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Nelsons Homeopathic Pharmacy #3

The previous instalments of this saga covered the MHRA's role in dealing with our complaints against Nelsons Homeopathic Pharmacy. Now the GPhC…


Our complaints arose from a visit we paid to Nelsons Homeopathic Pharmacy in Mayfair, London on 12 May 2015. We were appalled by what we saw there and, in summary, we submitted the following complaints about the pharmacy, their pharmacy website and their Nelsons Natural World website, each complaint following the previous because we felt they were not dealt with properly:

Complaint 1: 28 May 2015 Joint complaint to the MHRA and GPhC about Nelsons' pharmacy and website.

Complaint 2: 28 July 2016 Second joint complaint to the MHRA and GPhC about Nelsons' pharmacy.

Complaint 3: 28 November 2016 Third joint complaint to the MHRA and GPhC about Nelsons' pharmacy.

For the background to all this, see:

Nelsons Homeopathic Pharmacy #1

Nelsons Homeopathic Pharmacy #2

Rubbing salts into the wounds of homeopathy

May 2015So far, so good. But a major part of our complaint about Nelsons Homeopathic Pharmacy concerned the General Pharmaceutical Council (GPhC), the regulator for pharmacists and pharmacies. 

Our complaint was submitted to both the GPhC and the medicines regulator, the MHRA, in May 2015. We weren't sure what specific aspects each would deal with and neither, it seems, did they. The GPhC had to discuss the case with the MHRA and decide what their remit was and took legal advice.

What were we complaining about?

Our complaint covered a number of issues that concerned us (including the kits of homeopathic products that were on sale, tissue/cell salts, point of sale (POS) advertising, various herbal products and their price list) but we will focus on the main one here: on our first visit to Nelsons premises, Maria self-selected a tube of a homeopathic product labelled 'Diarrhoea'.

Why was this a problem?

This product is not registered and not authorised by the MHRA. As such, it is essentially an unlicensed medicine (technically, the MHRA had not determined its status but it clearly was not a registered and not an authorised homeopathic product), it should not have had indications (in this case diarrhoea), should not have been advertised, should not have been available for self-selection by a customer and should not have been sold other than in very limited circumstances — more on that later.

This tube was just one of many:


The labels on the front of the boxes tells us they contained homeopathic products for:

Aching legs
Acidity & heartburn
Alert mind
Arthritis & Rheumatism
Back ache & sciatica
Bites and stings
Boils & carbuncles
Chesty cough
Cold sore relief
Computer eye strain
Detox support
Dry cough
Flu relief
Food poisoning
Gout relief
Grief and Bereavement
Hayfever & allergy
Healing combo
Healthy hair
Jet lag
Lactation blend
Menopause relief
Mens [sic] health
Migraine headaches
Morning sickness
Mouth ulcers
Nervous anxiety
Post flu tiredness
Sports injuries
Womens [sic] health
Youthful skin

That's quite a list of medical conditions, but the one we selected was labelled:

SINCE 1860
Relieves symptoms of diarrhoea & vomiting due to consumption of unwashed fruits, vegetables, bad meat or fish.
Take 2 pills every hour until better.
Arsenicum 30C, Podophyllum 30C, Pyrogen 6C, Carbo Veg 30C, Nux Vom 30C
Expires End 06/18
Batch D1653 Approx 84 PILLS
Take away from food and drink
Keep out of the reach of children

That is a very bold therapeutic claim: as well as breaching the medicines regulations, we believed this was highly irresponsible. Note that it doesn't say to consult your GP if symptoms, just your (homeopathic) practitioner.


The most interesting ingredient here is the Podophyllum: also known as May Apple, Devil’s Apple, Wild Lemon and Indian podophyllum, it is a herbaceous perennial plant in the family Berberidaceae, and is poisonous. As such, it is designated as a banned and restricted herbal ingredient by the MHRA and medicines containing it are classed as Prescription Only Medicines (POM).

The label on the diarrhoea product claims it is diluted to 30C, that is, one part in 1,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000, but, of course, that depends on it having been properly manufactured. The MHRA decided it wasn't a POM because it was diluted so much.

That out of the way, the GPhC turned to dealing with our complaint.

Eventually, in February 2016, we were told the case was going to be sent to their Investigating Committee. It took a while to get our witness statements sorted out but they eventually took our statements, our full complaint, the video we had taken and the MHRA's decision to their committee. We didn't get their decision on the complaint until May 2016, one full year after we had submitted our complaint. They said:

The GPhC has reviewed all of the available information and we have concluded that the matter you have made a complaint about is not a matter that requires regulatory action. Accordingly this case file has been closed.

Considering the seriousness of the issues we complained about, we found this dismissal astonishing. However, the four reasons they gave for this decision were, we believed, entirely spurious and erroneous:

  1. There is no requirement for the pharmacist to identify herself, other than to display an Responsible Pharmacist notice. The video you supplied shows the Responsible Pharmacist notice behind the person serving Ms MacLachlan. In addition, the pharmacy produced the Responsible Pharmacist log to the GPhC confirming the pharmacist who was on duty that day.
  2. The medicines were not used inappropriately and no harm was caused.
  3. There is no information to suggest the sale and display of homeopathic medicine was in breach of any legislations [sic].
  4. The issue regarding the leaflets is a matter for the advertising unit of the MHRA, but do not breach regulations relating to the sale and supply of POMS.

