Friday, 17 March 2017

Communication with NICE about the revision of the Clinical Guideline 53


On 12th March 2017, Margaret Williams sent a letter and an open memo to Professor Mark Baker at NICE. The letter and the memo are shown below. A pdf version of both can be downloaded by clicking the link above.

Letter to Professor Mark Baker

Dear Professor Baker

The attached Open Memo addressed to you is about to be distributed via various internet channels, so I wanted to assure you that it is in no way an ad hominem attack on you personally.

It is simply a last-ditch attempt to prevent more harm being done to the many thousands of ME sufferers in the UK whose life has been wrecked by an utterly devastating neuro-inflammtory disease which has nothing whatever to do with “chronic fatigue” or with “aberrant illness beliefs” or with “hypervigilance to normal bodily sensations” as reiterated by those who were so influential in the production of the original Guideline CG53.

Over the last 30 years I have accumulated a huge library of books, articles and international conference reports on ME/CFS, resulting in a vast database.  Despite frequent claims that little is known about it, on looking at this published evidence, I am always struck at the enormous amount that is actually known about the disease. 

For example, there has been much discussion about the recent findings by Naviaux et al that ME/CFS patients are in a hypometabolic state, but evidence of this was presented by Tavio et al from Aviano, Italy, at the AACFS International Conference on (ME)CFS in San Francisco in 1996, which is 21 years ago. 

Those findings were publicly dismissed by Dr Simon Wessely but they were replicated in 1998 by D. di Giuda and D. Racciatti et al from Rome, who found brainstem hypoperfusion in 83.9% of (ME)CFS patients studied and who concluded that their study confirmed previous reports of brain perfusion impairment in (ME)CFS patients and provided objective evidence of central nervous system dysfunction. 

What is so disturbing is that in the UK, the disproportionate influence of the psychosocial lobby has succeeded in ensuring that this enormous knowledge-base of multi-system dysfunction has been suppressed, dismissed and ignored; had that lobby not achieved this suppression of the evidence, their own beliefs would long ago have been exposed as null and void, as has now finally happened.

That they were able to achieve such control has been due in no small measure to the instrumental role played by the Science Media Centre (of which Professor Sir Simon Wessely is a founder member and whose advisory board includes James Gallagher, the BBC’s Science Editor). The SMC’s active campaign against the acceptance of ME/CFS as a neuroimmune disease is undeniable and has been documented by Professor Malcolm Hooper (www.meactionuk.org.uk/MW/2013/role-of-science-media-centre-and-insurance-industry.pdf).

Indeed, I was personally told by the medical editor of a major broadsheet that they would not publish anything about ME/CFS unless they received it from the Science Media Centre which, sadly, gives undue weight to the psychosocial voice, so – despite the internet -- the wealth of evidence showing significant pathology is not easily available in the UK.

In 2003 Carruthers et al published “Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols. A Consensus Document” (JCFS: 2003: 11(1):7115) and an Overview published in 2005 confirmed the compelling research evidence of physiological and biochemical abnormalities which identify ME/CFS as a distinct, biological, clinical disorder with autonomic, endocrine and immune dysfunction, stating categorically that it is not synonymous with psychiatric disorder.  The Overview draws specific attention to the dangers of “unwisely” prescribed graded exercise because of the evidence of suboptimal cardiac function and because patients have different physiological responses to exercise than healthy controls. It also points out that the standard battery of tests is inadequate to reveal the many abnormalities present. 

You will doubtless be aware that the UK psychosocial lobby refuses to accept any of this evidence and disparages the world-class experts from thirteen countries who compiled the Consensus and who, collectively, have 400 years of clinical experience of ME/CFS and who have diagnosed and treated approximately 50,000 patients with ME/CFS.

The crushing impact of ME/CFS was emphasised by Dr Julie Gerberding, Director of the US CDC, when on 3rd November 2006 she announced the CDC’s Toolkit to draw attention to the “tremendous impact” of (ME)CFS and to patients’ “courage” and to their “incredible suffering”, and she emphasised the underlying biological nature of the disease. This is very different from the message in the UK, which is that “CFS/ME” is a behavioural disorder and if patients would only co-operate and engage in “cognitive restructuring” and graded aerobic exercise, they could recover.  Nothing is further from the truth. 

It is notable that the interventions of CBT and GET which were part of the CDC Toolkit have now been archived (http://www.cdc/gov/cfs/toolkit/archived.html) and that the National Institutes for Health (NIH) have advised that the Oxford criteria used in the PACE trial are flawed: “Specifically, continuing to use the Oxford definition may impair progress and cause harm…Thus, for needed progress to occur we recommend that the Oxford definition be retired” (http://annals.org/article.aspx?articleid=2322804).  Their conclusions were based on comprehensive reviews of over 9000 peer-reviewed research papers and testimony from expert researchers and clinicians.

