R E V I E W

Focus on Alternative andComplementary Therapies

Volume 18(2) June 2013 51–63© 2013 Royal Pharmaceutical Society

DOI 10.1111/fct.12018ISSN 1465-3753

British general practitioners’ attitudes towards and usage ofhomeopathy: a systematic review of surveys

Rachel Perry, Leala K Watson, Rohini Terry, Igho Onakpoya, Edzard Ernst

AbstractBackground General practitioners (GPs) often refer patients to complementary and alternative medicine practitioners.One of the more popular yet controversial therapies for patients to request is homeopathy.Objectives To assess GP/primary care physician involvement with and attitudes towards homeopathy.Methods Seven electronic databases were searched to identify all relevant UK surveys of GPs/primary care physiciansconducted between 1995 and 2013. Data extraction of all included trials was conducted by three independent reviewers.Results Thirteen surveys (from 15 articles) met the inclusion criteria. Less than 10% of GPs treated patients withhomeopathy directly; referral rates ranged from 4–73%. Views on the effectiveness of homeopathy ranged from 29–48.7%,and opinions on whether it should be funded by the UK National Health Service ranged from 19–64%. Three surveysreported on GP professional training levels in homeopathy and two investigated GP knowledge of the evidence base ofhomeopathy.Conclusions Homeopathy is currently being utilised by the UK medical profession to a minor degree. Referral rates varyconsiderably nationally but, on average, are low.

KeywordsGeneral practitioner • homeopathy • survey • systematic review • UK

IntroductionComplementary and alternative medicine (CAM) useis reported to be substantial and increasing in manycountries,1,2 although there is considerable variationin the extent to which CAM is practised byphysicians.3–6 In the UK, the Health Survey forEngland (HSE) indicated that, in 2005, the lifetimeand 12-month prevalence of CAM use in England was44% and 26%, respectively. Other UK survey datahave identified a substantial use of practitioner-provided CAM and over-the-counter CAM remedies,even amongst those taking prescription drugs.7 Therange of therapies generally placed under the headingof CAM is extremely wide and support from generalpractitioners (GPs) is likely to differ according tomodality.

Until recently, one of the most widely used andreadily available forms of CAM was homeopathy. It isamongst the most controversial of CAM therapies,8

being based on a very different paradigm to conven-tional medicine,9 yet it has been widely utilised byGPs, particularly for referrals. The number of practis-ing medical homeopaths in the UK remains small(approximately 400/41 000), but since the late 1960sthere has been rapid growth in the number of layhomeopaths (i.e. homeopaths that have not receivedfull medical training, but have studied anatomy,physiology, diagnostics and biochemistry)10 who areable to work within the UK NHS.

The provision of homeopathy is still available onthe NHS today, though homeopathy services aremainly purchased by patients out of pocket. There

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51

were originally five homeopathic hospitals in the UK,which were incorporated into the NHS in 1948,which include hospitals in London, Tunbridge Wells,Liverpool, Glasgow and Bristol. Only three of thesehospitals remain open (i.e. Glasgow, Bristol andLondon), though it is still possible to make NHSreferrals to the Liverpool Medical HomeopathyService. Homeopathy is also the main CAM therapyutilised in general practice for the treatment of child-hood ailments.11

Homeopathy’s popularity amongst medical practi-tioners appears to have diminished in recent years,which is reflected in the dramatic decline of NHSprescriptions for remedies: over an 85% reductionfrom 2000–2010 according to the Information Centrefor Health and Social Care.12 In 2010, a reportpublished by the House of Commons Science andTechnology Committee recommended that the gov-ernment should no longer fund homeopathy on theNHS,13 but this was rejected by the House and thegovernment has, in turn, given that decision over tothe individual primary care trusts (PCTs).13

Literature relating to the use of homeopathy byGPs in the UK, and the factors influencing GP refer-rals for homeopathic treatments (for example, per-sonal use or training), has not been systematicallyinvestigated since 1995.14–16 Thus, the aim of thecurrent investigation was to critically evaluate datafrom UK surveys of GPs/primary care physiciansand to assess their involvement with and attitudestowards homeopathy. Whilst maintaining anexploratory approach, we specifically aimed toextract data relating to prescribing behaviour, per-sonal usage, training levels, effectiveness ratings andunderstanding of homeopathy’s evidence base.

Methods

The following electronic databases were searchedfrom inception to August 2012: MEDLINE, EMBASE(via OVID), PsycInfo (via OVID), AMED (via EBSCO),CINAHL (via EBSCO), The Cochrane Library and ISIWeb of Knowledge. Search terms were constructedusing freetext terms and medical subject headings for‘General Practitioners’ and ‘Homeopathy’. Variationsand derivatives of these terms were included in thesearch strategy, which was adapted for each database.No limits were applied for language, and date limitswere applied manually. For an example of the searchstrategy used for MEDLINE, see Table 1. The authors’own departmental files and the reference lists of allincluded articles were searched for further relevantstudies (LW).

Articles were included if they reported on surveydata from UK GPs (GPs are the main gatekeepers foraccess to medical services). Surveys that assessedother physicians’ opinions were included if at least50% of the sample were GPs17 or if less than 50% were

GPs, the GP data could be easily extrapolated. Onlysurveys published from 1995 were included as previ-ous reviews by Ernst et al.,14 Astin et al.15 and Bottingand Cook16 examined surveys prior to this time-point. Surveys were only included if they reporteddirectly on homeopathy.

