Running an NHS community homeopathy clinic e 10-year anniversary 2001e2011

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1 (2012) 101, 51e56 Ó 2011 The Faculty of doi: /j.homp , available online at ORIGINAL PAPER Running an NHS community homeopathy clinic e 10-year anniversary 2001e2011 Stella Bawden* The Cornwall Road Medical Practice, 3 Frederick Treves House, St John Way, Dorchester, Dorset DT1 2FD, UK An outcome series was conducted over a five-year period of patients attending a community NHS homeopathy clinic in Dorchester, Dorset. 273 new patients were seen. 183 (67%) questionnaires were completed at six months after consultation. 44% of patients had been unwell for more than five years; 19% of all patients for more than 15 years. A wide variety of conditions were seen, the largest group with depression, anxiety or grief. For follow-up patients 75e81% indicated an improvement in their symptoms and activity while 58% recorded an improvement in their overall wellbeing. Six months after the initiation of treatment 155 (84.7%) felt an improvement in their condition with 148 (81%) attributing this to homeopathy. Nobody reported deterioration due to homeopathic treatment; conventional drug use was reduced in 46 patients (25%). (2012) 101, 51e56. Keywords: clinic; General practice; Case series; Outcome Introduction February 2011 marked the 10-year anniversary of the NHS homeopathy clinic in Dorchester, Dorset, run by the author, during a half-day session. Originally it was funded to take General Practitioner (GP) referrals from the West Dorset Primary Care Trust (PCT) area subsequently the referral area has broadened to now include Southwest Dorset (PCT). Previous studies have looked at the outcome of homeopathic consultations in the primary care setting. Robinson showed beneficial effects of treatment within 10-min GP consultations. 1 Collective data from a number of GPs, also during brief consultations, showed beneficial outcomes. 2 Other studies have looked at outcomes in NHS clinic settings 3 and in the private health setting. 4 NHS hospitals have also reviewed the success of homeopathic treatment. 5 The present report is the first five-year outcome study within primary care. Each year an outcome audit has been produced, the same questionnaire format has been used every year and this paper reports a five-year outcome series including all patients. *Correspondence: Stella Bawden, The Cornwall Road Medical Practice, 3 Frederick Treves House, St John Way, Dorchester, Dorset DT1 2FD, UK. Bawden.Stella@gmail.com Received 6 May 2011; revised 19 October 2011; accepted 24 October 2011 Methods The author is a GP partner and has studied homeopathy since Originally she attended courses at the Royal London Homeopathic Hospital and later the Oxford based Homeopathic Physicians Teaching Group (HPTG). She qualified as a Member of the Faculty of (MFHom) in Each clinic had two new patient appointments of 1 h and 3, 20-min follow-up appointments. Occasionally the session had one new patient and six follow-ups. Patients were seen for an average of four follow-ups, depending on results. New patients were sent a general questionnaire to complete before their appointment and on arrival were asked to complete a short questionnaire based on MY- MOP 6 (Measure Your Own Medical Outcome Profile), a research tool developed by Dr Charlotte Paterson (see Appendix 1). Patients were asked to write down the problem they wished to be helped with homeopathy and to describe two main symptoms they had been experiencing during the last month and an activity they had not been able to fully achieve. All were scored from 1 to 7 where 1 was as good as it could be and 7 was as bad as it could be. They were also asked to score their wellbeing. Permission was sought to send them a follow-up questionnaire. This was then sent to their home address six months after their consultation (see Appendix 2). The previous