I’m sure you will have seen the latest open letter about the PACE trial to the editors of Psychological Medicine, a letter which has 101 international signatories, but in case you missed it, here is the link:

Without doubt you have a very difficult task ahead of you and I can only wish you strength and courage in “standing up for science” (this, ironically, being the citation in the award of the inaugural John Maddox prize in 2012 to Simon Wessely).

With kind regards

Margaret Williams

Open Memo to Professor Mark Baker

Now that it has been agreed that the NICE Clinical Guideline on “CFS/ME” (CG53) that was published in August 2007 is to be removed from the static list and reviewed this year, it may be helpful for everyone involved to consider a few relevant facts.

As you have worked for NICE since 2009 and as you are now the Centre for Guidelines Director, you will, of course, be familiar with the following points but, given their importance and given the extent to which they were ignored in the production of the original Guideline, it seems prudent to draw renewed attention to them.

As NICE is funded by – and is accountable to – the UK Department of Health, it should go without saying that NICE adheres to DH published policy, but it would appear that in the production of CG53 there was no such adherence.

Relevant Facts

1.  “The Expert Patient: A New Approach to Chronic Disease Management for the 21st Century” was launched in September 2001 by the Chief Medical Officer (DH 2001).  The programme was to be mainstreamed throughout the NHS between 2004 and 2007.  The underlying purpose of The Expert Patient Programme (EPP) was, of course, to get patients with chronic diseases to police their own behaviour and thereby reduce their dependence on State resources (From 1984 to 2004: Double think, social movements and health policy: Ruth McDonald, National Primary Care R&D Centre, University of Manchester, 2004) but the nominal aim was self-explanatory: it was to empower patients in decision-making about the chronic illness with which they lived and, being “user-led”, the sharing of expertise between clinicians and patients would lead to a better quality of life for those living with chronic diseases.  It was recognised that such patients are well-informed about their condition and therefore partnerships between patients and professionals were essential.  

This did not happen in the production of CG53.  Even though NICE received over 11,000 pages of submissions about this particular Guideline and despite ostensible patient representation on the Guideline Development Group (GDG), the voice of the expert patient was over-ruled.  The Chairman of the GDG, Professor Richard Baker, failed in his remit to uphold Government policy by permitting influential members of the GDG to refuse to accept the WHO classification of ME/CFS as a neurological disorder as directed by NICE itself: on 10th September 2002 the Communications Director (Anne-Toni Rodgers) of NICE Special Health Authority issued a Communications Progress Report which, at section 2.7.1.5 was clear: “The ICD-10 classification is used for the recording of diseases and health related problems…The WHO produces the classifications and ICD-10 is the latest version…the classification codes are mandatory for use across England”.

Given that the DH accepts that ME/CFS is a neurological disorder (letter dated 11th February 2004 from Lord Warner, Parliamentary Under Secretary of State, Department of Health; confirmed on 2nd June 2008 by Lord Darzi, Parliamentary Under-Secretary of State, Department of Health: “My Lords, I have acknowledged that CFS/ME is a neurological condition… as I said earlier, (it) is a neurological rather than a mental condition”), will you personally ensure that the revised Guideline makes it clear that NICE also accepts the WHO classification of ME/CFS as a neurological disorder? 

2. On 21st March 2002 in the BBC Radio 4 programme “You and Yours”, the issue of patient /professional co-operation was discussed in relation to the then-recent Report of the UK Chief Medical Officer on “CFS/ME”.  The interviewer said: “Now the government says it wants patients to sit alongside clinicians and become amateur experts and contribute to a whole range of treatments.  But putting theory into practice has proved problematical…Tony Britton from the ME Association thinks the use of expert patients for some conditions is vital”.

One of the reporters, Margaret Collins, said: “The theory then is fine, it is putting the concept of the ‘expert patient’ into practice that’s the real challenge.  When the Independent Working Group on CFS/ME was set up to improve the quality of care and treatment, clinicians and patients could not agree and several resigned….The clinicians felt that there was sufficient evidence for the treatments they wanted to recommend.  Dr Peter White resigned over evidence about the treatment”.