Titles and abstracts were screened by three review-ers (RP, IO, LW), and any surveys not meeting theinclusion criteria (see Figure 1) were excluded. Allother articles were obtained in full and independ-ently considered for inclusion by two of the reviewers(RP, IO). The independent decisions were recorded,and any disagreements resolved by discussion. Datafrom the articles were independently extracted fromall included surveys by two reviewers (RP and eitherLW or RH) using pre-designed data extraction formscorresponding to the data presented in Tables 2 and3.8,11,17–29 Discrepancies were recorded and resolved byreferring back to the papers and discussion betweenthe authors. Due to the heterogeneity of the dataobtained, a meta-analysis was not possible. A moredetailed protocol is available from the lead author(RP) upon request.

Results

The literature search identified 3696 potentially rel-evant titles and abstracts. After removing duplicates(n=1488), a further 2198 articles were excluded;reasons for exclusion are presented in Figure 1. Anadditional five articles were identified through themanual search and through the primary author’sown recent work. This resulted in a total of 15 articles(13 UK-only surveys). The 13 UK-only surveys werepublished between 1995 and 2013.

Response rates varied from 30.6–78.6%, and samplesizes ranged from 66–964 (Table 2). The surveys

Table 1 MEDLINE search strategy

1 (homeop$ or homoeop$ or homoop$).ti,ab,tw.2 exp homeopathy/3 1 or 24 Doctor$.ti,ab.5 General Pract$.ti,ab.6 GP$.ti,ab.7 Family med$.ti,ab.8 Family Pract$.ti,ab.9 Physician$.ti,ab.

10 Primary Care$.ti,ab.11 Primary Health Care$.ti,ab.12 exp Family Practice/13 exp General Practice/14 exp Physicians, Family/15 exp Physicians/16 exp Primary Health Care/17 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14

or 15 or 1618 3 and 17

Focus on Alternative and Complementary Therapies June 2013 18(2)52

investigated different aspects of GP involvement inhomeopathy. The types of questions asked can befound in Table 2. The main findings are summarisedin Table 3 and described below.

Three surveys used a national random samplingmethod18–20 and eight surveys sampled all GPs locatedin different regions of the UK.17,21–27 Ekins-Daukeset al.11 used sub-group samples (e.g. GPs who hadprescribed and GPs who had not prescribed home-opathy in a 12-month period). Schindler et al.25

sampled all decision makers/opinion formers in fiveEuropean countries.

Demographic informationSix surveys reported on GP gender.17,22,23,26–28 Onaverage, more male GPs responded to the question-naires than females (mean percentage 68% vs. 33%,respectively), which is not surprising given thegreater proportion of males to females in the UK GPworkforce. However, two surveys26,27 compared theproportion of male and female responders to the totalpopulation questioned and found proportionallymore females responding than males. Only foursurveys reported on the age of the GP. Perry andDowrick26 found younger GPs (under 40 years) weresignificantly more likely to respond than older GPs(over 50 years); 67% vs. 41% (X2=13.30, d.f. = 4,P=0.01). Yet, in their 2013 follow-up survey,27 therewas no difference in the age of respondents. Schmidt

et al.28 on the other hand found the mode age rangewas 50–59 (44% of the sample).

Reliability and validity of questionnaireThe validity and specific nature of the questionnaireused for data collection was not reported in themajority of surveys. Just one22 had reported question-naire validation by a statistician. The origin/design ofthe questionnaire was rarely described. Perry andDowrick,26 Perry et al.27 and Thomas et al.19 used ques-tionnaires that had been utilised in previous surveys.

TreatmentEight11,18,19,23,24,26–28 surveys questioned GPs onwhether they had treated patients with homeopathy.The findings indicate that, in most cases, less than10% of GPs reported using homeopathy to treatpatients directly. In the Ekins-Daukes et al.11 survey,5% of GPs were categorised as frequent prescribers(i.e. more than once a month). This survey specifi-cally examined the main conditions for which chil-dren received homeopathy, such as colic, cuts andbruises, teething, dermatological conditions, earache,flu and upper respiratory tract infections, cough,vomiting and diarrhoea. Outcomes, adverse effects,the placebo effect and failure of conventional medi-cine were significantly associated with overall pre-scribing frequency. Lack of both proven efficacy andproven safety were significantly associated with GPsnot prescribing.

ReferralThe majority of surveys (12/13) assessed referralrates.8,11,17–24,26–29 The data suggest that referral ratesfor homeopathy vary widely, ranging from 4–73%(but mostly around 40%). The national follow-upsurvey by Thomas et al.19 indicated an increase inUK homeopathic referral rates by approximately 5%from 1995–2001. From the regional surveys, itseemed that referral rates tended to be higher in areasthat had easy access to one of the homeopathichospitals (particularly Glasgow and London). Referralrates in these areas ranged from 35–73%, whereasreferral rates in other regional surveys were muchlower; between 4 and 19%. The referral rates in Liv-erpool had reduced from 18–4% in the last decade,possibly due to the closure of the main homeopathichospital. In general, there was a lack of clarity onwhether the GPs had access to homeopaths in theirpractice and this, rather than lack of willingness, mayhave led to the low referral rates.

