NHS “Any Qualified Provider” Initiative is a Bonanza for Quacks

gold rushAs we were all watching the Tiswas Select Committee questioning the Murdochs, the government were letting out press releases saying they were to hand over a billion pounds of NHS services to private companies and charities.

The announcements say that patients will be given a “wider choice of providers” for some services and that “the goal is to enable patients to choose from any qualified provider where this will result in better care.”

What is noticeable is that in the first phase many of these services will be for the sort of long term and difficult to treat problems that quacks like to prey on, such as back pain, leg ulcers, counselling and wound healing.

Should we be worried that this announcement is a herald for a quack gold rush?

There are worrying signs.

Back pain is a classic problem that quacks make money from. It is serious enough for sufferers to want to go to significant lengths to find relief. It is self-limiting, in that most cases resolve themselves in weeks or months. And importantly, there are few good treatments that can actually make a difference. Importantly, mainstream advice is rather low key – keep mobile and take some painkillers. Patients want more – they expect more  – and quacks can fill the gap between expectations and what doctors can actually offer during the time the pain resolves itself.

This gap is routinely filled by chiropractors and osteopaths and these pseudo-medical practitioners appear to be exactly the sort that the government see as ‘any qualified provider’. Quack lobby groups, such as the misleadingly named College of Medicine, have been pushing hard for the public funding of superstitious and pseudoscientific treatments for back pain, such as acupuncture and chiropractic. This is despite serious concerns about such options, on safety and efficacy grounds, from the medical community.

But, offering frustrated back pain sufferers such options is indeed extending patient choice. The problem is that this is not a meaningful choice, but one that simply satisfies a natural demand that ‘something must be done’. No doubt, patient satisfaction with such a choice will be high – finally, “someone is taking me seriously”. However, it is unlikely to improve their outcomes and will cost the tax payer a lot more than standard advice.

Is there anything else in this announcement that suggests quackery may be filling this gap?

One of the other services to be privatised is treatment for leg ulcers. A case study is provided by the Department of Health that makes incredible claims for private practice success in this area. Leg ulcer healing can take a very long time – the press release claims that “wounds have had an average duration of 3.3 years when patients arrive at the centre”. The cost to the NHS is high – the government claim that the “NHS pays out £18,000 per patient over four years, often without curing them”.

To show the advantages of going to private businesses to help, the department gives a case study based around the Wound Healing Clinic in Eastbourne. The claim is that – and hold onto something tight – the clinic has “both a high success rate and is cost-effective, 82-3% of patients have their wounds healed over a 6-week period – one of the highest in the UK.”

What a good advert for taking services out of “ineffective” and “costly” public services and handing them to “innovative” private businesses.

When I see such incredible health claims, one should always suspect quack exaggeration. How is the Wound Healing Clinic innovating here and getting such remarkable results?

The clinic is run by nurses, but the the first worrying sign is that the clinic actually employs a “registered” Homeopath. Cathie Bree-Aslan is their Narnia medicine specialist. Bree-Aslan tells us that,

Homeopathy uses natural substances in minute doses to gently stimulate the body from the inside out. It is useful in all manner of health problems including allergies and ongoing and recurrent illness. Cathie Bree-Aslan is registered with the Society of Homeopaths and is a Registered Nurse.

Cathie specialises in treating people with chronic wounds such as leg ulcers by treating the underlying causes and coupling this with specialist wound care interventions.

Now when a homeopath states that they are treating the “underlying causes” of an illness, they do not mean killing off infections or looking at lifestyle or behavioural issues, they mean they want to rebalance the yin-yang miasm chakra or something by the application of sugar pills.

It is unclear to me how offering a sugar pill service to people with leg ulcers can improve their healing times and decrease costs for the tax payer. It does though extend “patient choice”. Not a health choice, but a lifestyle choice. But the two will be happily conflated.

Other aspects of the Wound Healing Clinic’s treatments are concerning. They use manuka honey dressings on leg ulcers too. Manuka Honey, a staple of New Age health food shops, is supposed to have remarkable wound healing properties. Whilst infinitely more plausible than homeopathic sugar pills as a treatment, the evidence base for honey is not good. In 2009, the Cochrane Collaboration published a review of using honey on wounds and concluded for leg ulcers,

In chronic wounds two trials evaluated the effect of honey in venous leg ulcers and one trial in pressure ulcers, infected post-operative wounds, and Fournier’s gangrene respectively. Two trials recruited people with mixed groups of chronic or acute wounds. The poor quality of most of the trial reports means the results should be interpreted with caution, except in venous leg ulcers. In acute wounds, honey may reduce time to healing compared with some conventional dressings in partial thickness burns (WMD -4.68 days, 95%CI -4.28 to -5.09 days). All the included burns trials have originated from a single centre, which may have impact on replicability.

