Introduction

Homeopathy is a controversial treatment, and NHS England has recently consulted on future prescribing within the NHS,1 with guidance having been issued, which suggests homeopathic prescribing should not be issued for new patients and should be deprescribed in existing patients.2 Cochrane systematic reviews have assessed the evidence for homeopathy in numerous conditions, including irritable bowel syndrome,3 attention deficit/hyperactivity disorder4 and dementia,5 all of which found insufficient evidence to support use of homeopathy. A 2015 Australian government report concluded that ‘there are no health conditions for which there is reliable evidence that homeopathy is effective’.6

Homeopathy also has low biological plausibility. Homeopathic treatments are made by identifying a substance believed to elicit the symptom being treated (such as nausea) and then diluting this by one drop of the initial substance in 100 drops of water, typically for 30 sequential dilutions, resulting in a solution of 1 in 1060. Although no molecules of the active ingredient remain, homeopaths assert that water has a memory for substances previously diluted in it.7 A drop of this water is then shaken in a container with lactose pills. Homeopaths assert that the pills receive and transmit the qualities memorised previously by the water. Between each dilution, homeopaths state that the flask must be struck firmly against a surface of leather overlaid on horsehair, in order to ‘potentise’ the water.8 Tablets prepared in this fashion can then be prescribed to patients by doctors using a standard NHS FP10 prescription form.

Despite the lack of evidence for homeopathy, and its lack of a plausible mechanism, some NHS doctors still prescribe it. However, there is limited evidence on clinician factors associated with choosing to use homeopathy, mostly based on surveys. German medical students taking elective modules in homeopathy scored lower in ‘science orientation’, but higher in ‘care orientation’ and were less motivated by ‘status’ compared to their peers.9 A commonly cited advantage of homeopathy is safety, and in a small survey of healthcare staff from general practice in London, 70% thought homeopathy could reduce costs for some conditions; however, 55% thought it could increase costs for others.10 Globally, personal use of homeopathy in doctors has a strong association with prescribing of homeopathy.11 There is also some evidence on patient factors associated with choosing homeopathy, again based on surveys: patients are most likely to be female, better educated, have healthier lifestyles and report lower tendency to seek medical help when their child is ill.12,13

Using publicly available data, practices may be measured on their prescribing quality through assessment of the cost-effectiveness, efficacy and safety of medicines prescribed, based on national guidelines. Practices may also be judged by their quality outcomes framework score and patient recommendation rates. We hypothesised that practices that prescribe any homeopathy might differ in their prescribing in other measurable ways. We therefore set out to explore whether general practices prescribing homeopathic remedies also behave differently on these other measures of general practitioner behaviour.