The incompetence here is quite astounding. Addressing each of these points briefly (and this really didn't cover all of our complaint):

  1. This was irrelevant because Maria was sold an unauthorised medicinal product by someone who wasn't a pharmacist and without a prescription. We had never questioned the identity of the pharmacist.
  2. Goodness knows what they deemd appropriate use of the sugar pills, but we never said — and were never asked — whether we had taken any of the product or whether we had been harmed, so we had no idea how the GPhC had arrived at their conclusion.
  3. We provided clear video evidence of the multiple breaches — and they could easily have verified it with a site visit if they had wanted — so we are at a loss to understand this.
  4. None of the homeopathic products were POMs but were unauthorised medicines.

We complained again, taking apart this wholly inadequate decision, and this was passed to the investigator's line manager to deal with. We got his response a few months later in July 2016. It was confusing and totally unhelpful in understanding the original decision and simply raised more questions than it answered.

It really did beggar belief that a statutory regulator could have produced such a sloppy and ill-reasoned response.

Needless to say, it essentially upheld the original decision. However, on the point of the unauthorised medicines being on sale, the manager decided there was now enough evidence and has issued 'formal advice' to the Superintendent Pharmacist at Nelsons, Suzanne Haar — this was to be kept on record and referred to whenever the site is next due for a routine inspection. We were not given a copy of this advice despite attempts to find out so we could better understand the legal position regarding these unlicensed products.

19 July 2016Complaint 2

Because we were completely unsatisfied with this response, we paid Nelsons another on 28 July 2016. Guess what Maria was able to purchase? Exactly the same diarrhoea product she did the first time. We also noticed the same unauthorised products on sale as well as unauthorised tissue salts products. Perhaps the most galling thing was that the booklet Which remedy do I need? that was banned by the MHRA from Holland and Barrett was still there despite that being part of our complaint. It's not believable that Nelsons were not aware of our three MHRA complaints on this and the MHRA's decision.

It appears that despite our complaints to the MHRA and the GPhC and despite their investigations and the formal advice given to them, absolutely nothing had changed.

So, we responded to both the MHRA and the GPhC again with all we found and we were told that they were both considering this as new complaints against Nelsons and the pharmacist/pharmacists.

As we said in the last instalment, we kept it as a joint MHRA/GPhC complaint because we didn't want anything to fall through the cracks. We have copied correspondence to both regulators throughout: that seems to have been a wise move. We said:

We're sure you will be as concerned and as disappointed as we are that despite previous rulings that the POS [Point of Sale] material was not permitted and despite your previous action, this and other materials are still being used and that unauthorised medicines are being displayed and sold. It is difficult to understand why these obvious breaches have not been properly addressed by all concerned long before now and that we have had to submit a further complaint.

In summary, our concerns are that Nelsons are still:

  1. selling unauthorised medicinal products (with indications) in breach of the regulations.
  2. offering for sale on their premises and on their website unauthorised medicinal products (including herbal mother tinctures), many with indications.
  3. using point of sale materials that have indications for homeopathic medicinal products for which indications are not permitted.
  4. offering for sale Schuessler Salts products with indications in breach of your ruling on this after our previous complaint - I was unable to verify whether they were described as homeopathic or whether their dilution was given in homeopathic terms.
  5. offering for sale Dr Reckeweg 'tissue salts' products that are labelled with a 'homeopathic' dilution.
  6. advertising in their price list unauthorised medicinal products (including herbal mother tinctures), many of which have indications.
  7. advertising in their price list unauthorised kits of homeopathic products with indications.

We sincerely hope that our complaints will now be fully and thoroughly investigated and that any breaches of the regulations are finally dealt with.

 Some of these points relate to the complaint to the MHRA so read the previous newsletter to find out what they are all about. The GPhC seemed a tad confused:

It is unclear at this stage whether these new concerns relate to the same matters that we have addressed in our recent investigation. Once we have conducted a full review of the documentation we will confirm whether we will be opening a new case. We will also consider if any aspects of your new concerns should be referred to the MHRA for further investigation.

It's difficult to understand what was unclear.

While we were waiting for the GPhC to deal with this, we received a reply from the MHRA telling us they had received confirmation from Nelsons that they had taken action to address points 1, 2, 3, 4, 5 and 7. We wanted to check to see what had changed, so we paid them another visit.

28 November 2016Complaint 3

We told both the MHRA and the GPhC:

We are sure you will be as disappointed and frustrated as we are to discover that they still do not appear to have addressed all the issues.

Maria visited the shop this afternoon:

  1. She self-selected and purchased yet another tube of 'Diarrhoea Relief' homeopathic product.
  2. It is not known whether the member of staff who sold the Diarrhoea Relief product to Maria was a pharmacist or not (but we are certain it was not the Superintendent Pharmacist, Suzanne Haar), but she was asked no questions whatsoever about the product, who it was for or for what medical condition it was being purchased. The till receipt (see attached scan) gives the name 'Marlyn Hap'.
  3. The clear plastic boxes of these unauthorised medicinal products with lists of indications on the front were on two shelves in the same place in the shop as before and fully accessible to members of the public.
  4. There were two notices attached to the edge of the lower shelf. One said: 'Not for self selection' and the other said: 'Please ask a member of staff for help. Thank you' but it was not clear whether this referred to the products on the shelf to which it was attached or those on the shelf below. The upper shelf of unauthorised medicinal products had no such notices.
  5. The 'Which remedy do I need?' wire-bound point of sale promotional material for their registered and authorised homeopathic products was still attached to the rack of products.
  6. The Schuessler Tissue Salts products on the shelves gave the potency as a numeric value such as 6X on the front of the label. The display shelving unit (that housed all the above-mentioned products) was labelled 'Homeopathy' at the top.