Peter White responded:  “We need to know what treatments work for our patients in general rather than specifically what particular patients know works for them.  That’s the way we can reassure our other patients that there is evidence that a particular treatment works…We are talking about a hierarchy of evidence that is most convincing.  If I wanted to persuade someone who is sceptical about what I have to say, the best way to do that is to show scientifically repeatedly that what I say is true….I think the ‘expert patient’ programme will work best when there is consensus about the way forward….When it is a chronic condition for which there is no immediate chance of a cure, when the programme is properly resourced… to get the patients who are going to provide the evidence…then the ‘expert patient’ programme could work well”.  (Plainly, Peter White was saying that only if the ‘expert patient’ concurred with his own views would a partnership be possible).

The interviewer then introduced Anne-Toni Rodgers from NICE and asked her: “From NICE’s point of view, wouldn’t academics and researchers…have their own agenda – that’s the real world, and patients perhaps will have theirs, and that’s perhaps how never the twain will meet?” Anne-Toni Rodgers replied: “We are trying very hard to study our guidelines process to prevent that happening….One way we have actually focused in supporting patients in this relationship is by establishing something called a ‘Patient Involvement Unit’…we fund it (and) we are very clear about patients that we want involved in clinical guidelines… so then we have a broad understanding of the condition….When you have lived with a condition for20 years, you often know more about it”.

The interviewer then said “But that’s what the doctors object to….So the doctors get in the way – they say they don’t agree with patients….When push comes to shove, doctors are going with their own scientific instincts, aren’t they, rather than whatever patients may tell them”, to which Dr Rona McDonald, Assistant Editor, BMJ, replied: “I am afraid that that actually may be the case, even though it’s one that I absolutely abhor myself….The whole problem is that the patients have never been included from the start”  (Transcript by Doris M Jones, 19.04.2002).

3.  In March 2008, the British Medical Association published its report “Public and Patient Involvement (PPI) in the NHS” which called for active involvement of the public who fund it and the patients who use it. The BMA found that public and patient involvement was at risk of being seriously weakened and offered recommendations on the necessary structures and processes that would ensure that PPI is robustly established as an integral and collaborative process in the NHS in order to develop productive partnerships between patients, the public, health professionals and policy makers.

Given the requirement for the active involvement of the “expert patient”, will you ensure that in the current revision, NICE accepts the voice and the experience of the expert ME/CFS patient? What the expert ME/CFS patient has consistently said is that the behavioural interventions  recommended in the original Guideline do not work and, given the indisputable evidence that people with ME/CFS (as opposed to chronic fatigue) are in a hypometabolic state, graded aerobic exercise may be actively harmful.

4.  On 6th January 2011 Frances Rawle PhD, Head of Corporate Governance and Policy at the Medical Research Council, wrote to Professor Malcolm Hooper confirming about CBT/GET that, prior to the PACE Trial: “there was insufficiently strong evidence from randomised controlled trials to support their effectiveness”.  This was a surprising admission, because the NICE Guideline that advocated CBT/GET was published in 2007, which was four years before the initial results of the PACE Trial appeared.  Given Dr Rawle’s confirmation that in 2007 there was insufficiently strong evidence, NICE should not have recommended such interventions for national implementation, as further confirmed by the House of Commons Health Select Committee, First Report of Session 2007-08, Volume I:29, whose members were unequivocal that NICE should not recommend interventions when the evidence is weak.  

Indeed, in the absence of sufficiently strong evidence, in the 2007 Guideline the interventions of CBT and GET should have been sanctioned only for use in research and should not have been promoted for national implementation.

As is now undeniable, it cannot be credibly disputed that the PACE Trial failed, so there is still no robust evidence that the interventions promoted in CG53 are appropriate or effective.

The fact that currently there is no effective treatment for ME/CFS should be admitted and should not be the reason for the recommendation of interventions that have been shown to be harmful.

Will you personally ensure that, in the current revision, any recommendations you make will be supported by transparent evidence of effectiveness?  

4.  In 2006 NICE received The Clinical Guideline Development Programme: A Review by the World Health Organisation: May 2006, in which the WHO said: “The Report contains a series of recommendations on how NICE could further develop the Guideline development process”.

Two key recommendations with which the WHO required NICE’s compliance would seem to be relevant to the current situation:

Key recommendation 1: “NICE should develop several types of clinical guidelines, rather than continue to use the current ‘one size fits all’ approach”.

Key recommendation 12:  “NICE should strengthen collaboration with national and international groups”.

In its response of January 2007 to the WHO recommendations NICE said:

Key recommendation 1:  “We are reviewing our scoping process in 2007 with the aim of producing more focused guidelines.  When updating full guidelines, we will focus on the key points of the pathway where guidance is most needed”.

