Memo to the Health minister

The effectiveness of any “new and innovative treatments and medicines” should be proven to work beyond the placebo before being publicly funded. Otherwise it’s funding based on a super-natural belief. Health minister Michael McGimpsey attended a complementary and alternative therapies and medicines conference at Belfast City Hospital today. And he’s released a short statement. On which I have a few points to make, some of which I may have made before – see below the fold.From the Health minister’s statement

“We have a wonderfully diverse health and social care system here, not least because of our patient-centred approach to meeting need. This diversity is one of its main strengths, and CAM has a role to play.”

A diversity of treatments is only a strength if those treatments work beyond the placebo – otherwise, just stick to the sugar pills.

He said: “The CAM pilot is unique within the UK, in that it provides some GPs with the opportunity and support to refer patients directly to a range of complementary therapists to treat ailments such as back pain and depression, stress and anxiety.”

Great. A burgeoning publicly funded sugar pill industry. Ever wondered why that pilot is unique within the UK? Partly because Peter Hain was a believer.

Meanwhile, elsewhere within the UK, those alternative treatments face having NHS funding for them withdrawn – Because they can’t provide evidence of effectiveness beyond the placebo.

And if anyone thinks that this report on acupuncture if evidence to the contrary.. think again – Bad Science’s Ben Goldacre dismantles that claim here. And he tackles herbalists here.

Finally on the current ‘pilot’ scheme

According to the notes to today’s statement

The CAM pilot project will run until March 2008 and will be independently evaluated by Social Market Research (SMR).

Great… [off sarcasm]

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  • It would be nice to think Goldacre and others who have long toiled on this issue were actually taken more seriously by the powers that be. I think you’re absolutely correct as regards the point that treatments have to work beyond the placebo. Whether others agree is a different matter.

  • Two Nations

    Pete Baker

    Is your whole belief system based around what Richard Dawkins believes?

  • Frank Sinistra

    Pete,

    While I can understand scepticism over many CAM therapies it is useful to note that Chiropractics and Osteopathy are often included in the definition and afaik they are universally accepted as medically beneficial.

  • Pete Baker

    Two Nations

    You just don’t get the science bit do you..

    Frank

    And I’d prefer it if they weren’t all put together in the same bag as the rest of the sugar pills.

    But if they can provide evidence that they work better than the placebo then they should be available on public funds.

    If not, there are plenty of examples were restricted funds mean that proven treatments are not as widely available as they should be.

  • Turgon

    Frank Sinistra,
    No they are not universally accepted at all. Many doctors regard them as non qualified physiotherapists, though in fairness many have a physiotherapy background but it is that rather than the chiropractice or ostepopathy which do the good. There are also a number of conditions where osteopaths can make the situtation worse.

    Overall this is another example of throwing good money after bad. Already this week McGimpsey has made one daft decision, he is now supporting therapies which whilst they make make people feel a bit better have no evidence base at all and have little in serious illnesses.

    Some complementary medicine can help some people feel batter and may have a small (non evidence based) niche. However, since our health service has considerable problems; many of which stem from poor and wasteful use of resources, there are much more important things the NI NHS could be spending money on than complementary therapies.

    The even bigger danger is that some people will use these therapies rather than real treatments for serious aliments which can and at times is a life threatening error.

  • agh

    You have to remember that if a person truely believes a ‘treatment’ will work they will probably get some benefit from it. If you have a box of pills saying placebo, it prob won’t do the same job as a nicely marketed homepathic product containing the same ingredients.
    As long as the alternative treatments are cost effective with regards to the benefit derived (whether imaginary or not) compared to the amount it costs I don’t have a problem with it. It’s when eejits sell products at ridiculous prices get a tad annoyed!

  • Pete Baker

    Turgon

    He hasn’t, yet, thrown any more money at these ‘therapies’.

    agh

    I have some sympathy for your argument.

    But there is a drawback to it – at least one.

