Selected Investigations Completed April - September 1999

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Part II - Full Texts of Selected Investigations

Complaint against: East Sussex, Brighton and Hove Health Authority

Complaint as put by Mr W

1. The account of the complaint provided by Mr W was that he had received treatment for psoriasis (a genetically determined chronic skin disease which affects 1-2% of the population of the United Kingdom) and psoriatic arthropathy (a form of arthritis caused by psoriasis and found in 3-5% of those suffering from psoriasis) for many years without any significant improvement of his condition. In view of this, in 1992, he was referred to a consultant rheumatologist (the consultant), who provided homoeopathic treatment which proved to be effective. Mr W's treatment was initially funded by the Health Authority; but that responsibility was later taken over by his general practitioner (GP) when the practice gained fundholding status. In May 1997 Mr W's then GP (the first GP) wrote to the Health Authority, asking them to resume responsibility for funding Mr W's treatment, as a change of status meant that the practice could no longer do so. On 5 June the Health Authority refused to provide funding. On 6 October the GP (the second GP) with whom Mr W was registered following the first GP's retirement, wrote to the Health Authority asking them to review the position. The Health Authority confirmed that they would not provide funding; and on 11 May 1998 Mr W wrote to the chief executive complaining about the decision. Mr W was supported by the consultant (who was also the medical director of the hospital at which the treatment was provided), who wrote to the Health Authority pointing out that Mr W had benefited from homoeopathic treatment.

2. On 26 June the Health Authority reiterated their earlier decision, which they said was based on a lack of evidence of the effectiveness of homoeopathy in the treatment of Mr W's condition. On 4 July Mr W requested an independent review of his complaint, but the Health Authority's convener rejected his request on the grounds that he had received full responses to his concerns.

3. The complaint investigated was that the Health Authority acted unreasonably in deciding not to fund Mr W's continuing treatment.

Investigation

4. The statement of complaint for the investigation was issued on 27 November 1998. The Health Authority's comments were obtained, and relevant papers were examined. One of the Ombudsman's investigators took evidence from Mr W and Health Authority staff. The investigator also took evidence from the consultant and other staff at the hospital where Mr W received his homoeopathic treatment, although their actions are not the subject of this investigation. Two independent professional assessors were appointed to advise on the clinical issues. Their report is attached as an Annex.

National guidance

5. In 1993 the Department of Health issued FDL(93)07, which gave guidance on extra contractual referrals (ECRs). It defined an ECR as 'a referral to a provider unit for which there is no existing contract with the patient's district of residence.' It stated that the grounds on which an ECR could be refused were very limited and that purchasers should respect the clinical judgement of GPs and other clinicians who decided on individual referrals. Refusals might be acceptable if the referral was not justified on clinical grounds; but in making such a judgement, the Health Authority would be expected to ensure that it took appropriate clinical advice. Where funding for a particular ECR was refused, it was the responsibility of the purchaser to inform the patient of the decision, as well as the provider. Reasons for the refusal should be made clear.

The Health Authority's guidance

6. The Health Authority published its draft purchasing intentions for 1998/99 in September 1997. Section 4.3.7 of that document read:

'.... we have given notice that we do not intend to routinely purchase non-conventional services, including .... homoeopathy .... Exceptions will be made on an individual basis where there are strong clinical grounds for funding such treatment ....'.

Sequence of events and clinical background

7. I now summarise certain events relating to the funding of Mr W's treatment from May 1997:

27 May 1997 The first GP wrote to the Health Authority's ECR manager asking if the Health Authority would take over responsibility for funding Mr W's treatment.

5 June The ECR manager replied to the first GP stating that the Health Authority had decided not to fund homoeopathic treatment 'due to the lack of evidence around the effectiveness of Homoeopathy, compared to conventional treatments.' (Note: Mr W received further treatment from the consultant in September 1997 and in February 1998—see paragraph 9 and Annex, paragraph 13.)