Key recommendation 12:  “NICE already has strong collaborative links with national professionals and stakeholder organisations and research groups.  It is involved in several international projects and initiatives…It is a member of the Guidelines International Network (G-I-N)…It has established links with other guidelines organisations in Europe and has regular exchanges with similar North American organisations.  These links…need to be balanced with the institute’s primary responsibility to prepare and disseminate its guidance”.

Given that there is no literature bearing the imprimatur of UK Royal Colleges acknowledging that the PACE results are inaccurate due to multiple deviations from its published protocol, will you ensure that the current revision of CG53 concurs with key recommendations of the WHO and that NICE will pay requisite heed to the international biomedical evidence which demonstrates what patients have been saying for decades, namely that CBT and GET do not help patients with ME/CFS and that GET in particular is likely to cause iatrogenic harm?  

GET cannot help overcome chronic inflammation and it was ten years ago that Nancy Klimas, President of the International Association for CFS/ME and Professor of Medicine and Immunology, University of Miami, said: “Unquestionably, the name CFS has done harm both to patients who are dismissed as merely chronically fatigued and to the credibility of professionals who are attempting to understand and treat a complex illness that involves neuroinflammation, autonomic and immune peturbations, and hormonal dysregulation”, the substantial published evidence of which NICE comprehensively ignored.

As the Guidelines Development Manual requires equal weighting of the evidence, will you personally ensure that the “expert patient’s” voice is given equal weight to the well-orchestrated voice of one particular group of professionals with confirmed vested interests and will you personally ensure that the evidence upon which NICE’s revised Guideline is predicated is seen to be fact, not fiction?


Monday, 13 March 2017

Science, Politics, .......and ME: A health scandal in our generation

http://amzn.eu/i0e59tt

by Dr Ian Gibson (Author), Ms Elaine Sherriffs (Contributor)

The Dedication –

To all patients suffering from ME and their families and carers. You have been let down by governments, healthcare departments, the media and by those in positions of influence who could have made a difference but have totally failed you.

From the back cover –

Few diseases can have been so maligned by false information, so manipulated by an insidious establishment-controlled ideology, or so poorly dealt with by those holding the purse-strings for research into the disease, than Myalgic Encephalomyelitis (ME). 

This book examines a scandal in our generation – a scandal still being played out by corrupt, apathetic, inept or ignorant attitudes in governments and Medical Research Councils and health services. 

One of the authors (Dr Ian Gibson) in his ‘ Retirement’ has written this book with a political friend (Elaine Sherriffs). Ian Gibson has a passing interest in the current political scene across the world and regularly speaks on these issues. When it comes to universal health, he has pointed out on many occasions that governments often ignore scientific evidence. ME, as described in the book, is a major problem where evidence is relegated to psychiatric explanations. It is a desperate need for scientists as far as health issues are concerned to look for biomedical evidence and ME is a major example. This book describes the political manoeuvring which features just like those in the TV programme The House of Cards in the USA & the UK which described the games that are played in both parliaments. He has previously addressed these problems in an early book in 1981 – called ‘Class, Health & Profit’.

Ian and Elaine have penetrated the murky world of politics which features in the world of ME. It is long past the time to treat this as a serious illness and the need for serious biomedical research. This will only come about when politicians and the media stop trivialising the illness.

Science, Politics …… and ME is a book which will serve as a reference for the dark times, when patients were ill-served by the clash of interests between truths and untruths. It is also a book which comes at a time where a brighter future may be in the making for people with ME and their families.


Saturday, 4 March 2017

My Grace Is Sufficient For Thee

http://bible.christiansunite.com/Morning_and_Evening/chme0304.shtml 

C H Spurgeon's Morning Devotional for 4th March

“My grace is sufficient for thee."

2 Corinthians 12:9

If none of God's saints were poor and tried, we should not know half so well the consolations of divine grace. When we find the wanderer who has not where to lay his head, who yet can say, "Still will I trust in the Lord," or when we see the pauper starving on bread and water, who still glories in Jesus; when we see the bereaved widow overwhelmed in affliction, and yet having faith in Christ, oh! what honour it reflects on the gospel. God's grace is illustrated and magnified in the poverty and trials of believers. Saints bear up under every discouragement, believing that all things work together for their good, and that out of apparent evils a real blessing shall ultimately spring-that their God will either work a deliverance for them speedily, or most assuredly support them in the trouble, as long as He is pleased to keep them in it. This patience of the saints proves the power of divine grace. There is a lighthouse out at sea: it is a calm night-I cannot tell whether the edifice is firm; the tempest must rage about it, and then I shall know whether it will stand. So with the Spirit's work: if it were not on many occasions surrounded with tempestuous waters, we should not know that it was true and strong; if the winds did not blow upon it, we should not know how firm and secure it was. The master-works of God are those men who stand in the midst of difficulties, stedfast, unmoveable,-

"Calm mid the bewildering cry,
Confident of victory."

