Appendix1, p.29) that there is not a single party within this working group with the relevant and necessary specialist knowledge and expertise to assess homeopathic medicines.
Again, the canard that somehow evaluation of the evidence for the efficacy needs specialist knowledge. This is not the case and has been dealt with here.

It is also clear that the HRI has a limited understanding of the NHS, ethics and economics. It also engages in whataboutism.

The HRI suggest that prescribing of homeopathic medicines could only be prescribed by "specialists". This is nonsensical given that i) homeopathy is not recognised as a speciality and ii) it would have to be done in secondary care, which would have to be commissioned by CCGs locally. The latter will be discussed in greater depth in a future post but these services no longer exist in England except at the Portland Centre of Integrative Medicine (PCIM) in Bristol and the Royal London Hospital for Integrated Medicine (RHLIM) and thus are not accessible to the majority of the population. It will not come as a surprise that Elizabeth Thompson, head of the PCIM, is a trustee of the HRI. Peter Fisher of the RHLIM sits on their "scientific" panel - they have a vested interest in this model. Although the costs of such provision are not precisely known, the Good Thinking Society (GTS) came up with some figures - comparing these with a previous post the comissioning of secondary care homeopathic services costs NHS England a lot more than GP prescribing. Rather than save money, the HRI are de facto suggesting more money should be spent.

The HRI makes some statements about the ethics of stopping GP prescribing of homeopathic medicines yet fails to tackle the thorny issue of the ethics of prescribing placebo.

  • It is only ethical to remove homeopathic medicines if an alternative treatment option is provided which gives similar or superior clinical benefits.
  • It is only economically justified to remove homeopathic medicines if the replacement treatment options cost the same or less than homeopathic prescriptions.
The problem is that given there is no evidence of efficacy beyond placebo for homeopathic medicines and it could be argued that prescribing almost anything else (including not prescribing anything) would be more effective. Given what is known about medicines costs and dispensing fees, many medicines cost NHS England a lot less than homeopathic ones.

The most bizarre statements regard "equality".

  • It is only legal if NHS E’s actions comply with the Equality Act 2010 (see below).
Which is followed by

4. Evidence that removing homeopathic medicines will not put NHS E in breach of the Equality Act 2010 (a risk identified in Appendix 3, CD p.33). This requires an assessment of patients currently using homeopathy in terms of ‘age, disability, gender reassignment, race, religion or belief, sex, sexual orientation, marriage and civil partnership, pregnancy and maternity’.  
But it has to a large degree. NHS England did conduct a health equality assessment which is sufficient to satisfy best practice guidance for public consultation. The responses to Consultation also provided additional data on patients, putting aside the question of astroturfing. As discussed previously, the only major potential impact is on patients who are exempt from prescription charges and then only those who are economically deprived - eg many pensioners have a decent income and could easily afford the prescription charge. Note no mention of this in the above statement.

From practical experience such an assessment would be difficult, time consuming and expensive. For one thing, GP prescribing data held by NHS England does not contain unique patient identifiers, which would be required to link to other data held elsewhere. It is very possible that the results of any such analysis would not be to the liking of supporters of homeopathy. Nana medicine for one thing.

It is worth pointing out that the British Homeopathic Association (BHA) did try this approach when applying for a judicial review in the past and it failed.

One key message from the HRI submission is it that it fails to understand the concept that its extraordinary claims require extraordinary evidence. It attempts to hold NHS England to a standard that the HRI falls well short of.

Submissions #2 - Society of Homeopaths
The submission from the Society of Homeopaths (SoH) cites a number of cherry-picked studies. The Nightingale Collaboration examined some of these here although they were responding to a SoH intiative to help individual members promote their businesses.

They also mention "patient choice" -
Homeopathy has been part of the NHS service in the UK for over 60 years and is a popular choice for many patients and parents. In 2013 homeopathy was the second most popular complementary therapy in the UK (Watson, Leala KPosadzki, Alotaibi, and Ernst 2013). Orthodox medicine does not meet the needs of every patient (Franzel et al. 2013; Posadzki et al. 2013).The inclusion of homeopathy extends the range of patient choice and supported self-care within the NHS. 
UK NHS patients come from many cultures and ethnic origins, including those from countries such as India, France and Switzerland where homeopathy is widely used as part of the primary healthcare system. Recommending the de-prescribing of homeopathy on the NHS cannot claim to be in the interests of equality and diversity, and certainly not in the interest of patient choice. 
The French are also very keen on suppository forms of some analgesics. The suggestion that homeopathy is a "popular" choice is largely unfounded. The choice between medicine and placebo is not a choice though. And the NHS is more utilitarian in nature than being driven by notions of "patient choice" which is relatively recent concept - arguably first rose in importance under Tony Blair, although some of the nonsense about "internal markets" popped up earlier. Whilst it is difficult to swallow for many, what most people want is decent local provision of services at a high standard rather than "choice".