6 October The second GP wrote to the Health Authority asking them to fund Mr W's referral to the consultant as an ECR.

7 November The Health Authority's consultant in public health medicine (the public health consultant) wrote to the second GP stating that his request had been considered at a specially convened homoeopathic meeting but that the panel had decided not to fund Mr W's ongoing treatment. She explained that

'.... there has been a thorough examination of the clinical and scientific evidence surrounding Homoeopathy and that has guided our decision.'

31 March 1998 Having received a proforma request for funding from the hospital at which Mr W had been treated, the ECR manager wrote to the second GP's practice reiterating that the Health Authority had decided not to fund homoeopathic treatment. She added that

'.... This decision was made due to the lack of evidence around the effectiveness of Homoeopathy compared to conventional treatments ....'.

4 April Mr W wrote to the Health Authority's director of performance (the director) expressing concerns about the decision not to fund his treatment.

29 April The Health Authority's homoeopathy ECR panel considered Mr W's case and endorsed the decision not to fund his treatment, subject to checking the Health Authority's position with the director. The panel confirmed its decision at a meeting on 6 May.

11 May Mr W wrote to the Health Authority's chief executive complaining about the decision not to fund his treatment.

12 May The consultant wrote to the Health Authority's director of public health. In part, his letter read:

'.... On the whole [Mr W] has done well with homoeopathic treatment. His psoriasis is now virtually clear and there has been slow but steady improvement in his psoriasis [sic - ? psoriatic arthropathy] with a resulting improvement in his mobility and function. In view of his good response to homoeopathic treatment, severe and long-standing disease and adverse reactions to a range of conventional treatment, I would be most grateful if you would reconsider your decision to refuse his ECR at this hospital'.

18 May The chief executive wrote to Mr W stating that

'.... Our general position is that there is little scientific evidence to suggest that homoeopathy works for many health problems. Our medical advice is that the lack of evidence around effectiveness of homoeopathy for the treatment of Psoriatic Arthritis and Psoriasis means that it would be inappropriate for us to fund such treatment .... However you have provided me with a lot of information in your letter and I will ask for the decision to be reviewed once again ....'.

24 June The homoeopathy ECR panel confirmed the decision not to fund Mr W's treatment.

26 June The chief executive wrote to Mr W again stating:

'.... The Health Authority has reviewed its position with regard to commissioning homoeopathy treatments as well as looking at individual ECR requests and the Health Authority Board agreed that the current policy should remain unchanged. This means that ECR requests for homoeopathy treatment will only be agreed in exceptional circumstances, for example in a patient who is terminally ill'.

there is little scientific evidence to suggest that homoeopathy works for many health problems. Our medical advice is that the lack of evidence around effectiveness of homoeopathy for the treatment of Psoriatic Arthritis and Psoriasis means that it would be inappropriate for us to fund such treatment .... However you have provided me with a lot of information in your letter and I will ask for the decision to be reviewed once again ....'.

24 June The homoeopathy ECR panel confirmed the decision not to fund Mr W's treatment.

26 June The chief executive wrote to Mr W again stating:

'.... The Health Authority has reviewed its position with regard to commissioning homoeopathy treatments as well as looking at individual ECR requests and the Health Authority Board agreed that the current policy should remain unchanged. This means that ECR requests for homoeopathy treatment will only be agreed in exceptional circumstances, for example in a patient who is terminally ill'.

The clinical background to Mr W's complaint is set out in the Annex to this report.

Mr W's evidence

8. Mr W told the Ombudsman's investigator that there was a gradual improvement in relation to his psoriasis and arthritic pain after he started homoeopathic treatment. He felt that by the time his treatment was stopped his condition had improved significantly. Since then his psoriasis had started up again, possibly due to stress caused by the withdrawal of the funding. Mr W said that he felt the Health Authority had ignored the evidence from his GP and the consultant that his condition had improved while he had been under the care of the consultant.