He who would glorify his God must set his account upon meeting with many trials. No man can be illustrious before the Lord unless his conflicts be many. If then, yours be a much-tried path, rejoice in it, because you will the better show forth the all-sufficient grace of God. As for His failing you, never dream of it-hate the thought. The God who has been sufficient until now, should be trusted to the end.

Wednesday, 1 March 2017

Two ME Films

There are two short films about ME that have recently been produced and I would recommend them to you.

A 10 minute film on ME was shown on Carte Blanche, South Africa’s longest-running TV investigation show, on 20 February 2017. It has won plaudits from around the world for its straight talking about this illness, and choice of interview subjects – particularly Dr Ron Davis and David Tuller. The UK ME Association has made the film available on it’s website and you can watch it by clicking here.

In the other film, which lasts for 18 minutes, Dr Ron Davis presents an ME/CFS research update from his lab at the Stanford Genome Technology Centre in California, USA. The Centre has made significant breakthroughs towards understanding the molecular mechanisms of the disease and is now in a position to test chemical compounds for treatment.

The film is available to watch on YouTube, thanks to the Open Medicine Foundation – click here – and you can read a transcript of all that was said on the ME Association website by clicking here.


Friday, 24 February 2017

Metals Debris Found in Vaccine Supply


A landmark new study has found metal debris and biological contamination in every human vaccine tested. The study should have profound and immediate impact on public health policies and vaccine industry procedures around the globe.

A team of scientists used a highly sensitive technology—an Environmental Scanning Electron Microscope equipped with an x-ray microprobe—to scan for solid contaminants in 44 samples of 30 vaccines. The researchers reported their results in the International Journal of Vaccines and Vaccination. They found widespread contamination by toxic aluminum salts, red blood cells of unknown origin and inorganic, foreign particle debris in aggregates, clusters and independent particulates. The composition of those clusters, the researchers observe, are consistent with "burnt waste."

Further analyses of those particles revealed them to be "non-biocompatible and bio-persistent foreign bodies" composed of lead, stainless steel, chromium, tungsten, nickel, iron, zirconium, hafnium, strontium, antimony and other metals. The investigators also identified some particles embedded in a biological substrate, probably proteins, endotoxins and residues of bacteria. The researchers found contamination in 43 of the 44 vaccine samples tested. The authors stated that these contaminants should not be present in any vaccine, and that their presence was not declared by the manufacturers. Ironically, the one sample that came back clean was a veterinary vaccine.

The team of scientists from the International Clean Water Institute, USA and the Italian National Research Council Institute of the Science and Technology of Ceramic materials, and Nanodiagnostics srl, Italy, was lead by Dr. Antonietta Gatti. In interviews with myself and James Lyons-Weiler, Dr. Gatti recounted the history of the investigation:

Our analyses on vaccines started by accident about 15 years ago when Germany's University Hospital of Mainz asked us to analyze samples of an anti-allergy vaccine they administered." The vaccination had caused painful swellings around the injection point, and the formation of wheals that refused to subside. "We analyzed the samples of both vaccines and wheals and found solid particles inside both of them. Those particles should not have been there." 
Dr. Gatti explains that the discovery of vaccine impurities shocked the researchers. "We had never questioned the purity of vaccines before. In fact, for us the problem did not even exist. All injectable solutions had to be perfectly pure and that was an act of faith on which it seemed impossible to have doubts. For that reason, we repeated our analyses several times to be certain. In the end, we accepted the evidence."

The revelations at Mainz caused the scientists to wonder if the debris problem might be more widespread and whether it might help explain a slew of mysterious adverse vaccine reactions reported by the industry. As an example, the authors quote post-marketing adverse event surveillance data associated with Tripedia (DTaP) vaccine, as reported by the manufacturer in the product insert. These reactions included "idiopathic thrombocytopenic purpura, SIDS, anaphylactic reaction, cellulitis, autism, convulsion/grand mal convulsion, encephalopathy, hypotonia, neuropathy, somnolence and apnea." According to Gatti, "No satisfactory explanation has been given as to why these adverse events occur." These questions prompted the researchers to investigate material contamination in vaccine products.