Submissions #3 - British Homeopathic Association
Given that the British Homeopathic Association have been arguably the most aggressive group in terms of challenging the NHS England consultation, it is strange that their grounds for challenge aren't exactly transparent. It is known that they made a submission but it doesn't seem to appear anywhere on the internet. It is known that it contained "evidence".


The Special Pharmacy Service was asked to review the evidence the BHA submitted. The results of that review can be found here.

Outcome of Consultation
On 30/11/2017, the NHS England board met. The agenda can be found here. As can be seen, it considered other matters than just the Consultation. The outcome can be found in this document. The most important part is this -
38. Having considered the wide range of responses to our consultation, and taking into account of the findings of the SPS review, the clinical working group was of the view that the scientific review of the evidence should be preferred to the anecdotal evidence from patients and, notwithstanding what we perceive to be marginal cost issues, that the initial recommendations should stand.
The intial recommendations being -
  • That prescribers in primary care should not initiate Homeopathy for any new patient
  • To support prescribers in deprescribing Homeopathy in all patients
Then -
43.In relation to a number of drugs, the consultation feedback included requests that the particular drug should be formally placed on the 'blacklist'. This is not a matter for NHS England, but rather one for the Secretary of State to consider. Subject to the Board’s agreement to the recommendations in this report, it is proposed that NHS England recommends that the Secretary of State formally consider blacklisting the following drugs:
  • Co-proxamol
  • Glucosamine and Chondroitin
  • Herbal Treatments
  • Homeopathy
  • Lutein and Antioxidants
  • Omega-3 Fatty Acid Compounds
  • Rubefacients (excluding topical NSAIDS) 
44.If the Secretary of State decides to proceed with any such recommendation, there will be a further formal consultation on the proposals.
This press release shows that the NHS England Board approved these recommendations.

Reaction
Mainstream media reaction was quite muted and reporting quite accurate although some did get confused between NHS England recommending products be blacklisted and them actually being blacklisted. The only major concerns raised in reporting was that some would be unable to afford OTC products that were previously prescribed for free but this applies to all OTC products, not just homeopathic medicines.

As might be expected supporters of homeopathy were up in arms. With one curious exception from the Faculty of Homeopathy
Although disappointing, this decision was not unexpected. The gradual withdrawal by CCG’s of funding for homeopathy has resulted in patients finding it increasingly difficult in recent years to access the therapy through the health service. And while removing homeopathy from NHS prescribing is a blow to morale, its actual impact will be negligible on the majority of Faculty members. This is because most members are in private practice, many of whom report an increase in the number of patients they are seeing. Evidence from various market research surveys support what Faculty members are experiencing, with forecasts showing an increase in sales of homeopathic medicines in the coming years. It could also be argued that the slow demise of NHS homeopathy removes the “waste of valuable NHS resources” argument frequently used by our opponents. This is not to say that we are abandoning our support for NHS homeopathy, and I can assure all members who work at the Royal London Hospital for Integrated Medicine and the Portland Centre for Integrative Medicine in Bristol, the Faculty remains committed to defending the valuable services they provide.
The statement goes onto say -
Nevertheless, it would be remiss of me as chief executive and of the Faculty council if we were not to take a pragmatic view and make plans for a future where possibly homeopathy is no longer available on the NHS. To this end we a have already investigated opportunities to work more closely with other organisations promoting the use of complementary therapies as part of an integrative approach to healthcare. Furthermore, while we are beset with challenges here in the UK, homeopathy receives a less hostile reception in other parts of the world. Therefore, the Faculty is looking to build on its enthusiastic international membership, where we hope to see our global influence in matters relating to the training and practice of homeopathy increase. 
An example of leadership rarely seen in the world of homeopathy. 

As discussed in previous posts, the guidance is not binding and only the Department of Health has the power to blacklist medicines and the outcome of the consultation makes this very clear. This was something that many got very wrong but no mention is made of this.

