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10:23

Mote Prime > Paranonsense

The CHNC and the ASA

The Complementary and Natural Healthcare Council are lobbying for a lower bar of evidence for claims made in advertising by the members. How is this consistent with their remit of protecting the public?

The Problem

In their September 2013 newsletter, the Complementary and Natural Healthcare Council announced that it will be lobbying the Advertising Standards Authority for a change to its rules, effectively lowering the standard of evidence required by its members.

Specifically, it says:

"Rather than relying solely on RCTs [Randomised Controlled Trials], CNHC wishes the ASA and CAP to take a broader view of the hierarchy of evidence to include research which ranges from systematic reviews to case study reports."

If enacted, this would effectively establish a double standard for medical claims in advertising, and prevent poorly-evidenced claims from being challenged by the ASA. How this can possibly be in the public interest is beyond me.

CNHC

So, on 22 September 2013, I wrote to Margaret Coats, their chief executive:

 Dear Mrs Coats,
 
 I am writing to ask for clarification on your latest newsletter
 (www.cnhc.org.uk/assets/pdf/7-083.pdf), in particular
 the article "Making a Difference to the Advertising Rules".
 
 As I understand it, you are hoping to persuade the Advertising
 Standards Authority to change its standard for evidence for medical
 procedures which fall under the CAM umbrella. CAM therapies would
 then not require the "gold standard" of randomized controlled trials,
 but instead could be passed based on the lower standards of evidence
 provided by case studies and systematic reviews.
 
 Your website states: "The key purpose of CNHC is to act in the public
 interest and enable proper public accountability of the complementary
 therapists that it registers." This seems fundamentally at odds with
 negotiating with the ASA for preferentially lower standards of evidence
 for your members. I would be interested to hear how scrapping the reliance
 on RCTs for your members is in the public interest, or enables proper
 public accountability.
 
 You also mention in the article that RCTs are "quite rare" in the CAM
 sector, which is true. However, this suggests to me that the focus should
 be on increasing the number of RCTs performed, especially since the
 profitable CAM sector spends much less on research (per pound of profit)
 than "conventional" medicine. Do you have a stance on this issue?
 
 Finally, you say: "The more legitimate research exists to demonstrate the
 benefits of complementary therapies, the more you will be able to say in
 your advertising." Lowering the bar for evidence will result in less good-
 quality evidence, not more. Again, I see this as being squarely at odds with
 your role as a regulator acting in the public interest. The focus on
 expanding what CNHC members may claim also seems to me to be more
 appropriate for an industry trade body than a regulator.
 
 I look forward to hearing from you on this matter.
 
 Yours,
 
 Sean Ellis

Update 1: - I received a prompt reply on Tuesday 24 September:

 Dear Mr Ellis
 
 Thank you for your email and your continuing interest in the work of CNHC. 
 
 The purpose of our collaborative work with the Advertising Standards Authority
 and the Committee of Advertising Practice is to seek a better match between
 evidence based practice on the part of complementary therapists and advertising
 guidance.
 
 And I just wanted to flag up that CNHC would never suggest that its registrants
 carry out “medical procedures”, since the general public is most likely to
 understand that terminology as relating to interventions carried out by
 registered medical practitioners.
 
 I do hope this response is helpful.
 
 Yours sincerely
 
 Margaret Coats
 Chief Executive & Registrar
 Complementary and Natural Healthcare Council (CNHC)

Well, that was pretty much as I expected, so I fired a response back again:

 Dear Mrs Coats,
 
 Thank you for your prompt reply. However, I do not feel that it adequately
 addresses the concerns that I raised.
 
 > The purpose of our collaborative work with the Advertising Standards
 > Authority and the Committee of Advertising Practice is to seek a better
 > match between evidence based practice on the part of complementary therapists
 > and advertising guidance.
 
 As far as I can see, "seeking a better match" requires the ASA to change its
 rules to use a weaker standard of evidence to accommodate complementary
 therapists. A weaker standard of evidence necessarily will result in a lower
 standard of regulation and detrimental changes to the quality of patient care.
 
 Efforts should instead be made to ensure that complementary therapists seek a
 better match by bringing their standards of evidence up to those required by
 the ASA, which are not onerous. Having robust evidence that the treatment you
 are selling actually works seems to me to be an absolute minimum hurdle to
 clear, rather than an insurmountable barrier requiring a changing of the rules.
 
 > And I just wanted to flag up that CNHC would never suggest that its
 > registrants carry out “medical procedures”, since the general public is most
 > likely to understand that terminology as relating to interventions carried
 > out by registered medical practitioners.
 