Dr. Gatti and her husband, Dr. Stefano Montanari, are well-known as the discoverers of nanopathologies—diseases caused by micro and nano particles. Dr. Gatti speculated about the fate of the inorganic vaccine contaminants in the human body:

"The particles, be they isolated, aggregated or clustered, are not supposed to be there. … Our tissues perceive these foreign bodies as potential enemies. The biological reactions are expected to be fairly complicated, with macrophages that try to engulf them the way they do normally with bacteria and parasites to form a protein corona. Unfortunately, though, the particles we found in vaccines, are not biodegradable. So, all the macrophages' efforts will be useless, and depending on the exact chemicals involved, the particles may be especially toxic. Cytokines and pro-inflammatory substances in general are released and granulated tissue forms, enveloping the particles. This provokes inflammation which, in the long run, if locally persistent, is known to be a precursor to cancer."

Asked to explain how the contamination got into the vaccines, Dr. Gatti replied, "That's a question we can't answer. We would need to inspect the laboratories where vaccines are produced, but no pharmaceutical company would allow us to do so."

Gatti told me that she contacted Sanofi Pasteur, a manufacturer of one of the contaminated vaccines. The company's only reaction was to dismiss her findings as impossible. Gatti speculates that the companies ignore this type of contamination because regulators are focused only on biological impurities in the manufacturing process.

She said, "Generally speaking, the good manufacturing procedures those laboratories are bound to follow, are focused on organic and biological matter, but disregard inorganic particulates." Dr Gatti remarked on the researchers' finding that the animal vaccine (Feligen) was clean of any particulate matter, debris or other contaminants, saying, "It is evidently possible to produce a clean vaccine."

Gatti told me that she and her research team have reported their alarming findings to the vaccine industry and to Italian health authorities. They urged that regulators and industry begin employing technologies to prevent this kind of contamination. "From my point of view, which is a merely technical one, she said, it's easy, you learn how to check vaccines … you forbid polluted vaccines to be distributed. This would immediately ensure that producers take appropriate counter-measures, for example, by working in a truly clean environment and carrying out their analyses the way they should be done."


Monday, 20 February 2017

Absence of Evidence


Margaret Williams       18th February 2017

Introduction

As is widely known, Professor Sir Simon Wessely is President of the Royal College of Psychiatrists and is President-elect of The Royal Society of Medicine; his GP wife Dr Clare Gerada, now Lady Wessely, was Chair of the Council of the Royal College of General Practitioners. 

A “Joint Commissioning Panel for Mental Health” from these two Royal Colleges has just produced a 24 page document entitled “Guidance for Commissioners of services for people with medically unexplained symptoms – practical mental health commissioning” in which they include myalgic encephalomyelitis/chronic fatigue syndrome as a functional somatic syndrome ie. as a mental disorder (http://www.jcpmh.info/wp-content/uploads/jcpmh-mus-guide.pdf).

The document is intended for, amongst others, Commissioners of NHS services, Directors of Adult Social Services, the Royal College of Nursing and the Clinical Commissioning Groups that are run mostly by GPs who commission local health care. 

This could sound the death knell for people with ME/CFS who currently receive care packages funded by their Local Authority because there is abundant evidence that cash-strapped Local Authorities spend next to nothing on mental health.

For decades, the proponents of the now-infamous PACE Trial -- particularly Professors Simon Wessely and Peter White -- have maintained that without hard evidence of organic pathology, they will not accept the WHO classification of ME/CS as an organic disorder and they insist that it is a functional somatic syndrome (FSS). 

In other words, ignoring the existing evidence-base of pathoaetiology, since there is not as yet a definitive test for ME/CFS, they believe that absence of evidence really is evidence of absence, so they continue to categorise ME/CFS as a behavioural disorder that can be “cured” by cognitive behavioural therapy (CBT) and graded exercise therapy (GET) and they advise Departments of State that these interventions are both effective and cost-effective.

In their own insular world of psychiatry, however, they appear to have convinced themselves that absence of evidence is not evidence of absence when it comes to the clinical and cost-effective benefit of CBT/GET for people with ME/CFS.

The PACE Trial was funded because it was acknowledged that previous trials of CBT and GET were insufficiently robust. As is now undeniable, the PACE Trial failed, so not only is there no evidence that ME/CFS is a functional somatic syndrome but there is no credible evidence that CBT/GET are effective interventions for its management.

Lack of evidence of both clinical benefit and cost effectiveness

1. In 2001 the York Centre for Reviews and Dissemination reviewed the available evidence for the clinical effectiveness of CBT/GET in ME/CFS; the review team’s negative comments referred to methodological inadequacy; study withdrawal; drop-out rates for CBT; drop-put rates for GET; the unacceptability of treatments; reported improvements may be illusory (“the modest gains may be transient and even illusory”); there was no objective evidence of improvement and there was little lasting benefit from CBT (Interventions for the treatment and management of chronic fatigue syndrome: a systematic review.  Whiting P, Bagnall AM et al: JAMA 2001: Sept 19:286(11):1360-1368).