 This was our third complaint to both statutory regulators about the exact same issues. It has taken eighteen months thus far. We said:

As we said, it was disappointing that we had to submit a complaint the first time (and we would remind you that was on 28 May 2015). The various regulations surrounding the advertising, sale and supply of homeopathic products and unauthorised medicinal products are straightforward and it is the responsibility of the Pharmacists and Nelsons to ensure compliance. We are at a loss to understand why - after eighteen months and two previous complaints about essentially the same breaches - that these issues have not been fully and properly resolved. Your previous actions against Nelsons have clearly been wholly inadequate and it is disappointing that it has been necessary to submit yet another complaint.

We sincerely hope that the combined efforts of the MHRA and the GPhC will - this time - ensure that Nelsons Homeopathic Pharmacy finally comply with all the various regulations they must know they have to comply with.

We also said to the GPhC:

Now that the MHRA has concluded their second investigation and ruled that Nelsons Homeopathic Pharmacy have again breached various regulations concerning the advertising and supply of both unauthorised medicinal products and registered homeopathic products and herbal products, we would ask that you take these into account in your consideration of our previous complaint about the Registered Pharmacists at Nelsons Homeopathic Pharmacy and our further complaint detailed above.

It beggars belief that Nelsons thought that putting up a notice on the shelf saying 'Not for self selection' would be considered anywhere near adequate: the products were still available for self-selection.


The GPhC eventually referred the case to their Investigating Committee (IC) and a further eight months later in July 2017, we received their outcome. The allegations they considered were:

On 22 June 2017, the Investigating Committee considered the following allegations against Nelsons pharmacy, [Navreet Chaewla and Susanne Haar]:

  • From 27 January 2014 to December 2016 the Pharmacy did not move all unlicensed medication as instructed from the front of the premises so that they were not available for self-selection in accordance with:

The action plan issued by the GPhC inspector on 27 January 2014; and

GPhC guidance, as set out in the letter dated 12 May 2016.

  • Failed to ensure that the counter staff of Nelsons Pharmacy asked sufficient questions to determine that the treatment is suitable for the patient before the sale is completed

Haar is the Superintendent Pharmacist at Nelsons Homeopathic Pharmacy and, as such, takes responsibility for the way in which a company carries out its professional pharmaceutical activities. The decision they came to included:

In this case, the Investigating Committee decided to issue a warning to Susanne Haar and to give advice to Navreet Chaewla. This means that the Investigating Committee has concluded that the allegations need not be considered by the Fitness to Practise Committee. The Committee felt that it would be appropriate for the matter to be disposed of by the Investigating Committee.

In order to receive the warning, the committee had to adjourn and inform the registrant that that was what they were minded to do and gave the registrant the opportunity to make submissions about the proposed course of action or, if the registrant wished, to have the case heard by the Fitness to Practise Committee. In this case the registrant accepted a warning.

Please note that the letter of warning is a formal sanction that will stay on the registrant’s legal history with the GPhC for 5 years and on the public register for 2 years, and may be taken into consideration if any further allegations are made about the registrant.

We have also shared the outcome of the Investigating Committee with our local inspectors who may consider this as intelligence as part of any future inspection.

The warning placed on Haar's record is:

On 22 June 2017 the General Pharmaceutical Council’s Investigating Committee considered an allegation in relation to Mrs Susanne Skovgaard HAAR, registration number: 2039122 and determined to issue the registrant concerned with a warning in relation to the conduct alleged.

The warning has been issued to ensure public confidence in the profession and the regulatory process and to protect the public by reminding the registrant concerned to adhere to all legal and professional obligations in their practice in the future.

So despite all the issues we found, the multiple failings by Nelsons to abide by the regulations and to heed advice given to them by the regulators, it was not deemed to be a fitness to practice issue.

Although we received this last July, we were waiting for the MHRA to publish their final decision notice, which they did last week.

Three years, a 22-page initial complaint, two further complaints, two statutory regulators, multiple occasions where we had to chase both regulators and multiple occasions where we had to correct their misunderstandings and errors, but we finally got there.


We did not do this to have anyone punished: we started this as an attempt to discover and understand precisely what pharmacies and pharmacists were and were not permitted to do in terms of selling homeopathic products and to test the statutory regulators' resolve to enforce those rules and regulations. The failures of Nelsons Homeopathic Pharmacy to implement the guidance provided by the regulators are what have caused this to have dragged on so long. But a complaint should never have been necessary in the first place: understanding the Human Medicines Regulations, the Medicines Act and all the other legislation surrounding the operation of pharmacies are part of the responsibilities of pharmacists. There can be no excuses. It should not have taken one complaint, never mind three, and it should not have taken nearly three years to resolve these very simple and straightforward issues.

What can we learn from this? What can homeopaths and homeopathic pharmacies learn from this? What, precisely, can pharmacies do in terms of selling homeopathic products, whether authorised, registered or neither?

This exercise has revealed a lot about all that, but that's for the next instalment.

26 February 2018

Nelsons Homeopathic Pharmacy #2

It's been over two-and-a-half years since Nelsons Homeopathic Pharmacy last featured here. The saga continues…

The last time we looked at Nelsons, we told you of our complaint against them that the medicines regulator, the MHRA, upheld. This concerned their advertising on their websites of homeopathy products that were not within the terms of their registrations.