 Are you claiming that CNHC registrants are not offering medical treatments?
 They are operating in the healthcare field, are described above as
 "therapists", and are offering procedures described as "therapy" or "treatment"
 which claim to affect the health of their patients. Some treatments are
 invasive (e.g. acupuncture). They are quite clearly offering interventions that
 most people would interpret as medical.
 
 If they are offering medical treatments, then these procedures must either
 conform to the same rules that the rest of the medical community is expected to
 follow. If not, they should be promoted as non-medical, in which case any
 claims to affect healthcare outcomes should be removed.
 
 As for the rarity of Randomized Controlled Trials in the CAM sector, this is
 often blamed on expense. Yes, RCTs can be a little tricky to design -
 especially with hands-on therapies where the nature of the control is
 important - but they are not difficult to understand and not particularly
 expensive to conduct. As an example, a group of volunteers, over one weekend,
 conducted a randomized, double-blind, placebo controlled trial of a sport-
 enhancing wristband. 
 www.merseysideskeptics.org.uk/testing-shuzi/the-protocol/
 
 I cannot see how allowing one sector of the healthcare industry to play by
 different rules to the rest, and creating a double standard, can be beneficial
 to consumers.
 
 Yours,
 
 Sean Ellis 

Ball back in their court, for now.

Update 2: - I couldn't leave this alone, so on 26 September I wrote about that "medical procedures" claim.

 Dear Mrs. Coats,
 
 Although this is a little off-topic from my original email, I was intrigued by
 your statement that the CNHC would never suggest that its registrants carry out
 medical procedures. How would the CNHC react to claims by its registrants that
 do appear to offer medical procedures?
 
 As a quick spot-check, I decided to type in my postcode, choose 8 nearby
 practitioners, and take a quick look at their websites. One had no website,
 one was offline, two made no medical claims, but the other four made what I
 would consider to be offers of "medical procedures":
 
 www.healthyinfluence.co.uk/nutritional_therapy.html
 
 "Nutritional Therapy is a natural approach to health, which uses dietary
 changes, sometimes accompanied by nutrient supplementation, along with advice
 on healthier lifestyle choices, to promote well-being, prevent disease or help
 manage more serious conditions. It is a therapy based on scientific medical
 research, which utilises the latest developments in nutritional medicine."
 
 This was the first one I looked at, and as luck would have it the clearest.
 With terms like "prevent disease", "help manage more serious conditions",
 "scientific medical research", and "nutritional medicine", I think that a
 reasonable person would conclude that the service being offered here is medical
 in nature.
 
 
 www.trance-formed.com/therapy
 
 On a page titled "Therapy", this claims to help with "asthma, eczema" and "high 
 blood pressure". I would say that management of serious conditions such as
 asthma and blood pressure is a medical procedure.
 
 
 restoringbalance.org.uk/index.html
 
 "If you have been ill, under stress, or suffering from a chronic condition,
 your body will be in a state of imbalance. Reflexology can be used to restore
 that imbalance, maintaining the body's natural equilibrium and encourage
 healing."
 
 The "encourage healing" wording is vague, but the mention of illness and
 unspecified "chronic condition" at least give the impression of medical claims.
 
 
 www.nutritionalbenefits.co.uk/
 
 This page lists a range of conditions which are undoubtedly serious and medical
 in nature, including endometriosis and polycystic ovaries. A procedure that is
 aimed to help these conditions would, I would think, be described as "medical".
 
 
 If this pattern is typical, then around 50% of your registrants would appear to 
 be offering services against your advice.
 
 One other thing - will you be publishing the responses to your consultation on
 your revised Code of Practice?
 
 Yours,
 
 Sean Ellis

I'm not really expecting a response to this one.

ASA

I also wrote to the ASA in similar vein:

 I am writing to ask for clarification on an article published in the
 latest newsletter from the Complementary and Natural Healthcare Council
 (www.cnhc.org.uk/assets/pdf/7-083.pdf), in particular the section
 "Making a Difference to the Advertising Rules".
 
 As I understand it, the CNHC are hoping to persuade the Advertising
 Standards Authority to lower its standard for evidence for medical
 procedures which fall under the Complementary and Alternative Medicine
 umbrella. CAM therapies would then not require the "gold standard" of
 randomized controlled trials, but instead could be passed based on the
 lower standards of evidence provided by case studies and systematic reviews.
 
 This seems fundamentally at odds with the application of common (and high)
 standards of evidence for all medical claims. I would be interested in
 hearing what you think about the CNHC lobbying the ASA to preferentially
 grant lower standards of evidence for the adverts from CNHC members,
 and how this could affect the ASA's reputation for fairness and public
 protection.
 
 I look forward to hearing from you on this matter.
 
 Sean Ellis

When I get a reply, I will post it here.