1

Student: Christopher Martin

Supervisor: Dr Louise Mercer
Year: 2012

Should Homeopathy be funded by

the NHS?

10 pages

Should Homeopathy be available on the NHS?

Lay Abstract

Homeopathy is a medical practice supported by people such as the Prince of Wales

that involves the dilution of certain substances to incredibly low levels. It is often a
target of scientific criticism for its continued availability and funding from the NHS,
which is around 4 million pounds a year. There have been multiple experiments
performed to look at the effects of homeopathy and whilst there are some trials that
claim it performs better than a placebo (Something which resembles medicine but
only works via the patients own thoughts) the majority of scientific evidence claims
otherwise. Placebos are harmless and diseases such as Parkinson's disease and
depression treatments are claimed to rely on placebo effects but there are problems
with prescribing things that dont have a direct effect. I came to the conclusion that
whilst homeopathy is an effective placebo and that placebos are an effective
treatment in certain circumstances, they should not be prescribed on the NHS and
therefore neither should homeopathy, because they deceive the patient as to their
nature, a violation of GMC and NHS guidelines on probity and honest.

Scientific Abstract

Homeopathy is a 400 year old healing practice and is a large component of

Complementary and Alternative Medicine. It costs the NHS an estimated 4m per
annum yet it has been a target of criticism by both Government committees and
notable scientists. Numerous meta-analyses commissioned both independently and
by the Cochrane Collaboration have found homeopathy to be nothing but a placebo.
Therefore I explored the placebo effect and found that whilst it involves a necessary
deception of the patient, it has held clinical significance for over 200 years and
treatments for diseases such as Parkinson's disease or depression are heavily
involved in debates as to how much of their effect is actually down to the placebo
effect. I came to the conclusion that under certain circumstances placebos can be
perceived as ethical but with organisations such as the NHs having such strict
focuses on honesty and probity, it would not be right to prescribe a substance on the

3
basis

of

deceit.

Introduction

The debate as towards the place of homeopathy in society has been a recent hot
issue in the scientific and political community, with even members of the Royal
Family as proponents(3). Movements opposed to homeopathy such as (4)10:23 have
targeted companies such as Boots and they're willingness to trade in substances that
'having nothing in it' and Tom Dolphin of the BMA actively referred to it as
witchcraft(5) before apologising to the witches. However the NHS still continues to
provide treatment for a variety of diseases via homeopathic methods and hospitals in
cities such as London, Liverpool, Bristol and Glasgow. The concern in this comes
from times of NHS cuts making any unnecessary spending a target for removal and
with the estimated expenditure of homeopathy to be around 4m per annum(6),
requests have even been made by homeopaths such as Dr Mathie of the BHA
(British Homeopathic Association) for a 'cost-effectiveness evaluation' into the NHS
usage of this treatment(6). This essay hopes to address the history of homeopathy,
its proposed mechanisms of actions and the ethics of using placebos. Through this I
hope to establish what the apparent scientific consensus is on the overall issue and
whether

homeopathy

should

truly

be

available

on

the

NHS.

What is Homeopathy?
Homeopathy is a practice beginning in 1796 relating to the treatment of disease(7). It
was founded by the German doctor Samuel Hahnemann. It relies on two principles,
the first principle being that 'like-cures-like', i.e. a substance such as quinine which
has been used for over 400 years to treat malaria in high doses causes
chinchoism(8) which is similar to the symptoms of malaria in that it produces
symptoms such as vomiting, headaches and fever. This particular example led
Hahnemann to form his theory of 'like-cures-like' officially referred to as the 'law of
similars.(9) The process of finding a suitable substance is referred to as a proving, in
which the substance is consumed either in high-concentrations or in its usual dilute
form and its effects are observed and used to decide whether it is suitable for
prescription. This 'law of similars is complemented by 'ultra-dilution', the belief that

4
the more dilute a substance is the stronger its 'vital-effect'. This is achieved through
the process of potentisation in which the mixture is diluted in a 1 to 100 ratio, referred
to as a 1C concentration and then strongly struck against a substance such as
leather 10 times in another process referred to as succussion. This was believed by
Hahnemann to strengthen the mixture. One drop of this mixture can then be taken,
diluted by the same ratio and undergo succussion to form the 2C concentration, this
said scale being logarithmic. This was recommended by Hahnemann to be continued
until the 30C concentration at which point the substance has been diluted to be one
part in 1060. Homeopathy since then has evolved into many different forms. For the
purposes of convenience one trial(1) classified it into four different forms, them being
classical, clinical, complex and isopathy. Classical was seen as homeopathy
involving a long in-depth assessment of the patients history followed by a single
remedy made for the patient, Clinical was a single remedy issued without any
examination of the patients history, Complex involved the issuing of multiple distinct
remedies and Isopathy required the remedys mother tincture to be comprised of the
initial

cause

of

the

symptoms

e.g.

pollen

for

asthma.

