Download Lectures on Biostatistics (1971). Corrected and searchable version of Google books edition
Download review of Lectures on Biostatistics (THES, 1973).
A constant theme of this blog is that the NHS should not pay for useless treatments. By and large, NICE does a good job of preventing that. But NICE has not been allowed by the Department of Health to look at quackery.
I have the impression that privatisation of many NHS services will lead to an increase in the provision of myth-based therapies. That is part of the "bait and switch" tactic that quacks use in the hope of gaining respectability. A prime example is the "College of Medicine", financed by Capita and replete with quacks, as one would expect since it is the reincarnation of the Prince’s Foundation for Integrated Health.
One such treatment is acupuncture. Having very recently reviewed the evidence, we concluded that "Acupuncture is a theatrical placebo: the end of a myth". Any effects it may have are too small to be useful to patients. That’s the background for an interesting case study.
A colleague got a very painful frozen shoulder. His GP referred him to the Camden & Islington NHS Trust physiotherapy service. That service is now provided by a private company, Connect Physical Health.
That proved to be a big mistake. The first two appointments were not too bad, though they resulted in little improvement. But at the third appointment he was offered acupuncture. He hesitated, but agreed, in desperation to try it. It did no good. At the next appointment the condition was worse. After some very painful manipulation, the physiotherapist offered acupuncture again. This time he refused on the grounds that "I hadn’t noticed any effect the first time, because there is no evidence that it works and that I was concerned by her standards of hygiene". The physiotherapist then became "quite rude" and said that she would put down that the patient had refused treatment.
The lack of response was hardly surprising. NHS Evidence says
"There is no clinical evidence to show that other treatments, such as transcutaneous electrical nerve stimulation (TENS), Shiatsu massage or acupuncture are effective in treating frozen shoulder."
In fact it now seems beyond reasonable doubt that acupuncture is no more than a theatrical placebo.
According to Connect’s own web site “Our services are evidence-based”. That is evidently untrue in this case, so I asked them for the evidence that acupuncture was effective.
I’d noticed that in other places, Connect Physical Health also offers the obviously fraudulent craniosacral therapy (for example, here) and discredited chiropractic quackery. So I asked them about the evidence for their effectiveness too.
This is what they said.
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Many thanks for your comments via our web site. In response, we thought you might like to access the sources for some of the evidence which underpins our MSK services: Integrating Evidence-Based Acupuncture into Physiotherapy for the Benefit of the Patient – you can obtain the information you require from www.aacp.org.uk The General Chiropractic Council www.gcc-uk.org/page.cfm We have also attached a copy of the NICE Guidelines. |
So, no Cochrane reviews, no NHS Evidence. Instead I was referred to the very quack organisations that promote the treatments in question, the Acupuncture Association of Chartered Physiotherapists, and the totally discredited General Chiropractic Council.
The NICE guidelines that they sent were nothing to do with frozen shoulder. They were the guidelines for low back pain which caused such a furore when they were first issued (and which, in any case, don’t recommend chiropractic explicitly).
When I pointed out these deficiencies I got this.
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Your email below has been forwarded to me. I am sorry if you feel that that that information we pointed you towards to enable you to make your own investigations into the evidence base for the services provided by Connect Physical Health and your hospital did not meet with your expectations. ‘ ‘ ‘ Please understand that our NHS services in Camden were commissioned by the Primary Care Trust. The fully integrated MSK service model included provision for acupuncture and other manual therapy provided by our experienced Chartered Physiotherapists. If you have any problems with the evidence base for the use of acupuncture or manual therapy within the service, which has been commissioned on behalf of the GPs in Camden Borough, then I would politely recommend that you direct your observations to the clinical commissioning authorities and other professional bodies who do spend time evidencing best practice and representing the academic arguments. I am sure they will be pleased to pick up discussions with you about the relative merits of the interventions being procured by the NHS. Yours sincerely, Mark Mark Philpott BSc BSc MSc MMACP MCSP
Head of Operations, Community MSK Services Connect Physical Health 35 Apex Business Village Cramlington Northumberland NE23 7BF |
So, "don’t blame us, blame the PCT". A second letter asked why they were shirking the little matter of evidence.