We briefly mentioned that this was part of a larger complaint: our MHRA complaint ran in parallel with another complaint we had submitted to the General Pharmaceutical Council (GPhC), the regulator for pharmacists and pharmacies. That was completed some months ago but we were waiting for the MHRA to announce their decision on their part of that complaint.

Yesterday the publication by the MHRA of their decision on that complaint so we can now reveal that and regale you with the catalogue of errors and mishandling by the GPhC now everything has been properly — and finally — resolved.

We submitted our original complaint on 28 May 2015 — nearly three years ago. It's just as well we are determined and patient!

Although the two stories are closely intertwined, for simplicity, we will detail the MHRA parts of the complaints here and will address the GPhC complaints in a subsequent newsletter. As you will appreciate, this is a long and involved story, but we feel it's necessary to put much of it into the public domain.


Our complaints arose from a visit we paid to Nelsons Homeopathic Pharmacy in Mayfair, London on 12 May 2015. We were appalled by what we saw there and, in summary, we submitted the following complaints about the pharmacy, their pharmacy website and their Nelsons Natural World website, each complaint following the previous because we felt they were not dealt with properly:

Complaint 1: 28 May 2015 Joint complaint to the MHRA and GPhC about Nelsons' pharmacy and website

Complaint 2: 20 July 2016 Second joint complaint to the MHRA and GPhC about Nelsons' pharmacy.

Complaint 3: 28 November 2016 Third joint complaint to the MHRA and GPhC about Nelsons' pharmacy.

Complaint 1

The MHRA and GPhC took some nine months just to sort out among themselves what parts of the complaint came under their respective remits: it wasn't until January 2016 that the GPhC contacted us to progress the complaint.

However, the website parts of the complaint are the responsibility of the MHRA. They dealt with this and this was what we wrote about in our earlier newsletter: Nelsons Homeopathic Pharmacy #1 in August 2015. Another part of that complaint was about Schuessler Tissue/Cell Salts products that were on sale in the pharmacy. This was also dealt with separately by the MHRA as it raised different issues. For further details, see: Rubbing salts into the wounds of homeopathy and see below.

Although the MHRA upheld these parts of the complaint, they failed to mention what we believed to be issues concerning the pharmacy premises that we understood fell within their remit. We therefore submitted a second complaint.

Complaint 2

The GPhC were still dealing with our first complaint but this is an extract from our second joint complaint, submitted after a second visit to Nelsons. We kept it as a joint MHRA/GPhC complaint because we didn't want anything to fall through the cracks.

We're sure you will be as concerned and as disappointed as we are that despite previous rulings that the POS [Point of Sale] material was not permitted and despite your previous action, this and other materials are still being used and that unauthorised medicines are being displayed and sold. It is difficult to understand why these obvious breaches have not been properly addressed by all concerned long before now and that we have had to submit a further complaint.

In summary, our concerns are that Nelsons are still:

  1. selling unauthorised medicinal products (with indications) in breach of the regulations.
  2. offering for sale on their premises and on their website unauthorised medicinal products (including herbal mother tinctures), many with indications.
  3. using point of sale materials that have indications for homeopathic medicinal products for which indications are not permitted.
  4. offering for sale Schuessler Salts products with indications in breach of your ruling on this after our previous complaint - I was unable to verify whether they were described as homeopathic or whether their dilution was given in homeopathic terms.
  5. offering for sale Dr Reckeweg 'tissue salts' products that are labelled with a 'homeopathic' dilution.
  6. advertising in their price list unauthorised medicinal products (including herbal mother tinctures), many of which have indications.
  7. advertising in their price list unauthorised kits of homeopathic products with indications.

We sincerely hope that our complaints will now be fully and thoroughly investigated and that any breaches of the regulations are finally dealt with. 

Some of these points relate to the complaint to the GPhC so read the next newsletter to find out what they are all about.

The MHRA duly dealt with this and told us:

We have received confirmation from Nelsons that they have taken action to address points 1-5 & 7 above.

Great. All sorted then…

Complaint 3

However, we paid their premises a third visit and found the 'Which remedy do I need?' wire-bound point of sale promotional material for their registered and authorised homeopathic products was still attached to the rack of products. We also found Schuessler Tissue/Cell Salts products on the shelves that gave the potency as a numeric value such as 6X on the front of the label. These were clearly against what the MHRA had ruled for these products, had told Nelsons and what Nelsons had supposedly addressed, so we had to submit a third complaint.

The MHRA published their decision on that complaint yesterday.


As we've mentioned before, what the MHRA publishes on their website about the outcome of complaints can, at best, be described as sketchy. We did mention this to the MHRA and we're pleased to see this latest report has significantly more detail:

MHRA Nelsons decision 22 February 2018

It has taken them over two months just to publish this,

In their 'final' letter to us for this complaint they gave more details on each of the points we identified above:

Thank you for your email of 28 July 2016 concerning the promotion of homeopathic medicines by Nelsons Pharmacy.

We have been in correspondence with Nelsons and have completed our investigations. We provided the following guidance on our interpretation of the law, numbered as per your original complaint, and requested confirmation that the necessary action has been completed:

1&2 Under Section 10 of the Medicines Act a pharmacist may supply unlicensed medicines when requested to do so by a patient. These products may not be advertised. We also understand from colleagues in Regulatory Advice that unlicensed medicines supplied under section 10 of the Medicines Act should not be available for self-selection.

3 Point of sale material should not promote unlicensed homeopathic remedies or provide indications for those registered without indications.

