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Meeting of Bristol Clinical Commissioning Group Governing Body
To be held on Tuesday 26 April 2016 commencing at 1:30pm at the Vassell Centre,
Gill Avenue, BS16 2QQ
Title: Commissioning of Homeopathy
Agenda Item: 16
1
Purpose
To inform a Governing Body discussion and decision on the medium and long
term plan for commissioning Homeopathy.
2
Background
Bristol, North Somerset and South Gloucestershire (BNSSG) CCGs
commissioned a review of Homeopathy services to help inform a decision on the
future commissioning arrangements. This review is attached (appendix one) to
this paper along with a brief covering note. The review considered a number of
options, and was discussed at the BNSSG Partnership meeting. At this meeting
the CCGs agreed to ask their decision making bodies to consider plans for
Homeopathy. This proposal focused on a recommendation that each CCG
undertook a public engagement exercise and that if all three CCGs agreed on
this course of action a single engagement exercise be considered. It was noted
that each CCG would need to consider the resource implications associated with
such an exercise. The agreed policy paper is attached for information.
3
How have service users, carers and local people been involved?
The review involved an interview with a patient and considered other forms of
patient feedback.
4
Implications on equalities and health inequalities.
Any decision regarding the commissioning arrangements for a service and ant
associated public engagement exercise would need to take into account
equalities and health inequalities. .
5
Evidence Informed Commissioning
A previous evidence-based review was undertaken in BNSSG on the efficacy of
Homeopathy. This is referenced in the attached review. The attached review
considers patient feedback, activity data and clinical professional views. The
suggestion to undertake a public consultation is considered best practice when
potentially making material changes to the commissioning of services.
6
Financial Implications
If you need this document in a different format telephone the CCG on 0117 900 2632
Page 1 of 2
Meeting of Bristol CCG – 26 April 2016 – Commissioning of Homeopathy
There is a, as yet unknown, resource implication in relation to the proposed
public engagement exercise.
7
Legal implications
In making any decision regarding the commissioning arrangements for a service
the CCG must have due regard to the legal duties set out in the Health and
Social Care Act 2012.
8
Risk implications, assessment and mitigation
The risks are outlined in the review paper.
9
How does this fit with Bristol CCG’s Operational Plan or Strategic
Objectives?
This service is not referred to in the CCG Operational Plan.
10
Recommendation(s)
The Governing Body is asked to agree that:
•
A public engagement exercise on the future commissioning of
Homeopathy is completed and
•
Consider a joint public engagement exercise with North Somerset and
South Gloucestershire CCGs
•
North Somerset and South Gloucestershire CCGs are also considering
this decision, and if all agree to this recommendation it is suggested that
one public engagement exercise is undertaken across all three CCGs.
•
Consider the resource requirement for a public engagement exercise
Sarah Swift
Delivery Director, SCWCSU
18 March 2016
Martin Jones
Clinical Chair, Bristol CCG
18 March 2016
Page 2 of 2
Bristol, South Gloucestershire & North Somerset CCGs' review of
Integrative Medicine
1. Purpose of this document
This document has been written on behalf of Bristol, North Somerset and South Gloucestershire
(BNSSG) Clinical Commissioning Groups (CCGs). Its purpose is to present information that will assist
in a BNSSG review of the NHS homeopathy services commissioned from University Hospitals Bristol
NHS Foundation Trust.
On 6 August 2015 a meeting of BNSSG CCG representatives was held, to define this review. The brief
was then agreed by the Partnership Group of the three CCGs in October 2015. The Partnership Group
has no decision-making authority, and thus any decisions on the future of homeopathy
commissioning must be made by each CCG independently.
This document aims to:
1. Review the needs of the patients currently accessing homeopathic services commissioned by
BNSSG CCGs, and
2. Appraise the options for commissioning arrangements to best meet the needs of these
patients.
The document does not set out recommendations, but is intended to give sufficient information to
enable a considered decision to be made.
2. Executive summary
Medically-led homeopathy has had a long and, right from the start, controversial history in the
wider Bristol area.
People who seek NHS homeopathic treatment are: predominantly women or children; mostly
people who are seeking alleviation of long-term symptoms; reported as often finding the
treatment of value. Referrals are mostly from GPs, and, contrary to expectation, geographically
quite widespread across the local area.
The simple arguments 'for and against' can be summarised as 'we are still looking for the
explanation, but it works for me' versus 'it doesn't make any sense medically, and so we should
be spending the money on something else.' Conversations with referrers show more modulated
views and behaviours: there are clinicians who don't 'believe it' medically but nevertheless refer.
The provider of the NHS service is sub-contracted for this work from University Hospitals NHS
Foundation Trust. The provider is in transition to a social enterprise. This brings opportunities
for change, as well as complexities around contracts and employment. Recent CCG
commissioning changes include a local commissioning policy, which has probably been the cause
of a recent reduction in referrals.
1
The paper reminds decision-makers of the considerations they need to take in making a
decision, and cautions against simplifying the decision into a for-or-against debate. Any decision,
including the status quo, will have implications for patients and for staff. Decision-makers are
also reminded that there other consequences, but these may not necessarily be constitutionally
legitimate or primary grounds for a decision [e.g. legal consequences, reputation, management
time]. In summary, this decision is not a puzzle with a right or wrong answer, but a challenge to
the quality of decision-making.