The consultant's evidence

9. The consultant said that he thought that the original funding was by block contract with the Health Authority. When Mr W wrote to him in March 1997 asking if he could be treated privately, if necessary, the consultant checked his Trust's computer record, which confirmed that funding was available. Consultations which Mr W had in April and September 1997 and February 1998 would have been covered by that. The consultant said that the Health Authority never asked him for evidence of the effect of homoeopathic treatment on conditions such as those Mr W suffered from, or about Mr W's treatment in particular. However, in May 1998, as a result of Mr W's concerns, he wrote to the Health Authority.

10. The consultant said there had been eight to ten clinical trials on the effect of homoeopathic treatment of rheumatic conditions, but nothing specific on psoriatic arthropathy. The likely course of Mr W's disease, if he no longer continued to receive homoeopathic treatment, was difficult to forecast as the progress of the disease was very variable. Mr W could remain stable if the disease burned itself out, or there could be a slow, intermittent deterioration. He was most concerned about Mr W's joints, as further deterioration could be crippling. He felt that Mr W should have the opportunity to return to him if he did experience another flare up of his condition.

Evidence of Health Authority staff

11. The ECR manager said that under a block contract the Health Authority had funded Mr W's referral to a rheumatologist. The latter subsequently referred him to the consultant for homoeopathic treatment. Mr W's GP's practice had been granted fundholding status on 1 April 1992, and took over responsibility for funding his treatment. The practice's fundholding status had been removed with effect from 1 April 1997. After that, the first approach to the Health Authority for funding had been the first GP's letter of 27 May 1997. The Health Authority had reviewed its position on homoeopathic treatment and had decided at senior management level not to purchase such treatment. It was for that reason, following instructions, that she refused the first GP's request.

12. The ECR manager said that by the time the Health Authority received the second GP's request in October 1997, they had set up an ECR panel specifically to consider requests for homoeopathic treatment. The panel discussed whether there was evidence to support the effectiveness of such treatment in each case. (Note: I have seen a note dated 6 November 1997, by the ECR manager which states 'Discussed [with the public health consultant] No evidence of proven effectiveness demonstrated by clinical trials'.) In Mr W's case, it had not been felt necessary to seek clinical advice because the public health consultant had previously consulted a dermatologist about another similar case. In March 1998 she refused the hospital's request for funding on the basis of the panel's earlier decision. When Mr W telephoned to say how unhappy he was with that decision she decided that, to be fair, she would submit the request to the panel again. The ECR panel meeting on 6 May confirmed the decision not to fund Mr W's treatment.

13. The director explained that he had set up the ECR panel system for the Health Authority. His own role on the panels was that of budget holder and manager of the ECR team. In early 1997 there had been various discussions at director level about the lack of evidence supporting homoeopathic treatment. A paper on that subject, produced by a doctor in the directorate of public health medicine of another health authority, was circulated. It was then decided at director level that the Health Authority would no longer fund homoeopathic treatment in 1997/8, except in exceptional circumstances or where a patient was in the middle of a course of treatment. Initially, there had been no formal panel process: and it was the director level decision on which the ECR manager based her decision to refuse the ECR request for Mr W.

14. The director said that a joint paper on commissioning complementary therapies was written by himself and the public health consultant, who carried out the clinical review (see paragraph 17). The purpose of the paper was to consult Health Authority members over the consequences of their earlier decision not to fund homoeopathic treatment; to note how that had given rise to a number of complaints; and to allow members to reconsider their decision if appropriate. There were no detailed notes of the policy and performance committee meeting concerning their discussions about the paper, other than the minute provided which recorded the decision not to change the situation. The director said that the exceptional circumstance of a terminally ill patient had been used as an example in the paper. However, that was not to say that other circumstances would not also be considered if they arose. He said it was the public health consultant's role to provide clinical advice and to bring to bear relevant experience and expertise in individual cases. If something new, unusual or different was raised he would ask the public health consultant to investigate the matter further and evaluate the risks and implications regarding funding. Occasionally, matters would be discussed at a full Health Authority board meeting, but only very rarely would an individual case be raised at that level.