It was unclear in most surveys, with the exceptionof Hamilton,22 Thomas et al.,18,19,29 and Grenfellet al.,21 whether referrals were to medical homeo-paths or lay homeopaths. Hamilton22 found that 85%of the referrals were to either the NHS GP clinic orthe Glasgow Homeopathic Hospital. Grenfell et al.21

found that 73% of responding GPs referred to the

Total number of hits for electronic search: 3696

Articles from electronic search examined for inclusion: 10

Duplicates removed: 1488

Articles excluded: - Published before 1995: 274 - Not on homeopathy: 101 - Not measuring attitudes: 1389 - Not involving GPs: 207 - Not in the UK: 128 - Not a survey: 99

Total number of articles included in review: 15 (reporting on 13 surveys)

Number of relevant articles found in reference lists of relevant reviews and through author’s own work: five

•

•

Figure 1 Flow chart of study selection process.

Review 53

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Focus on Alternative and Complementary Therapies June 2013 18(2)54

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in19

9529

Review 55

Table

2C

ontin

ued

Firs

tau

thor

,re

fere

nce

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mp

lin

gm

eth

odSa

mp

lesi

ze,

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rate

and

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nes

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ple

Des

crip

tion

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P:m

ean

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and

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der

Qu

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fre

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ted

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asth

eq

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tion

nai

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Has

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2004

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05/3

70(R

R=5

5%)

ofw

hic

h14

9/20

5(7

3%)

wer

eG

PsM

ean

age

NR

;G

Ps:

M=7

3/14

9(49

%)

F=72

/149

(48%

)(t

hre

en

otsp

ecif

ied

)

Sect

ion

1–

atti

tud

esto

war

dC

AM

,ty

pe

ofC

AM

refe

rral

s,re

ason

sfo

rre

ferr

al,

con

dit

ion

sre

ferr

ed;

sect

ion

2–

pos

sibl

em

odel

sof

inte

grat

ion

inp

rim

ary

care

;se

ctio

n3

–re

sear

chin

tere

st/

exp

erie

nce

;se

ctio

n4

–d

emog

rap

hic

dat

a

NR

Wh

ite23

1997

Post

alsu

rvey

toal

lG

Psin

Dev

onan

dC

orn

wal

l

N=4

61/9

72(R

R=4

7.4%

);re

pre

sen

tati

veof

age

and

gen

der

ofG

Psin

Dev

onan

dC

orn

wal

l

‘Mea

nag

esi

mil

arto

that

ofal

lG

Psin

Dev

onan

dC

orn

wal

l’M

=77%

F=33

%

Usa

geof

CA

Min

pre

viou

sw

eek

(tre

ated

/ref

erre

d/e

nd

orse

d);

effe

ctiv

enes

sra

tin

gof

CA

M;

con

fid

ence

ind

iscu

ssin

gC

AM

ther

apie

sw

ith

pat

ien

t;ad

vers

eev

ents

rep

orte

d

NR

;q

ues

tion

2w

asta

ken

from

Th

omas

etal

.18(w

ith

per

mis

sion

)

Wyl

lie24

1998

Post

alsu

rvey

toal

lG

Psin

Loth

ian

N=3

04/5

40(R

R=5

6%);

rep

rese

nta

tive

nes

sof

sam

ple

not

asse

ssed

Mea

nag

eN

R;

gen

der

NR

Hav

eyo

ure

ceiv

edan

ytr

ain

ing

inco

mp

lem

enta

rym

edic

ine?

hav

eyo

uev

erre

com

men

ded

/re

ferr

edp

atie

nts

for

com

ple

men

tary

trea

tmen

t?w

ould

you

like

furt

her

trai

nin

gin

com

ple

men

tary

ther

apie

s?w

hat

isyo

ur

opin

ion

abou

th

omeo

pat

hic

refe

rral

s?d

oyo

uth

ink

ther

esh

ould

bea

spec

iali

sth

omeo

pat

hic

faci

lity

inLo

thia

n?

wh

ere

do

you

thin

ksu

cha

faci

lity

shou

ldbe

base

d?

NR

UK

surv

eys

(as

par

tof

ala

rger

Euro

pea

nsu

rvey

)Sc

hm

idt28

2002

Post

alsu

rvey

toG

Psin

sou

thw

est

UK

wer

ese

lect

edac

cord

ing

toge

ogra

ph

ical

loca

tion

N=6

6/97

(RR

=68%

);re

pre

sen

tati

ven

ess

ofsa

mp

len

otas

sess

ed

Mea

nag

eN

R;

mod

eag

era

nge

50–5

9ye

ars

M=6

2/66

(94%

)F=

4/66

(6%

)

Ove

rall

atti

tud

eto

war

ds

CA

M;

nu

mbe

rof

refe

rral

sm

ade;

spec

ific

illn

esse

sto

betr

eate

dw

ith

CA

M;

per

son

alC

AM

pra

ctic

ean

du

se;

per

ceiv

edsa

fety

ofC

AM

;im

ple

men

tati

onan

dp

opu

lari

tyof

CA

M

NR

Sch

ind

ler25

2001

533/

1577

pos

tal

surv

eys

sen

tto

all

opin

ion

form

ers/

dec

isio

nm

aker

sin

Au

stri

a,B

elgi

um

,Fr

ance

,G

erm

any

and

the

UK

,in

clu

din

g36

2G

Ps,

91of

wh

omre

spon

ded

(25.