The NHS and Homeopathy

Homeopathy and the NHS have had a long relationship, it has been part of its
available services since the NHS's inception in 1948(6). As mentioned early, there is
no exact knowledge of NHS expenditure on homeopathy, with most estimates giving
the rough figure of 4m per annum but this is believed to exclude the 20m spent on
renovating and restoring the Royal London Homeopathic Hospital (now known as the
Royal London Hospital of Integrated Medicine) as well as the general costs involved
in maintaining and running the other hospitals over the time frame this figure was
calculated. There appears to be no actual reason for the NHS to provide homeopathy
as it was criticised in a government commissioned independent analysis which
unambiguously concluded that 'placebos should not be routinely prescribed on the
NHS and that the funding of homeopathic hospitalshospitals that specialise in the
administration of placebosshould not continue, and NHS doctors should not refer
patients to homeopaths(6). The main government response from the Department of
Health being that homeopathy is 'important for patient choice'(10). Whilst I'll be
tackling whether this is suitable grounds for prescription purposes first I'll discuss the

5
evidence-based studies of homeopathy to decide Does Homeopathy even work?

Scientific Studies related to the effects of homeopathy

A study by Taylor et al of the Glasgow Homeopathic Hospital(2) found that in treating
patients with allergic rhinitis, homeopathy was more effective than placebo. In this
study, designed to show that a previous three trials were not due to the placebo effect
they took 51 patients suffering from perennial allergic rhinitis, recruited from four
general practices over London as well as outpatients from an ENT department which
were randomised to receive either a 30C concentration of their main allergen or a
placebo. (Figure 1)

Figure 1. Recruitment
process for patients in trial
by Taylor et al (2)

After this the groups were left for four weeks with a diary to record their peak nasal
inspiratory flow rate (PNIFR) measured three times in quick succession twice a day
(morning and evening) with as well as recordings of how symptoms had interfered
with their sleep on a 4 point scale as well as a measurement on a 100 point scale of

6
how the patient felt that day using the phrasing 'Overall today I felt...' with 100 being
the worse feeling and 0 being feeling fine. Adverse effects were also measured as
well as aggravations, which is when the initial symptoms of the disease are
increased, believed to hold some importance in homeopathy(11). Also any usage of
the drugs initially prescribed for when the disease was deemed to require them at the
sake of the trial was also recorded. Results were then analysed

The outcome of these results was interesting. For instance Table 1. shows the
change in PNIFR over the course of the observation and treatment for both the
homeopathy and placebo control.
Table 1. Mean baseline values and changes in PNIFR and visual analogue score
taken from trial by Taylor et al(2)
Mean (Standard Deviation) Baseline

Homeopathy

Placebo

Mean (Standard Error) Change from baseline

Homeopathy

Placebo

value

Difference

between

groups
Mean

(95%

Confidence

P
Value

Interval)
Visual

39.5(12.9)

analogue

38.1

0.76

-5.0 (3.3)

-4.0 (2.8)

1 (-9.8 7.8)

0.82

0.62

25.1 (5.9)

-0.3 (3.0)

25.4 (11.7

0.0008

(18.7)

scale
results
(mm)
PNIFR(l/min)
Morning

98.1 (34.5)

103.2
(32.9)

Evening

110.7 (46.7)

115 (42.2)

39.2)
0.75

19.5 (5.7)

5.4 (3.3)

12.1

(0.6

0.04

27.6)
Average

104.4 (41.1)

109.1
(37.9)

0.58

22.3 (4.1)

2.5 (2.3)

19.8 (10.4

0.0001

29.1)

Here there appears to be a clear difference between the placebo, the homeopathy
having produced an average increase in PNIFR of 22.3% whilst the placebo group
only had an average increase of 2.5%, the levels of difference being shown in this
study would according to the surveys statistical analysis show a significant difference

7
(P<0.0001). This led the authors to conclude that homeopathy is different from
placebo on both subjective and objective measures. The other area that was studied
was the patients perception of their own illness via the 100 point visual analogue
scale, which showed no difference between the two groups i.e. no benefit derived
from

homeopathy.

