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Should NICE evaluate complementary and alternative ?

David Colquhoun

BMJ 2007;334;507- doi:10.1136/bmj.39122.551250.BE

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Demand for complementary and is high despite limited evidence. Linda Franck and colleagues believe that a thorough review by NICE would benefit the NHS and patients, but David Colquhoun argues that it cannot afford to re-examine evidence that has shown little benefit

David Colquhoun professor of ­happening, possibly because he or she can There is no need to subscribe to the Department of Pharmacology, University College London, foresee the obvious outcome. early 19th century pseudoscientific London WC1E 6BT Since referral to NICE would remove com- [email protected] plementary medicine from the NHS, I should, hocus pocus of homoeopathy to treat One of the most important perhaps, favour it. Nevertheless, a strong sick patients roles of the National Institute argument can be made for NICE not hav- NO for Health and Clinical Excel- ing to spend time and money going through, Medicine “has not proved effectiveness for lence (NICE) is to assess which treatments yet again, evidence that we already know to any ‘alternative’ method. It has added evi- produce sufficient benefit that the National be inadequate. In fact NICE has alternative dence of ineffectiveness of some methods that Health Service should pay for them. Since treatments in several of its reports—for exam- we knew did not work before NCCAM was the money available to the NHS is not infi- ple, the reports on supportive and palliative formed”6 despite spending almost a billion nite, making choices of this sort is inevita- care, obsessive-compulsive disorder, and mul- dollars.7 ble, and it is in the interests of patients that tiple sclerosis and draft guidance on chronic dispassionate judgments are made on the fatigue syndrome.2 In all these cases NICE Lack of evidence efficacy of treatments. has found no good evidence for anything It is not necessary to take the word of sceptics If the effectiveness of a treatment is dis- more than placebo effects. about the lack of evidence. The more hon- puted, what could be more obvious than est advocates of complementary and alter- to refer it to NICE for a judgment of the Unaffordable luxury native medicine admit it themselves. Peter evidence? Nothing is more disputed than NICE has around 240 employees and costs Fisher, clinical director of the Royal London the effectiveness of alternative medicine, so £27.6m (€41m; $54m) a year,3 and it never- Homoeopathic Hospital, on the radio said, “It why has NICE not adjudicated? Even the theless comes under constant criticism for not is true that there is not as much evidence as Smallwood report, sponsored by the Prince responding quickly enough to really impor- you would like.” (Vanessa Feltz Show, Radio of Wales, did not pretend to find good evi- tant questions, most recently over treatments London, 26 Jan 2007 www.ucl.ac.uk/Pharma- dence, but recommended that NICE should for cancer and Alzheimer’s disease. It can’t cology/dc-bits/quack.html#rose1). Dantas be invited “to carry out a full assessment of afford the time to do again what has already and colleagues concluded that: “The central the cost-effectiveness of the therapies”1 The been done. question of whether homeopathic medi- Smallwood report was greeted warmly by Since we already know there is little evi- cines in high dilutions can provoke effects in many of the complementary medicine frater- dence for the effectiveness of complementary healthy volunteers has not yet been defini- nity despite its principal recommendation. medicine, should more research be done? I tively answered, because of methodological That reaction is welcome, if a little surpris- wonder whether that is worth while either. weaknesses of the reports.”8 Consider also the ing, because the evidence, such as it is, has Homoeopathy has had 200 years to come up National Library for Health, Complementary been reviewed endlessly, and it is obvious with evidence. and traditional and Alternative Medicine (www.library.nhs. that if NICE were to apply its normal crite- Chinese medicine have had thousands of uk/cam/). In July 2006, not one entry con- ria, almost all complementary and alterna- years. Yet still there is little convincing evi- cluded that there is good evidence for the tive medicine would be removed from the dence. Isn’t that long enough? The House of effectiveness of homoeopathic treatment, NHS immediately. Why, then, has NICE Lords report on complementary and alter- although this library is compiled by support- not considered complementary medicine, native medicine in 2000 recommended that ers of complementary medicine. Likewise, despite recommendations from experts? three important questions should be exam- search of the Cochrane Library for homoe- The answer seems to be that someone in ined in the following order: does the treat- opathy finds very few positive reviews. the Department of Health is stopping that ment offer therapeutic benefits greater than None of what I have said is intended to placebo? is the treatment safe? how does it deny the important role of supportive and compare, in medical outcome and cost effec- palliative care of patients for whom that is the tiveness, with other forms of treatment?4 best that can be done. But it is perfectly pos- Money was made available for research but sible to provide such care honestly.9 There is was spent on projects no need to subscribe to the early 19th century that almost all pseudoscientific hocus pocus of homoeopa- failed to address thy to treat sick patients sympathetically and the first prior- holistically. And there is no need for NICE ity.5 In the US, to spend time and money coming to that con- the National clusion when it has more important things C e n t e r f o r to do. Complementary Competing interests: None declared. and Alternative References are in the full version on bmj.com

BMJ | 10 March 2007 | Volume 334 507 HEADhead TOto HEADhead Downloaded from bmj.com on 8 March 2007 Should NICE evaluate complementary and alternative medicine?