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In response to your last email, I would like to say that Connect does not wish to be drawn into a debate over two therapeutic options (acupuncture and craniosacral therapy) that are widely practiced [sic] within and outside the NHS by very respectable practitioners. You will be as aware, as Connect is, that there are lots of treatments that don’t have a huge evidence base that are practiced in mainstream medicine. Connect has seen many carefully selected patients helped by acupuncture and manual therapy (craniosacral therapy / chiropractic) over many years. Lack of evidence doesn’t mean they don’t work, just that benefit is not proven. Furthermore, nowhere on our website do we state that ALL treatments / services / modalities that Connect offer are ‘Evidence Based’. We do however offer many services that are evidence based, where the evidence exists. We aim to offer ‘choice’ to patients, from a range of services that are safe and delivered by suitably trained professionals and practitioners in line with Codes of Practice and Guidelines from the relevant governing bodies. Connect’s service provision in Camden is meticulously assessed and of a high standard and we are proud of the services provided. |
This response is so wrong, on so many levels, that I gave up on Mr Philpott at this point. At least he admitted implicitly that all of their treatments are not evidence-based. In that case their web site needs to change that claim.
If, by "governing bodies" he means jokes like the GCC or the CNHC then I suppose the behaviour of their employees is not surprising. Mr Philpott is evidently not aware that "craniosacral therapy" has been censured by the Advertising Standards Authority. Well he is now, but evidently doesn’t seem to give a damn.
Next I wrote to the PCT and it took several mails to find out who was responsible for the service. Three mails produced no response so I sent a Freedom of Information Act request. In the end I got some
"Connect PHC provide the Community musculoskeletal service for Camden. The specification for the service specifically asks for the provision of evidence based management and treatments see paragraph on Governance page 14 of attached.. Patients are treated with acupuncture as per the NICE Guidelines (May 2009) for the management of low back pain … . .. Chiropractors are not employed in the service and craniosacral therapy is not provided as part of the service either."
Another letter, pointing out that they were using acupuncture for things other than low back pain got no more information. They did send a copy of the contract with Connect. It makes no mention whatsoever of alternative treatments. It should have done, so part of the responsibility for the failure must lie with the PCT.
The contract does, however, say (page 18)
The service to be led by a lead clinician/manager who can effectively demonstrate ongoing and evidence-based development of clinical guidelines, policies and protocols for effective working practices within the service
In my opinion, Connect Physical Health are in breach of contract
Another example of Connect ignoring evidence
The Connect Physical Health web site has an article about osteoarthritis of the knee
Physiotherapy can be extremely beneficial to help to reduce the symptoms of OA. Treatments such as mobilizations, rehab exercises, acupuncture and taping can help to reduce pain, increase range of movement, increase muscle strength and aid return to functional activities and sports.
There is little enough evidence that physiotherapy does any of these things, but at least it is free of mystical mumbo-jumbo. Although at one time the claim for acupuncture was thought to have some truth, the 2010 Cochrane review concludes otherwise
Sham-controlled trials show statistically significant benefits; however, these benefits are small, do not meet our pre-defined thresholds for clinical relevance, and are probably due at least partially to placebo effects from incomplete blinding.
This conclusion is much the same as has been reached for acupuncture treatments of almost everything. Two major meta-analyses come to similar conclusions. Madsen Gøtzsche & Hróbjartsson (2009) and Vickers et al (2012) both conclude that if there is an effect at all (dubious) then it is too small to be noticeable to the patient. (Be warned that in the case of Vickers et al. you need to read the paper itself because of the spin placed on the results in the abstract.). These papers are discussed in detail in our recent paper.
Why is Connect Physical Health not aware of this?
Their head of operations told me (see above) that
"Connect does not wish to be drawn into a debate [about acupuncture and craniosacral therapy]".
That outlook was confirmed when I left a comment on their osteoarthritis post. This is what it looked like almost a month later.
Guess what? The comment has never appeared..
The attitude of Connect Physical Health to evidence is simply to ignore it if it gets in the way of making money, and to censor any criticism.
What have Camden NHS done about it?
The patient and I both complained to Camden NHS in August 2012. At first, they simply forwarded the complaints to Connect Physical Health with the unsatisfactory results shown above. It took until May 2013 to get any sort of reasonable response. That seems a very long time. In fact by the time the response arrived the PCT had been renamed a Clinical Commissioning Group (CCG) because of the vast top-down reorganisation inposed by Lansley’s Health and Social Care Act.
On 8 May 2013, this response was sent to the patient, Here is part of it.