4&5 Tissue Salts/Schuessler Salts are generally considered to be medicinal products if any of the following appear in promotional material or product labelling:

a. the terms ‘homeopathic remedy’, and/or ‘homeopathy’ and/or ‘homeopathically prepared’

b. a numerical value for the potency e.g. 6X and/or the word ‘potency’ itself

c. indications for use in a medical condition

If they are not licensed or registered and any of the above appear then such products would be likely to be considered unlicensed medicines and should therefore not be advertised. Our advice above would also apply.

6 Any claims for registered/licensed medicinal products must comply with the product SPC, including the specified indication wording for homeopathic remedies and traditional herbal medicines. Listings for unlicensed medicines (including unregistered homeopathic remedies) must not include any product claims.

7 Our advice above will also apply to these products.We have received confirmation from Nelsons that they have taken action to address points 1-5 & 7 above. They have also confirmed that, in line with point 6, all material will be further reviewed and amended as necessary to ensure that all promotional material is compliant with the SPC for licensed/registered medicines by the end of 2016.

Essentially, it took three complaints and several years to get this sorted. Nelsons should now be in no doubt of their responsibilities under the Human Medicines Regulations 2012 (HMR) and the Medicines Act 1968 as they relate to the following distinct areas:

A. The supply, sale and advertising of unauthorised homeopathic medicinal products (as the HMR calls them), ie those homeopathic products that are not authorised under the National Rules (NR) Scheme or not registered under the Homeopathic (Simplified) Rules (HR) Scheme — we can ignore any Product Licences of Right as they effectively no longer exist.

B. The supply, sale and advertising of Schuessler Tissue/Cell Salts.

C. The terms of the authorisation or registration of NR and HR scheme products.

There is more to be said about these, particularly the first one, but we first need to look at our complaints to the GPhC, how they dealt with them and what the outcomes were. We hope to publish that comedy of errors in the few days.

To be continued…

 23 February 2018

The Society of Homeopaths: failing to make the case for homeopathy

Homeopaths publish ten studies they claim affirm the ‘potential benefits of homeopathy for a range of health problems’, but do they withstand scrutiny?

sugarpills1Homeopathy is under severe pressure in the UK with what little credibility it had, destroyed. The ending of referrals from GPs in Liverpool and the Wirral over the last year or so and consultations on the future of homeopathy in Clinical Commissioning Groups in Bristol and Enfield, and more recently by NHS England, have piled on top of the decline by 96% of NHS prescriptions for homeopathy in England in the past 20 years.

We have also seen the recent announcement that Weleda (a supplier of homeopathic and anthroposophic products to the NHS) is ending the production of their ‘bespoke’ homeopathic products. The pending outcome of a consultation by the Charity Commission on CAM charities could add yet more woe.

We could be seeing the final death throes of homeopathy on the NHS with possible knock-on effects on the businesses of lay homeopaths: many relying on the false imprimatur leant to it by the NHS.

In November, the Council of the Royal College of Veterinary Surgeons (RCVS) issued a position statement including ‘Homeopathy exists without a recognised body of evidence for its use. Furthermore, it is not based on sound scientific principles.’

This followed a statement in September 2017 from the European Association of Science Advisory Councils, which represents the national science academies of 27 countries, concluding that homeopathy ‘can actually be harmful: by delaying or deterring a patient from seeking appropriate, evidence-based, medical attention and by undermining patient and public confidence in scientific evidence.’

Homeopaths are also under pressure from the Advertising Standards Authority to make sure their advertising is ‘legal, decent, honest and truthful’, but many still seem to have difficulty with those principles. To protect the public from misleading claims, the ASA rightly sets a high standard of evidence — one clearly too high for homeopaths. But the ASA make it easy for homeopathy advertisers, stating: “Practitioners should therefore avoid making direct or implied claims that homeopathy can treat medical conditions.” Crystal clear.

Whether it concerns human or animal health, the debate is clearly about the consideration of the best available scientific evidence; to that battle, homeopaths come unarmed.

Read more: The Society of Homeopaths: failing to make the case for homeopathy

The end of homeopathy on the NHS in Bristol?

Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups (CCGs) are consulting on their proposal to decommission all NHS-funded homeopathy.

After the Bristol Homeopathic Hospital closed in January 2013, homeopathy continued to be provided by a small clinic at the South Bristol Community Hospital. Just three years later, in October 2015, this too closed to be replaced by a private clinic, the Portland Centre for Integrative Medicine. That is not part of the NHS but is contracted by the CCGs to provide homeopathy services.

Now the group of CCGs wants to end all homeopathy referrals to that clinic.

The consultation consists essentially of just two simple questions:

  • Do you understand the reasons for our proposal to stop NHS funding for homeopathy treatment? Yes|No
  • Do you agree or disagree with our proposal to cease NHS funding for homeopathy? Agree|Disagree

…with the opportunity to explain your answers and provide further information.

The consultation closes next Tuesday, 15 August 2017 so plenty of time to submit your response, but don't leave it too late!

Homeopaths and their trade bodies (including the Faculty of Homeopathy and the British Homeopathic Association) have been urging their members to respond: we know decisions should not be made on the popularity of a treatment but on the best evidence, but the more the CCGs hear about the evidence-based position, the easier it will be for them to make the right decision.

We will be submitting our own comprehensive response to the CCGs and we will publish it later in the year.

There is another consultation running at the moment, this time by NHS England that would effectively blacklist homeopathy, but that doesn't close until October so we'll leave that for another time.

It'll only take you a minute to respond to this consultation: why not do it right now?