1%)

Tota

ln

resp

ond

ers

from

UK

=115

/37

6(3

0.6%

);re

pre

sen

tati

ven

ess

ofsa

mp

len

otas

sess

ed

Mea

nag

eN

R;

gen

der

NR

Soci

o-d

emog

rap

hic

fact

ors;

per

son

alex

per

ien

cew

ith

H;

asse

ssm

ent

ofcl

inic

alas

pec

tsof

H;

econ

omic

imp

act

ofH

wit

hin

the

hea

lth

syst

em

NR

but

des

ign

edto

the

stan

dar

ds

ofem

pir

ical

soci

alre

sear

ch

F,fe

mal

e;G

P,ge

ner

alp

ract

itio

ner

;H

,h

omeo

pat

hy;

M,

mal

e;N

,n

um

ber;

NR

,n

otre

por

ted

;PH

CT,

pri

mar

yh

ealt

hca

rete

am;

RR

,re

spon

sera

te.

Focus on Alternative and Complementary Therapies June 2013 18(2)56

Table

3M

ain

resu

ltsfro

m15

GP

surv

eys

Firs

tau

thor

,re

fere

nce

Usi

ng

Hto

trea

tp

atie

nts

End

orsi

ng

HR

efer

ral

rate

Trai

nin

gin

Hor

req

ues

tfo

rfu

rth

ertr

ain

ing

Effe

ctiv

enes

sra

tin

gof

HO

pin

ion

sof

pro

visi

onof

Hon

NH

S

Gen

eral

view

(pos

itiv

e/n

egat

ive)

Evid

ence

base

dm

edic

ine

ofH

Con

clu

sion

(reg

ard

ing

H)

Bai

ley20

NR

NR

33%

ofm

edic

alce

ntr

esre

ferr

edto

ah

omeo

pat

h

NR

NR

NR

8%of

med

ical

cen

tres

hav

ea

hom

eop

ath

wor

kin

gat

the

cen

tre

NR

No

con

clu

sion

sre

gard

ing

hom

eop

ath

y

Ekin

s-D

auke

s11Fr

equ

ent

pre

scri

bers

=22

(5%

–m

ore

than

1/m

onth

);oc

casi

onal

=34

(13%

);ra

re=

44(1

7%);

nev

er15

7(6

1%)

NR

Tota

lof

35%

rep

orte

dre

ferr

ing

Hto

vary

ing

deg

rees

91%

offr

equ

ent

pre

scri

bers

(20/

22G

Ps)

had

rece

ived

form

altr

ain

ing

(7%

ofto

tal

GP

resp

ond

ers)

and

77%

offr

equ

ent

pre

scri

bers

(17/

22G

Ps)

kep

tu

pto

dat

ew

ith

thei

rtr

ain

ing

(6.5

%of

tota

lG

Pre

spon

der

s);

25(1

0%)

keep

up

tod

ate

NR

NR

28%

ofG

Psp

resc

ribi

ng

Han

d68

%of

GPs

not

pre

scri

bin

gst

ated

lack

ofef

fica

cyas

ad

isad

van

tage

ofH

NR

‘In

pri

mar

yca

rep

aed

iatr

icp

resc

ribi

ng

ofh

omeo

pat

hic

med

icin

esm

ost

com

mon

lyoc

cur

inse

lf-l

imit

ing

con

dit

ion

sin

infa

nts

less

than

1ye

arol

d.

Alt

hou

ghth

ecu

rren

tle

vel

ofp

resc

ribi

ng

islo

w,

the

wid

esp

read

use

inth

eco

mm

un

ity

sugg

ests

that

atle

ast

som

ekn

owle

dge

ofth

em

ain

ind

icat

ion

sfo

rh

omeo

pat

hy

and

the

pre

par

atio

ns

use

dw

ould

beof

ben

efit

tom

edic

alp

ract

itio

ner

s.’

Gre

nfe

ll21

NR

Six

pra

ctic

es(7

%)

curr

entl

yof

fer

H

36%

ofp

ract

ices

refe

rif

His

avai

labl

elo

call

y;73

%of

GPs

refe

rred

pat

ien

tsto

the

Roy

alLo

nd

onH

omeo

pat

hic

Hos

pit

al;

NR

NR

NR

Six

(7%

)p

ract

ices

curr

entl

yof

fer

Han

dre

ferr

als

are

mad

eto

the

Roy

alLo

nd

onH

omeo

pat

hic

Hos

pit

al

NR

No

con

clu

sion

sre

gard

ing

hom

eop

ath

y

Ham

ilto

n22

NR

NR

41%

had

pat

ien

tsre

qu

esti

ng

Hw

ith

inth

ela

stm

onth

,16

refe

rral

sw

ere

toa

GP

clin

ic,

13to

Gla

sgow

Hom

eop

ath

icH

osp

ital

,th

ree

top

riva

tep

ract

ice

and

two

toa

GP

coll

eagu

e;69

.3%

ofre

ferr

als

req

ues

tsw

ere

dec

lin

ed

NR

44(G

Ps)

44%

show

edan

inte

rest

inlo

cal

trai

nin

gof

H

NR

NR

86.1

%ex

pre

ssed

anin

tere

stin

usi

ng

the

loca

lN

HS

clin

ic

Ran

kor

der

ofev

iden

ceon

e(m

ost

imp

orta

nt)

ton

ine

(lea

stim

por

tan

t):

1–

RC

Ts2

–au

dit

dat

are

gard

ing

effi

cacy

3–

safe

typ

rofi

le4

–p

atie

nt

sati

sfac

tion

5–

cost

-ef

fect

iven

ess

6–

per

son

alex

per

ien

ce7

–p

atie

nt

dem

and

8–

coll

eagu

eop

inio

n9

–th

eory

ofH

‘As

GPs

hav

ebo

thfi

nan

cial

and

clin

ical

infl

uen

cean

evid

ence

base

isn

eces

sary

for

H.

toco

mp

ete

wit

hot

her

NH

Sp

rior

itie

s.’