Linda Franck professor University College London as current usage statistics indicate, patients This leaves two final reasons for the absence Institute of Child Health, London WC1N 1EH are choosing complementary therapies to of NICE guidance. There may be an attitudi- Cyril Chantler chair King’s Fund, London W1G 0AN promote health and wellbeing and there are nal bias against complementary therapies or Michael Dixon chair NHS Alliance, Retford, Nottingham inequalities in terms of access. a lack of resources. Some people within con- DN22 6JD A second reason is that there are not ventional medicine remain deeply convinced [email protected] always adequate methods for evaluating these that alternative medicine cannot have any The National Institute for therapies with the same rigour as applied to possible benefit,5 but this is all the more rea- Health and Clinical Excel- conventional medicine. Some therapies, such son that these therapies should be rigorously Yes lence (NICE) guidance is as herbal, nutritional, or homoeopathic rem- evaluated. The lack of resources for evalua- built on the rigorous appraisal of scientific edies, can be evaluated in standard double tion is equally difficult to defend, but perhaps evidence and the evaluation of the cost effec- blind randomised placebo controlled trials.11 understandable when there is great pressure tiveness of diagnostics and treatments.1 2 For other therapies that are heavily depend- to evaluate high cost drugs and technologies. The Secretary of State for Health refers ent on the individual therapist, double blind- topics for development of guidance based ing may be impossible. However, these Benefits of review on national priorities.3 NICE has received research design problems are no different However, failure to evaluate complementary international recognition for its topic selec- from those for conventional therapies such therapies leads to health inequalities because tion and appraisal processes and “commit- as surgery. Research methods used for com- of uneven access and missed opportunities. ment to using the best available evidence for parative trials of behavioural interventions For example, as complementary therapies ­decision making.”4 offer a way forward.12–14 In order for alterna- are often relatively cheap, if shown to be Complementary and alternative medicine tive therapies to be compared with conven- effective they could save money currently covers a heterogeneous group of therapies tional treatments, more work is needed to spent on costly drugs. that share a focus on, or integration of, treat- define the most important outcomes and to In summary, NICE already has a system- ment of mind and spirit as well as body.5 measure them appropriately.15 atic review process that takes into account all The main goals of these treatments are often available evidence, including observational framed in terms of feeling better (that is, Failure to evaluate complementary studies.18 Recent publicity on the use of relief of symptoms) or prevention (promo- therapies leads to health inequalities complementary medicine in the NHS sug- tion of general health and wellbeing) rather because of uneven access and gests that it should receive greater priority in than cure.6 7 They may therefore be particu- missed opportunities topic selection. Applying the same standards larly relevant for patients with long term as we apply to conventional medicine, we disease, who account for 80% of general A third reason NICE may not have been simply need to ask is it safe, is it effective practice consultations and who, by defini- commissioned to evaluate complementary in relieving symptoms compared with no tion, are unlikely to be cured. Furthermore, therapies is that there is insufficient evidence treatment, how effective is it (the number most people seek complementary therapies with which to develop guidelines. However, needed to treat), how much does it cost, and as an adjunct rather than substitute for con- there are numerous Cochrane reviews of is it affordable (quality adjusted life years)? ventional medicine.8 complementary therapies.16 NICE has made Complementary and alternative therapies Complementary therapies are widely used some recommendations about benefits (or deserve a full evaluation from NICE and, if by the public. Around half of general prac- risks) of some complementary therapies the evaluation is favourable, they should be titioners provide access to complementary within condition specific guidelines—for adopted either on their own or integrated medicine,9 and two thirds of Scottish general example, pregnancy, multiple sclerosis, with conventional medicine. practitioners prescribe herbal or homoeo- Parkinson’s disease, hypertension, and Competing interests: None declared. pathic medicines.10 However, NICE has not depression.17 The guidance and support- been asked to develop guidance on these ing documentation available on its website therapies.3 Given the high public interest suggests that these “recommendations” of in complementary medicine, we find this a few complementary therapies have not surprising. been subjected to the same rigour as those of traditional medical interventions. Fur- Explanations thermore, NICE has not addressed the There are several possible explanations for important questions of comparative efficacy the lack of investigation. The first is that or additive value in relation to current treat- complementary therapies are not relevant ments being offered in the NHS. Where to NHS priorities of reducing health ine- there is insufficient evidence, NICE could qualities, promoting health and wellbeing, draw attention to this in order to stimulate patient choice, and patient involvement. Yet more research.

506 BMJ | 10 March 2007 | Volume 334 Rapid Responses to:

FEATURE: David Colquhoun Should NICE evaluate complementary and alternative medicines? BMJ 2007; 334: 507 [Full text]

Rapid Responses published:

Leave alternative therapists in peace John R King (13 March 2007) Fairies and leprechauns David Colquhoun (16 March 2007)

Leave alternative therapists in peace 13 March 2007 John R King, Consultant Psychiatrist Hill Crest, Redditch, B98 David Colquhoun (“NICE should not have to evaluate alternative medicine”) 7WG makes a better case than Linda Franck et al. Space researchers do not, after all, waste time trying to disprove the beliefs of flat- earthists. Neither would it Send response to journal: be helpful for a Nobel prizewinning chemist to stride into a church and Re: Leave alternative denounce the holy water there as nothing more than H2O. There is a very therapists in peace large and ever expanding array of alternative treatments, some more bizarre than others, which could tie up the resources of NICE for an indefinite period. But if people want to believe in them – or in fairies or leprechauns – they should be left in peace to do so. It is no concern of scientific medicine.

Competing interests: None declared

Fairies and leprechauns 16 March 2007 David Colquhoun, Nobody is proposing to ban fairies or leprechauns. It would be both Prof of Pharmacology UCL UCL WC1E 6BT undesirable and impossible.

Send response to journal: There does seem to be a case, though, for not providing leprechauns at the tax

Re: Fairies and leprechauns payers' expense. And really all leprechauns that are sold to the public should have labels that don't make false claims for their powers. Unfortunately the MLRA (Medicines and Leprechauns Regulatory Agency) has let us down in the matter of labelling. I suspect infiltration of the Department of Health by little green men.

Competing interests: None declared