3. Scope and exclusions
In scope


Out of scope



Review of the needs of the patients currently accessing the NHS homeopathic service
provided by University Hospitals Bristol
Appraisal of future options for these patients
Review of complementary and alternative medicines which are not homeopathic
Homeopathy services provided by others, such as high street retailers and non-NHS
practitioners
Demand and capacity modelling of other referral pathways i.e. describing the knockon effects of any commissioning changes e.g. on pain clinic referrals
Assumptions stated in the brief for this document:
Clinical evidence on the efficacy of homeopathy has not changed since July 2014.
Therefore, the [South West] CSU’s July 2014 review of homeopathic evidence will be
accepted as sufficient for the purposes of this review.
4. Recent BNSSG homeopathy commissioning reviews
In 2010/11 work was undertaken by the local Primary Care Trusts with Bristol Homeopathic Hospital
to review the levels of activity and explore the potential for a policy to be introduced around
homeopathy. A policy was worked up that was intended to reduce new referrals from the BNSSG
area. Discussions were also held with the service about the follow-up ratio, and the optimum number
of follow-up appointments.
In 2014 the service was again reviewed1. Discussions were held with the homeopathic service, and a
clinical commissioning policy was agreed in principle, which was to be taken to the individual BNSSG
CCG Boards for decision. The policy was expected to reduce activity by approximately 30-50% if
applied as 'Prior Approval' being required for each new referral.
5. How the service is currently commissioned
Following the 2014 local review, South Gloucestershire and North Somerset CCGs adopted the
proposed policy; it was not adopted by Bristol CCG. The current arrangement is thus:
1
Recorded in minutes of Bristol CCG meeting 29 July 2014
2
CCG
Type of Policy
North
Prior Approval (PA)
Somerset and
South
Gloucestershire
Bristol
Open
Further details
A process that requires the referrer to
obtain prior authorisation for patients
who meet the criteria. If the patient
demonstrably meets the criteria, then the
application must be forwarded to the
Commissioners for approval - and
confirmation of funding received before a
referral is made.
Referrals are passed directly from the
referrer to the provider
Criteria
See
Appendix
16 2
None
The current policy for North Somerset and South Gloucestershire CCGs states:
The CCG has accepted that there are some circumstances where the referring clinician and their
patient consider homeopathic management to be the appropriate means of managing their health
condition. All requests to fund such referrals will be assessed individually and evidence of clinical
effectiveness will be taken into account.
6. The local NHS homeopathy service
Homeopathy has been offered in the Bristol area since the 1850s. From 1902 a service ran from a
hospital in Brunswick Square; from 1925-2012 it was run from the Bristol Homeopathic Hospital; and
then from the new South Bristol Community Hospital. Practitioners were invariably qualified doctors,
and the current service is also medically-led.
Currently all approved referrals from GPs or local secondary care clinicians are passed to the single,
local NHS homeopathy service3. This service is commissioned by the BNSSG CCGs from University
Hospitals Bristol (UHB). Features of the local NHS homeopathy service include:
 Outpatient service only [i.e. no beds]
 Appointments for both adults and children
 Clinician-led, including doctors and occupational therapists
 Patients are offered a first appointment and then no more than four follow-up
appointments. Around a third of patients do not use all five appointments. In certain
circumstances, such as long-term cancer, a further four appointments are available.
Until recently the service was wholly part of University Hospitals Bristol. By mutual agreement, the
lead consultant Dr Elizabeth Thompson developed a plan to offer a wider integrative medicine
service [e.g. acupuncture], with homeopathy as part of this, and for the whole to become a social
enterprise. As the business model relied on a large proportion of NHS referrals, aspects of 'due
diligence' and the 2014 review of homeopathy held back this plan for a while.
The plan came to fruition in 2015, and the service is now provided by the Portland Centre for
Integrative Medicine (PCIM), an employee-owned social enterprise. The service runs from premises
in Clifton. It is effectively a 'sub-contractor' of University Hospitals Bristol. The PCIM is in a transition
phase in its relationship with University Hospitals Bristol. This has enabled both the 'due diligence'
and employment aspects to so far be managed thus:
2
Also see https://www.southgloucestershireccg.nhs.uk/media/medialibrary/2015/12/homeopathy_policy_.pdf
There are also non-NHS providers, but the referral criteria used mean that no referrals have been made to these since the
inception of the commissioning policy
3
3


PCIM are responsible for the operating costs of running their services, which is offset by the
outpatient tariff received for appointments. This is paid monthly as 1/12 of predicted annual
income.
Administrative and clinical staff remain University Hospitals Bristol staff, and are seconded to
PCIM. For technical reasons, this is until March 31st 2016.
In summary, patients receive NHS funded appointments, in much the same way that other local
services are run by non NHS organisations, such as the Community Interest Companies running
community health services in each of the local CCGs. The aspiration of PCIM to offer a broader range
of integrative medicine services is mentioned later in this paper.