In chronic wounds, honey in addition to compression bandaging does not significantly increase healing in venous leg ulcers (RR 1.15, 95%CI 0.96 to 1.38).

So, the clinic appears to be using honey when the best evidence to date would suggest that it is not an effective treatment. In addition, there is some evidence that using Manuka honey can actually be harmful for certain sorts of leg ulcers. Again, how this gives real patient choice, and better value for NHS money, is not clear.

Their web site also suggests that patients also eat chocolate to help wound healing and buy vitamin pills. Not just any chocolate. But Belgian chocolate. To complete the package, the clinic also offers Wound Healing Holidays. Their treatment is ‘so intensive’ it makes sense for you to stay at their ‘partner hotel’ on the Sussex coast.

Of course, you might argue that these details are not important, but that the “total package of care” is what matters. Indeed, the clinic may well use standard practice too. But how such a service can provide better outcomes, in record time, with a fraction of the cost whilst layering any standard treatments with highly questionable ones is, to me, a complete mystery. How such a service can be rated as a ‘qualified provider’ suggests the qualification criteria are somewhat loose.

The Department of Health do not link to any sources to back up their claim of remarkable success with a clinic that treats long term wounds with sugar pills, chocolate, honey and a trip to the coast. But if this is supposed to be a great example of how this new policy works then I would suggest that it is a fundamentally flawed policy that risks undermining publicly funded services based on best evidence.

To satisfy the dogmatic chant of ‘patient choice’ it looks like our public health service is to be sacrificed to “Any Willing Chancer” who is able to convince the government that their ‘innovation’ is able to deliver miraculous outcomes at a very low cost whilst fuelling the right wing fantasy that our public medical staff are ineffective and too costly.

If I was a chiropractor or homeopath, I would see this week’s announcement as the start of a gold rush for me. Happy days.

On this theme…

21 Comments on NHS “Any Qualified Provider” Initiative is a Bonanza for Quacks

  1. I tweeted about this last night – glad I wasn’t the only one to pick up the rather dubious point about a homepath/herbalist on staff. Having worked in care, I’d be very interested in any procedures that showed this kind of improvement in wound care. Especially true as the website talks up things like vitamins, which if that good would be more widely used already…

  2. I must admit I glanced at the Wound Healing Clinic’s website yesterday, but was on my way out to the pub, so obviously didn’t look too closely! I saw it was run by a nurse, but didn’t go any further than that. Good investigation, Andy!

  3. Firstly, I agree very strongly with your concerns in general about the NHS changes, and the dangers of so-called patient choice. Also, if the claims made by this clinic really are exceptional then it would be worth checking that the methods used to generate those statistics are fair.

    However, from reading your post I got the impression that the clinic promotes alternative treatments to at least a significant extent, and that the nurse you mention is either typical (i.e. all/most nurses there have some interest in alternative treatments), or is actually employed mainly due to her homeopathic interests. Looking at the website, I don’t think that’s the case at all.

    You actually write “Indeed, the clinic may well use standard practice too”, as if you were so swamped by information about their alternative treatments you could hardly find anything about standard practice. Actually from my non-expert reading of their website it looks like the vast majority of what they do is standard/reasonable practice, and the only bit of woo that I saw was the bit about eating chocolates, which doesn’t really seem enough to warrant such condemnation. Maybe I missed something… but then you didn’t link to where they say they do honey dressings (and I didn’t find that).

    So… I’m a little bit disappointed that you seemed to misrepresent this case in order to argue a point I agree with. Hope I’m wrong!

      • Thanks. However, I don’t see it as particularly damning. If they use honey-impregnated dressings for non-diabetic ulcers then probably the only harm is slightly increased cost to them, with possibly some benefit. The paper you link to mentions two papers showing clinically (but not statistically) significantly worse healing in diabetic ulcers. It concludes “We believe that honey is an effective alternative dressing for treatment of many types of chronic wounds. However, MG may have a detrimental effect on diabetic ulcers.”. Even then you don’t know (presumably) whether the Wound Healing Centre already considers that in its treatment.

