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?
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.
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.
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.