10 August 2017

NHS Homeopathy: 20 years of decline

Data published today by NHS Digital shows that homeopathy prescriptions in England fell by nearly a quarter in 2016

Continuing its inexorable two-decade decline from its peak in 1996, the number of prescriptions for homeopathy products supplied in community pharmacies in England fell by 23% in 2016.

Data released today by NHS Digital show that homeopathy prescriptions fell from 8,894 in 2015 to 6,821 last year, a drop of 96% since its peak in 1996:

The decline of homeopathy in the NHS 2016

This drop is a welcome sign that the NHS continues to understand the need for robust evidence for treatments and that it does not exist for homeopathy. Although the mantra of choice is frequently repeated by supporters of homeopathy, providing a treatment for which there is no good evidence of specific patient benefit does not provide a choice to patients: they deserve better.

The House of Commons Science and Technology Select Committee in its Evidence Check on homeopathy concluded:

157. By providing homeopathy on the NHS and allowing MHRA licensing of products which subsequently appear on pharmacy shelves, the Government runs the risk of endorsing homeopathy as an efficacious system of medicine. To maintain patient trust, choice and safety, the Government should not endorse the use of placebo treatments, including homeopathy. Homeopathy should not be funded on the NHS and the MHRA should stop licensing homeopathic products.

In the most comprehensive review to date of the evidence for homeopathy, the Australian National Health and Medical Research Council concluded:

Based on the assessment of the evidence of effectiveness of homeopathy, NHMRC concludes that there are no health conditions for which there is reliable evidence that homeopathy is effective. Homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness. People who are considering whether to use homeopathy should first get advice from a registered health practitioner. Those who use homeopathy should tell their health practitioner and should keep taking any prescribed treatments. 

With such damning conclusions, patient choice cannot be heralded as sacrosanct. Consumers are perfectly free to buy their own homeopathy products, but it behoves the NHS to provide treatments that are based on robust scientific evidence.

Rising costs

The drop in the number of prescriptions is not matched by a corresponding fall in the total cost of those prescriptions: the number fell by 23% but the overall cost of these prescriptions only fell by 2%. How can this be?

The rising cost of homeopathy in the NHS 2016

For some reason, the average cost for each homeopathy item jumped by 28% to £13.55 compared to the previous year's £10.60. This is a substantial rise and may have been due to a jump in the cost of raw sugar… or maybe the suppliers wanted to try to compensate for the decreased sales volume? Looking at what happened in 2010, there could be a pattern.


The next release of data for Scotland will be in June and will cover prescriptions from 01 April 2016 to 31 March 2017. There's no reason to suppose a similar decline won't be seen there too, particularly given the closure of the final seven in-patient beds at the Glasgow Homeopathic Hospital tomorrow: the legitimacy given to homeopathy by the NHS is slowly but surely being removed.


Proponents of homeopathy frequently state that it's used by 10% of the population. They usually don't cite any evidence to substantiate that figure, but it could come from the statement made by Prof Kent Woods — the then Chief Executive of the MHRA — when giving evidence to the Select Committee in 2009 (Q182, Ev 65):

From the point of view of evidence, certainly from a regulatory perspective, it is very important evidence that something like ten per cent of the population have used a homeopathic remedy or have gone to a homeopath in the previous 12 months, and that I think is a starting point for deciding what is the public health significance of this phenomenon.

He didn't provide a source for that figure and it's always been contentious. Now, however, we have a more up-to-date figure from the European Social Survey. In their 2014 survey, they asked questions about the use of a number of CAM practices (acupressure, acupuncture, Chinese medicine, chiropractics, herbal treatment, homeopathy, hypnotherapy, massage therapy, osteopathy, physiotherapy, reflexology and spiritual healing) in the previous 12 months in 21 countries. For homeopathy, they found that only 1.3% of people had used it:

Homeopathy use in 21 countries

Ranking fifth, the UK compares very favourably with the other countries surveyed, and the usage is considerably less than previously claimed. It is also likely that even this is an over-estimate as the survey didn't provide any guidance to participants about what homeopathy was, so it's likely respondents may have included the use of all sorts of herbal or home remedies rather than just homeopathic products.

The same survey gives a picture of the usage of other practices in the UK:

CAM use in UK

However, for homeopathy on the NHS, it's difficult not to come to the conclusion that it's dying.

30 March 2017

The growing pains of osteopaths

The Advertising Standards Authority has today published new guidance on advertising claims made by osteopaths

Like all other advertisers, osteopaths have to comply with the ASA's CAP Code and the ASA/CAP publish specific guidance to help them — in addition to the more general guidance on health claims and their substantiation.

However, it seems that some osteopaths thought the CAP Code and guidance required some clarification.

Today, the ASA have published even more detailed guidance for those advertising osteopathy services.

This new document provides that clarity and further restricts the claims they can make about the use of osteopathy with pregnant women, children and babies, particularly non-musculoskeletal conditions such as colic and problems allegedly caused by 'birth trauma'.

A cursory glance at osteopaths' websites will find many such claims. See, for example, the results returned by this simple search for colic: osteopathy clinic colic. This is a widespread problem.


The new guidance is yet another joint initiative by the ASA and the osteopaths' statutory regulator, the General Osteopathic Council (GOsC) to reign in their registrants and they have written to all 4,800 UK of them informing them of the new guidance and the consequences of failing to comply:

The Osteopathic Practice Standards place a duty on all osteopaths to ensure their advertising complies with the CAP Code (Standard D14). Failing to comply with the Code and associated guidance or rulings could result in GOsC fitness to practise proceedings.

