Homeopathy & Iscador Treatment Adherence to Evidence Based Medicine Programme Evidence Summary Pack (Version 2) Homeopathy & Iscador Treatment Local commissioners working with local people for a healthier future

About the AEBM Programme Enfield Clinical Commissioning Group, along with our North Central London colleagues, wants to the secure the greatest health impact it can with its resources by adhering as closely as possible to the clinical evidence base available. There is considerable national and international evidence that many procedures offered routinely by the NHS are of limited clinical benefit to patients in some or all circumstances. Therefore there needs to be careful consideration as to whether or not a procedure is going to be of any benefit to an individual patient before deciding to undertake it. To do this we must use the best and most up to date clinical advice and evidence to ensure we have the best chance of delivering a benefit to each individual patient who is put forward for treatment. This  evidence published by the National Institute for Health & Care Excellence(NICE) as well as available evidence published by the Royal Colleges and other Clinical Commissioning Groups. This will also ensure the best value from the services we commission. To ensure this decision making process is applied consistently, Enfield Clinical Commissioning Group along with the other Clinical Commissioning Groups in North Central London, adopted a common policy concerning these procedures that have limited clinical effectiveness in 2012 based on the best available evidence at that time. As the clinical evidence base moves on we are now undertaking a further review to ensure that we are using the best and latest clinical evidence in our decision making. We are also looking at the range of procedures where the evidence base now suggests we need to make changes to the guidance for individual patient situations to avoid the risk of undertaking procedures that have little or no benefit to patients or even where the undertaking of the procedure could result in a risk of harm. Clinical Leaders at the Clinical Commissioning Group with the full support of the Governing Body are leading this review. Enfield Clinical Commissioning Group will engage widely and consult formally on the proposals which emerge, while continuing to work closely with partner Clinical Commissioning Groups in North Central London.

About the Evidence Pack This evidence pack summarises the evidence that the Clinicians working on the AEBM Programme have reviewed prior to the commencement of the consultation process. Due to the nature of many of the documents reviewed it is not possible to repeat the evidence in its entirety. The first version of these Evidence Packs only contained highlights of the information and clinical evidence reviewed and based on feedback from our public this was seen as an oversight and therefore a more comprehensive summary is now being provided. These packs will be made available along with the underpinning documents that were used. The purpose of the Consultation is to enable clinicians, patients, our public and other stakeholders to contribute to the debate including identifying additional evidence that may have been missed by the clinicians working on the programme during the pre-consultation phase. The views of all participants in the consultation along with any additional evidence that comes to light during the consultation programme will be taken through further clinical review at the end of the consultation programme. We would like to thank all who have contributed during the extensive pre-consultation phase (that lasted from October16 through to March 17) and all who are now taking the time to contribute during the formal consultation phase.

About the Approach Taken In preparing these Evidence Packs we undertook an extensive review of available clinical data and evidence and looked in detail at the evidence used (or at least reviewed) by other Clinical Commissioning Groups during similar exercises. The span of this work included (but was not limited to) the following: NICE BMA Royal Colleges All London CCGs CCGs outside of London including Cambridge, Berkshire, North Staffordshire and many others Guidance documents available from relevant stakeholder websites We then collated the evidence including eligibility criteria that CCGs had reviewed (although it is noted not all may have gone on to implement the changes) and then added in local data such as activity and spend, trend analysis and benchmarking. This collated data and evidence was then reviewed by a wide range of clinicians including secondary care representatives before being summarised into these Evidence Packs for use during the consultation. The purpose of these Evidence Packs is to provide a summary of the extensive clinical review that was undertaken prior to the commencement of the Consultation Period but we recognise that further evidence might come to light during the consultation process and this is the reason for undertaking the consultation before any decisions are made to ensure we have used all of the available evidence in our final decision making processes.