However this study was later criticised for using flawed statistical methods. Whilst the
calculations used as metrics would have been correct for the 121 patients originally
screened for eligibility they were not suitable for the
included(12).Further criticism

51 that actually were

came for a meta-analysis of

three previous

homeopathic studies that the authors included (13). Said studies had such high
heterogeneity that it was not possible to compare them fair. The final criticism was
that there was a distinct possibility the patients did not have allergic rhinitis as they
had not responded to topical steroids, response to this treatment being a classic
marker of allergic rhinitis(14). This calls into question the suitability of the sample,
which is already rather small.

Whilst there may be other trials and meta-analyses supporting homeopathy, they are
disparate and these meta-analyses have come under fire for cherry-picking(15). The
trials

themselves

have

been

criticised

for

poor

sampling,

design

and

measurement(16). The Cochrane Collaboration has conducted two reviews into

homeopathic treatments. The first was a study into attention deficit disorder and the
second chronic asthma. In the first study(17) only RCTs were looked at as resources
for the meta-analysis but quasi-randomised trials were studied for investigations into
efficacy and effectiveness with all types of trial involved in the study as towards the
safety of homeopathy.. The results of the meta-analysis showed that in the eyes of
the childrens parents there was no difference between the placebo and active
medication for the ADHD index, inattention index, restless/impulsivity index; anxiety,
conduct and emotional liability levels also showed no hints towards homeopathic
effectiveness. Only one of the studies involved looked at teacher perceptions who
also noticed no changes. Direct assessments of the children in the trial also showed
no significant change for inattention or impulsivity leading the researchers to
conclude that There is at present insufficient evidence to recommend the use of
homeopathy for children diagnosed with ADHD. The second study(18) used 6 trials

8
with an overall participation of 556. All the trials involved were placebo-controlled
RCTs with double blinding however the researchers involved admit that their was not
enough focus on homeopathys benefits from individualised treatment and its general
package of care. This is important in regards to the theory that homeopaths elicit a
strong placebo effect due to the way they treat the patient, a theory supported by this
study (19) by Brien et al, showing that whilst homeopathy as a medication had no
significant difference from placebo, the full consultation that accompanied it was what
made the difference. The actual Cochrane meta-analysis
showed that there was no clear outcome from the trials, and therefore could not
assess reliably the possible role of homeopathy in the treatment of asthma but was
critical of homeopathy in making research difficult by a paucity of information on
what homeopaths actually do with practicing homeopaths coming under particular
fire by Dr Ernst(20) of the Peninsula Medical School for being afraid of research in
Field

Number of

case the answers will not show what they had

paired

hoped. Whilst there was a third Cochrane Review

studies

for homeopathy, in relation to dementia treatment it

URTIs

21 (19%)

Asthma/

16 (15%)

OB/GYN

14 (13%)

Surgery/

12 (11%)

purpose in my paper other than to reaffirm that

there is far too little homeopathic research.
However a 2005 study published in the Lancet was

Anaesthesia
Gastroenterology 12 (11%)
11 (10%)

deemed so definitive the journal chose to write an

editorial

inspired

Homeopathy(21).

conditions
Neurology

10 (9%)

Other

14 (13%)

Table 2. Distribution of study topics

involved in meta-analysis
from Shang et al(1)

assessed as being unfit for inclusion due to small

sample sizes (<20) and therefore serve little to no

hayfever

Musculoskeletal

does not actually analyse any studies as they were

taken

matched

110

by
The

it

titled
paper

homeopathy

The
in

and

End

of

question(1)
conventional

medicine trials which had a median of 65

participants and the trials were paired across a
variety of different diseases (Table 2.) and with
multiple forms of homeopathy (classic, clinical,

complex and isopathic) including one trial where the actual form of homeopathy was
unclear. Of these trials it was assumed that the effects seen in the homeopathy trials
were due to a combination of methodological deficiencies and biased reporting and

9
that these biases could not explain the results that were discovered in the
conventional medicine trials. The findings of this study supported this as when
analysis was restricted to the trials assessed to have higher quality by the papers
criteria there was found to be no evidence supporting homeopathy against clinical
medicine as the odds ratios for health improvement became 0.88 (0.65-1.18) and
0.58 (0.39-0.85) respectively, with the lower the number indicating a more beneficial
treatment. This showed a much clearer improvement in patients on conventional
medicine than those undergoing homeopathic treatment. The authors concluded that
whilst the effects seen in placebo-controlled trials of homoeopathy are compatible
with the placebo hypothesis this did not remove homeopathy as an option that
complements conventional medicine. From the body of evidence opposed to
homeopathy, we can conclude it is but water and placebo. Therefore it is time to
explore the placebo effect in more depth and the ethics of treating patients with
placebos.