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I have received your email of complaint from the NHSNCL complaints department regarding your care. You raise some very clear concerns and I will attempt to address these in order. 1) The fact that you felt pressurised into having acupuncture is a concern as everybody should be given a choice. As part of the informed consent relating to acupuncture you should have been told about the treatment, it’s [sic] benefits and risks and then you sign to confirm you are happy to proceed. I understand that this was the case in your situation but I have reinforced that the consent is important and must be adhered to by the provider Connect Physical Health. There are clear standards of clinical practice that all Chartered Physiotherapists must follow which I will discuss further with the Connect Camden team Manager Nick Downing. I do disagree with you around acupuncture; there is no conclusive evidence for acupuncture in frozen shoulder but I have referenced a systematic review which concludes the studies were too small to draw any conclusions although shoulder function was significantly improved at 4 weeks (Green S et al. Acupuncture for shoulder pain. Cochrane Database Syst Rev 2005; 18: CD005319). There is a growing body of evidence supporting the use of acupuncture and until such time as there is specific evidence against it I don’t think we would be absolutely against the practice of this modality alongside other treatments. .Best wishes Strategy and Planning Directorate |
This response raises more questions than it answers.
For example, what is "informed consent" worth if the therapist is his/herself misinformed about the treatment? It is the eternal dilemma of alternative medicine that it is no use referring to well-trained practitioners, when their training has inculcated myths and untruths.
There is not a "growing body of evidence supporting the use of acupuncture". Precisely the opposite is true.
And the statement "until such time as there is specific evidence against it I don’t think we would be absolutely against the practice of this modality alongside" betrays a basic misunderstanding of the scientific process.
So I sent the writer of this letter a reprint of our paper, "Acupuncture is a theatrical placebo: the end of a myth" (the blog version alone has had over 12,000 page views). A few days later we had an amiable lunch together and we had a constructive discussion about the problems of deciding what should be commissioned and what shouldn’t.
It seems to me to be clear that CCGs should take better advice before boasting that they commission evidence-based treatments.
Postscript
Stories like this are worrying to the majority of physiotherapists who don’t go in for mystical mumbo-jumbo of acupuncture. One of the best is Neil O’Connell who blogs at BodyInMind. He tweeted
Physio fail, sigh RT@david_colquhoun: Yet more #acupuncture. Sold to the NHS by private contractor @ConnectPHC http://t.co/HylkwMCVTh
— Neil O'Connell (@NeilOConnell) June 10, 2013
It isn’t clear how many physiotherapists embrace nonsense, but the Acupuncture Association of Chartered Physiotherapists has around 6000 members, compared with 47,000 chartered physiotherapists (AACP), so it’s a smallish minority. The AACP claims that it is “Integrating Evidence-Based Acupuncture into Physiotherapy”. Like most politicians, the term “evidence-based” is thrown around with gay abandon. Clearly they don’t understand evidence.
Follow-up
12 June 2013
The Advertising Standards Authority has, one again, upheld complaints against the UCLH Trust, for making false claims in its advertising. This time, appropriately, it’s about acupuncture. Just about everything in their advertising leaflets was held to be unjustifiable. They’ve been in trouble before about false claims for homeopathy, hypnosis and craniosacral "therapy".
Of course all of these embarrassments come from one very small corner of the UCLH Trust, the Royal London Hospital for Integrated Medicine (previously known as the Royal London Homeopathic Hospital).
Why is it tolerated in an otherwise excellent NHS Trust? Well, the patron is the Queen herself (not Charles, aka the Quacktitioner Royal), She seems to exert more power behind the scenes than is desirable in In a constitutional monarchy
29 June 2013
I wrote to Dr Gill Gaskin about the latest ASA judgement against RLHIM. She is the person at the UCLH Trust who has responsibility for the quack hospital. She previously refused to do anything about the craniosacral nonsense that is promoted there. This time the ASA seems to have stung them into action at long last. I was told
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In response to your question about proposed action: All written information for patients relating to the services offered by the Royal London Hospital for Integrated Medicine are being withdrawn for review in the light of the ASA’s rulings (and the patient leaflets have already been withdrawn). It will be reviewed and modified where necessary item by item, and only reintroduced after sign-off through the Queen Square divisional clinical governance processes and the Trust’s patient information leaflet team. With best wishes Gill Gaskin Dr Gill Gaskin |
It remains to be seen whether the re-written information is accurate or not.
The rules for advertising
The Advertising Standards Authority gives advice for advertisers about what’s permitted and what isn’t.
Acupuncture The CAP advice
Craniosacral therapy The CAP advice
Homeopathy The CAP advice and 2013 update
Chiropractic The CAP advice.
17 Responses to Connect Physical Health sells quackery to NHS
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[…] By David Colquhoun […]
I suspect that a lot of quackery will sneak in like this – lax standards, cost-cutting, a race to the bottom and poorly-worded contracts will allow them in through the back door. Patients will suffer as a result and the ones who will benefit will be, as always, the privateers and the lawyers.