15. The public health consultant said that her role was to ensure that the Health Authority's limited resources were spent in the most effective way in commissioning healthcare. Her role on the homoeopathy panel was to help the ECR manager make decisions following queries arising from the decision not to fund homoeopathy treatment as a general rule. That included taking account of the evidence base for the effectiveness of treatment as well as taking individual circumstances into account, and ensuring equity of cases. She had not been party to the original decision not to fund homoeopathic treatment. She first recalled Mr W's case being discussed at the October 1997 ECR panel. Her recollection was that it was discussed in general terms, and that the circumstances fitted with the view that there was no evidence to support the effectiveness of homoeopathic treatment and that there were no exceptional circumstances in his case.

16. The public health consultant said that she did not recall anything special about Mr W's case, or taking specific clinical advice about it. She explained that she would usually contact a clinician, but did not do so in Mr W's case because she had recently discussed a similar case of a child with eczema with a dermatologist and felt it was not necessary to consult a clinician again. Also, Mr W was not seeking new treatment but to continue existing treatment for which there was no proven clinical evidence. She was aware that he had improved slowly, but she also knew that his condition was of a chronic relapsing and remitting nature. She felt that the evidence of his improvement was anecdotal: there was no real evidence that it was the homoeopathic treatment that caused the remission. Her view did not change at the subsequent panel hearings.

17. The public health consultant said that, in respect of her joint report with the director, there had been a number of patients who felt strongly about the Health Authority's decision not to fund homoeopathic treatment. The need for a paper had been considered for some time. It was felt there was a need to check they were still firmly of the view that it should not be funded. She carried out the background research, and drafted the background, summary and statistics on contracts on the basis of data provided. She recalled that discussion about the paper at the policy and performance committee had been mainly about points of interest and for clarification. She said that she had elaborated on the question of exceptional circumstances at the meeting. It was felt that agreeing to treatment only on compassionate grounds was acceptable. She, the ECR manager and the director had a broad agreement on what exceptional circumstances should be, but each case was taken on its merits. Mr W could be on homoeopathic treatment for the rest of his life on the basis that he thought it was curative. She would be uneasy about that because of the lack of proven evidence.

18. The director of public health said that he considered that the Health Authority's current interpretation of exceptional circumstances as meaning 'on compassionate grounds' was reasonable. Mr W had made a point about the low cost of his treatment; but the issue was the overall spend not the cost for an individual. In Mr W's case there was also the fact that his condition was one which involved periods of remission.

Findings

19. Mr W's homoeopathic treatment under the consultant began in 1992 and was initially funded by the Health Authority. When Mr W's GP practice gained fundholding status they funded the treatment until 31 March 1997 when they lost that status. The Health Authority was then asked to resume responsibility for funding Mr W's treatment. However, by that time the Health Authority had reviewed its policy on homoeopathic treatment and had decided to fund only in exceptional circumstances.

20. It is not open to the Ombudsman to question discretionary decisions of health bodies made without maladministration. It falls within the discretion of health authorities to decide what treatments they should fund. In this case, the Health Authority's decision to cease funding of homoeopathic treatment was made in the light of concerns about the efficacy of such treatment and following a review of the available evidence about that. The Ombudsman's assessors have concluded (Annex A, paragraph 21 a)) that the Health Authority followed a reasonable and acceptable process in reaching its general decision. I agree. I see no maladministration in the way in which the Health Authority reached its decision that, as a matter of policy, it would not fund homoeopathic treatment.

21. That said, I would expect the Health Authority's policy to be applied fairly and rationally on a case by case basis, and for the merits of individual cases to be assessed properly. The decision in June 1997 by the ECR manager not to fund Mr W's treatment was based on the general policy decision taken by the Health Authority not to purchase homoeopathic treatment. It would appear that the ECR manager's decision was taken without sufficient consideration of whether in this case there might be any circumstances which could justify departure from the general policy.