The Society of Homeopaths response can be found here and it still gets things wrong.
Mark Taylor, Chief Executive of the Society of Homeopaths, said: “Our original argument still stands: the consultation process was flawed and it seems unjust for NHS England to press ahead until the case for a judicial review has been heard.”
The British Homeopathy Association response is here. It contains the following statement -
Instead of listening to patients who have benefited from the therapy, or to the doctors who have treated them, NHS England chooses to base its decision on the discredited House of Commons Science and Technology Committee’s report from 2010 and the 2015 study by Australia’s National Health and Medical Research Council, which is so flawed it is currently being investigated by the Commonwealth Ombudsman, facts NHS England conveniently failed to mention in the reams of documentation it produced for its board meeting.
The STC report is not discredited. The story behind the statement that the NHMRC is under investigation is very murky as there is there no sign of any submission to the Ombudsman. Apparently, it was prepared by the HRI.
The BHA is still going ahead with its legal challenge calling for a judicial review of NHS England’s consultation.
Which is strange given that NHS England has very firmly put the ball into the DH's court regarding blacklisting. Even assuming that leave was granted for judicial review, and even assuming that a judgment was made to overturn the findings of the Consultation, surely the BHA et al should be more concerned by what the DH intend to do next and whether they will consult on the blacklisting of homeopathy?

Next Steps
What is likely to happen now is that NHS England will start to put together the actual guidance. It is unclear what form it will take but it has to -
  1. Explain very clearly to GPs why they should not prescribe homeopathic medicines in terms that even Anthroposophists understand
  2. Provide GPs with the necessary supporting information to be used to convince patients that they do not need homeopathic medicines - even Nana.
Whether the handful of GPs who routinely prescribe homeopathic medicines will comply with the guidance is moot although the existence of the OpenPrescribing tool makes non-compliance highly visible to the public. It is known that various persons/organisation do use the tool to monitor GP prescribing even within the NHS.

Blacklisting
The willingness of the Department of Health (DH) to blacklist homeopathic medicines is not known. That NHS England recommends that they do is difficult to ignore. At the very least, the DH need to consider the matter and in time issue a statement. Historically, the DH and in particular Secretary of State for Health Jeremy Hunt have given very mixed messages - phrases like "patient choice" and "clinical freedom" are said along side the need for "evidence based practice".

The more cynical will point to a more "hands off" approach by the DH to bodies under their control such as NHS England as essentially an attempt to distance the current Government from politically unpalatable realities, shifting blame. This is a question beyond the scope of this blog.

However, NHS England asking the DH to do something it wants but lacks the legal power to do is somewhat different from the usual political arguments over funding and closures of services. That the DH has devolved many powers to NHS England is one thing but that it has not devolved the power to control GP prescribing is remiss. 

Although the NHS England states that if the Secretary of State wishes to proceed with blacklisting a further consultation would be required, this is not strictly true. It is good practice but not a legal requirement. Of course, the decision to act without consultation could be subject to judicial review but the irony is that the decision not to act at all could also be subject to judicial review and much more likely to suceed. The Good Thinking Society have in the past stated that they would seek judicial review if the DH did not act but called off the action. It could be argued that given the low value of homeopathic medicines now prescribed on the NHS, it is an expensive route to nowhere.

The DH powers to blacklist derive from the National Health Service Act 2006 et al and most importantly the National Health Service (General Medical Services Contracts) (Prescription of Drugs etc.) Regulations 2004 and any following Regulations. Notionally, the Regulations should be updated on a regular basis but the last was in 2014.

It is important to note that the Regulations are a Statutory Instrument - secondary legislation that does not need to be approved by a vote in Parliament. A Statutory Instrument is subject to Parliamentary control either by a negative resolution procedure or affirmative resolution procedure. The former requires that the instrument is published and will come into law unless resolution is passed to annul the instrument but this first requires that an MP raises a motion to annul. However, unless a large number of MPs sign the motion, there is no guarantee that a debate will be granted and a vote made. The latter is much rarer and does require that the Government raises a motion itself.

In both cases, it is extremely rare for instruments not to make their way into law. The last time this happened was in 2000.

If such a Statutory Instrument did become law then there is still the possibility of legal challenge via the Supreme Court which has the power to overturn secondary legislation if found ultra vires but technically, this would not be the case as powers to blacklist well within the remit of the Act. However, the Supreme Court also has the power to make a declaration of incompatibility with Human Rights legislation. Other courts have the power to do this too but they often refer upwards on matters of legislation. It would be difficult to argue for a human right infringement.