7. The needs of patients: why do patients and doctors refer?
The lead consultant for the service, Dr Elizabeth Thompson, describes some of the typical
presentations for which people seek homeopathy:
 Children: eczema; autism; anxiety; behavioural disorders; chronic fatigue; postural hypertension
 Adults: depression; menopausal symptoms; vertigo ; anxiety; unstable mood; control of
symptoms or side effects in cancer treatment; irritable bowel syndrome; post-viral fatigue;
rheumatoid arthritis
What are the outcomes that people seek and the benefits they experience? The brief for this paper
did not include consultation with patients, but we have interviewed a local patient to illustrate the
patients’ perspective:
I'd always had chronic allergies - I'd been in hospital all through childhood. This meant,
as an adult, I was allergic to dust, food and other unidentifiable causes. I had to live in
virtually hermetically sealed rooms; I couldn’t sleep in the same room as my wife; I had
itches; used inhalers; couldn’t have a dog, and I was off sick from work a lot.
I was on antihistamines, but they weren't having much of an effect, and the only
avenues my GP could explore - higher doses, allergy tests - weren't getting anywhere.
As a research scientist I had always considered it a pseudo-science – I couldn’t believe
there was a whole hospital devoted to it when I drove past once, and that it was on the
NHS. I used to think this was an absolute joke.
But I decided to ask my GP for a referral – I was sceptical but desperate. I had an
appointment and was prescribed – and I went from not being able to function to
everything working in two days. This was the first summer I had gone hay fever-free for
my entire life... and that was three summers ago.
I was trying other self-help things too – cleaning up my diet, for example. I charted
some of my main symptoms, and my diet made 10-15% difference, whilst the
homeopathic remedy was 90%.
I thought – this can't just be the placebo effect. Because I am a scientist, I couldn’t
believe it, so I asked a friend at work to do a blind-trial on me. I got him to give me
water or a homeopathic remedy; within 2-3 days my symptoms would improve, but
with water they came back.
But what's the future of homeopathy? Where is the voice? It needs to be kept a lifeline
until the science becomes clearer.
4
In compiling this report, referring GPs said that people are not led to expect a 'miracle cure', but
more a relief from the symptoms with which they are living, or treatment of side effects.
The brief for this paper does not include further reviewing the published evidence of the
comparative effectiveness of homeopathy vis a vis other treatments/placebos. However from the
patients' perspective, it is useful to note a recent study4 undertaken by the local homeopathy service
on the outcomes reported by 200 patients. In this study there was a significant reduction in 'problem
symptoms' and an increase in reported well-being [as described in the quote above].
There are a number of ways of categorizing the needs of people who are referred for homeopathy.
As well as categorizing people by their medical conditions, a local clinician describes it thus:
As a GP you know there is little else you can do with conventional medicine. They have
a significant, chronic problem but not usually diagnosed. I will have done a full range
of tests – CT scan, X ray etc and there appears to be no significant cause.
The other main group of patients is those who are very aware of integrative medicine
and request homeopathy at an early stage.
The first of these categories can include medically diagnosed conditions (e.g. depression) where
conventional medicine is not being effective for that person, as well as 'medically unexplained
symptoms.'5
Regarding the second group mentioned in the quote above, in a study of 100 patients undertaken by
the local homeopathy service, five were reported as seeking homeopathy because they would
not/never use conventional or 'allopathic' medicine, whilst the remaining 95 were primarily seeking a
holistic approach to their health.
In summary, it seems as though the majority of people using the service are those for whom
conventional medicine has either run its course, or failed to unearth medical causes of continuing
pain, concerns or symptoms. Some of these are seeking an approach that they see as holistic and
safe, particularly when given alongside other conventional interventions. A minority wish, from the
start, to eschew a conventional 'allotropic' approach.
8. What do we know about the population who are referred for homeopathy?
At population level, data are available on, for example, gender, age and place of residence. Whilst
none of these is a ground for decisions about commissioning, the data illustrates the diversity of
people being referred. The data below are drawn from all recorded applications for referral from
people registered with a BNSSG GP practice [both direct referrals from a GP and those from a
secondary care clinician]. The period is December 2014 – November 2015, and the total is 116.
4
Carried out by Dr David Spence, using the Measure Yourself Medical Outcome Profile [MYMOP]
Medically unexplained symptoms (MUS) is the term used to refer to disorders where the patient’s physical
symptoms have no medical explanation.
5
5
Gender profile
women
men
Age profile
Referrals by age
116 referrals across BNSSG Dec 2014 - November 2015
35
30
Number
25
20
15
10
5
0
0-9
10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99
Age
For interest, though clearly not a ground for commissioning decisions, Appendix 17 shows the
referral rate from BNSSG GP surgeries [including those who are referred by a secondary care
consultant.] Nothing about clinical need can be drawn from this data, but it does show that the
population is widespread and not concentrated in one area.