Review 57

Table

3C

ontin

ued

Firs

tau

thor

,re

fere

nce

Usi

ng

Hto

trea

tp

atie

nts

End

orsi

ng

HR

efer

ral

rate

Trai

nin

gin

Hor

req

ues

tfo

rfu

rth

ertr

ain

ing

Effe

ctiv

enes

sra

tin

gof

HO

pin

ion

sof

pro

visi

onof

Hon

NH

S

Gen

eral

view

(pos

itiv

e/n

egat

ive)

Evid

ence

base

dm

edic

ine

ofH

Con

clu

sion

(reg

ard

ing

H)

Perr

y8,26

Eigh

tG

Ps(6

%)c

inth

ep

revi

ous

wee

k

Nin

eG

Ps(7

%)

inth

ep

revi

ous

wee

k

23G

Ps(1

8%)c

inth

ep

revi

ous

wee

k8%

had

rece

ived

trai

nin

gin

Hou

tof

21%

wh

oh

adre

ceiv

edtr

ain

ing

inC

AM

;12

%w

ould

like

furt

her

trai

nin

gin

H

VA

S–

mea

nef

fect

iven

ess

rati

ng

48.7

%(S

D24

.1)

thou

ght

itw

asef

fect

ive

49%

ofG

Psth

ough

tit

shou

ldbe

fun

ded

byth

eN

HS,

18%

said

itsh

ould

not

befu

nd

edan

d21

%w

ere

un

cert

ain

48.7

%fe

ltit

was

effe

ctiv

eal

thou

ghon

ly23

%th

ough

ith

asan

yth

eore

tica

lva

lid

ity

NR

‘Res

pon

den

tsw

ere

gen

eral

lyu

nce

rtai

nab

out

the

vali

dit

yof

the

theo

reti

cal

basi

sof

H.

des

pit

ea

28%

usa

ge.

Th

em

ajor

ity

ofre

spon

der

sw

ere

pre

par

edto

use

,re

fer

oren

dor

seth

eu

seof

H.

ofte

nd

esp

ite

litt

lekn

owle

dge

ofth

eir

con

ten

tor

con

vict

ion

ofth

eir

vali

dit

y.’

Perr

y27O

ne

GP

(1.2

%)

inth

ep

revi

ous

wee

k

On

eG

P(1

.2%

)in

the

pre

viou

sw

eek

Th

ree

GPs

(4%

)in

the

pre

viou

sw

eek

NR

VA

S–

mea

nef

fect

iven

ess

rati

ng

21.9

%(S

D26

.9)

thou

ght

itw

asef

fect

ive

19%

ofG

Psth

ough

tit

shou

ldbe

fun

ded

byth

eN

HS,

48%

said

itsh

ould

not

befu

nd

edan

d19

%w

ere

un

cert

ain

‘Hom

eop

ath

y..

.h

adve

ryli

ttle

sup

por

tfo

rth

eir

theo

reti

cal

vali

dit

y’

NR

‘...

the

dec

reas

ein

GP

fait

hin

hom

eop

ath

yas

anal

tern

ativ

etr

eatm

ent

toco

nve

nti

onal

care

.’

Th

omas

18,2

96.

7%p

rovi

sion

ofH

bym

embe

rof

PHC

T

NR

16.8

%of

feri

ng

refe

rral

via

any

typ

eof

pro

visi

on,

6.7%

bym

embe

rof

PHC

T,<1

%by

ind

epen

den

tH

wor

kin

gin

pra

ctic

e,12

.4%

via

NH

Sre

ferr

als

NR

NR

NR

<1%

pro

visi

onof

Hp

rovi

ded

byon

site

CA

Mp

ract

itio

ner

NR

No

con

clu

sion

sre

gard

ing

hom

eop

ath

y

Th

omas

198.

3%p

rovi

sion

ofH

bym

embe

rof

PHC

T

NR

21.1

%of

feri

ng

refe

rral

via

any

typ

eof

pro

visi

on,

8.3%

bym

embe

rof

PHC

T,2.

7%by

ind

epen

den

tH

.w

orki

ng

inp

ract

ice,

14.9

%vi

aN

HS

refe

rral

s

NR

NR

NR

2.7%

pro

visi

onof

Hby

onsi

teC

AM

pra

ctit

ion

er

NR

No

con

clu

sion

sre

gard

ing

hom

eop

ath

y

Van

Has

elen

17N

RN

R12

0/17

1(7

0%)

ofal

lre

spon

der

sw

ho

wer

ere

ferr

edto

ath

erap

ist,

wer

ere

ferr

edto

Ha

NR

NR

NR

NR

Gen

eral

CA

Mop

inio

ns

only

No

con

clu

sion

sre

gard

ing

hom

eop

ath

y

Focus on Alternative and Complementary Therapies June 2013 18(2)58

Wh

ite23

27G

Ps(5

.9%

)62

GPs

(13.