    There’s the danger of creating a burgeoning ‘sugar pill’ industry with new sugar pills appearing in increasing numbers – ‘better than the last sugar pill!’

    And there’s the knock-on effect of undermining, even further, the public understanding of science – real evidence based science.

  • Turgon

    Pete Baker,
    I agree entirely. Do not worry I am completely with you on this.

    I am completely convienced of the total lack of benefit of complementary therapies. They have an extremely small niche role in places like hospices where they make people feel better and have greater wellbeing. Examples of this are things like aromatherapy. Tt is harmless and ineffective but makes a nice smell and I would have no problem with a few pounds being spent on it in the hospice.

    To waste money on using alternative therapies as a significant adjunct let alone major part of medical therapy would be a total waste of money. I fear, however, that the minister might (just might) put some money into it as it would garner support from the chattering classes who being wealthy and still healthy do not yet need to avail of proper treatments which tend to be rather expensive.

    I am reminded of the terrifying story of a consultant surgeon in London who saw a middle aged man with bleeding from the back passage. The patient had a small very localised cancer. The surgeon told him it needed immediate attention. The patient said he would go on the NHS to his own GP immdeiately. Over a year later the man returned with pain in his back passage. He had inoperable cancer and was going to die. The horrified surgeon told him it was the cancer. The patient professed amazement as he had gone to an alternative care practitioner and received alledgedly curative treatment.

  • Fraggle
  • Frank Sinistra

    Fraggle,

    Linking to a website that recently lost a libel case brought by a chiropractor isn’t the best of rebuttals.

  • Fraggle
  • Two Nations

    Pete,

    You just don’t get that condescending, polemic, trite rantings of a person who is not as smart as he believes himself to be is equivalent to scientific understanding.

    But I’m sure you’re dead-on in real-life Pete.

  • Pete Baker

    Two nations

    I’m not going to labour the point..

    But if you think that I believe anything that’s said on the basis of who it was that said it you’re sadly mistaken.

  • pauljames

    What concerns me Pete, is that this is a GP referal scheme, within the NHS. The question is do our Doctors support this quackery or is it an easy way to sidetrack patients who they can offer no further existing rational treatment?

  • Therapy, by definition, should have a therapeutic value. CAM, by its nature allows time to discuss lifestyle etc, thereby producing an outcome that is apparently beneficial. To say that it should be tested and subject to scrutiny (peer review, statistical analysis etc) is a logical step for any treatment…indeed it is the steps that ‘conventional’ treatments/medicines must go through. Given that the NI Executive is set to announce ‘economy’ as its priority it is strange in the extreme to have CAM given money when other services are struggling under agenda for change and cash squeezes! Oh, and Pete’s discussed dawkins, but never been a proponent of narrow science, rather from his posts has encouraged debate where other prefer dogma

  • Pete Baker

    pauljames [and Jonny]

    The GP referral issue within the NHS is a concern.

    Better for money to be spent prodiving for a better GP service, where the time [or ritual] spent can produce the same placebo effect there rather than through the pseudo-science that this pilot presents.

  • steve48

    Since my staff actually made a presentation at yesterdays event I find Pete’s rant relatively ill informed.

    Yes there are elements of CAM that I am yet to be convinced of however much of the focus yesterday was on the use of CAM with cancer patients not as a cure but as a way of alleviating the distressing symptoms. In many cases therapies such as reflexology produce significant benefits for the patients and help them cope with the traditional chemo or radiotherapy.

    My staffs presentation focussed on a programme we run in schools promoting self esteem which given the increase in mental health issues amongst young people is a major issue.

    Sweeping statements by Pete and others fail to recognise that for many people there are complementary therapies that help them as opposed to having a society who exist and function in the drug induced haze of prescription medicine.

  • Pete Baker

    “for many people there are complementary therapies that help them..”

    Yep. It’s called the placebo effect. And it, at least, is well understood. But at least you’ve declared an interest in the funding.