The GOsC and the osteopaths' trade body, the Institute of Osteopathy (IO) will be following this up with further communications and articles in various magazines and the GOsC will also be contacting the various osteopathy training organisations to make sure students are fully aware of their responsibilities. We hope that many students will ask questions of their tutors about why they are being taught something they are not allowed to advertise because of the lack of good evidence. Perhaps the GOsC should be asking themselves the same questions and revist their educational requirements.


There is a lot of work to be done by osteopaths.

For example, the Osteopathic Centre for Children — part of the Foundation for Paediatric Osteopathy whose tag line is "Paediatric osteopathy is the gold standard in holistic healthcare for children" — state:


An osteopathic check-up following the birth can help pin-point potential problems and helps to ease the dramatic transition from life inside the womb to the outside world. This initial adjustment involves many bodily systems such as breathing and digestion.

Stresses and strains from the labour or pregnancy can lead to unsettled behaviour and difficulties with feeding, winding, bowel movements and sleeping. Relieving any physical strains with gentle osteopathic treatment can be very helpful and relaxing. The care of the entire family unit is of the utmost concern for an osteopath.


This is a time when children learn to crawl, walk, run and communicate and are keen to explore their environment and to interact socially. It is desirable to monitor the progress of these early developmental milestones and to address the effects of any major physical mishaps or developmental lag to prevent problems developing in future.

In many ways these are mild claims; one osteopath's website more worryingly states:


In the birthing process babies are subjected to enormous forces during their passage through the birth canal. Small amounts of movement exist in the infant skull to permit the baby’s head to adapt to these forces of labour. However when birth is difficult, unduly slow or fast, or complicated by the need for forceps ventouse or cesarean section delivery, the infant head may not fully recover from this distortion. If the baby is unable to resolve the stressors and strains naturally through breathing and suckling, these pressures with in the skull may lead to problems settling, feeding difficulties, disturbed sleep patterns and recurrent infections. Osteopathic treatment using a variety of gentle non invasive techniques may help improve the function of the musculoskeletal system and aid in the reduction of these symptoms.

During childhood, in addition to any earlier trauma or strains the body has to adapt with the growth and development of the bones and muscles. Postural changes and activity level changes with participation in sports can also produce aches and pains which may be eased with manual therapy. Restrictions in the musculoskeletal system can sometimes cause delay reaching developmental milestones for behaviour, speech and learning and may benefit from osteopathic assessment and treatment.

What parent would not be distressed by such stark warnings and sign their new-born up for immediate (and life-long?) treatment?

ASA guidance

Getting back the the ASA's new guidance on osteopathy, it states:

Following a review by CAP of the Bronfort et al Review in 2010, CAP accepts that osteopaths may claim to help a variety of medical conditions, including:

  • generalised aches and pains,
  • joint pains including hip and knee pain from osteoarthritis as an adjunct to core OA treatments and exercise
  • arthritic pain,
  • general, acute & chronic backache, back pain (not arising from injury or accident)
  • uncomplicated mechanical neck pain (as opposed to neck pain following injury i.e. whiplash)
  • headache arising from the neck (cervicogenic) / migraine prevention
  • frozen shoulder/ shoulder and elbow pain/ tennis elbow (lateral epicondylitis) arising from associated musculoskeletal conditions of the back and neck, but not isolated occurrences
  • circulatory problems,
  • cramp,
  • digestion problems,
  • joint pains, lumbago,
  • sciatica,
  • muscle spasms,
  • neuralgia,
  • fibromyalgia,
  • inability to relax,
  • rheumatic pain,
  • minor sports injuries and tensions.

The Bronfort review was commissioned by the General Chiropractic Council (GCC) in 2009 after I submitted 523 complaints to the GCC about claims being made by chiropractors on their websites — the GCC needed the review because they didn't have a clue about the evidence for the claims their registrants had been making. It was little more than a quick literature review carried out by chiropractors in the US.

Even though Bronfort et al. considered all manner of treatments including reflexology, massage and chiropractic manipulations and not just osteopathic techniques specifically, it did look at various paediatric conditions. In terms of the non-musculoskeletal conditions, Bronfort identified a number of systematic reviews and additional RCTs for these conditions. None was positive for any treatment.

However, it only gave results for the treatment of manual therapies for musculoskeletal conditions for adults and is silent on pregnant women, children and babies, so it's quite a leap to extrapolate to those patient groups from adults.

The National Council for Osteopathic Research (NCOR), funded by osteopaths and the GOsC, is currently undertaking a systematic review of manual therapies in the treatment of children and babies. It'll be interesting to see what they finally publish.

Meanwhile, it seems that the ASA believe that osteopaths are trained to treat pregnant women, children and babies and that they should therefore be allowed to make claims about these patient groups, despite being no good evidence that osteopathy is effective for these conditions. This simply raises the question as to what they are being taught if there is no good evidence it is effective for those groups in the first place.

The question of dose response is not addressed either nor the potential for harm — particularly the many claims that it is 'safe and gentle'.

However, that only applies to musculoskeletal conditions: the new guidance prevents them from directly or indirectly referring to conditions such as colic, growing pains, excessive crying and those allegedly caused by 'birth trauma'. As we have shown above, these are frequent claims.


Because they are statutorily regulated, the ASA states osteopaths may: 

…refer to conditions for which medical supervision should be sought if they hold convincing evidence of the efficacy of their treatments (Rules 12.1 and 12.2).