Beyond that, an appeal to the European Court of Justice would be possible but difficult, slow and very unlikely to suceed - it would be hard to make a cases that blacklisting infringes EU law. Likewise, an appeal to the European Court of Human Rights would be difficult to make.

Sunday, 3 December 2017

NHS Homeopathy #3 - Analysis GP Prescribing data

A previous post discussed the now closed Items which should not be routinely prescribed in primary care: A Consultation on guidance for CCGs, the petition created by supporters of homeopathy and how wrong the supporters of homeopathy were about the Consultation.

It also discussed some of the workings of the NHS.

Decline in Prescribing
One thing that it very clear from even the most cursory analysis of NHS England GP prescribing data is that the prescribing of homeopathic medicines has declined enormously. This article from the Nightingale Collaboration clearly demonstrates this. There seem little point in duplicating its content - please do read it.

What the article does not explain is why there has been such a dramatic decline. Unfortunately, this is an impossible question to answer. It is possible to speculate on potential reasons and they fall into a number categories -

  1. Decreased Patient Demand - It has been suggested that to some degree prescribing of homeopathic medicines is patient driven ie patients specifically ask for them. The numbers of patients asking could have declined. This could be due to demographic change or it could be due to changes in public attitudes. Although there seems to have been a drop in the number of lay homeopaths in recent years, this is not a good proxy for patient demand for homeopathy.
  2. Typical GP Behaviour - There's an acronym that used to appear on GP notes - TEETH - "tried everything else, try homeopathy". How widespread this attitude was in the past is unclear. Typical GP attitudes may have changed. The prescribing of placebo is seen by some as unethical. In recent years opponents of homeopathy within the medical profession have become increasingly vocal. As discussed in the previous post, CCGs have increasingly recommended not prescribing homeopathic medicines but it is difficult to guage what impact this has had directly - also the decline started way before the re-organisation that created CCGs. It is know that there were locally argeed forumlaries in some areas prior to this but they are difficult to get hold of.
  3. True Believers - GPs who are enthusiasts for homeopathy are not exactly common. Various numbers have been suggested for the number of GPs with "training" in homeopathy but it is impossible to determine how many. It may well be the case that there are fewer of them now. If the historical high levels were associated mainly with prescribing by "true believers", as they leave the NHS GP practice (retire or move into private practice) and fewer younger GPs are becoming "true believers", this could well account for the decline in prescribing. It is worth pointing out that no NHS GP could get away with 100% prescribing of homeopathic medicines. That's only possible in the private sector and even it would carry considerable risks. Although CCGs have no power to prevent such a thing, peer pressure and patient disatisfaction would make it impossible. Even "true believers" may have changed their behaviour as a result.
  4. Economics - As mentioned in the previous post, it makes economic sense for many patients and NHS England that GPs suggest to patients which homeopathic medicine to buy themselves rather than write a prescription. Changes in prescription charges vs cost of homeopathic medicines could drive GPs to increasing to suggest rather that prescribe. It is also the case that GP perception of increased financial pressures on NHS England could drive such a change. If this were the case the ratio of prescriptions for patients exempt from charges should have changed over time,
Even if were possible to obtain data to confirm or refute these speculations, it would not be an easy or cheap process. Given that the cost of GP prescribing of homeopathic medicines is so small and still seems to be decline there seems little point in doing so. It could cost NHS England more to do the analysis that the actual cost of the products!

Demographic Analysis
Along side the Items which should not be routinely prescribed in primary care: A Consultation on guidance for CCGs, NHS England also published an equality analysis. Much of it is irrelevant to homeopathic medicines but contains some key demographic details.

In 2016, there were 1541 (63.2%) prescriptions dispensed to female patients and 889 (36.8%) to male patients. It is not number of unique patients, so it is not possible to derive an average number of prescriptions, prescription items or cost per patient. That would have provided an insight into the type of conditions (acute vs chronic) being prescribed for.

In terms of age bands - 


Age BandNumber of PrescriptionsPercentage of Total
Under 1835914.71%
18 to 3027311.19%
31 to 4438615.82%
45 to 6463526.02%
65 and over78732.25%
Total2440

It is worth noting that those under 16, between 16 and 18 in full time education and those over 60 are automatically exempt from prescription charges.

It would be useful to have had this information over time but...

