Transcript: Fit To Practise
First broadcast on BBC Radio 4
Tuesday 19/10/04 2100-2130
Nobody can treat an animal unless they have a veterinary licence but anybody can treat the animal’s owner without any kind of licence whatsoever.
Statutory regulation is not a panacea, you can’t protect, for example, unqualified practitioners from practising, even if you have a statutory scheme.
Here we’re trying to bring together Western medical treatments, so orthodox medicine, complementary medical practitioners, the Chinese community, the nursing profession and somehow we’re trying to find a way of all working together.
Complementary and alternative medicine is such a vast and varied field, it doesn’t easily lend itself to regulation. At the moment apart from chiropractors and osteopaths, practitioners don’t have to join any official register or take any course of training before they start to practise. But with so many of us using this form of healthcare today, the government is planning to take action, both to regulate the practitioners and the thousands of products for sale.
ACTUALITY - TRADE FAIR
My name’s David Cann, I’m the managing director of Target Publishing and the Natural Trade Show and we’re standing on the gallery at the Brighton Metropole looking down on 130 exhibitors. This trade show that we have developed is for wholly independent retailers and practitioners within the natural product, organic and complementary industry.
That trade is currently worth about £800 million a year. Independent retailers and individual herbalists are very concerned at what the regulation may mean.
ACTUALITY - TRADE FAIR
My name’s Ralf Pike, I’m the director of the National Association of Health Stores. It’s the biggest issue that we’ve had in this country for a long time because it comes down to freedom of choice, how you look after yourself, what you want to do with your own health - whether you want to have no alternative to drugs, that choice is being taken away from us essentially by a raft of European directives, the first ones are already in place now called the Food Supplements Directive and that’s going to take around 5,000 products off the marketplace on the 1st August 2005.
My name is Sue Croft and I’m a director of Consumers for Health Choice. I’ve come to Brighton today because I’m very concerned that our supporters - the consumers out there of these products - are going to lose out and lose a great many of their most popular supplements. Now these are not just any vitamin and mineral product, they are specialist formulations, they are high dose levels, many of them have been on the market for possibly up to 50 years but Brussels says we can’t have them, therefore they will either be removed from the market completely or will have to be reformulated but also the dose levels will be substantially reduced.
Well I’m David Adams, I’m director of the Health Food Manufacturers’ Association. My association has joined with another in actually taking legal action and trying to have one particular directive anulled. We would much prefer to actually have common-sense discussions with the government and with the EU and actually arrive at solutions that both preserve consumer choice but also obviously give them a guaranteee of continued safety.
The body charged in part with implementing the EU regulation in this area is the MHRA, part of the Department of Health. They couldn't give us an interview but they sent us this statement:
"There is wide agreement across almost the entire herbal sector that the current regulatory arrangement for unlicensed herbal remedies is unsatisfactory. Whilst there are many responsible producers out there, the Medicines and Healthcare Products Regulatory Agency has also come across repeated examples in UK of unsafe and poor quality unlicensed products, containing illegal ingredients, the wrong herb or poor labelling. We want to protect public health, enhance the status of herbal medicine and maintain wide consumer choice."
So regulating products is proving controversial, but the government hopes it will safeguard the public’s interests: just as in the future we can expect statutory regulation of practitioners and their therapies to be tightened up too. But how might that benefit patients?
My name is Keith Boughton and I live in Bournemouth in Dorset. I suffer with asthma, a specific type of asthma called brittle asthma. What makes brittle asthma different to normal asthma is that it’s generally very, very severe and it comes on very, very quickly.
After a decade struggling to manage his asthma with steroids, Keith decided that he would look for an alternative and chose acupuncture. But finding a reputable therapist was far from easy.