The caveat of holding the necessary standard of evidence is important, but it is not clear to us why statutory regulation should confer any special privileges: whilst the Osteopaths Act 1993 does provide for a means of regulating some aspects, it's primarily a means of protecting the title 'osteopath', ensuring registrants are appropriately insured and that there's a code of conduct and a complaints procedure. Notably, the Act does not prescribe any scope of practice, nor proscribe any treatments. This leaves the public open to being misled.


The new guidance sets out four principles:

Principle 1: Marketing claims

Claims made on osteopaths’ websites that serve the purpose of encouraging consumers to make a transactional decision (i.e. claims that directly or indirectly invite individuals to consider seeking osteopathic treatment for themselves or someone else must comply with the Advertising Code.

Principle 2: References to treating medical conditions

As healthcare practitioners regulated by statute, osteopaths may offer advice on, diagnosis of and treatment for conditions for which medical supervision should be sought. Those claims should be limited, however, to those for which the ASA or CAP has seen evidence for the efficacy of osteopathy for the particular condition claimed, or for which the advertiser holds suitable substantiation (references to conditions which the ASA or CAP accept osteopathy can help with should be understood on this basis, the ASA acknowledges that new evidence may emerge).2 The ASA retains the right to ask to review evidence for the purposes of resolving complaints should it consider the need to do so. Osteopaths should therefore ensure that they have access to substantiation before making such claims, including implied claims to treat a particular condition.

Principle 3: Substantiation for treatment claims

Where the efficacy of osteopathy for treating a particular condition has already been established, treatment claims that do not stray beyond the principles set out in the CAP Guidance will be considered compliant with the Code.

Principle 4: Osteopathy for general and specific patient populations

Osteopaths may make claims to treat general as well as specific patient populations, including pregnant women, children and babies provided they are qualified to do so. Osteopaths may not claim to treat conditions or symptoms presented as specific to these groups (e.g. colic, growing pains, morning sickness) unless the ASA or CAP has seen evidence for the efficacy of osteopathy for the particular condition claimed, or for which the advertiser holds suitable substantiation. Osteopaths may refer to the provision of general health advice to specific patient populations, providing they do not make implied and unsubstantiated treatment claims for conditions.

The principles don't say anything new, but the fourth one is important: osteopaths can claim to treat pregnant women, children and babies, but they can only do so in terms of the conditions listed above and it clearly states the conditions they should not claim to treat.

The guidance also gives some examples of claims that are likely and unlikely to be acceptable. The ASA, quite rightly, steer clear of saying outright what is and isn't acceptable: every claim has to be analysed individually in its proper context. We hope that osteopaths will take note of these carefully and not try to take advantage of any perceived equivocation.

baby cryingExample claims which are unlikely to be acceptable:

  • Osteopaths often work with crying, unsettled babies (Implies colic, which is not supported by evidence)
  • Birth is a stressful process for babies
  • Babies’ skulls are susceptible to strain or moulding, leading to asymmetrical or flattened head shapes. This usually resolves quickly but can sometimes be retained. Osteopathy can help
  • If your baby suffers from excessive crying, sometimes known as colic, osteopathy might help
  • Children often complain of growing pains in their muscles and joints; your osteopath can treat these pains
  • Osteopathy can help your baby recover from the trauma of birth; I will gently massage your baby’s skull
  • If your baby is having difficulty breastfeeding, osteopathy might be able to help
  • Osteopathy can also play an important preventative role in the care of a baby, child or teenager and bring the body back to a state of balance in health
  • In assessing a newborn baby, an osteopath checks for asymmetry or tension in the pelvis, spine and head, and ensures that a good breathing pattern has been established
  • Cranial osteopathy releases stresses and strains in the skull and throughout the body
  • Osteopaths can feel involuntary motion and mechanisms within the body
  • Cranial osteopathy aims to reduce restrictions in movement

It might take osteopaths a while to clean up their websites.

All in the head

The weakest point of the new guidance is what it permits to be claimed about cranial osteopathy/craniosacral technique. It is a frequent treatment of choice by osteopaths for babies and children. Prof Ernst describes it:

Craniosacral therapy (CST), which, confusingly, is sometimes also called ‘cranial osteopathy’, was invented less than half a century ago by an osteopath. He thought that the spinal fluid is pulsating, the cranial bones are sufficiently movable to enable a therapist feel this pulse from the outside, and that it is possible to influence this process with very gentle manual manipulations which, in turn, would restore health in sick individuals. According to the inventor, the CST-practitioner uses his or her own hands to evaluate the craniosacral system by gently feeling various locations of the body to test for the ease of motion and rhythm of the   fluid pulsing around the brain and spinal cord. Soft-touch techniques are then used to release restrictions in any tissues influencing the craniosacral system.

It's entirely fanciful, of course, but many osteopaths seem to believe it is effective for many childhood conditions and is seen by some as the 'bait and switch' used by some osteopaths to get new customers from a very early age.

But at least now they cannot claim that they can feel these movements nor that they can then manipulate the skull to alleviate anything.

Right direction

This guidance is a great step forward. Osteopaths now have absolute clarity about what they can and cannot claim for pregnant women, children and babies and we hope to see speedy changes to websites.

We also welcome the actions taken by the General Osteopathic Council to ensure their registrants stop misleading the public and we hope they will follow through when they are made aware of non-compliant websites; we also hope they will be pro-active in this and not simply wait around for others to submit complaints.

We now hope the ASA and the General Chiropractic Council will now do the same for chiropractors — it is long overdue and, arguably, a much larger problem. The list of allowed chiropractic claims will be shorter, of course, and the list of unacceptable claims longer. Much longer.

02 December 2016


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