        As I said before, I’m already convinced of the overall argument. However, I don’t think this case is a good one to be using…

      • And:

        Our Key Success Factors include:

        Providing a holistic treatment of the wound through a multidisciplinary team consisting of nurses, an Occupational Therapist, Podiatrist, Lymphoedema specialist, Homeopath and Ultra Sound Consultant

        (My emphasis)

        Source

      • Actually, there are several warning signs in that document that require explanation:

        Healing 82% of chronic venous leg ulcers, and an overall healing rate of 72% on all wound types, in an average of 6 weeks, against a national average of 30% [over 3 years]

        A zero rate of infection

        The Key Success Factors are achieved by:
        Only treating wounds that have not healed following a 4 to 6 week treatment regime provided by District or Practice Nurses

        The fastest healing rate has been 2 patients with wounds of 2.5 years, both healed in 5 days

        Do some of these seem too good to be true?

    • Their costs need looking at as well.

      In their Business Overview document, they compare their alleged 6 weeks healing cost of £720 with the (allegedly comparable) £17,107 PCT cost over 3.3 years.

      However, if the PCT only knew what Wound Healing Centres did and were able to achieve the same healing times (it’s not obvious why they shouldn’t), the cost to the PCT would be just £598, calculated pro-rata, making WHC look somewhat pricey at £720.

  4. Amazing. Your lack of understanding of Wound Care is quite remarkable.

    This is not quackery, this is a science and is evidence based.
    Honey has evidence, leg ulcer healing has evidence.

    Don’t be scared to admit you don’t understand something rather than pick on small bits of information that suit your needs.

    • Perhaps you would like to point me to some better evidence than the Cochrane review I discuss?

      Would you also by any chance be the job pimp Paul Saunders who specialises in “Wound Care People provides a segment specific service that delivers results for employers and candidates at all levels of commercial, sales, marketing, business development and market access roles within the Wound Care market.”

      Would you be by any chance likely to benefit from a huge rise in private funding for wound care?

  5. Doesn’t the honey just gradually dissolve in the wound fluid (exudate) and form a sugar solution that bacteria can get their teeth into (so to speak)? Perhaps there are types of bacteria that enjoy full-strength honey too of course. I don’t claim to be an expert 😉

  6. Hang on a sec, it doesn’t matter whether the Wound Healing Centre’s claims sound good to be true. What matters is whether they held, at the time of making the claims, robust evidence to support them.

    Alan or Andy, who wants to ask the ASA to have a look?

    How about reporting the DoH for the potentially misleading claims it is making about a private company?

    • Good point BSM. There are quite a lot of very specific claims being made that the ASA would require the advertiser to hold substantiation for.

      Having to remove some claims or an adverse ASA adjudication would be somewhat embarrassing for them, the DH and Lansley.

  7. ‘Patients want more – they expect more – and quacks can fill the gap between expectations and what doctors can actually offer during the time the pain resolves itself.’

    Yes, the mantra we used to shout as children when ‘something happened’ was, ‘Do something, do something, do something’, because adults always wanted something done about something.

    Politicians are elected because they promise to ‘do something’ about something. What’s happening here falls into this category. They don’t care about the legitimacy of what they do, as long as they’re seen to be ‘doing something’.

    The more I read about the quackery in health care, the more I’m amazed that such spurious and illegal practices are encouraged and funded by people who have control of our money and, in some cases, of our lives.

    The basics of evidence-based science seem to be lost on many of our politicians and many of the people of this country. It is not, however, lost on many of the quacks who want to use some of the terminology of evidence-based science, mixed with the woo words they’re so good at inventing, to con people into parting with their money. For me, this just reinforces the fact that they know exactly what they’re doing. They are just conmen and women at heart.

    Keep up the good work Andy.

  8. It is deeply depressing that the “informed” part of informed choice is not given even a nod in these absurd “any qualified provider” tenders. This is NHS money. The NHS is under fire for making hard choices about funding expensive experimental therapies, and much of this is fuelled by assiduous promotion of cherry-picked data in the press. To see the Government joining the cherry-pickers and actively promoting what will in many cases be not just poor value but in some cases actively dangerous (chiro) pseudoscience is depressing indeed.

    • Ah! We’ve all misunderstood what ‘informed choice’ means. It’s actually all about being informed we have a choice, even if those choices are useless quackery, not that we’ll be properly informed about each choice…

  9. Same thing happens in my work – IT support. Usre has a problem, say, with a printer on our network. I might see the fix is for something to be done to the server that looks after it and can fix it in a few moments.
    But the user is much more impressed if a Tech goes to fetch the printer & keeps it for half a day or more. On its return, everything is fine.

    Who gets the credit…?

    • But the user is much more impressed if a Tech goes to fetch the printer & keeps it for half a day or more. On its return, everything is fine.

      That’s kind of a longwinded way of turning it off and then on again, but I guess it would work.

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