In depth (but quick and dirty) GP Prescribing data Analysis
It is possible to download NHS England GP prescribing data. Data is released on a monthly basis. Unfortunately, the files generated are very law. Typically, they contain 4 million rows of data. It would a mammoth task to download the available historical data and the data would have to imported into a proper database. This would be beyond the casual user.

Fortunately, the OpenPrescribing initiative has done that hard work all ready. It provides a simple to use tool to explore the data in a number of ways. It can drill down from CCG level to GP practice level. Also, it's possible to download the data to to manipulate in ways that they tool can't do, although it is tricky to deal with. This has been done. The resulting analysis is very interesting and seems to disprove some of the contentions of UK homeopathy groups as well as misreporting by the media.

As OpenPrescribing plan to publish a more academic analysis, this analysis will be somewhat cursory.

Some of the terms used require some explanation. Prescription is obvious. Items is the effectively the number of medicines ordered on a prescription. It is surprising that more than one homeopathic medicine is sometimes prescribed - this goes against the tenets of classical homeopathy. Actual cost is the cost to NHS England to re-imburse community pharmacies for the cost of medicines. It does not include the £1.25 per item dispensing fee or the potential £20 "specials" fee. It's not possible to determine the value of these fees but they could be considerable. 

Looking at CCG level, for the period 2012-07 to 2016-06 (neatly 5 years), those CCGs with more than 1% of the total spend are -


Total Result £556,994.37 Percentage
NHS BRISTOL CCG £93,603.72 16.81%
NHS GLOUCESTERSHIRE CCG £58,854.62 10.57%
NHS WEST KENT CCG £44,747.14 8.03%
NHS LIVERPOOL CCG £34,222.06 6.14%
NHS HIGH WEALD LEWES HAVENS CCG £33,764.88 6.06%
NHS HERTS VALLEYS CCG £14,570.72 2.62%
NHS NORTHERN, EASTERN AND WESTERN DEVON CCG £12,801.84 2.30%
NHS SHEFFIELD CCG £10,649.43 1.91%
NHS DORSET CCG £10,269.83 1.84%
NHS SOMERSET CCG £9,846.58 1.77%
NHS SOUTH WORCESTERSHIRE CCG £9,681.01 1.74%
NHS HARINGEY CCG £8,896.19 1.60%
NHS CANTERBURY AND COASTAL CCG £7,460.52 1.34%
NHS LEWISHAM CCG £7,455.12 1.34%
NHS KERNOW CCG £6,773.46 1.22%
NHS WILTSHIRE CCG £6,618.03 1.19%
NHS SHROPSHIRE CCG £6,457.52 1.16%

The OpenPrescribing tool did not like all of those CCGs selected - CCGs up to Lewisham were input. Unfortunately, when drilling down to Practice level, OpenPrescribing data downloads do not provide CCG. Not that this matters.

Below is a list of those Practices within the selected list of CCGs. Only those with spend over £3k in the period are are shown.


HELIOS MEDICAL CENTRE £66,513.14
ST.LUKE'S MEDICAL CENTRE £47,630.25
BELMONT SURGERY £30,750.81
BLACKTHORN £30,653.53
ISLINGTON HOUSE MEDICAL CENTRE £19,331.93
BEDMINSTER FAMILY PRACTICE £12,799.56
THE JENNER PRACTICE £6,327.80
THE VILLAGE MEDICAL CTRE £6,069.44
TENBURY SURGERY £5,895.32
MARKYATE SURGERY £5,646.89
SOUTHMEAD & HENBURY FAMILY PRACTICE £5,336.61
RICHMOND MEDICAL CENTRE £5,189.62
FRIARY HOUSE SURGERY £4,909.97
BRIDGE HOUSE MEDICAL PRACTICE £4,519.90
KINGS LANGLEY SURGERY £4,186.88
OLD SCHOOL SURGERY £4,137.42
DOVERCOURT GROUP PRACTICE £3,711.17
DR M FLYNN'S PRACTICE £3,536.52
CHARTHAM SURGERY £3,155.67

Helios Medical Centre makes up for 12% of total spend in the period, which is extraordinary. It falls under Bristol CCG whose local formulary does not include homeopathic medicines. Bristol CCG will be well aware of the prescribing via reporting. Although the data does not drill down to which GP is prescribing, the staff list suggests that Dr Frank Mulder and Dr Joan Platford could be responsible for the majority of the prescriptions. Both have links to Anthrosophy and anthroposophic medicine. There would appear to be no or little change in the value of prescriptions over time.