6
9. How many people use the service?
To illustrate any trend in referrals, figures have been aggregated for the BNSSG CCGs. New and
follow-up appointments are shown below, for the last 2.5 years, up to the most recently available
data:
New Outpatients Activity
M1 2013/14
M2 2013/14
M3 2013/14
M4 2013/14
M5 2013/14
M6 2013/14
M7 2013/14
M8 2013/14
M9 2013/14
M10 2013/14
M11 2013/14
M12 2013/14
M1 2014/15
M2 2014/15
M3 2014/15
M4 2014/15
M5 2014/15
M6 2014/15
M7 2014/15
M8 2014/15
M9 2014/15
M10 2014/15
M11 2014/15
M12 2014/15
M1 2015/16
M2 2015/16
M3 2015/16
M4 2015/16
M5 2015/16
M6 2015/16
50
45
40
35
30
25
20
15
10
5
0
Follow-up Outpatients Activity
M1 2013/14
M2 2013/14
M3 2013/14
M4 2013/14
M5 2013/14
M6 2013/14
M7 2013/14
M8 2013/14
M9 2013/14
M10 2013/14
M11 2013/14
M12 2013/14
M1 2014/15
M2 2014/15
M3 2014/15
M4 2014/15
M5 2014/15
M6 2014/15
M7 2014/15
M8 2014/15
M9 2014/15
M10 2014/15
M11 2014/15
M12 2014/15
M1 2015/16
M2 2015/16
M3 2015/16
M4 2015/16
M5 2015/16
M6 2015/16
200
150
100
50
0
A linear trend line has been applied to the New Activity data. Using this (although not a wholly
reliable tool), the data can be interpreted to read that there has been a downward trend in activity.
One possible cause, as was intended, is the implementation of Prior Approval for referrals from
South Gloucestershire and North Somerset CCGs.
10. What is the cost of referrals?
Comparative data on activity and cost6 are available for 2013/14 and 2014/15. For 2013/14 this data
is for all ages; for 2014/15 it is available split by adults and children.
Data for this current year-to-date can also be made available; at month 6 the forecast total activity
for the year is, for all three CCGs, lower than that in 2014/15.
6
Speciality no:0770 HRG ID Homeopathy
7
2013/14
Work type Description
Value £
Volume
Follow-up Outpatients
New Outpatients
111,224
34,196
145,420
19,791
4,974
24,765
19,444
4,725
24,169
961
275
1,236
171
40
211
168
38
206
Work type Description
Value £
Volume
Adults
Adults
Paediatrics
Paediatrics
Follow-up Outpatients
New Outpatients
Follow-up Outpatients
New Outpatients
Adults
Adults
Paediatrics
Paediatrics
Follow-up Outpatients
New Outpatients
Follow-up Outpatients
New Outpatients
Adults
Adults
Paediatrics
Paediatrics
Follow-up Outpatients
New Outpatients
Follow-up Outpatients
New Outpatients
£101,006
£19,475
£23,826
£5,512
£149,819
£21,090
£4,164
£5,016
£1,225
£31,496
£22,344
£3,674
£2,850
£612
886
159
209
45
1,299
185
34
44
10
273
196
30
25
5
£29,481
256
NHS Bristol CCG
NHS Bristol CCG Total
NHS North Somerset CCG
Follow-up Outpatients
New Outpatients
NHS North Somerset CCG Total
NHS South Gloucestershire CCG
Follow-up Outpatients
New Outpatients
NHS South Gloucestershire CCG Total
2014/15
NHS Bristol CCG
NHS Bristol CCG Total
NHS North Somerset CCG
NHS North Somerset CCG Total
NHS South Gloucestershire CCG
NHS South Gloucestershire CCG
Total
8
11. What are the options for commissioning local homeopathy services?
The main options are set out below. They are not mutually exclusive. For example, Option D would
take time to develop, and therefore an interim decision based on the other options would need to be
made. Equally, Option C, for example, could be decided on for a limited time and then reviewed [all
IFR reviews have a date for review].
Option A: no
change
Continue to commission, using the same approach to referrals i.e. ‘prior approval’ for
patients in South Gloucestershire & North Somerset, and open access for those in
Bristol.
Option B: cease
commissioning
NHS
homeopathy
services
In addition to a simple cessation of NHS referrals, a further sub-option arose in
discussion, that of having homeopathy available (only) through Personal Health Budgets
[PHB]. It would be a way of meeting some patients' needs alongside a decision to cease
direct commissioning. One clinician stated:
PHB is about well-being, and thus this detaches it from the medical scientific
criticism. If the clinical and patient agree this will help, then the PHB is used;
there are many ‘private’ homeopaths, and so the patient could use these. This
would also move away from the position that the CCGs are commissioning from
one provider.
CCGs are currently planning the implementation of national policy, whereby PHBs "will
be extended to those with long term conditions (including mental health conditions)
who could benefit." The policy describes this as:
The provision of greater choice and improving the personalisation of treatment,
via opening up a wider range of non-traditional treatment options as
alternatives to NHS services for people with ongoing conditions.
If this option were chosen it would be a way of meeting some patients' needs, as part of
managing the impact of Option B7.
Option C:
continue but
with altered
approvals policy
Continue with referrals to the service, but introduce either
 Prior Approval [for Bristol] using the criteria used by the other two CCGs or
 Individual Funding Requests [for all or any of the CCGs].