2 52 Table 1 New patients attending the homeopathy clinic 2006e2010 symptoms activity and wellbeing were written on the follow-up questionnaire, but without the patient scores and they were asked to score these again. They were also asked questions to determine whether they thought any improvement or side effects were due to their homeopathic treatment. Information about their conventional drug use was also sought; whether it had remained unchanged, decreased or was not applicable. At the end of the consultation, patients were given an information leaflet and advised how to get their homeopathic medicines either via their own GP on NHS prescription, or to purchase them for themselves. Many used local pharmacies or contacted a homeopathic pharmacy. GPs were contacted by fax and most were willing, when requested, to give their patients a prescription. Data were collected each year from 1st July to 30th June. Results Female Male Total Thirty-seven GPs from fifteen different practices referred 273 patients. Patient numbers attending the clinic varied; they were reduced in 2006 due to my illness and in 2009 due to sabbatical leave. 82% of patients referred were female (Table 1). All age ranges were seen but predominantly women aged 36e55 years (Table 2). Many patients had been unwell for a number of years before attending the clinic (Table 3). A large variety of conditions were seen. Anxiety, depression, grief, insomnia, menopausal, gynaecological and chronic skin complaints accounted for 63% of referrals (Table 4). Average return of satisfactorily completed questionnaires was 68%. Data relate to the patient s condition at six months from presentation. Results for Symptom 1 show patients improved considerably at six months with 81% indicating an improvement; 6.5% were worse. Symptom 2 also shows a positive outcome with 75% recording an improvement; 11% reported this symptom worse. 75% patients scored an improvement in their activity while 9% reported it was worse. Overall wellbeing was scored as Table 3 Duration of symptoms in years Unwell (years) Total 0e (24.2%) >1e (12.5%) >2e (19.4%) >5e (16.5%) >10e (8.4%) > (19.0%) improved by 58% of patients; 18% reported feeling worse. Some patients felt worse overall but recorded their specific symptoms and activity scores as improved (Table 5). Table 6 shows the mean difference at six months in symptoms, activity and wellbeing scores for each year. On a seven-point scale, the mean change was 2.3 for Symptom 1; 1.8 for Symptom 2; 1.9 for activity and 1.3 for wellbeing. Combining the symptoms, activity and wellbeing scores give the MYMOP-Dorchester version profile score. The mean improvement at six months was 1.9/7 (27%). 155 (84.7%) patients rated their overall condition improved at six months; of these 99 (54.1%) were much better and 56 (30.5%) were a little better. 148 (81%) patients felt homeopathy had improved their clinical state. No one had attributed a worsening of his or her symptoms to homeopathy. From completed questionnaires, 180 of the 182 patients had found the consultation helpful, two had not, one patient did not answer. 46 (25%) patients reported a reduction in conventional drug usage at six months (Table 7). Table 4 Condition Medical conditions referred Anxiety/depression/OCD/grief/insomnia 65 Menopause 40 Gynaecological/PMT/Postnatal depression 38 Eczema/psoriasis/warts/abscesses/acne 28 Irritable bowel syndrome/eating disorder 19 Recurrent cough/allergy/sinusitis 17 Chronic fatigue/fibromyalgia 13 Unexplained medical symptoms 12 Chronic headaches/migraine 9 Arthritis 7 Side effects cancer treatment 7 Neurological-MS/PD/cranial dystonia/neuralgia 6 Recurrent thrush/cystitis 4 Restless legs/cramps 4 Hypertension/atrial fibrillation 3 ADHD 1 Total 273 Numbers Table 2 clinic Ages and genders of patients attending the homeopathy Ages (years) Female Male Total 0e e e e e > Total Table 5 MYMOP Symptoms 1 and 2, activity and wellbeing scores, in 183 patients six months after consultation (%) Symptom 1 Symptom 2 Activity Wellbeing Improved 148 (81%) 138 (75%) 137 (75%) 106 (58%) Same 22 (12%) 23 (13%) 24 (13%) 40 (22%) Worse 12 (6.5%) 21 (11%) 16 (9%) 33 (18%) Unanswered 1 (0.5%) 1 (0.5%) 6 (3%) 4 (2%)

3 Table 6 Mean scores for Symptoms 1 and 2, activity, wellbeing and MYMOP-Dorchester scores at start and 6 months Year Mean symptom scores MYMOP-Dorchester score Symptom 1 Symptom 1 6 months Symptom 2 Symptom 2 6 months Activity Activity 6m Wellbeing Well 6m Initial 6 months Mean change Discussion Few GPs subject their work to detailed analysis over time. I undertook yearly outcome audits to demonstrate activity and effectiveness of homeopathy for the Primary Care Trust and as a learning tool. MYMOP appeared ly suitable as it is designed to measure person change over time and can be used for a variety of conditions. In 1999 it was revised and revalidated as MYMOP2. 