    Reflexology indeed.

  • turgon

    steve 48,
    I do not want to attack you but I find this statement potentially unhelpful “having a society who exist and function in the drug induced haze of prescription medicine”

    Yes benzodiazepine sedatives (such as valium/diazepam) were significantly over used in the past, yes they are probably still over used. They do have some sedative effect but they are usually used short term now.

    Antidepressants may also be over used at times but most modern antidepressants (contrary to popular belief) have very few sedative properties and are non addictive.

    I do not mind niche roles for some complimentary therapies, though I have concerns about the use of precious resources. I do, however, feel that comments like yours above about prescription drugs can be misunderstood and people can fail to take or stop taking medications which are doing them considerable good.

  • Hasn’t all that self-esteem stuff been shown to be bullshit every bit as much as CAM?

  • I am in definate agreement with that. Listening yesterday to CSR row on The World at One, and then the announcement about the increased funding to the health service (in provision of 3 000 extra CBT proffesionals), I couldn’t help but cringing at the amount of money to be spent on all these homeopathic treatments that have no evidence of working.

  • NIGP

    Re GP involvement or interest, we were not consulted, when the pilot was announced some practices were told they could refer under this scheme, it is geared towards ordinary primary care patients with aches/pains/stress/mild depression, none of the bumpf sent to us suggested any role for cancer patients.

    It’s crap, no evidence base, and when they are invited to take part in proper studies (eg by Peninsula Medical School) they refuse.

    It’s a waste of money

  • Dread Cthulhu

    Chiropratic started to gain some legitimacy in US mainstream medicine about the same time they proposed “deep manipulation” therapy, which required the services of an anesthesiologist and an inpatient stay… funny thing that.

    Speaking of the NHS…

    “Whatever you made of the Chancellor’s various sleights of hand on Tuesday, lurking beneath his Budget plans was one inescapable fact. The hungry maw of the NHS is swallowing more and more resources, at the expense of virtually everything else. The defence budget is at its lowest since 1930, despite our dwindling troops being dotted across three continents. Prison overcrowding is at such record levels that Jack Straw will have to release even more inmates early in a few weeks’ time. But the health service marches relentlessly on, having hoovered up two thirds of the increase in public spending in the past five years. ”

    full text

  • Comrade Stalin

    steve48, I think I see how this works :

    1. Invent bullshit product that doesn’t work and pawn it off on the health service
    2. Accuse anyone who says that it’s bullshit of taking happiness away from terminal patients
    3. Profit!

    There’s a hell of a lot of bullshit out there.

    Dread, I don’t have one jot of a problem with defense and prison spending being cut back to improve the health service. What’s your point ?

  • Dread Cthulhu

    Comrade Stalin: “I don’t have one jot of a problem with defense and prison spending being cut back to improve the health service. What’s your point ? ”

    Simply put, the system is unsustainable. The assumptions that existed when it was created — birth-rate, ratio of tax-payors to total population, etc., does not exist at this point in time. Likewise, as noted above, the system is open to manipulation and, because its a public service, is seen as just another honey pot.

    Likewise, when the consequences of cutting prisons and defense, when the other shoe drops, I suspect you won’t be nearly so blaise.

  • NIGP

    Dread

    Valid point, any health service anywhere will spend whatever you give it and still ask for more.

    A possible solution or at least a possible counterbalance, fix either a total health spend or fix a percentage of GDP and stick to it, take the control of that amount away from politicians, give it to an NHS Board with a lay majority who decide how to spend it. Then stick with that budget allocation for 1-3 years before it can be changed.

    If people want anything not covered (eg drugs, newer treatments) they can insure for it, pay for it privately, ask for charitable donations to fund it or perhaps get it free as part of a trial of a new or experimental treatment.