22. When, in October 1997, the second GP renewed the request for funding, the Health Authority had established the homoeopathy ECR panel to look at such requests. The panel considered Mr W's case on four occasions. The general policy decision not to fund homoeopathic treatment was also reviewed and endorsed at Health Authority board level. However, on the evidence available it is difficult to determine how the panel examined Mr W's case and, in particular what criteria they applied. The public health consultant's recollection was that in October 1997 the panel considered his case only in general terms; and I am unsure whether the consultant rheumatologist's letter of 12 May 1998 (see paragraph 7 of this report) was even considered by the panel in June. The panel's decisions were very briefly recorded, but not the considerations which were taken into account in reaching their decision. There seems to have been no clear indication about what sort of issues might count as exceptional circumstances which could justify the funding of homoeopathic treatment: there was not any clear consensus among Health Authority staff on that matter. I criticise these shortcomings.

23. Given the rare and serious nature of Mr W's condition, I am surprised that the Health Authority did not consider clinical advice relating specifically to his condition and treatment, and liaise with the second GP and the consultant rheumatologist about his treatment needs. I consider that in the circumstances of this case there were sufficient indications to warrant the Health Authority making further enquiries in line with the Department of Health guidelines (paragraph 5); and I consider that their failure to do so constituted maladministration. I therefore recommend that the Health Authority ensure that the case for funding Mr W's homoeopathic treatment is reconsidered taking account of the opinion of his medical carers and that, when a decision has been made, the reasons for it are fully recorded and communicated to Mr W. I uphold the complaint on the basis outlined above.

Conclusions

24. I have set out my findings in paragraphs 19-23. The Health Authority have asked me to convey—as I do through this report—their apologies for the shortcomings I have identified and have agreed to implement my recommendations in paragraph 23.

Annex to E.1316/98-99

Professional Assessors' Report

Matters considered

1. The matter subject to investigation was that East Sussex, Brighton and Hove Health Authority acted unreasonably in deciding not to fund Mr W's continuing homoeopathic treatment. We were asked to address the following issues:

a) Was the Health Authority's process in reaching their decision reasonable in the light of the medical nature of his complaint?
b) Did the Health Authority put themselves in a position to adequately assess the medical evidence concerning the use of homoeopathy in psoriasis and in particular psoriatic arthropathy?

Basis of the report

2. In producing this joint report we have considered and taken into account copies of the following documentation:

i. Health Authority documentation including correspondence on the complaint, the Health Authority purchasing intentions for 1998/9, and a paper on commissioning complementary therapies dated 10 June 1998.
ii. Correspondence from the complainant to the Ombudsman.
iii. GP medical records 1968-1998.
iv. Clinical correspondence relating to Mr W.
v. Notes of an interview with Mr W.
vi. Notes of an interview with the consultant
vii. Notes of interviews with staff employed by East Sussex Brighton and Hove Health Authority.

Relevant clinical history

3. Mr W was in his early 20s when he was first diagnosed as having psoriasis (a genetically determined chronic skin disease) and psoriatic arthropathy (a form of arthritis caused by psoriasis). From 1970 to 1974 he received intermittent treatment from his GP with first line agents such as simple pain killers and non-steroidal anti-inflammatory drugs (NSAIDS). In 1974 he had his first specialist rheumatology opinion which was that he suffered from mild psoriatic arthropathy and that no specific treatment was needed. In 1977 it was reported that he had an episode of indigestion when taking a second line drug called prednisolone (a steroid drug). During 1978 to 1984 Mr W continued to have intermittent flare-ups of his psoriatic arthropathy which were treated with a variety of NSAIDS. This is a recognised normal pattern for psoriatic arthropathy. It was noticed that he had shown some improvement with the use of NSAIDS. Mr W saw a consultant rheumatologist at a Sussex hospital and also saw a private physician in Harley Street. In 1985 at the age of 52 Mr Belson took retirement on medical grounds.