2. In 2005, Bagnall AM et al from the same Centres for Review and Dissemination produced the 488-page “York Review” of the “evidence” of the effectiveness of CBT/GET from the same studies they had reviewed in 2001 (The diagnosis, treatment and management of chronic fatigue syndrome (CFS) / myalgic encephalomyelitis (ME) in adults and children – Work to support the NICE Guidelines).  

Notably, given that the same RCTs were scrutinised, all previous negative comment from 2001 had disappeared from the 2005 version, but in both the 2001 and 2005 versions, two important issues were not mentioned: (i) corrupted data and (ii) follow-up data revealed relapse, but the 2005 version was the “evidence” upon which the NICE Guideline was predicated.

3. In August 2007 NICE duly produced its Guideline on “CFS/ME” in which it acknowledged the lack of adequate research evidence whilst simultaneously asserting:  “The guideline provides recommendations for good practice that are based on the best available evidence of clinical and cost effectiveness”.  

In his CV, Professor Sir Simon Wessely states about the NICE Guideline: “My work has significantly influenced the management of chronic fatigue syndrome, reflected in the 2007 NICE Guidelines”.

Not only did NICE rely on “illusory” clinical benefit, it manufactured its own evidence on the cost-effectiveness of CBT and found no convincing evidence of the cost-effectiveness of GET.

There were numerous basic arithmetical errors in the Guideline (conceded by Professor Peter Littlejohns, Clinical and Public Health Director of NICE, in his Witness Statement for the High Court Judicial Review) but, importantly, NICE’s own cost-effectiveness search found that out of 60 papers reviewed, only three were considered suitable.

One was a study by Wessely et al which showed no benefit from CBT (BJGP 2001:51:15-18).

Another was the Severens et al paper  (Severens JL et al, Q J Med 2004:97:153-161), which in turn relied on the flawed Prins et al study (Lancet 2001:357:841-847), a study about which in his evidence for the Judicial Review, Martin Bland, Professor of Health Statistics, University of York, presented convincing evidence showing why “the entire Prins trial” was “invalidated”.

NICE, however, decided that the Severens et al paper upon which its entire costing analysis  had to rely had under-reported the benefit because the timescale used was insufficient to show long-term benefit (its timescale being only 14 months in total and not the desired five years).

NICE therefore decided to “extend” the Severens timescale to fit its own requirements to show long-term cost benefit of CBT.  

Since there was no evidence of long-term cost-effectiveness in the Severens et al paper, NICE decided to use the 2001 study by Deale et al which was a five-year follow-up of their 1997 paper (Long-term Outcome of Cognitive Behavioural Therapy Versus Relaxation Therapy for Chronic Fatigue Syndrome: A 5-Year Follow-Up Study.  Alicia Deale, Trudie Chalder, Simon Wessely et al.  Am J Psychiat 2001:158:2038-2042). 

To obtain the “evidence” it needed, ignoring the fact that the two trials used different cohorts and different criteria, NICE extrapolated Deale et al’s 2001 results published in the American Journal of Psychiatry and projected those results into the Severens et al’s 2004 paper to produce what NICE thought might have been Severens’ results in five years’ time. 

Of importance is the fact that this sole 5-year follow-up study by Deale et al suffered from corrupt data: the authors themselves acknowledged that: “56% of the patients undergoing CBT reported receiving further treatments for their chronic fatigue symptoms; other treatments used were antidepressants, counselling, physiotherapy and complementary medicine”, and over the course of the five year follow-up, treatment of many patients had deviated from the trial protocol, rendering the outcome measures meaningless.  

This did not deter NICE from using the corrupted data from the Deale et al study to create its own cost effective “best evidence” in relation to CBT for ME/CFS. 

It is difficult to understand how NICE could get away with creating “evidence” which did not exist and relying on the “evidence” it had created to underpin a national Guideline that claimed to set out best practice.

In the key (Severens) paper upon which NICE relied as “evidence” of the cost-effectiveness of CBT, the Guideline Development Group did not have access to the source data (conceded on page 209 of the Full Guideline). When it subsequently became available, the objective actometer data showed no statistically significant difference between cohort and controls. 

This means that NICE produced a Guideline with a potential catchment of 240,000 sick people based on a flawed analysis that failed to consider objective data which showed no benefit from CBT. 

With regard to GET, the single study which attempted to examine the relative cost-effectiveness of CBT and GET found that the cost-effectiveness of CBT and GET were similar but the study was limited by its small size and by “the use of a non-randomized comparison” (McCrone P et al: Psychological Medicine 2004:34:991-999).