A further option is to develop different criteria
Option D: to
continue to offer
referrals but as
part of a wider
well-being
service
Homeopathy is most frequently sought by those with a long term condition, and Option
D has arisen from discussion with commissioners and individual clinicians. Homeopathy
would not be seen as a discrete service, but as one of a range of options [not necessarily
from one provider]. Referrals would still be offered but as part of a wider 'holistic' wellbeing service; in the words of a commissioner, 'for people where treatment doesn’t fit
into a straight medical interpretation. This might include talking therapies. Currently the
service offered via UH Bristol is almost too specific'
One commissioner said of the current provider 'They provide a range of services that
look potentially far more interesting from a CCG perspective, not least NICErecommended mindfulness-based cognitive therapy'.
This would be a planned change as part of a wider commissioning strategy around self
care and long term conditions. How such a service would be commissioned and from
whom is a matter for further discussion. Commissioners would need to consider how
they could support a range of 'Any Qualified Providers' in this field.
7
A commissioner further developed this proposal:
I would want to see a consistent commissioning approach to complementary treatments, .. this is best approached from
the perspective of increasing choice and personalisation via the development of Personal Health Budgets. The
introduction of PHBs will potentially provide access to a greater range of non-traditional treatments that patients may
wish to take up instead of mainstream NHS services. It would be consistent with enabling greater patient choice to fund
homeopathy, only when agreed as part of a package of care under a PHB.
9
The option of removing the current prior approval policy is not explored here, as it was seen to be
very unlikely to be approved by local CCGs.
12. What issues need to be considered in any possible changes in commissioning?
CCGs' constitutions require them to make decisions based on a number of criteria. The most
relevant, taken from the local constitutions & local policies are summarized below:
1. ..commissioning (certain) health services that meet the reasonable needs of .. all people
registered with member GP practice
2. Take an evidence-based approach utilising public health and clinical advice
3. …act effectively, efficiently and economically, with particular respect to commissioning
decision making, procurement and financial procedures
4. A duty of equality
5. Adhering to national and local policies
The following sections list these key considerations required of CCGs in their decision-making. Each
option is appraised in the light of these factors. Any views expressed are based on discussion with
some of the key stakeholders listed in the Appendix.
12.1 The needs of patients
Section 7 described some of the health needs for which patients seek treatment through a referral to
homeopathic services8. There is no doubt that a proportion of people who have received treatment
feel that it has been beneficial.
In compiling this report, experienced clinicians have described two perspectives on this need, and the
impact of Options B or C [further restriction or withdrawal of the service].
If people are not referred, their need doesn’t go away. It is most likely that the patient
will continue to request multiple investigations, multiple visits to primary care and to
secondary care outpatients. So the consequences of withdrawing the service are a
remaining ‘unmet need’. This type of service has been running for a long time, and it
has been valued by some – it has not suddenly become dangerous.
This view highlights that the effect of stopping a service that is valued by some is not simply like
turning off a tap. Some kind of need remains, and if this is to be met then that, too, would bear a
commissioning cost if it were to be met by the NHS.
A counter argument expressed is that:
I referred a patient with ME. [But] we already offer services for some of these long term issues–
such as the Chronic Fatigue Service. We do offer acupuncture on the NHS, which has a better
evidence base. If people want to use, for example, a chiropractor, they know they have to pay.
Despite the clinical & financial argument [about its evidence base and whether it should be funded]
neither of these clinicians denied a need exists; the difference of opinion is over the method of
supporting and funding this.
8
The brief for this paper excluded surveying patients needs, and so any views about patients in this section simply present
the broad views available in written papers and via clinicians
10
One further view, on behalf of patients, was expressed: 'if you offer homeopathy you might be
blocking/slowing down their journey to something more effective.'
In summary, the implications of the options for the needs of patients are:
Option
Option A: no change
Option B: cease commissioning
Option C: continue but with altered approvals
policy
Option D: offer referrals but as part of a wider
well-being service
Implication and issues
Current and future patients treated in the
same manner
The patient needs as described above would
need to be met with other treatment
options; or patient expectations managed, or
needs met privately without NHS funding
Reduced service, and thus much of Option B
would still need to be addressed
Discussed further in section 12.5 National
and local policies
12.2 Duty to '…take an evidence-based approach utilising public health and clinical advice'
The most frequently used view to support Option B (removing funding for referrals) is the quality of
the evidence base for homeopathic treatment.
Those who refer to a number of reviews and meta-reviews conclude that homeopathy is:
 Not effective – no better than a placebo or a glass of water
 Not cost-effective [obviously not, if it is not deemed effective]
 Misleading for patients who will then not accept other treatments
One commissioner said 'I certainly don’t think the same rigour has been applied to Homeopathy as
we would expect from a new cancer drug, for example.'
Those, such as the Homeopathy Research Institute, who take the view that it is a valuable treatment,
say:
 There is evidence that other very commonly used treatments [e.g. SSRIs] are 'no better than
placebos', and yet they are widely used
 There are studies which show a significantly reduced use of conventional medicines by
patients
 A considerable number of other treatments have a lower burden of proof – we still use them,
but we just don't understand how they work yet
 Observational studies show that patients report improved health
The brief for this paper is to refer to the local CCGs review of the evidence (Appendix 18).