4. Mr W's GP continued with intermittent NSAIDS and Mr W continued to consult a private rheumatologist who injected steroids into his knees. The private rheumatologist discussed using azathioprine which is an immuno-suppressant frequently used in the management of psoriasis. The side effects of azathioprine are mainly related to its potential effect on the liver and its propensity to suppress bone marrow. This necessitates at least three-monthly blood sampling for monitoring purposes. It was noted that Mr W was not keen on taking azathioprine due to the possible side effects and the need for regular blood monitoring.

5. In 1988 the private rheumatologist again recommended treatment with second line agents such as steroids or azathioprine. Treatment was never started. Throughout 1988 and 1989 Mr W remained on intermittent treatment with NSAIDS. In 1989 he again saw the private rheumatologist who noted that Mr W was still not keen on taking azathioprine. The specialist referred Mr W for a second opinion to a private dermatologist who recommended psoriatic therapy with an alternative immuno-suppressant such as methotrexate which Mr W declined. In 1990 Mr W decided to try evening primrose oil but was otherwise maintained on simple analgesics (pain killers).

6. In January 1991 Mr W was having pain at night and in the morning and was referred for a consultant rheumatological opinion. The consultant rheumatologist prescribed an NSAID and noted that Mr W might need azathioprine. In May 1991 he was noted to be better on the NSAID but the consultant still recommended azathioprine. The GP notes reflect that Mr W was considering azathioprine or homoeopathy.

7. During June 1991 there is correspondence with a variety of private homoeopathic doctors with whom Mr W briefly consulted over that period.

8. In March 1992 a consultant rheumatologist reviewed Mr W and agreed to refer him to the homoeopathic consultant for treatment. That consultant has stated that it is his normal practice to try patients on homoeopathic treatment for three to six months to see if there is improvement.

9. According to the GP's records, which include hospital letters, there was an apparent lack of improvement in Mr W's condition between 1992 and March 1994 in spite of his homoeopathic treatment. The consultant monitored Mr W's condition by use of x-rays. The x-rays showed no further progression of joint damage from at least 1991 which is prior to his commencement on homoeopathic treatment. However, x-ray findings do not necessarily reflect the degree of pain and discomfort experienced.

10. In 1994 it was noted that there had been some improvement in Mr W's psoriatic arthropathy in terms of pain relief. From 1994 to 1996 Mr W had intermittent flare-ups of his arthropathy which were treated with physiotherapy and homoeopathic preparations. This relapsing remitting course is typical of psoriatic arthropathy.

11. In September 1996 Mr W's GP, whose practice was fundholding at that time and therefore had been funding Mr W's homoeopathic treatment, wrote to the hospital where he was receiving the treatment to notify them that the GPs would only fund one further consultation. In December 1996 the hospital requested the GPs to fund a further package of three appointments and stated that Mr W's psoriasis had settled and the arthropathy had improved. The GPs confirmed that they would not be purchasing any further treatment.

12. In March 1997 shortly before the GPs ceased being fundholders they referred Mr W to a homoeopathic hospital in Kent, where he had one appointment. A Health Authority block contract existed at that time but the practice were still fundholding so are likely to have taken up the payment for that consultation.

13. Mr W also received three further consultations with the consultant, on 24/04/97, 04/09/97 and 12/02/98. Due to a mix up over appointment dates and a failure to identify the September appointment as the first of a new package of three consultations, those treatments were never charged for.

Health Authority's consideration of its policy on funding homoeopathy

14. In early 1997 there were several discussions at Director level within the Health Authority about the lack of evidence supporting homoeopathic treatments. The Health Authority based their decision not to fund homoeopathic treatment (except in exceptional circumstances) on a paper produced by a doctor in the Directorate of Public Health Medicine of another health authority, which reviewed the available scientific and clinical literature. The Health Authority's block contract at the hospital where Mr W received hishomoeopathic treatment ended on 31 March 1997.