I was very concerned initially about the aspect of cleanliness. I’m not averse to needles but I felt that sterility or cleanliness had to be paramount. I looked through yellow pages, I had no other referral points, and the qualifications varied so much and I became quite confused about who had what level of understanding or qualification or training. But I was a little bit concerned with one particular acupuncturist that I spoke to. I was concerned because firstly he said yes it always worked for asthmatics, so that tended to make me a little bit sort of cautious about what else he was going to say. And the other thing was he told me that I needed treatment at least three times a week, well everyone else said that once a week or twice a week was the most that I would ever need. I recall thinking that he was talking in a different light to other people and he could see me immediately and so I just got that feeling that I didn’t quite know who I was speaking to or what training he’d got.
Historically healthcare professions have always been regulated. That said complementary and alternative therapies until relatively recently have been outside the statutory regulation framework. That changed in 1993 when the osteopaths became the first CAM therapy to be statutory regulated, followed by the chiropractors a year later.
Julie Stone is a lawyer with many years experience of tackling thorny issues in complementary medicine such as ethics and regulation. She’s also the deputy director of the Council for Healthcare Regulatory Excellence - a new government body set up in the wake of the Shipman inquiry - which in effect, regulates the regulators. CHRE oversees organisations like the General Medical Council and the General Osteopathic Council.
Regulation has two sides to it. By becoming statutory regulated there’s no doubt that it confers a certain status and legitimacy on a therapy. That said that is very much the secondary aim of professional self-regulation, professionally led regulation, which is of course to protect the public. Now it’s arguable that the higher the professional status the easier it is for public protection to be assured but public protection has to be the driving force behind regulation.
ACTUALITY - OSTEOPATHY STUDENTS
At the British School of Osteopathy, second year students practise handling patients in a clinical setting.
ACTUALITY - OSTEOPATHY STUDENTS
Okay what I think we’ll do is if we just have another for 10 minutes or so, 10 or 15 minutes of doing this
Osteopathy is a manual therapy that detects and treats damaged parts of the body such as muscles, ligaments, nerves and joints. The emphasis is on aiding the body’s health by correcting the alignment of the skeleton and restoring balance.
It was given statutory status in 1993 after a battle with orthodox medicine which lasted the best part of a century. Like other regulated healthcare professions, the General Osteopathic Council is headed by a lay chairperson, Nigel Clarke. I asked him what the main benefits of regulation have been.
The single most important thing it’s done is that when a patient goes to see an osteopath they know that that person has been - has demonstrated themselves to be safe and competent to a set of agreed standards. They also know that that practitioner is insured because all osteopaths registered with us must have professional indemnity insurance and they also know that if - were anything to go wrong - God forbid - there is a complaints mechanism and a proper way of bringing that osteopath to book if they have either demonstrated professional incompetence or unacceptable professional conduct.
Do osteopaths now feel that they are a profession - they’re properly regarded as a profession?
Yes they do.
And what is their relationship now with GPs would you say?
I think it’s variable, if one’s to be fair. Quite a number of osteopaths work closely with local GPs, others don’t have a particularly close relationship with them and in some areas GPs don’t have any contact at all with osteopaths. But compared with say 10 or 15 years ago even that is quite a big change.
And what would you do if there were a registered osteopath who was guilty of unprofessional conduct in some way?
Well we have a number of options available to us. First of all, having made a complaint it’s investigated by our investigating committee who determine whether there is a case to answer. If they so determine it’s referred to the professional conduct committee and if they find that that person is guilty of unacceptable professional conduct or professional incompetence they can either be struck off the register - erased from the register - which means they can’t practise as osteopaths, they can be suspended for up to a year, we can impose conditions of practice to ensure that they become safe and competent, they can be admonished which is effectively a slap on the wrist but in a small profession is a significant gesture or there can be interim suspensions if more needs to be determined before a decision can be made.
Chiropractic, not dissimilar to osteopathy, came in from the cold in 1994. Twenty-five years ago it was a disciplinary offence for a GP to refer patients to a chiropractor, such was the hostility towards them. So how has regulation changed that experience? Scott Middleton practises in Manchester and is a spokesperson for the British Chiropractic Association.