Generally, the most commonly quoted NHS paper is the House of Commons Science and Technology
Committee's Evidence Check 2 Homeopathy. A useful quote from this makes the distinction made
between efficacy and effectiveness;
We have set out the issue of efficacy and effectiveness at some length to illustrate that
a non-efficacious medicine might, in some situations, be effective (patients feel better)
because of the placebo effect. That is why we put more weight on evidence of efficacy
than of effectiveness.
In summary, the implications of the options for the duty to take an evidence based approach are:
11
Option
Option A: no change
Option B: cease commissioning
Option C: continue but with altered approvals
policy
Option D: offer referrals but as part of a wider
well-being service
Implications and issues
The CCG would attract criticism from some
of its GP members9, as well as from others
within and outside the local health
community
This option would satisfy CCG Governing
Bodies where the criterion of 'evidencebased' is their main factor in decision-making
This option would not substantially change
the current commissioning approach that
local CCGs have adopted
Discussed in section 12.5 National and local
policies
12.3 Duty to ‘…act effectively, efficiently and economically, with particular respect to
commissioning decision making, procurement …'
The annual costs of outpatient referrals to the local service are shown in section 10. There is no
suggestion that the current service could be commissioned for a significantly lower cost.
In appraising the options against this duty there are two viewpoints that local stakeholders have
raised.
One viewpoint is the 'opportunity cost' i.e. with a limited budget there are other NHS treatments
which CCGs could commission/expand if this was not spent on homeopathy10. Clinicians described
services in other clinical areas that they would like to offer, that are limited by funding, such as the
Community Heart Failure Service. Other clinicians described the missed opportunity to invest more in
services specifically related to the typical problems of homeopathy patients, such as acupuncture.
The alternative viewpoint expressed is to take the total cost of a full 'pathway of care', rather than
homeopathy being a stand-alone cost. One stakeholder said:
I’m sure there are difficult and/or impossible to assess medical treatments (less so
surgical treatments) that cost the NHS and the CCG far greater sums of money than the
obvious attributable costs of Homeopathy. As Homeopathy is also seen almost as a last
resort option, the cost of treatments up to and including Homeopathy itself maybe
should be considered. It may well be that Homeopathy is actually a more cost-effective
placebo than a continuation of ‘traditional’ prescription medicines.
In summary, the implications of the options for the duty to act efficiently and economically are:
Options
Option A: no change
Option B: cease commissioning
Implications and issues
The service would continue to cost around
£117 per person for a completed treatment
This option would release money to off-set
against savings requirement or reinvest in
9
GPs form the membership of the CCG. Whilst views have not been sought comprehensively, local GP leaders are of the
view that the majority of members do not accept homeopathy is sufficiently evidence-based. This is not to be confounded
with a view that it should not be used, as some GPs hold both views.
10
One clinician stated: 'we are not denying you want homeopathy, we are not denying you might benefit, but [the CCG is]
not paying with tax payers money'
12
Option C: continue but with altered approvals
policy
Option D: offer referrals but as part of a wider
well-being service
other services. For the reasons described
earlier, patients would still seek treatment
for their symptoms, and thus the savings
would be less than the total current
homeopathy spend.
This option would reduce the spend
Discussed in section 12.5 National and local
policies
12.4 Duty of Equality
If changes are to be made to commissioning i.e. Options B, C & D, then expert advice is that an
equalities impact assessment would need to be made.
12.5 National and local policies
In making a decision on homeopathy commissioning, the local CCGs need to take account of national
policies and their local strategies, policies and operational plans. The most relevant for the patient
group being considered are those relating to the support of self-care, especially for people with a
long term condition. The national Five Year Forward View and each of the BNNSG CCGs have this as
an important part of their strategy.
Homeopathy is most frequently sought by those with a long term condition, and Option D has arisen
from discussion with commissioners and individual clinicians. This would be to continue to offer
some referrals but as part of a wider 'holistic' well-being service.
13. Practical and managerial issues
Each of the options brings a number of practical consequences. These may or may not be factors of
which a CCG needs to take account in discharging its duties. In brief, these include:
13.1 Public consultation
Expert advice is that any change to the service will require public consultation. This would be for a
minimum of four weeks. For a substantial change, such as Option B, cessation of commissioning,
consultation would include working with the wider public, not just those currently using the service.
13.2 The impact on the providers [UH Bristol and PCIM] and staff
Options B (cease commissioning) and C (continue but with stricter criteria, which would be likely to
lower referrals) could make the sub-contractor PCIM unviable. There is a level of referrals at which it
is not viable for the fixed costs of employing staff. Although PCIM's plan is to build their portfolio
[e.g. further 'Kitchen on Prescription' work on nutrition and obesity; and mindfulness services] the
great majority of their current income is from local NHS referrals for homeopathy.
If these options were implemented so swiftly as to make the service unviable, then there are
contractual and employment consequences. There would need to be a staff consultation carried out
by the employer, which remains UH Bristol, as the staff are seconded. Redundancies would be
avoided if possible, but there are liabilities [e.g. for pensions] held by UH Bristol.
