Will regulating alternative health practitioners improve public safety?

BEFORE he became the world’s first professor of complementary medicine and an outspoken opponent of non-evidence-based healthcare, University of Exeter professor Edzard Ernst was, in fact, a homeopath himself.

But after devoting the past 18 years testing the science behind the claims of homeopaths and other alternative practitioners, he has come to label his past profession as “useless.”

His first post as a junior doctor in Germany was at a homeopathic hospital where he not only learned the tricks of that trade, but also practised acupuncture and several other alternative approaches.

His critics have claimed he’s just a mouthpiece for the pharmaceutical industry, an accusation Professor Ernst has flatly rejected. If he’d taken industry cash, his program would certainly not be closing down due to lack of funding, he rebuts.

“They tried to brand me as a quack-buster who is bought by Big Pharma. In truth, I am just a scientist who wants to determine the truth,” he says.

“Science is not a tool to prove that your ideas are correct, it is a tool to test whether this is the case... A thin veneer of respectability is often given to areas that do not deserve it, and as a result the public is being frequently misinformed about alternative medicine and misled to make dangerously wrong therapeutic decisions.”

That idea-- that vulnerable people, particularly those with chronic diseases, could receive inadequarte care as a result-- is among the concerns driving a push for increased regulation of alternative medicine practitioners.  In February, the Australian Health Minister’s Advisory Council (AHMAC) began a national consultation to discuss the options. Some 350 people attended the nine forums held throughout the country, and 181 submissions were received. A final report is expected to be sent to health ministers this month, says Anne-Louise Carlton, manager of health practitioner regulation for Victoria’s Department of Health, which was contracted by AHMAC to hold the  consultations.

While the majority of unregistered health practitioners practise in a safe, competent and ethical manner, says AHMAC, a minority is engaging in conduct so serious that they would have been prevented from practising had registration existed – yet they are allowed to continue with impunity. And the number of complaints is increasing.

“The complaints numbers are very small, but some of the submissions have been saying there’s significant under-reporting because people don’t know where to make a complaint,” Ms Carlton says.

AHMAC has proposed three options: no change; a voluntary code of practice for unregistered health practitioners; or a national statutory code of conduct.

While some have argued that registration would lend too much credibility to certain professions, Ms Carlton says that’s not the point. Decisions over which professions must register are made based on two key criteria, she says: how risky the profession is considered, and how much public protection is deemed necessary.

Since the Chinese Medicine Registration Board of Victoria began operating in 2002, it has run nearly 30 prosecutions and several disciplinary cases, and during the ‘grandparenting’ period, the board refused registration to about 10% of applicants it determined didn’t meet its standards for being sufficiently qualified.

Those urging reform say they are particularly concerned about practitioners who target treatment at patients with serious, life-threatening conditions such as cancer, and engage in a way that “could be considered predatory”.

In other words, they encourage unreasonable expectations, use false or misleading advertising, charge exorbitant prices for treatments that are sometimes of questionable quality, and sometimes mislead people into believing they’re more qualified than they are, Ms Carlton says.

What often happens, she explains, is that a questionable practitioner may come in contact with a range of regulators over a number of years – for example the TGA, the Department of Fair Trading, a state medical board or the Australian Competition and Consumer Commission – “and each of those bodies looks at the practitioner’s conduct in terms of their own regulatory responsibilities, but nobody is able to look at the conduct in its totality.”

Several such examples are listed in the consultation paper posted on AHMAC’s website.

One describes an inquiry by Victorian Health Services that found one shamanic healer had engaged in sexual  relationships with several of his clients. But the Health Services Commissioner did not have the power to ban the “healer” from practice and was limited to public “naming and shaming”.

The exception is NSW, which, following several scandals of its own, including some involving patient fatalities, became the first – and so far only – state to enact a code of conduct in 2008.

In NSW, the Health Complaints Commissioner has the power to investigate breaches and, in serious cases, to prohibit
the practitioner from practising.

South Australia has also recently completed a parliamentary inquiry into the provision of healthcare services by unregistered practitioners, and legislation to introduce a similar scheme to that in NSW is before that state’s parliament.

Ms Carlton says the consultations and submissions to AHMAC generated “strong support for further government action in this area, and strong support for the NSW model that’s already been implemented.”

That support is also coming from alternative therapies practitioners themselves. In their submissions, the Australian
Association of Clinical Hypnotherapy and Psychotherapy, Reiki Australia and the Australian Register of Naturopaths and Herbalists all argued strongly for increased government regulation and, specifically, legislation similar to that implemented in NSW.

The Complementary Medicine Association also agreed that of the three options presented by AHMAC, “a national statutory code of conduct for unregistered health practitioners, who are qualified, offers the highest degree of protection to the public and to the professions”.

The Australian Homeopathic Association also supports a national code.

The AMA and the Consumers Health Forum of Australia have both backed a statutory code of conduct, on the grounds that consumers need more protection as their use of complementary medicine grows.

A small proportion of submissions argued that a national code isn’t strong enough, and are pushing for statutory registration and inclusion in the National Registration and Accreditation Scheme, but so far that seems to be a minority viewpoint.

Among those arguing for increased regulation, and possibly registration, is Professor Kerryn Phelps, president of the Australasian Integrative Medicine Association.

Professor Phelps believes it’s a “quality and safety issue”. She points out that many Australians are already using complementary therapies and regularly seeing natural therapies practitioners as part of their primary healthcare team.

“The problem is there is a vast difference in the level of training, qualifications and knowledge, and ability of these practitioners,” she told MO.

While some practitioners are very highly university trained and have a good understanding of the clinical situation and work well with doctors, others may be much less qualified and put patient safety in jeopardy.

As it stands, there’s no official way of recognising natural therapies practitioners and no accredited training courses producing them, she says, and that’s something she believes should change.

“If we’re looking at increasingly having an integrated healthcare system where all practitioners work together for the
benefit of patients, then if we have an overarching body, even if it has separate arms, I do believe natural therapies practitioners should fall under that umbrella body,” Professor Phelps says.

Professor Ernst, who, for the record, openly acknowledges the benefits of acupuncture and herbal remedies in certain cases, agrees that regulation is necessary, but he doesn’t mince his words.

“Regulation of nonsense will still result in nonsense,” he says.

“Regulation has to oblige practitioners to practise according to the best evidence. If not, patients are at risk.”

see the submissions at: www.ahmac.gov.au

First published August, 2011, Medical Observer.