Should NICE evaluate complementary and alternative medicines?

Abstract

Demand for complementary and alternative medicine 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

One of the most important roles of the National Institute for Health and Clinical Excellence (NICE) is to assess which treatments produce sufficient benefit that the National Health Service should pay for them. Since the money available to the NHS is not infinite, making choices of this sort is inevitable, and it is in the interests of patients that dispassionate judgments are made on the efficacy of treatments.

If the effectiveness of a treatment is disputed, what could be more obvious than to refer it to NICE for a judgment of the evidence? Nothing is more disputed than the effectiveness of alternative medicine, so why has NICE not adjudicated? Even the Smallwood report, sponsored by the Prince of Wales, did not pretend to find good evidence, but recommended that NICE should be invited “to carry out a full assessment of the cost-effectiveness of the therapies”¹ The Smallwood report was greeted warmly by many of the complementary medicine fraternity despite its principal recommendation.

That reaction is welcome, if a little surprising, because the evidence, such as it is, has been reviewed endlessly, and it is obvious that if NICE were to apply its normal criteria, almost all complementary and alternative medicine would be removed from the NHS immediately. Why, then, has NICE not considered complementary medicine, despite recommendations from experts? The answer seems to be that someone in the Department of Health is stopping that happening, possibly because he or she can foresee the obvious outcome.

Since referral to NICE would remove complementary medicine from the NHS, I should, perhaps, favour it. Nevertheless, a strong argument can be made for NICE not having to spend time and money going through, yet again, evidence that we already know to be inadequate. In fact NICE has alternative treatments in several of its reports—for example, the reports on supportive and palliative care, obsessive-compulsive disorder, and multiple sclerosis and draft guidance on chronic fatigue syndrome.² In all these cases NICE has found no good evidence for anything more than placebo effects.

Unaffordable luxury

NICE has around 240 employees and costs £27.6m (€41m; $54m) a year,³ and it nevertheless comes under constant criticism for not responding quickly enough to really important questions, most recently over treatments for cancer and Alzheimer's disease. It can't afford the time to do again what has already been done.

Since we already know there is little evidence for the effectiveness of complementary medicine, should more research be done? I wonder whether that is worth while either. Homoeopathy has had 200 years to come up with evidence. Acupuncture and traditional Chinese medicine have had thousands of years. Yet still there is little convincing evidence. Isn't that long enough? The House of Lords report on complementary and alternative medicine in 2000 recommended that three important questions should be examined in the following order: does the treatment offer therapeutic benefits greater than placebo? is the treatment safe? how does it compare, in medical outcome and cost effectiveness, with other forms of treatment?⁴

Money was made available for research but was spent on projects that almost all failed to address the first priority.⁵ In the US, the National Center for Complementary and Alternative Medicine “has not proved effectiveness for any ‘alternative' method. It has added evidence of ineffectiveness of some methods that we knew did not work before NCCAM was formed”⁶ despite spending almost a billion dollars.⁷

Lack of evidence

It is not necessary to take the word of sceptics about the lack of evidence. The more honest advocates of complementary and alternative medicine admit it themselves. Peter Fisher, clinical director of the Royal London Homoeopathic Hospital, on the radio said, “It is true that there is not as much evidence as you would like.” (Vanessa Feltz Show, Radio London, 26 Jan 2007 www.ucl.ac.uk/Pharmacology/dc-bits/quack.html#rose1). Dantas and colleagues concluded that: “The central question of whether homeopathic medicines in high dilutions can provoke effects in healthy volunteers has not yet been definitively answered, because of methodological weaknesses of the reports.”⁸ Consider also the National Library for Health, Complementary and Alternative Medicine (www.library.nhs.uk/cam/). In July 2006, not one entry concluded that there is good evidence for the effectiveness of homoeopathic treatment, although this library is compiled by supporters of complementary medicine. Likewise, search of the Cochrane Library for homoeopathy finds very few positive reviews.

None of what I have said is intended to deny the important role of supportive and palliative care of patients for whom that is the best that can be done. But it is perfectly possible to provide such care honestly.⁹ There is no need to subscribe to the early 19th century pseudoscientific hocus pocus of homoeopathy to treat sick patients sympathetically and holistically. And there is no need for NICE to spend time and money coming to that conclusion when it has more important things to do.