It is understood that UH Bristol would be willing to see the provider PCIM move to being fully
independent from its current transition phase, once the sharing of the risks and liabilities is agreed
and the service is viable. If the commissioning of the service remains in doubt, then it is unlikely that
there would be sufficient 'due diligence' to enable staff to be fully transferred and be employed by
PCIM.
13
For option B (cessation) the sub-contract would need to be extended beyond March 31st 2016, if the
commissioners decide to honour a commitment to existing patients' follow-up. UH Bristol would
need a 'contract variation' if this were the case.
13.3 Challenges to the CCGs' decision
The commissioners are likely to face challenges to a decision to continue in some form, and also if
they decide to cease commissioning. These challenges may come from:




GP members of the CCG
The local public and specific local stakeholders
Current users of homeopathy services
Lobbying groups or organizations. Most notably, these could include the Good Thinking
Society and the British Homeopathic Society.
13.4 Commissioning issues
Because of the risk of the challenges mentioned above, it may be unwise to enter into a full one-year
contract with UH Bristol until both a decision has been made and the practical implications
understood in detail, particularly the timescales [either a public consultation or a legal challenge will
both take several months]. Alternatives to extending the sub-contract with UH Bristol for some or all
of 2016/17 include directly commissioning the service from PCIM.
'Commissioning intentions' are the first conventional indication from commissioners to providers
before contracts are completed.
14. Options appraisal
Section 9 describes the main options in detail. The table below summarises the main issues
associated with each of these options.
Any decision will attract interest, and the status quo is unlikely to go unnoticed.
All of the main options – continuing or ceasing commissioning – will take managerial time to
implement.
Any of the options taken will require excellent communication in order to explain the reasons and
the consequences. This will include good communications with the public, with staff affected, and
with other stakeholders. Some might welcome a local discussion about holistic treatments and selfcare, and see it as an opportunity to explain the CCG's work and aims. Others might count the
managerial time that could be spent on other activities.
As mentioned above, the options are not mutually exclusive. For example, Option D would take time
to develop, and therefore an interim decision based on the other options would need to be made.
Equally, Option C, for example, could be decided on for a limited time and then reviewed [all IFR
reviews have a date for review].
14
Issues and implications
Option A: no change
1.
2.
3.
4.
Provides opportunity for patients to be funded by the NHS
Likely to be popular with the current referrers to the service
This position does not follow the evidence base
Unlikely to be popular with some clinicians who are seeking funding for
other evidence based treatments
5. Negotiations required with provider (UH Bristol) to address issues of due
diligence and employer liability as PCIM moves to full independence
Option B: cease
commissioning NHS
homeopathy services
1. Those patients who would have been referred to the service may take
up more NHS resource by being referred to multiple other services; may
be increased non-concordance with medications for those patients
1. This position follows the evidence base
2. This provides a clear and defendable statement
3. Requires a managed cessation to allow the provider time to change the
service to being for privately patients
4. Unlikely to be popular with former users of the service, and those
wishing to access the service on the NHS
5. Unlikely to be popular with those referring to the service
6. Would require public consultation & equalities impact assessment
7. UH Bristol would need a 'contract variation' to ensure current patients
can complete their treatment beyond March 31st 2016
Option C: continue
but with altered
approvals policy
1. This provides some opportunity for patients to be funded by the NHS
2. Those patients using the service may take up more NHS resource by
being referred to multiple other services
3. This position does not follow the evidence base
4. This policy is unlikely to be popular with the local providers of the
service and those referring to the service
5. The sub-contractor PCIM may become unviable, and cease; negotiations
required with provider (UH Bristol) to address issues of employer liability
8. May be advisable to have public consultation & equalities impact
assessment, even if not obligatory
Option D: to continue
to offer referrals but
as part of a wider
well-being service
1. This position does not follow the evidence base
2. Likely to be popular with the current referrers to the service
3. The wider service could be designed as a response to CCGs' self-care and
long-term conditions strategies i.e. as a planned way of addressing
identified need, rather than focussing on stand-alone service
4. Issues of Any Qualified Provider and other commissioning approaches
would need to be considered
5. As this option would take time to develop, an interim option would need
to be taken whilst this work was completed
6. Would require negotiation with provider to ensure changes were part of
a broader plan, and the shorter-term concerns managed and risks
shared
Author: Martin Howard, South, Central & West Commissioning Support Unit
15
APPENDICES
15. Glossary
University Hospitals Bristol – University Hospitals Bristol NHS Foundation Trust, which is
commissioned by the CCGs to provide outpatient homeopathy services.
Local CCGs – Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups
New and follow-up – A new appointment is the first (or first recent) appointment made by a patient
with the service. The appointment follows a referral from their clinician (their GP or a secondary care
clinician e.g. Breast Cancer Nurse). Follow-up appointments are agreed between the patient and the
service.
The service – the outpatient homeopathy service provided by UH Bristol.
CSU – South Central &West Commissioning Support Unit, the NHS body contracted by the BNSSG
CCGs to provide financial, contracting and other support.