4%)

21G

Ps(4

.6%

)N

RV

AS

mea

nef

fect

iven

ess

rati

ng

=29

%(a

pp

roxi

mat

ely)

NR

NR

NR

No

con

clu

sion

sre

gard

ing

hom

eop

ath

y

Wyl

lie24

30G

Ps(9

%)

NR

210/

304

GPs

(69%

);re

ferr

alp

atte

rns:

92%

wer

ew

illi

ng

tore

fer,

42%

wou

ldre

fer

ifre

qu

este

d,

41%

wou

ldco

nsi

der

Han

opti

onfo

rso

me

pat

ien

ts

49/3

04G

Ps(1

6%)

had

rece

ived

trai

nin

g;43

/304

GPs

(14%

)re

qu

este

dfu

rth

ertr

ain

ing

NR

74%

wel

com

edth

ep

rovi

sion

ofa

hom

eop

ath

iccl

inic

and

64%

thou

ght

itsh

ould

beav

aila

ble

inh

osp

ital

outp

atie

nt

dep

artm

ents

Posi

tive

view

NR

‘Res

ult

ssh

owsu

bsta

nti

alG

Psu

pp

ort

for

the

pro

visi

onof

hom

oeop

ath

icfa

cili

tyin

Loth

ian

.’

Sch

mid

t288%

pra

ctis

edin

the

UK

NR

Sign

ific

antl

ym

ore

UK

GPs

refe

rred

toa

hom

eop

ath

than

Ger

man

GPs

(33

vs.

21;

X2

P<0.

05)

NR

NR

NR

Ger

man

GPs

show

edan

(non

-sig

nif

ican

t)ov

eral

lm

ore

pos

itiv

eat

titu

de

tow

ard

sC

AM

than

Bri

tish

GPs

Gen

eral

CA

Mop

inio

ns

only

No

con

clu

sion

sre

gard

ing

hom

eop

ath

y

Sch

ind

ler25

NR

NR

NR

NR

GPs

opin

ion

son

effe

ctiv

enes

sof

H:

very

effe

ctiv

e=15

%,

rath

eref

fect

ive=

40%

,ra

ther

inef

fect

ive=

34%

,co

mp

lete

lyin

effe

ctiv

e=8%

b

NR

GPs

opp

osin

gH

=27%

GPs

ind

iffe

ren

tto

H=5

7%G

Pssu

pp

orti

ng

H=1

5%b

GPs

resp

onse

(n=9

1):

CT

=89%

OS=

66%

TM

=65%

CR

=58%

SH=5

7%LE

=41%

AE=

38%

b

‘Sin

cesp

end

ing

for

hom

eop

ath

icm

edic

ine

has

asi

gnif

ican

tim

pac

ton

hea

lth

care

exp

ense

,fu

rth

erin

vest

men

tsin

toco

ntr

olle

dst

ud

ies

onth

eef

fect

iven

ess

ofth

isco

mp

lem

enta

ryth

erap

yar

ew

arra

nte

d.’

AE,

anim

alex

per

imen

ts;C

R,c

ase

rep

orts

;CT,

con

trol

led

clin

ical

tria

ls;G

P,ge

ner

alp

ract

itio

ner

;H,h

omeo

pat

hy;

LE,l

abor

ator

yex

per

imen

ts(i

nvi

tro)

;NR

,not

rep

orte

d;O

S,ob

serv

atio

nal

stu

die

s;PH

CT,

pri

mar

yh

ealt

hca

rete

am;

SD,

stan

dar

dd

evia

tion

;SH

,sp

ecif

ich

omeo

pat

hic

stu

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Review 59

Royal London Homeopathic Hospital (renamed theRoyal London Hospital of Integrated Medicine in2010). Thomas et al.18,19 stated that homeopathywas provided by members of the primary health careteam, either as medical homeopaths, independentCAM practitioners at the practice (lay homeopaths)or via external NHS referrals.

Endorsement and personal usageThree surveys,23,26,27 assessed GP endorsement levelsof homeopathy and found less than 15% of GPswere endorsing homeopathy. ‘Endorsement’ in thiscontext was not formalised; instead, it was used toassess how many GPs expressed approval of or rec-ommended homeopathy during the consultation.Two surveys27,28 asked about GP personal usage ofhomeopathy; one found less than 10% had used itbefore, however, no time frame was specified. Theother study27 did not report the findings.

TrainingThree surveys11,24,26 reported that GPs had receivedtraining in homeopathy (between 7% and 16%);although the level of training was not assessed/reported. Three surveys also reported GP interest infurther training,22,24,26 and one11 found that 6.5% ofGPs had kept up-to-date with their training.

Provision of homeopathy by NHSThree surveys24,26,27 explored GPs’ opinions onwhether homeopathy should be funded by the NHS.In a 1999 Liverpool survey, nearly 50% of GPsthought homeopathy should be available on theNHS;26 this dropped to below 20% in the follow-upsurvey conducted in 2010.27 The reasons for thisdecline were not explored in the survey. Wyllie andHannaford24 found that 74% welcomed the provisionof a homeopathic clinic and 64% thought it shouldbe available in hospital outpatient departments.

Effectiveness rating of homeopathyFour surveys23,25–27 assessed GPs ratings of the effec-tiveness of homeopathy. The mean effectivenessrating ranged from 29–48.7%, with 15% reporting itto be ‘very effective’ in one survey.25 Perry et al.27

found opinions about the effectiveness of homeopa-thy have changed dramatically in the last 10 years, asit was previously considered to be moderately effec-tive (reducing from 48.7–21.9%).