  • NIGP

    btw, here’s a good precis of the dilemmas at the heart of alternative medicine and its use in the NHS

    http://dcscience.net/improbable.html

  • Dread Cthulhu

    NIGP: “Valid point, any health service anywhere will spend whatever you give it and still ask for more.”

    Budgetary logic — if I do my job and do it efficiently (i.e. don’t spend my full allotment), I will get the same or less next year. As a result, all monies are spent, regardless of need or efficiency.

    NIGP: “A possible solution or at least a possible counterbalance, fix either a total health spend or fix a percentage of GDP and stick to it, take the control of that amount away from politicians, give it to an NHS Board with a lay majority who decide how to spend it. Then stick with that budget allocation for 1-3 years before it can be changed. ”

    I suspect it’s too late for that, NIGP — its already been an open (i.e. not need based) entitlement for *HOW* long? I have yet to meet the politician with the spine and stomach to push that change, mores the pity.

  • NIGP

    Dread “Budgetary logic—if I do my job and do it efficiently (i.e. don’t spend my full allotment), I will get the same or less next year. As a result, all monies are spent, regardless of need or efficiency. “, absolutely, hence rush to spend “slippage” monies every March, the best time to try for a new desk or carpet for your office.

    But over and above that health wants (and probably needs) are infinite so even if the NHS never wasted a penny it would still always want more as people lived longer and fell prey to more and more long term conditions requiring more and more drugs, carers, physio, long stay beds etc. etc. ad infinitum.

  • Turgon

    NIGP,
    I understand your position and accept that we can never meet all need. I am not having a go at you but I think this bit is naive and I am sure you know it.

    “If people want anything not covered (eg drugs, newer treatments) they can insure for it, pay for it privately, ask for charitable donations to fund it or perhaps get it free as part of a trial of a new or experimental treatment.”

    We all know that many new treatments are extremely expensive. As such paying for it is impractical for practically everyone, charities could not afford the treatments. Insurers shy away from the people most likely to need given treatments and are reluctant to pay for new treatments. Trials always use patients who have few comorbidities and the exclusion criteria will omit the vast majority of the people you describe.

    If people do not get new treatments there will be massive political pressure, pressure politicians would find incredibly difficult to resist. Look at the Herceptin issue. The drug was not licensed for early stage breast cancer. The trials had not been finished; there were legitimate concerns about cardiovascular complications and yet the outcry was overwhelming and the government had to force the PCTs in England to provide the drug.

  • Dread Cthulhu

    Turgon: “If people do not get new treatments there will be massive political pressure, pressure politicians would find incredibly difficult to resist.”

    Having created an entitlement without a basis in need, the British gov’t grabbed the proverbial Tiger by the tail. You would seem to be of the opinion that no matter how marginal the treatment or how expensive, the state should pony up the dosh, or else they be voted out of office.

    The system, in its current form and given current demographics, is unsustainable. Where do you propose the necessary money come from? The honey-pot is not bottomless.

    Speaking of the NHS, a new entry in the Big Book of British Smiles…

    http://www.cnn.com/2007/WORLD/europe/10/15/england.dentists/index.html?iref=mpstoryview

  • Turgon

    No Dread I largely agree with you. I think the system is unfundable in the medium to long term. As indeed are most (? all) state run schemes. The American insurance based system also has massive problems and massive inefficiency. I do not have any clever ideas on this. I do not think banning new treatments for three years would be possible but I do not have a better idea. Any suggestions?

  • Dread Cthulhu

    Turgon: “The American insurance based system also has massive problems and massive inefficiency.”

    Ah, but health insurance in the United States became vastly expanded in an atypical economic environment — unable / unallowed to compete for labor on a wage basis, health insurance was extended to labor as a perk / sweetener during the Second World War. When the economy was normalized, the perk was not withdrawn. The fifteen years of boom economic years for the United States following the Second World War made it cheaper, in the short run, to simply give labor whatever it demanded, creating huge legacy costs for some corporations. Throw in the fact that pharmaceutical pricing schemes do not favor the United States and you have quite a pickle.