Partnership Group – the regular meeting between the three BNSSG CCGs where matters of common
interest are discussed. The partnership does not have decision-making powers.
Types of commissioning policy:



IFR - Individual Funding Request Panel (not routinely funded, requires panel decision)
CBA - Criteria Based Access (if patient meets criteria, refer directly)
PA - Prior Approval (seek approval from CCG and then refer if evidence provided)
PCIM - The Portland Centre for Integrative Medicine - 'an employee owned social enterprise, led by
healthcare professionals'. Effectively the sub-contractor providing the services discussed in this
paper.
16
16. Current criteria for approval of referrals by North Somerset and South
Gloucestershire CCGs
17
Page 2
18
17. Where do referred patients come from?
19
20
21
18. BNSSG CCGs' review of clinical evidence
22
23
24
25
26
27
19. Sources of views and information used in compiling this report
We wish to thank the following teams and individuals:







A local patient
South, Central & West Commissioning Support Unit:
o Contract and performance management
o Individual Funding
o GIS (maps)
Bristol, North Somerset & South Gloucestershire CCGs:
o Clinical Leads/Governing Body chairs
o Patient Engagement
o Governance
o Performance
o Equalities
o Commissioning
o CCG membership
Clinical Lead for the provider, the Portland Centre for Integrative Medicine
UH Bristol Divisional Director
Sample of referring GPs
Public Health [for the original evidence review]
28
TREATMENT UNDER THIS POLICY REQUIRES PRIOR APPROVAL FROM
THE CCG INDIVIDUAL FUNDING TEAM
THIS POLICY RELATES TO ALL PATIENTS
Homeopathy
Policy Statement: Date of Issue: 1 December 2014
The CCG has accepted that there are some circumstances where the referring clinician and their
patient consider homeopathic management to be the appropriate means of managing their health
condition. All requests to fund such referrals will be assessed individually and evidence of clinical
effectiveness will be taken into account. Prior approval must be gained before referring.
Policy - Criteria to Access Treatment – INDIVIDUAL FUNDING REQUEST APPROVAL
REQUIRED
Requests will be assessed for funding if the following criteria are met:
1. Severity of the Unresolved Health Issues
Where the patient has a significant condition which causes the patient significant health
problem(s) which have a severe impact on quality of life, defined as:
 Symptoms prevent the patient fulfilling routine work or educational responsibilities, or
 Symptoms prevent the patient carrying out routine domestic or carer activities
 Or where the patient is a child with significant health problems, significantly affecting
family life.
AND
2. Treatment Options
Where the condition has not been helped by conventional treatment, OR
Where conventional treatment is contraindicated, OR
Where conventional treatment is unacceptable to the patient and no acceptable alternative is
available OR
Treatment of side effects of mainstream treatments or medications that would otherwise mean
mainstream treatment would cease e.g. cancer treatments
NOTE: Homeopathy is NOT commissioned for patients with conditions where the standard
commissioned treatment is undertaken in primary care e.g. : facial blushing/ hot flushes, low back
pain, mild/moderate cough, allergies, rhinitis (chronic or seasonal), menopausal problems,
musculoskeletal pain, insomnia/ interrupted or unsatisfactory sleeping patterns, receding gums,
hyperhidrosis.
One new appointment and up to four follow up appointments are commissioned for each patient
when patients meet the above criteria. Further follow-up appointments would need to be agreed
via the Individual Funding Request (IFR) Process. Re-referrals within two years of referral will not
be expected, and would also require an IFR application.
Patients who are not eligible for treatment under this policy may be considered on an individual
basis where their GP or consultant believes exceptional circumstances exist that warrant deviation
from the rule of this policy.
Individual cases will be reviewed at the Commissioner’s Individual Funding Request Panel upon
receipt of a completed application form from the patient’s GP, Consultant or Clinician. Applications
cannot be considered from patients personally.
If you would like further copies of this policy or need it in another format, such as Braille or another
language, please contact the Patient Advice and Liaison Service on 0800 073 0907 or 0117 947
4477.
This policy has been developed with the aid of the following references and collaborations:
(a) Work with the homeopathy service locally
(b) A list of evidence for the effectiveness of homeopathic medicine for some illnesses
(http://www.facultyofhomeopathy.org/research/); and
(c) The fact that commissioners have to prioritise mainstream treatments for which there is
strong evidence of effectiveness.
Developed in Collaboration with Dr Elizabeth Thompson - Lead Consultant Homeopathic Physician
and Honorary Senior Lecturer in Palliative Medicine, University Hospital Bristol.
Approved by (committee):
Date Adopted::
Produced by (Title)
EIA Completion Date:
Review Date:
Bristol
CATEGORY
Not
Adopted
Clinical Policy Review Group
1 December 2014
Version:
1516.1
Commissioning Manager – Individual Funding
Undertaken by (Title):
Earliest of either NICE publication or three years from approval.
VERSION
North
Somerset
CATEGORY
Criteria Based
Access
VERSION
1516.1
South
Gloucestershire
CATEGORY
Criteria Based
Access
VERSION
1516.1