Research into homeopathyOne survey29 asked participants about the scientificapproaches they considered important for demon-strating the effectiveness of homeopathy. Schindleret al.25 found 89% of the GPs thought that controlledclinical trials were the most important approach,although other methods (Table 3) were also recog-nised as being important. The authors also examined

GPs’ views on the possible constraints on researchinto homeopathy; a lack of homeopathic researchinstitutes, opposition from the pharmaceuticalindustry, opposition from the medical establishmentand lack of funding were the main reasons listed byGPs. In another survey, Hamilton22 asked GPs to rankthe forms of evidence regarding homeopathy. Ran-domised controlled trials, audit data regarding out-comes, safety profile and patient satisfaction wereranked as the top four forms of evidence.

Discussion

Summary of previous findings (prior to 1995)Three previous reviews14–16 reported results from fiveUK surveys conducted between 1983 and 1995.30–34

The five surveys differed considerably in terms ofsample size, response rate and type of questionsasked.

Sample sizes ranged from 86–222. Three surveyedGPs only, one30 surveyed GP trainees and one34 sur-veyed GPs, hospital doctors and medical students.Between 1% and 7% of responders were practisinghomeopathy, 11–42% were referring to a homeopath,and 7–52% believed in the efficacy of homeopathy.Cameron-Blackie and Mouncer33 found that 13% ofGPs would use homeopathy to treat 10 specific con-ditions. Younger GPs were more likely than older GPsto refer to lay homeopaths. Reilly30 found 45% ofGP trainees thought homeopathy was useful, andalthough trainee GPs may take a more optimisticview of CAM therapies than their colleagues, theseresults indicate a positive attitude towards homeopa-thy. Perkins et al.34 found that GPs and hospitaldoctors had similar knowledge of five main CAMtherapies, whereas medical students had less knowl-edge but were keen for CAM therapies to be includedin the medical curriculum.

Summary of current findings (since 1995)The aim of this review was to investigate more recentlevels of GP involvement with homeopathy usingsurveys administered in the last 17 years. Treatmentrates were low at approximately 10%, and referralrates varied from 4–73%. This variation seemed to beregional with more referrals occurring in Scotlandand London, which might be due to the accessibilityof services. The number of GPs trained in homeopa-thy was also low (between 7% and 16%). When com-paring these results with the results from the surveysconducted prior to 1995,14–16 it appears that GPs’usage of homeopathy to treat patients, as well asreferral rates to homeopaths, had not changedmuch over time until the most recent survey byPerry et al.,27 which demonstrates a decline in bothtreatment, referral rates and positive opinions ofhomeopathy.

Focus on Alternative and Complementary Therapies June 2013 18(2)60

LimitationsThis current review has several limitations. Althoughthe search strategy was thorough, some surveys maynot have been identified. Our systematic and detailedsearch strategy should have assisted in identifying allsurveys and in reducing bias. Nevertheless, publica-tion bias is a problem in all medical research.35

The 13 surveys differed considerably in terms ofsample size, response rate and type of questionsasked. Sample sizes were generally small (rangingbetween 66 and 964; mean = 294), and althoughresponse rates varied between the surveys (30.6–78.6%), it is important to note that surveys withlow response rates (of less than 50%) could containpotential biases and may not be considered repre-sentative of the opinions of all physicians.23,25,27 It ispossible that non-responders were GPs with littleknowledge, interest or connection with CAM thera-pies; alternatively, it could be due to a lack of timeor questionnaire fatigue. The reasons for the poorresponse rates were not reported.

The findings from the surveys were diverse as eachsurvey assessed different aspects of CAM usage andattitude. The majority of the surveys assessed home-opathy as part of a general CAM survey; only threesurveys11,22,25 focused specifically on homeopathy,and therefore comparisons have to be consideredwith this in mind. Three surveys18,19,23 that assessedmultiple CAM therapies found homeopathy to beone of the most common therapies to refer to or to beprovided directly by the primary health care team.20,24

Restricting the search to just one country limits thegeneralisability of findings to other countries. Inter-national comparisons would be of interest; however,the inclusion of other countries was beyond thescope of this review. Also, the majority of studies wereregional surveys so, again, findings cannot be gener-alised to the whole of the UK. In addition, somesurveys were particularly pro-homeopathy,22 whichmay have biased the results.

The majority (12/13) surveys were conductedbefore 2005, so may no longer represent the views ofGPs practising today. Just one study27 reported morerecent opinions – a 10-year follow-up survey con-ducted in Liverpool – which demonstrated a declinein GP usage of homeopathy in this area. This declinemay be due to the closure of the Liverpool Homeo-pathic Hospital or the negative press homeopathyhas received in recent years; thus, the opinionsreported in the majority of these surveys may needrevisiting to establish whether a different patternemerges.

Further research areasIn three surveys,17,20,25 GPs’ opinions were assessed aspart of a larger sample of health professionals, andthus it was difficult to establish the specific views ofGPs compared to other primary health care workers.

One finding by Van Haselen et al.17 indicated thatnon-GP primary care professionals were generallymore convinced of the benefits of CAM than GPs.The reasons behind GPs prescribing homeopathywere not clear-cut, and it is difficult to clarifywhether prescribing patterns are GP or patient led.However, GP belief systems may play an importantrole and this requires further investigation. It oftenhas been found that a physicians’ own use of CAMis linked to their recommendation of CAM.36 Thiswould be an interesting line of enquiry to pursue infuture research to see if it can be specifically appliedto homeopathy.