I think it’s opened the doors, the modern GP or consultant who is au fait with modern medical research wouldn’t hesitate but to refer a patient to a chiropractor and be very happy with it. Because I’ve lectured so extensively in my area and to GPs and consultants over the years they roughly knew what we did anyway and I’m part of the post-graduate medical circuit for GPs and in the last three weeks I’ve had six medical doctors watching me work. That opens up the doors, once they realise our limitations, they realise that we’re very honest and we tell people what we can’t do they’re more than happy to refer patients to us.
By establishing these codes of conduct covering ethics and professional standards, organisations like the British Chiropractic Association try to ensure that their members don’t overstep the mark and make exaggerated claims about the therapeutic benefits of chiropractic, giving the public the wrong impression about what conditions can be treated and what can’t.
We don’t deal with immunisations or diseases in any way shape or form. There’s nothing chiropractic can do for a disease. We’re mechanical, we treat mechanical problems - we treat pain, pins and needles, numbness and weakness of mechanical origin, so we treat bad backs, sciatica and things - we don’t treat tumours, we don’t treat diseases, we don’t treat all the arthrotides or forms of arthritis. Individual chiropractors like individual doctors of medicine might give varying opinions but we shouldn’t move out of our field, we don’t need to.
ACTUALITY - SHIATSU CLASS
A key component of the drive towards greater regulation in CAM is higher educational standards. Over the last decade, two and three year courses have been developed in a variety of disciplines which ground students not only in the traditions of their chosen therapy, in this case shiatsu, but also in anatomy, biomedicine and practitioner development skills.
Having an interest in working directly with the body was something that attracted me to shiatsu. Also it being founded in Chinese medicine, which has got thousands of years of pedigree to it. And that’s been helpful for me to place that Western - the Western models in a broader context. So we do talk about physiology and anatomy and next year we’ll talk about pathology. My eyes have been opened actually to the value of Western models and Western approaches, having them placed within a much broader more holistic context.
Part of the trend towards professionalisation has seen a shift in the training and the education required to become a complementary or alternative practitioner towards more academic, more professionalised training and the key to that is that this is externally accredited training, in other words you can’t run your own training school and then set up a register for the graduates of your own training school.
More than 40 higher educational institutions now offer studies in one or more forms of complementary medicine, often at degree level. The pioneer, was the University of Westminster’s Department of Complementary Studies, whose chair is Brian Isbell. He explained that it’s a challenge to integrate traditional therapies into modern academia.
It’s been a very delicate balance because obviously making academic programmes out of therapies has been a challenge. But provided it’s a partnership between the practitioner resource that we’re using, the academics that we have, the professional bodies we can get the balance right. And the balance needs to be right because obviously we need skilled practitioners, ones that not only can talk about what they do but obviously practise effectively. In fact the themes of health sciences, practitioner development and research go throughout the courses. So it’s not as if there’s sort of a division or polarisation because obviously if we organise the course like that the students may see it in that way. So in fact their therapy plus the other themes are taught all the way through the course, so that they see it as integrated package. And the other thing which we feel is vital is that not only do they have the opportunity to of course learn in mixed groups - that is with those studying other therapies - but we do our utmost to make sure they get experience of working in the NHS as well.
Education, ethical guidelines and practitioner development - all positive moves towards best practice in the CAM world.
But as far as regulation goes, don’t expect a general council of aromatherapy or crystal healing in the near future, if ever.
When the House of Lords published its landmark report on complementary medicine in 2000, they recommended that only certain therapies would need to be regulated. They were those which "pose a direct risk to public health", which could demonstrate a significant body of research, and whose practitioners shared a common ideology. Two professions which have met most of those criteria are acupuncture and herbal medicine.
But the process has not been easy because of the political in-fighting between the different tribes within these professions. There are 7,000 registered acupuncturists in this country, spread over several organisations. The herbalists, both Chinese and Western, account for at least six different bodies.
A further recommendation by the Lords was, unlike the osteopaths and chiropractors, the creation of a single CAM council for all the other professions, which has proved to be an unpopular option. Mike O’Farrell is chief executive of the British Acupuncture Council.