Given that both clinical benefit and cost-effectiveness were based on very limited and poor quality evidence, the development of the Guideline was hardly a scientific approach, let alone one that was “excellent” by the-then titled National Institute for Health and Clinical Excellence.

In his CV, Professor Wessely states about the NICE Guideline: “My work has significantly influenced the management of chronic fatigue syndrome, reflected in the 2007 NICE Guidelines”.

4. In 2008 the Cochrane Systematic Review of CBT/GET found that costing was under-researched and that there was a pronounced lack of research into the likely costs to the NHS of CBT/GET for patients with ME/CFS.  Importantly, Cochrane regarded CBT and GET as integral: “For the treatment of CFS, CBT combines a rehabilitative approach of a graded increase in activity with a psychological approach addressing thoughts and beliefs about CFS that may impair recovery”, hence the Cochrane comments on costing applied to both CBT and to GET.

5. On 6th January 2011 Frances Rawle PhD, Head of Corporate Governance and Policy at the Medical Research Council, wrote to Professor Malcolm Hooper confirming about CBT/GET that, prior to the PACE Trial: “there was insufficiently strong evidence from randomised controlled trials to support their effectiveness”.  This was a surprising admission, because the NICE Guideline that advocated CBT/GET was published four years before the initial results of the PACE Trial appeared.

6. In 2012 McCrone et al published their cost-effectiveness results of CBT/GET based on the PACE Trial data (Adaptive Pacing, Cognitive Behaviour Therapy, Graded Exercise, and Specialist Medical Care for Chronic Fatigue Syndrome: A Cost-Effectiveness Analysis.   Paul McCrone, Michael Sharpe, Trudie Chalder, Martin Knapp, Anthony L. Johnson, Kimberley A. Goldsmith, Peter D. White  Published: August 1, 2012 http://dx.doi.org/10.1371/journal.pone.0040808). 

Over three years later, despite legitimate efforts by Professor James Coyne to gain access to the data so that he could independently verify McCrone et al’s economic analysis, since 11th December 2015 his request has been refused as a “Vexatious Request” by King’s College, London: “The university considers that there is a lack of value or serious purpose to your request. The university also considers that there is improper motive behind the request. The university considers that this request has caused and could further cause harassment and distress to staff”, hence there has been no independent scrutiny of McCrone et al’s claim of cost-effectiveness for CBT/GET in ME/CFS.

The PACE Investigators refuse to accept that their favoured interventions of CBT and GET are neither clinically beneficial nor cost-effective so, as Professor Jonathan Edwards notes on Phoenix Rising about their latest attempt to save face (http://forums.phoenixrising.me/index.php?threads/do-more-people-recover-from-chronic-fatigue-syndrome-with-cbt-or-get-than-with-other-treatments.49331/#post-813558): “We seem to live in a world full of people digging holes for themselves”.

Perhaps the best summary of what has become a farcical situation is provided by “Sean” who wrote on Phoenix Rising: “So let me get this straight: PACE was justified on the grounds that the existing literature was insufficiently robust and needed proper ‘definitive’ testing. 

“But when the results from PACE did not support the results from previous studies, nor hence the underlying theoretical model, the numbers were simply fiddled until they did, and this was justified by saying the new numbers now agree with those previous studies, the same ones that were insufficiently robust enough that they provided the justification and necessity for the "definitive" PACE in the first place. 

“So the previous results being tested by PACE, because they were not robust enough, became the standard by which the results from PACE were determined to be robust or not. 

“Circularity City, or what”.

Whilst the clinical benefit and the cost-effectiveness of CBT/GET may both be illusory, the Report for Commissioners from the two Wessely family-influenced Royal Colleges is anything but an illusion.

By categorising ME/CFS as a mental disorder, it intentionally disregards the mandatory use of the ICD-10 classification codes throughout England as required by NICE.  

This is a serious and dangerous situation: patients with the profoundly disabling neuro-immune disease ME/CFS are now likely to be subject to even more iatrogenic harm. 

Documented iatrogenic harm includes not only lack of medical care, where patients’ symptoms are ignored, dismissed and denied, but also abuse and ridicule. 

Sufferers may yet again be bullied into undertaking harmful management interventions and if they do not comply, their State and insurance benefits are likely to be reduced or withdrawn, putting their very survival at risk.


Thursday, 9 February 2017

Three New Items On The Margaret Williams Website

The Cost of Collusion? (8 February 2017)
Margaret Williams

The Power Of Propaganda? (4 February 2017)
Compiled by Margaret Williams

Letter to the Countess of Mar from the Public Accounts Committee Chair (1 February 2017)
Meg Hiller MP