This is depressing- your article prompted me to look up our local lincolnshire muscular skeletal service and it has been contracted out to care uk who provide acupuncture too.
Lincs County Hospital provide it too, and Boston do shiatsu too! When I asked for evidence, the consultant anaesthetist told me too that there was increasing evidence for it. I am still waiting for it.
@mrsP
This mantra about “increasing evidence” seems universal. Sadly it is no more than a made-up defensive reaction. You could try sending him a reprint of our recent paper. I’d be interested to hear his reaction,
Increasing evidence may well be right – it’s just that the evidence may not be going in the direction proponents would like it to go…
Do we know how these contracts are constructed?
If they paid per treatment then there is a clear incentive to offer anything in spite of the evidence.
@DC Thanks for the paper. Will send to him, although horses and water………..
“behind the scenes?” Our noble sovereign is also “Supreme Governor” of the Church; Head of the Armed Forces; and fundamental to the British legislature, which consists of the Sovereign, the House of Lords and the House of Commons. As the ‘Fount of Justice’, the Sovereign today still is the figure in whose name justice is carried out, and law and order is maintained. Civil and criminal proceedings cannot be taken against the Sovereign as a person under UK law. When it comes to the RLHIM, the problems at the Royal Society and so on I can’t help feeling that the problems of royal patronage in fields other than perhaps the arts and the charitable sector somehow misses the point.
One problem of the privatisation of both commissioning and delivery in the English NHS is that managers in CCGs are likely to move much more easily between these and providers. Meaning they have a career incentive to not rock the boat.
“It seems to me to be clear that CCGs should take better advice before boasting that they commission evidence-based treatments.”
There is increasing evidence that acupuncture is a placebo. However, the myth has taken root within as well as without the medical world that acupuncture really works. I think it has become one of the therapies of choice to offload awkward cases away from doctors surgeries. If fills in patients’ time and mind rather than the doctor. Too many health professionals are happy to conspire to protect the racket. Patients too perhaps.
[…] condemned by the ASA for the claims made for acupuncture by the RLHIM, at last we got action. All patient pamphlets have been withdrawn, and patient information is being […]
[…] RLHIM is a great embarrassment to the otherwise excellent UCLH Trust. It has been repeatedly condemned by the Advertising Standards Authority for making false claims. As a consequence, it has been forced to withdraw all of its patient […]
Courses on woo at UCLSOP? http://www.lotushealthinstitute.com/index.php/seminars-mainmenu-38/93-november-2nd-a-3rd-new-old-a-forgotten-remedies-london-england
@DC. There may be 47,000 physiotherapists registered with the CSP/HPC but many of these are assistants who are not qualified to treat musculoskeletal (MSK) conditions. So the 6,000 members of the AACP make up a significant proportion of practicing physiotherapists. Also many physiotherapists who offer acupuncture to patients are not members of the AACP. In other words the total number of physiotherapists offering acupuncture as a treatment for MSK conditions is very high.
Physiotherapists do not go out to deceive their patients. They actually believe that acupuncture is a viable treatment and are often taught on courses that it is evidence-based. These post-graduate courses are very expensive, so physiotherapists who have invested a small fortune in attending these courses (necessary for AACP membership too) resent anyone challenging their right to practice acupuncture.
However, it is not just acupuncture, cranio-sacral therapy, reflexology and energy therapy practiced by physiotherapists being a cause for concern. Even some of the so called conventional treatments such as ultrasound, pulsed short-wave and interferential therapy are practiced with gay abandon to the evidence. And again the post-graduate courses promoting these ‘conventional’ treatments also make dubious claims of them being evidence-based.
However, you are right to point out that the physiotherapy profession is a broad church and there are some physiotherapists out there that do understand evidence-based medicine and practice it very well.
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@Toots. I don’t think healthcare professionals conspire to fob people off with dubious treatments. The therapists themselves believe in these treatments and think they do good. There’s no conspiracy by the acupuncture practitioners themselves.
[…] RLHIM is a great embarrassment to the otherwise excellent UCLH Trust. It has been repeatedly condemned by the Advertising Standards Authority for making false claims. As a consequence, it has been forced to withdraw all of its patient […]
[…] RLHIM is a great embarrassment to the otherwise excellent UCLH Trust. It has been repeatedly condemned by the Advertising Standards Authority for making false claims. As a consequence, it has been […]