St. Luke's Medical Centre no longer exists. It was forced to close due inability to recruit staff. It closed back in July 2015. If it had not, its spend would have easily exceeded Helios. Although it did close, it re-opened in another guise St. Lukes Therapy Centre. Stroud is a hotbed of Anthroposophy and so is the Centre. Whilst it is true that many practices are having difficulties recruiting GPs, there is a question of whether GPs would be comfortable working with anthroposophic enthusiasts.

The Belmont Surgery is now Wadhurst Medical Group. Its staff list turns up Dr. Andrew Sikorski. Sikorsi's LinkedIn profile shows him to be an integrative medical consultant. He is a GP, not a Consultant according to the GMC register. Skorski's "treatments" include Psionic Therapy whatever that is. Sikorski is quite well known for his pro-homeopathy comments in various places on the internet. The value of prescriptions for homeopathic medicines has fallen over time though. Back in 2012 andd 2013, values of over £1,000 per month were routinely seen. In 2017, £100 would be more typical. The reasons for the decline are unclear.

The Blackthorn Medical Centre has links to the Blackthorn Trust which offers anthroposophic medicine. This page on the practice website states that the Trust certainly was funded by the NHS at one point. Whether this is still the case is another matter. The staff list when compared to this newletter from the Blackthorn Trust suggests that both Dr Martin Gerhards and Dr Saskia Renkema are involved in anthroposophic medicine. The newsletter also sheds some light on prior funding of the Blackthorn Trust by the NHS. Similar to the Wadhurst Medical Group, there seems to have been a decline the value of prescriptions. 

Islington House Medical Centre is in Liverpool.It is unusual in that it was set up in 1937 and would appear to have been in the hands of the same family since then. The prescribing patterns seem very strange. Back in 2012 and 2013, typical prescribing value was roughly £180. This has declined In 2017, there were months when there was no prescribing of homeopathic medicines. But then there are these outliers -

date name items actual_cost Average item
2016-05-01 ISLINGTON HOUSE MEDICAL CENTRE 17 2821.52 165.97
2016-06-01 ISLINGTON HOUSE MEDICAL CENTRE 12 3003.42 250.29
2016-09-01 ISLINGTON HOUSE MEDICAL CENTRE 4 2709.86 677.47
2016-12-01 ISLINGTON HOUSE MEDICAL CENTRE 4 2709.74 677.44

There is no immediate explanation for this. There is no known homeopathic medicine that costs £165 a go, let alone £677. Miscoding could be one explanation. Liverpool CCG will be approached to see if they can shed any light on this.

Bedminster Family Practice used to list homeopathy as one of the services provided. Dr Nick Wilson ran a clinic according to older documents. However, it is no longer listed on their Clinics and Services page. The prescribing history is similar to Islingthon House in that spend was generally a low, showing decline but certain months were outliers, but more so.


date name items actual_cost Average item
2015-08-01 BEDMINSTER FAMILY PRACTICE 4 1,120.94 280.24
2016-01-01 BEDMINSTER FAMILY PRACTICE 6 1,591.95 265.33
2016-03-01 BEDMINSTER FAMILY PRACTICE 2 543.50 271.75
2016-04-01 BEDMINSTER FAMILY PRACTICE 2 998.89 499.45
2016-08-01 BEDMINSTER FAMILY PRACTICE 2 566.70 283.35
2016-09-01 BEDMINSTER FAMILY PRACTICE 5 1,689.73 337.95
2017-01-01 BEDMINSTER FAMILY PRACTICE 4 1,949.37 487.34
2017-03-01 BEDMINSTER FAMILY PRACTICE 2 594.40 297.20
2017-04-01 BEDMINSTER FAMILY PRACTICE 2 1,090.08 545.04
2017-05-01 BEDMINSTER FAMILY PRACTICE 2 594.25 297.12
2017-09-01 BEDMINSTER FAMILY PRACTICE 3 1,852.42 617.47

Again, there are questions about the average value of the items prescribed. Bristol CCG will be contacted.


One GP practice of interest is not in this list. One of the partners at Plas Meddyg Surgery is Dr Ralf Schmalhorst is a member of the Council of the Faculty of Homeopathy. One of the reasons the practice is not on the list is that the spend is trivial. However this may be explained by Dr Schmalhorst offering homeopathy on a private basis.

Conclusions
It is very difficult to draw any firm conclusions from the data and investigations except that -

  • GPs who are interested in Anthroposophical Medicine are amongst the highest prescribers of homeopathy
  • There are some very strange high item value