7 However, I made several changes to the questionnaire as originally the information was intended for local use and it did not suit fully the purpose. However, there are sufficient similarities to make some meaningful comparisons. Patients usually completed their questionnaire before seeing the doctor. A few needed help interpreting the questions. Normally the MYMOP questionnaire is completed either during or at the end of the first consultation. I wanted to avoid any practitioner bias in either selecting the symptoms etc. or influencing the scoring. The questionnaires were sent out at six month as many people had chronic conditions, which needed time for change but to also reduce any influence of placebo effects. The questionnaire was also adapted to ask patients about how their condition had been in the previous month, rather than previous week as in MYMOP. Some patients had cyclical or recurrent conditions e.g., menstrual problems, chronic migraines, irritable bowel syndrome for which a time scale of one week would not have been sufficient. The follow-up questionnaire asked patients to record how Table 7 Responses in six month follow-up questionnaire (%) in 183 patients How would you rate your condition now compared to your visit Did you feel homeopathy had any effect on your problem? Did you find the homeopathic consultation helpful? Much better 99 (54.1) Little better 56 (30.6) Same 23 (12.6) Little worse 4 (2.2) Much worse 0 Unanswered 1 (0.5) Improved 148 (81) No change 30 (16) Deterioration 0 Unanswered 5 (3) Yes 180 (98.5) No 2 (1) Unanswered 1 (0.5) Conventional drug use Not applicable 102 (56) No change 35 (19) Reduced 46 (25) bad their symptoms, etc. had been since the first visit. On reflection, this is biased towards a worse score, since it includes values before treatment had taken effect. The scoring system is comparable to MYMOP, the range is 1e7 instead of 0e6, but both yield a seven-point scale. Additional questions were introduced to the follow-up questionnaire, to ask in various ways whether homeopathy had truly been responsible, as judged by the patient, for any changes. Although follow-up data from 33% of the patients is missing, this five-year study has shown, combining symptoms, activity and wellbeing scores, that 73% of patients who completed follow-up questionnaires, reported an improvement at six months. The patient scores were also added to produce the MYMOP-Dorchester profile score; the mean change in score was 1.9. Paterson found a mean change in score >1 was associated with a clinically important change for the patient. The rate of improvement varies between conditions. In this study, 85% of patients felt better and of these 54% felt much better and 81% of respondents put this down to homeopathic treatment. The additional questions corroborated the MYMOP scores, consolidating the interpretation of the scoring. Bristol Homeopathic Hospital conducted an outcome study across six years with over 6500 consecutive patients. 4 70% of follow-ups reported improvement with 50% describing major improvement. This single practitioner study has produced similar results. The natural history of many conditions is for them to improve but 44% of the clinic patients had had their problem for over five years and had not had satisfactory help from primary or secondary care. In general practice, patients sometimes report that their conventional treatment has not worked or that they have experienced adverse effects. Doctors may cause iatrogenic illness; 1:16 admissions to hospital are said to be due to adverse drug reactions. 8 Homeopathic treatment is safe in all age ranges when used appropriately and across the five years of this study, no one reported side effects because of it. The questionnaire offered space for patient comment. Although not documented in this paper, patients were often grateful to receive a complementary treatment from a conventionally trained doctor. They had found the homeopathic consultation helpful in nearly all cases. Nearly a quarter of patients reduced their conventional medications at six months. Homeopathic prescriptions are also cheap, often less than a conventional prescription charge. The annual cost of the clinic for 2010 was 7718