Only one survey27 investigated whether GPs ques-tioned patients on their private usage of homeopathybut only reported on CAM in general (36% regularlyasked). Data from the 2005 Health Survey forEngland, which examined nationwide usage of CAMtherapies, serves as a valuable reminder to medicalpractitioners to ask patients about CAM-use in orderto facilitate prioritisation of the research agenda inCAM.7

One particular population sub-group that fre-quently receives homeopathic medicine is that ofchildren. It has been reported in the UK that theprevalence of homeopathic prescribing for thoseunder 16 years of age has doubled from 2000–2005and is most frequently used for children less than1 year old, of whom 1% are prescribed a homeo-pathic remedy by GPs.37 Again, prescriptions for chil-dren would need to be examined for changes since2005.

The few surveys that investigated training levelsindicated that between seven and 16% of GPshave undertaken any training in homeopathy. Futuresurveys could investigate these training levels inmore depth. It was not surprising that in one sur-vey,26 those GPs who thought homeopathy was effec-tive correlated positively with perceived importanceof receiving further training. Previous UK research,31

conducted in 1986, also reported low levels of knowl-edge amongst their sample of GPs, despite training; itappears things have not changed very much sincethat time. This may reflect how complex these thera-pies are and how they cannot realistically be taughtor learnt effectively within a short course.

A final area of exploration would be to assess GPs’and other health professionals’ understanding ofevidence-based practice in relation to homeopathy.Several surveys made an attempt to examine the evi-dence base of CAM in general.17,22,25,28 It seems thatdoctors need to, and are prepared to, generate theirown risk–benefit analyses for particular therapies,such as homeopathy, based on anecdotal experienceand case examples until more RCTs are conducted.

The on-going debate regarding the scientific plau-sibility of homeopathy has recently been publishedin the British Medical Journal,38 again bringing into

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question the merits of this particular therapy.Whether the opinions expressed in this article impacton GP prescribing behaviour is yet to be seen. Inter-estingly, it has been noted elsewhere that referrals aremore commonly based on experience or traininglevels rather than on any scientific basis.39

The aim of this review was not to offer a critiqueof homeopathy; however, it is apparent that theevidence-based care, which should be based onthe same body of evidence, appears to differ withinthe UK giving rise to different patterns of usage.Given the number of consumers and non-GP healthprofessionals that use or endorse the use of homeopa-thy, it is imperative that GPs are aware of the currentevidence relating to efficacy (or lack of efficacy) ofhomeopathic interventions.

In an era of increasing levels of patient autonomyand choice, it is important to understand the GPs’decision-making processes that are involved inmaking referrals to services such as homeopathy. IfGPs are becoming more ‘patient-led’ in response topatients’ demand for choice, this may not be idealfor the patient’s health in the long run. It is impor-tant to encourage both GPs and complementarytherapists to communicate and collaborate with oneanother. It is also important to try to understandpatients’ decision-making processes. Apart from thepressure GPs feel in referring patients to variousCAM therapists, many GPs remain unaware ofwhich CAM therapies patients are using. It appearsthat patients often feel uncomfortable about discuss-ing CAM therapies such as homeopathy with amedical practitioner36 and do not tend to consultwith their GP before using a CAM therapy.21 Thismay be due to the patients’ perception that their GPwill be unsupportive or hostile to the patient’schoice, or just that their GPs do not think to ask.However, as data exist to show an ever-increasinguse of alternative healthcare choices, it is in thepatients’ and the therapists’ best interests to ensurethat any additional care provided is with the fullknowledge of the patients’ conventionally trainedhealthcare practitioner (GP); likewise the therapistshould also be aware of any conventional treatmentthe patient is currently receiving.

Conclusion

In conclusion, homeopathy is still, at present, beingutilised by the UK medical profession to a minordegree. Referral rates vary considerably, but onaverage are low. The most recent survey has indicateda decline in homeopathy use among GPs, althoughthis finding cannot be extrapolated to other areas.More up-to-date questionnaires might help to estab-lish more recent changes in the usage of homeopathywithin primary care.

Conflict of interest None declared.

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Rachel Perry, BA, MA, MPhil, Complementary MedicineResearch Group, Peninsula Medical School, Veysey Build-ing, Salmon Pool Lane, Exeter, EX2 4SG.E-mail: R.Perry@bath.ac.ukLeala K Watson, BSc (Hons), Complementary MedicineResearch Group, Peninsula Medical School, Veysey Build-ing, Salmon Pool Lane, Exeter, EX2 4SG.E-mail: Leala.Watson@pms.ac.ukRohini Terry, BSc, PhD, Complementary Medicine, Penin-sula Medical School, Veysey Building, Salmon Pool Lane,Exeter, EX2 4SG.E-mail: Rohini.terry@pms.ac.ukIgho Onakpoya, MD, MSc, Complementary MedicineResearch Group, Peninsula Medical School, Veysey Build-ing, Salmon Pool Lane, Exeter, EX2 4SG.E-mail: igho.onakpoya@pcmd.ac.ukEdzard Ernst, MD, PhD, FMedSci, FSB, FRCP, FRCPEd,Editor-in-Chief of FACT, Emeritus Professor, ComplementaryMedicine, Peninsula Medical School, Veysey Building,Salmon Pool Lane, Exeter, EX2 4SG.E-mail: E.Ernst@pms.ac.uk

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