It’s in our interests that we work together. I don’t think it’s in our interests or the public’s interests that we should combine acupuncture and herbal medicine in one generic body unless we’re able to clearly specify within that body the responsibilities of each. For me it’s very, very important that the public is able to look at a list or a register and say x is an acupuncturist, y is a herbal medical practitioner. Now they’re on that list, what exactly do they do?
It’s been presented to us that Chinese medical practice is dangerous and needs to be controlled. Actually I would take issue with that. Of course there are instances where it’s dangerous, where people improperly prescribe substances that are very fierce but I think there is very little evidence that it’s intrinsically dangerous if people are properly trained.
Dr Vivienne Lo practises acupuncture and is also a research fellow at the Wellcome Trust Department of the History of Medicine at University College, London. She echoes the concerns of the Chinese practitioner community who say that Chinese medicine is often misunderstood in the West and might be marginalised by new laws.
The beauty of most traditional medical practice is that it’s an art and if an environment can be created whereby practitioners are nurtured in their art then that’s a good thing. In the end there will be a board that registers the new practitioners and that could fall down on the side of a group of European practitioners who don’t want to register the Chinese, who don’t respect Chinese knowledge and who want to - who have their agendas about their own tradition and how they believe their own tradition is.
One of the things that I’ve been doing is to chair meetings between the Department of Health and the Chinese bodies to try and build some bridges and bring us all closer together because in the end the public have got to be able to feel that wherever the individual comes from, wherever they were trained, they are to a particular standard and that standard is reflected in the fact that they’ve been allowed to appear on the register.
Regulation is by no means universally popular amongst the practitioner community though opposition is dwindling. Apart from a dislike of bureaucracy, and issues of cost, there is a deeper concern that regulation will attempt to control the therapies rather than just the therapists.
In Hebden Bridge in Yorkshire, I met John Landale who's been in practice for 35 years. He was a member of the British Acupuncture Council but left after refusing to alter the way he works to fit in with their new rules. He describes himself as a neuro-acupuncturist.
I wanted to really find out what was really making acupuncture tick, why did it work in some people and perhaps didn’t work in others? And so I started looking for different points and I’ve come up with a whole class of new acupuncture points that do a better job.
That’s very interesting because the Chinese were doing this for 2,000 years and you’ve said not all of what they did was right, so you found a new way of doing acupuncture which you call neuro-acupuncture.
That’s correct but I’m not trying to say they were wrong. Acupuncture works whatever the name you give it, it’s just that some points are more powerful than others. So I’ve merely found other points to give me a stronger effect and I use them in my own manner, I don’t think in terms of fire, earth, metal, water and wood as a traditional acupuncturist would, I don’t look for chi energies because I don’t believe there are any. But it is your body’s own nervous energy that produces the changes.
Now this change in your thought process and in your practice led to a bit of a fall out with the British Acupuncture Council didn’t it?
Only in my method of description. The British Acupuncture Council wanted me to write my notes in a traditional manner and I didn’t want to do that - and in fact they gave me two weeks to do it in and I refused, and so I gave my resignation in because of that.
And has that had any implications for you, I mean has it meant that you can’t practise in this sphere?
Oh not at all, no. The British Acupuncture Council has no - has no authority as to whether anyone can practise - this is one of the thorns in the side of the acupuncturists at the moment because a lot of acupuncturists are masquerading as acupuncturists when really they’re not. There’s a lot of shops that’s grown up - I won’t name them - but the shops in almost every shopping centre but the people inside them are not qualified and so this is why the government through the British Acupuncture Council are now looking to register all acupuncturists and I strongly agree with that, I don’t agree with people doing acupuncture that are not capable.