15. In May 1997 the Health Authority's Director of Performance set up four ECR panels, one specifically for homoeopathy, to consider referral requests. Until then decisions had been made at Director level. The Health Authority was aware of the importance of treating patients equitably and it was agreed that all patients currently receiving homoeopathic treatment should be allowed to complete their course of three treatments before being reviewed by the ECR panel with a view to stopping funding. During 1997/98 there were 100 ECR requests and 18 were considered to be midway through treatment and therefore allowed to complete the course. Two cases were regarded as exceptional on grounds of terminal illness.

16. In June 1998 the Health Authority decided to re-examine its position adopted with respect to not funding homoeopathy and acupuncture. The public health consultant provided a report, the need for which arose out of patient disquiet at refusal to fund homoeopathic ECRs. The report noted that from April 1997 onwards the Health Authority had only purchased homoeopathy and acupuncture in exceptional circumstances. The Health Authority's document on purchasing intentions for 1998-99 had given notice that homoeopathy would not be routinely purchased. It did allow for exceptions to be made on an individual basis if there were strong clinical grounds for funding such treatment. The public health consultant's report noted that five other Health Authorities had a stated policy not to fund any complementary therapies.

17. Most of the remaining Health Authorities said that referrals for complementary therapy were considered on an individual basis and if funded it was as ECRs. It was noted that the review of evidence for homoeopathic treatment had found no high quality evidence that homoeopathic treatment is better than, or even equivalent to, standard medical treatment. In addition, a recent analysis of clinical trials of homoeopathy published in the Lancet found little evidence of effectiveness of any single homoeopathic remedy. The report summarised that there is no rational scientific basis for using homoeopathy and that there is no high quality evidence from randomised controlled trials that homoeopathic treatment is better than or equivalent to standard medical treatment.

18. The public health consultant's report acknowledged that the decision to terminate the homoeopathic contracts was not well handled in that there was no prior specific consultations either with the Trusts or local GPs and the patients themselves were not informed until after the event. However, this would not have effected Mr W's case as his funding had come from GP fundholding until 31 March 1997.

Health Authority's consideration of Mr W's case

19. The Health Authority was first approached for funding on 27 May 1997. The Health Authority's block contract at the hospital where Mr W had been treated had ceased on 31 March 1997. The decision to withdraw the contract had been made at a senior management level. In recognition of the disquiet expressed by individuals about this decision and recognition that a range of clinical expert advice was needed depending on the types of cases, the Health Authority's policy and performance committee reconsidered the Health Authority's policy on homoeopathy and based its decision on a paper prepared in June 1998 by the public health consultant and the director of performance management. In order to do this they had considered the scientific and clinical evidence for homoeopathic treatments. The ECR panel later reviewed Mr W's case in the light of the Health Authority's policy and performance committee having accepted that paper. Mr W's case was not regarded as an exceptional circumstance.

20. The practicalities of the case show that although requests for funding were taking place from May 1997 and the final consideration of Mr W's case was made through a formally constituted procedure on 6 November 1997, Mr W did in fact continue to receive uninterrupted homoeopathic treatment until February 1998.

21. In conclusion we advise that

a) The Health Authority followed a reasonable and acceptable process including reviewing the clinical evidence in its decision not to fund homoeopathic treatment on grounds of lack of clinical effectiveness.
b) In June 1997 the decision not to fund Mr W's homoeopathic treatment was taken on the basis of a general policy and there was no evidence that specific advice was sought in the particular case of Mr W.
c) Subsequently the Health Authority did put themselves in a position and took clinical advice in order to consider Mr W's case specifically. However, it is not clear how the decision not to regard him as an exceptional circumstance was made. The Health Authority did not seek or consider specific clinical information on Mr W. Despite this the Health Authority was reasonable in finding no scientific evidence to continue his homoeopathic treatment. Therefore, the Health Authority's decision to refuse funding of further homoeopathic treatment in Mr W's case was only partially considered.

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Short text of this investigation

Last updated: 9 January 2006