    The problem extends to the individual level, however. Folks have gotten it into their head that if they have insurance, it is not “their” bill. As such, they pay little attention to their bills, simply paying the deductible / coinsurance and moving on. Government reimbursement schemes, such as Medicare and Medicaid, have further distorted billing practices as provider act on regulations and the gov’t reacts to close perceived loopholes.

    Turgon: “I do not have any clever ideas on this. I do not think banning new treatments for three years would be possible but I do not have a better idea. Any suggestions? ”

    Clever schemes is how this mess was created, Turgon. I think hard choices are in order. Alas and alack, those choices have been left with politicians, who will, in all liklihood, punt, dither and fritter until too late. The catch is the cure will be a bitter pill and no politician likes to sell bitter pills.

  • kensei

    So DC, your solution boils down to let every f*cker fend for themselves because of moral hazard. The 19th Century says Hi, it’s concerned with the number of dead people.

    Can the NHS continue to receive growth massively above inflation every year? Clearly not. We are coming out of a time were there was a lot of money sloshing about and a government that was committed to spending it on health care.

    That is not a situation that will last forever. Eventually circumstances, government or both will change, the NHS will get less money, staff will get harder bargaining, drug rules will be applied more strictly and some more reforms will be brought in. The government of the day do it by stealth or will take some heat, but get away with it because it’s new, or because of other pressures.

    And the NHS will trundle on, because people value the big benefit of the NHS – security – above much riskier systems like the one in the US, or heaven forbid, something worse. And that becomes especially true as more and more risk gets placed onto people, as it has happened in so many other areas for the past 20 years.

  • Dread Cthulhu

    kensei: “So DC, your solution boils down to let every f*cker fend for themselves because of moral hazard. The 19th Century says Hi, it’s concerned with the number of dead people. ”

    Obviously, your reading comrehension skills are lacking. I said there would be hard decisions and a bitter pill. But, hey, demonizing those who don’t agree with you has seemingly always been your preferred tactic, why stop now?

    kensei: “Can the NHS continue to receive growth massively above inflation every year? Clearly not. We are coming out of a time were there was a lot of money sloshing about and a government that was committed to spending it on health care. That is not a situation that will last forever. ”

    Hallelujah… even the most one-eyed amongst us can see and agree there is problem.

    kensei: “Eventually circumstances, government or both will change, the NHS will get less money, staff will get harder bargaining, drug rules will be applied more strictly and some more reforms will be brought in. ”

    No, it won’t, largely for the dynamics that both I and Turgon have pointed out and you have so eloquently demonstrated. Open concern for the viability of the NHS as a open honey-pot for all comers is met with unreasoning demonization. Hell, kensei, the NHS’ talking head look at a slowing of growth as “a cut” in spending. The political class with dither and dick around, not wanting to rock the boat until its too late, for precisely the reason that the problem wasn’t addressed when the demographics were clear years ago — no one wants the hassle and the electoral fall-out that comes with trying to address the problem.

    kensei: “And the NHS will trundle on, because people value the big benefit of the NHS – security – above much riskier systems like the one in the US, or heaven forbid, something worse. And that becomes especially true as more and more risk gets placed onto people, as it has happened in so many other areas for the past 20 years. ”

    The demographics say you’re wrong. As lifespans increase and end of life medicine improves, the costs will increase and the demand for procedures will continue. That the people want it is not the end of the equation — will they be willing to pay what is necessary.

    The bulk of Medicare expansion has been “end of life” treatments — the sort of thing that adds about six months — medicated stents, etc. At some point, some hard questions are going to have to be answered.

    Now, to be frank, yes, I do think was foolish to establish an entitlement based on a static set of assumptions and not having the stomach to correct the system as things went along. I also don’t share your faith in the political class — their first job after getting elected is almost invariably getting re-elected and standing up and answering the hard questions is not their way.