Enfield CCG About Homeopathy Homeopathy Definition (NHS Choices) Homeopathy is a 'treatment' based on the use of highly diluted substances, which practitioners claim can cause the body to heal itself. Iscador Treatment Note It is noted that Iscador Therapy or Treatment has no definition on NHS Choices but is often referred to a Mistletoe Therapy and is an Homeopathic process given to Cancer Patients. Iscador is an extract of the European Mistletoe (Viscum Album). Iscador Treatment (which can be found under various other names) is considered a Homeopathic Treatment hence its inclusion in this document. Homeopathy in Popular Culture Daily Mail 13th November 2015 Ban homeopathy on the NHS because there is 'no evidence it works', ministers say. Daily Telegraph 27th April 2015 Health officials are to review the use of homeopathy on the NHS after a group of doctors accused them of wasting money on “deceitful” treatments which do not benefit patients. BBC News 6th October 2016 The NHS says there's "no good-quality evidence" that homeopathy is effective as a treatment for any health condition, yet it funds it. Why and to what extent?

Enfield CCG Evidence Summary NICE Guidance. Note: NICE does not issue guidance on either Homeopathy or Iscador Treatment and as such it is not recommended by NICE. The only references made by NICE are concerning the times when Homeopathy is considered harmful and therefore appears in the ‘Do Not Do’ list on the NICE Website. Do not offer homeopathy for treating lower urinary tract symptoms (LUTS) in men Guidance from June 2015 Do not use homeopathy to treat hyperbilirubinaemia Homeopathy is not recommended for the management of otitis media with effusion (OME) Healthcare professionals should inform women that the available evidence does not support homeopathy for induction of labour NHS Choices There have been several reviews of the scientific evidence on the effectiveness of homeopathy. The House of Commons Science and Technology Committee said there is no evidence that homeopathy is effective as a treatment for any health condition. Cancer Research UK Although there have been many research studies into homeopathy there is no scientific or medical evidence that it can prevent cancer or work as a cancer treatment. House of Commons Science and Technology Committee. Evidence Check 2: Homeopathy — Fourth Report of Sessions 2009–10. Conclusion; By providing homeopathy on the NHS and allowing MHRA licensing of products which subsequently appear on pharmacy shelves, the Government runs the risk of endorsing homeopathy as an efficacious system of medicine. To maintain patient trust, choice and safety, the Government should not endorse the use of placebo treatments, including homeopathy. Homeopathy should not be funded on the NHS and the MHRA should stop licensing homeopathic products. NHS Centre for Reviews and Dissemination. Homeopathy. Effective Healthcare Bulletin 2002 : 7(3): 1-12 Conclusion; There is currently insufficient evidence of effectiveness either to recommend homeopathy as a treatment for any specific condition, or to warrant significant changes in the current provision of homeopathy.

Enfield CCG Criteria Summary Agency or Organisation Key Notes NICE 2016 Does not recommend Homeopathy Liverpool CCG (2016) Suggested to decommission Homeopathy Wirral CCG (2016) Does not commission Homeopathy or Iscador Berkshire CCG (2016) Only commissions ‘in extremis’ via an IFR Cancer Research UK (2016) Does not recommend Homepathy or Iscador NHS Choices (2016) States there is no evidence to support Homeopathy Macmillan (2016) Dos not recommend Homeopathy or Iscador Bristol CCG (2014) Does not commission Homeopathy Greater Manchester PCTs (2010) Houses of Parliament Science & Technology Committee (2010) Does not support NHS funding for Homeopathy British Medical Journal (2006) States there is no evidence for using Iscador Treatment University of York (2001) Literature research show no benefit of Homeopathy

Spend & Activity Data including Trend Analysis and Benchmarking Local commissioners working with local people for a healthier future

Enfield CCG Activity & Spend Data The activity for Enfield CCG only occurs at UCLH. There appears no separate coding associated with Iscador Therapy suggesting that either it is not utilised or that it is coded as Homeopathy more generally. Activity and spend data is shown below for 2014/15, 2015/16 and a forecast outturn for 2016/17. This suggests the CCG spends ~£160k per year on Homeopathy. Based on the available evidence it is recommended that Enfield CCG decommission provision of Homeopathy and Iscador Treatment. 2014/15 2015/16 2016/17 (Apr - Aug) 2016/17 Forecast Outturn Activity Cost First Attendances 166 £41,990 114 £28,836 44 £11,074 106 £26,641 Follow-up Attendances 836 £124,765 913 £136,256 371 £55,090 893 £132,530 Total 1,002 £166,754 1,027 £165,092 415 £66,164 998 £159,171

For Further Information contact communications@enfieldccg.nhs.uk or call 0203 688 2814