I’m Katherine Armitage. I work as a homeopath from Health Foods, Fulham Road. I use flower essences and homeopathy as my main therapies, I also work as a healer. I’m not a member of the Society of Homeopaths, I’m actually not a member of any of the registering bodies for homeopaths, I’m a member of my college of homeopathy - which is the Lakeland College. Statutory regulation is a good thing and there are lots of people who are doing fantastic work to move towards that. My own personal feeling is that if I’m statutorily registered and I have to limit my practice of homeopathy to a certain way I would rather change the name of what I do - for example call myself a resonance therapist - and continue to be able to practise in the way that I practise now.
It’s important to remember that statutory regulation unless it protects function, as well as title, cannot stop people from practising in that particular area. It would stop me, for example, holding myself out or calling myself an osteopath, indeed it would be a criminal offence. That said there coexists a common law - freedom to practise - whereby anyone can practise provided they don’t use that title. Ultimately whether or not to seek a registered practitioner has to be a matter of public choice. Now personally I don’t buy into the idea that all patients are vulnerable but people have to exercise a level of choice and responsibility about the therapies which they access.
Though help is at hand because increasingly therapy bodies are unifying to create single registers with clear operating guidelines for practitioners, on a voluntary basis. A recent example of this is the Society of Homeopaths - the largest single body for non-medical practitioners. Melanie Oxley is a director of the society and a registered homeopath.
The first thing they must do is find out how the homeopath was trained and if they’re regulated by an existing registering body, such as our own. We have robust complaints procedure, we have our own professional conduct department. So we protect the rights of the patients and we support our members. So if they look for the letters after the name that say the homeopath belongs to - the Society of Homeopaths for instance - they know that all that has gone before.
Would you welcome a more statutory regulatory process?
This is a discussion that’s really only just beginning within the homeopathic profession. At this point we have to really heed what the Department of Health is advising us which is to get our own house in order first, in other words to pursue a route of voluntary self-regulation, to get a robust system up and running and then that will be the time to see what greater benefit can be afforded by statutory regulation.
The government is suggesting that there isn’t going to be a homeopathic council but they would like to see a general CAM council, do you think that’s a move in the right direction?
We have reservations about that and we wrote to the Department of Health to say that we did not think a joint CAM council was a very good idea. Logistically it would seem to be something that was destined to be enormous if it were to reflect all of those interests and let’s face it within acupuncture there are four or five different disciplines. If all of those practitioners could be represented on a council it would be huge and I think it would be unwieldy and probably very expensive.
Not surprisingly not all homeopaths agree on how best to regulate CAM. Dr Bob Leckridge is president of the Faculty of Homeopathy which represents medical homeopaths. Leckridge thinks that the opposition to the single council is misguided.
That thinking is coming from believing that a council has to represent a whole bunch of individual unique and different therapists. That’s not what we do. For example, the GMC regulates me in an identical way to a colleague who is a surgeon or a psychiatrist and yet on a day-to-day basis the three of us - psychiatrist, surgeon and homeopath - are using an extremely different skill set and working in very different clinical contexts. That works because it works on a basis of the core shared professional skills. Why can that not be applied in the world of complementary therapy?
This animated debate over single or multiple councils will come to a head when the Department of Health reveal their plans for CAM regulation, which they say they’ll do by the end of 2004.
But the regulation issue is just part of a more profound debate, one that has yet to be fully tackled either by CAM or by those in orthodox medicine. And that’s the question of whether complementary medicine with all its diversity of styles and views, will finally be able to make the transition from the fringes, to become an integrated part of the National Health Service.
And integration is the subject of our final programme in this series, next week.
Do they want to be accepted truly as healthcare professionals or not? And it’s not a matter of trying to defend their therapy or trying to defend their cause, but it is a matter of trying to say to the public that they are prepared to work on a day-to-day basis with the same standards as a doctor or a nurse or a pharmacist. And what that’s likely to lead to in terms of a pay-back is that the therapy itself becomes more legitimate, more understood and more accepted. And if we really want to be patient-centred and we want to pitch up each day and do a job on behalf of patients rather than on behalf of ourselves then I think it’s no good to stand and fight our own corners anymore.