Connect Physical Health sells quackery to NHS

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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.

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.

So, "don’t blame us, blame the PCT". A second letter asked why they were shirking the little matter of evidence.

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.

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

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.