The Placebo effect

Placebos, Latin for I will please(22), are quite difficult to define in a medical sense.
They were defined at one point as something that has properties objectively without
specific activity for the condition being treated(23). This loose definition has allowed
placebos to cover a wide array of topics outside of the established clinical usage(24).
Placebos have been in use for over 200 years(25), but research on the placebos
mechanisms of action only truly began recently after a 1978 trial(26) discovered that
naloxone, an opioid antagonist, could inhibit the placebo effect in regards to
analgesia. This trial led to later studies, in which it was discovered that the placebo
can also imitate side-effects. In one particular study(27) a patient being previously
treated buphrenorphine was switched on to a placebo without being informed. The
respiratory

depression

associated

with

said

analgesic

remained

until

the

administration of naloxone began to cease, as it would in the application of a true

narcotic. There have also been significant studies to suggest that the effect of SSRI
antidepressants is not much more than a placebo.(28, 29)

A major component of the placebo effect is the idea of conditioning and expectations.
This relies on the idea that what we expect the placebo to do is what it does to us, for

10
example when patients were told that the pill they were taking was an analgesic, their
pain tolerance increased but when they were informed it was more likely to cause
hyper-algesia, the pain tolerance dropped through what is known as the nocebo
effect (30). This verbal expectation significantly altered the subject-s perception of
the pills properties and therefore its effects on the body. Similar effects were
observed in patients with Parkinsons disease where turning off the subthalamic
stimulator had similar effects to only the suggestion that it had been switched off.

The evolutionary demand for a placebo effect is a particular point of interest as it

raises the question that if a body can heal itself, why does it not do this until pushed
by external suggestion?

It was theorised by Nicholas Humphreys(31) that we

evolved the placebo effect as a form of economically managing our health. First is to
remember that symptoms of disease are often the presentation of the bodys
defences. This means that subduing these symptoms could involve subduing a
response to a genuine problem, such as preventing vomiting stopping the body
ridding itself of toxins or by ridding oneself of pain means one puts themselves in
dangerous situations in which the body is not fit to cope. However this doesnt apply
in cases where the pathology is less self-generated, but the costs can make it seem
illogical to begin healing so quickly, such is the metabolic demand of the immune
system(32). Therefore the placebo by giving hope causes happiness in the patient
which alters the incentives as there is now no longer any reason to try to conserve
resources as the internal mood is reflecting a safe external environment. However
the placebo needs the patient to be deceived in at least some way as even though a
notable trial by Kaptchuk et al(33) claimed that Placebos work without deception it
still involved telling the patient that the placebo could cause improvements in the
condition of IBS patients through mind-body self-healing processes which is not true
as the placebo effect is believed to only be responded to by 35% of the
population(34) although this figure had varied from 27%(35) to 56%(36). Whilst this
might seem low, this is similar to response rates to intravenous morphine if given
unknowingly(37). Therefore the ethics of prescribing placebos must be explored.

The main ethical issue with placebos is lying to the patient(38) and that this
automatically makes the process unethical as it violates all concepts of informed

11
consent as the patient is no longer truly informed about the treatment they are
receiving, especially relevant under GMC guidelines which require a doctor to be
honest and trustworthy and act with integrity . However since only 35% of the
population respond to placebo, if a placebo is given with the full belief of the clinician
that it will cause the patient pain relief due to its indirect physiological effects from the
direct psychological effect, is this dishonesty? Another interesting point raised is
situations that can arise where a placebo is the preferred course of treatment, for
instance a patient suffering from anxiety or other psychological disorders who for
whom an inert substance fulfils all the effects of an active one but without the
potential side-effects or overdose risks. It is these kinds of situations that led the
authors of a paper(38) focused on the ethics of placebos in clinical practice to
conclude that placebos were ethical under a specific set of circumstances,
circumstances where the clinician was acting in a benevolent manner with intentions
of assuaging the patients suffering and the placebo is neither used in place of a
more effective treatment or its usage is neither continued when proved ineffective or
discontinued when effective, but most importantly in my opinion that the clinician is
honest to all patient enquiries. This avoids the issues of informed consent because
the doctor is willing to inform the patient what he believes to be true, so no
information

is

withheld.

Conclusion

Homeopathy is whilst not a major spend on the NHS, is still a cost in a time of
frugality. Whilst evidence has been presented to support it, it has been focused on as
being without merit and in contrast to the general scientific body of work. It is
perceived as lacking in rigorous standards and as dishonest and having no direct
therapeutic effect, it only acting as a placebo. Whilst ethical frameworks have been
devised for placebos, they are still fundamentally dishonest in some elements and
therefore in accordance with GMC guidelines on probity and honesty, it can only be
my thoughts that homeopathy should not be prescribed on the NHS, a statement I
echo from many in the scientific community and in government think-tanks.

12
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14
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