4 54 approximately equal to the cost of 1.3 hip replacements on the current NHS tariff but an average of nearly 55 patients a year have been seen and in many cases helped despite often difficult medical problems. This is likely to represent a significant cost saving. has been available within the NHS since 1948 but now more than ever its place is controversial. Over 51% of commonly used treatments have unknown effectiveness when assessed critically and 3% are likely to be ineffective or harmful. 9 A large number of patients in the homeopathy clinic had depressive or anxiety illness. Despite widespread and costly use of antidepressants, trial data suggests they are little better than placebo. 10,11 Although the mechanism of action of homeopathy is not known, that need not disqualify its empirical use; consider the use of drugs for general anaesthesia whose mode of action until recently was not or poorly understood. This outcome series has demonstrated an association between homeopathic treatment and improvement and that patients can be helped safely and cheaply with homeopathic treatment for a wide variety of conditions. Patients seek alternative therapies and the study has shown many GPs are happy for their patients to be referred for homeopathy in an NHS setting. Hamilton showed 86% of GPs in Dumfries and Galloway were in favour of a local NHS Specialist Clinic 12. Patient choice is part of the NHS agenda. Nevertheless, the homeopathy clinic has recently lost it s funding from the PCT, reducing patient choice and despite the positive findings presented. More positive research evidence will be needed to encourage greater use of homeopathy in the NHS. Acknowledgements I thank Dr Robert Mathie (British Homeopathic Association) for advice in writing up this paper. Appendix 1 TREATMENT USING HOMEOPATHY I would be grateful if you could complete this questionnaire and bring it along to your consultation. 1. What problem or condition do you wish to be helped by homeopathy? 2. How long has it been a problem for you? (Months or years) 3. Please list 2 of your main symptoms and show how bad they have been in the last month. Please circle the appropriate number. SYMPTOM 1. as good as it -> <- as bad as it could be could be SYMPTOM 2. as good as it -> <-as bad as it could be could be ACTIVITY I cannot.. able to do it -> <- not able to normally do it at all WELLBEING: How would you as good as it -> <- as bad as it rate your general feeling could be could be of wellbeing I agree to a follow up questionnaire YES NO

5 Appendix 2 55 FOLLOW UP QUESTIONAIRE: HOMEOPATHY I would be grateful if you could complete this questionnaire and send it back in the envelope provided. Please circle the number to show how severe your problem has been since your first consultation. SYMPTOM 1. as good as it -> <- as bad as it could be could be SYMPTOM 2. as good as it -> <-as bad as it could be could be ACTIVITY I cannot.. able to do it -> <- not able to normally do it at all WELLBEING: How would you as good as it -> <- as bad as it rate your general feeling could be could be of wellbeing How would you rate your condition now compared to your consultation. (tick one only) Much better ( ) A little better ( ) About the same ( ) A little worse ( ) Much worse ( ) Since having homeopathic treatment, has your conventional treatment for your main problem been: Unchanged ( ) Reduced ( ) Not applicable ( ) Did you feel homeopathy had any effect on your problem? IMPROVEMENT /NO CHANGE /DETERIORATION Did you find the process of the homeopathic consultation helpful? YES NO Any comment? References 1 Robinson TW. Responses to homeopathic treatment in National Health Service general practice. 2006; 95: 9e14. 2 Mathie RT, Robinson TW. Outcome from homeopathic prescribing in medical practice: a prospective, research-targeted, pilot study. 2006; 95: 199e Richardson W. Patient benefit survey: Liverpool regional department of homeopathic medicine. Br Homeopath J 2001; 90: 158e Sevar R. Audit of outcome in 829 consecutive patients treated with homeopathic medicines. Br Homeopath J 2000; 89: 178e187. 5Spence D, Thompson E, Barron SJ. Homeopathic treatment for chronic disease: a 6-year university-hospital outpatient observational study. J Altern Complement Med 2005; 11(5): 793e Paterson C. Measuring outcomes in primary care: a patient generated measure, MYMOP, compared with the SF-36 health survey. BMJ 1996; 312: 1016e1020.

6 56 7 MYMOP [ [website e accessed March 2011] 8 Pirmohamed M, James S, Meakin S, et al. Adverse drug reactions as a cause of admission to hospital: prospective analysis of patients. BMJ 2004; 329: 15e19. 9 Clinical Evidence. How much do we know? BMJ Publishing Group, [website accessed March 2011]. 10 Ioannidis JP. Effectiveness of antidepressants: an evidence myth constructed from a thousand randomized trials? Philos Ethics Humanit Med 2008; 3: Thase ME. Do antidepressants really work? A clinicians guide to evaluating the evidence. Curr Psychiatry Rep 2008; 10: 487e Hamilton E. Exploring General Practitioner s attitudes to homeopathy in Dumfries and Galloway. 2003; 92: 190e194.