Single Umbrella Regulatory Body?
5.64 We have also considered the option of a single
"umbrella" regulatory body to cover all CAM therapies,
or a significant number of them. There are currently several umbrella
CAM voluntary regulatory bodies which plan to regulate practitioners
from a range of different disciplines
5.65 We received written evidence from the Institute
for Complementary Medicine, one such umbrella body. They told
us: "The Institute for Complementary Medicine favours a single
Act which recognises the autonomous divisions of specialist treatments
as being the most beneficial, cost effective and efficient method
of protecting professional practitioners whilst offering a transparent
service to the public" (P 136). However, we are uncertain
as to what they would do to overcome the fact that the diverse
range of therapies which come under the title of CAM have a huge
range of different educational and regulatory needs, while some
have a weak, or even non-existent, evidence base[40].
5.66 We also heard from the British Complementary
Medicine Association. This claims to be "…the major
Complementary Medicine multi-therapy umbrella body in the United
Kingdom, representing some 45 single therapy organisations (some
of which are in themselves umbrella bodies for a single therapy)"
(P 32). The British Complementary Medicine Association told us
how they thought the diversities could be overcome so that therapies
could unite under one body: "The first breakdown should be
into alternative and complementary, as we have defined it. That
gives you a good structure - those who make a medical diagnosis
and those who do not. Then you come to the others. The system
we operate is that each therapy has its own organisation and some
of them have achieved an umbrella group for themselves in one
therapy. What we would like to do is to say that a therapy must
get together, whether it is inside the British Complementary Medicine
Association or not. There is only one way to go, which is to get
a body representing all the therapists in a particular therapy.
That is the way, we feel, that you can combine strength, good
practice, good regulation and so on" (Q 622).
5.67 The option of a single umbrella body was not
favoured by most of the evidence we received, including the evidence
of the Department of Health. Yvette Cooper MP, Parliamentary Under
Secretary of State for Public Health, told us that she "would
be personally uneasy about going too rapidly towards umbrella
organisations that do not have sufficient concentrated expertise
or thoroughness when it comes to regulating a particular area"
(Q 1876). We recommend against it for several reasons. Umbrella
groups do not, in themselves, obviate the need for all practitioners
within one particular discipline to come together and agree standards
of training, professional practice and requirements for Continuing
Professional Development. It is impossible adequately to enforce
any code of practice unless these basic fundamental provisions
are in place. In short, common codes of practice are irrelevant
until there are agreed standards of clinical care for each discipline
and only the practitioners of each discipline can determine this
by coming together and achieving a consensus. Umbrella bodies
may also give a cloak of respectability to practitioners who may
have minimal training in one or more of the different therapies.
They may also encourage multi-therapy practitioners who want to
mix a number of different therapies without being properly trained
in one or more of them. There is an argument that anyone practising
more than one therapy should at least have a grounding in a discrete
clinical discipline so they have been exposed to training in basic
medical sciences.
Regulation of Conventional
Healthcare Professionals Practising CAM
5.68 The current position relating to the regulation
of statutory regulated health professionals such as doctors, nurses,
dentists and veterinary surgeons, who wish to incorporate CAM
practice into their repertoire of therapies is very different
from the position of CAM practitioners.
5.69 The GMC, the regulatory body for doctors, gave
evidence to us. The code of ethics and disciplinary procedures
of the GMC extend to the use of all the therapies a doctor may
use in treating patients and therefore the GMC is responsible
for regulating the use of all CAM therapies by doctors. They acknowledged
that under the Medical Act 1983 a registered medical practitioner
is technically free to practise any form of CAM or other therapy
they believe will help their patients (Q 1045). However, they
told us that "...we would wish them to practise within their
competence. If they practised outwith their competence we would
have strong views on that" (Q 1045). "These individuals
need to be appropriately trained for the practice that they are
going to be pursuing. So there is a gradation of training from
undergraduate to post-graduate and then when problems do arise
there is the policeman role of the General Medical Council, which
will deal with a very small minority of medical practitioners.
It is an unfortunate necessity" (Q 1061).
5.70 The GMC acknowledged that problems may arise
with doctors practising CAM poorly and needing to be subject to
a disciplinary action that might be consistent with a CAM regulatory
body's process, but inconsistent with a GMC disciplinary process.
Because of this they stated that "…it does mean that
where such a body could be set up the interaction with the General
Medical Council has got to be very close…there is no reason
to doubt that there could be a very smooth interaction between
such regulatory bodies. The example, I think, is again the General
Dental Council and the General Medical Council, which has worked
extremely well" (Q 1051).
5.71 The GMC also explained that they could discipline
a doctor, not only for practising a therapy for which he had not
received proper training but also for putting patients at risk
by practising a totally unproven therapy, not supported by any
evidence (Q 1053).
5.72 The GMC has guidelines on the position of medical
practitioners wishing to refer patients to other practitioners
and, although these guidelines are general, they expect doctors
to observe them in relation to CAM referrals as with all other
referrals: "Where doctors refer patients to an alternative
or complementary practitioner, Good Medical Practice requires
doctors to be satisfied that the healthcare workers concerned
are accountable to a statutory regulatory body" (P 96). In
terms of the position of a doctor who delegates treatment to a
non-statutory regulated practitioner and still retains full responsibility
for the patient's healthcare they explained: "...the doctor
cannot delegate responsibility completely to another non-professional
colleague but could delegate part of the treatment task to that
individual. They retain overall responsibility for the care of
the patient. I think, because of that, they have got to take great
care in what they seek to delegate to someone else" (QQ 1059
& 1060).
5.73 The regulatory body for nurses, the United Kingdom
Central Council for Nursing, Midwifery and Health Visiting (UKCC),
told us that their members could practise CAM as long as they
did so within the general guidelines on conduct and professional
practice set out by the UKCC to apply to all nursing practice:
"The UKCC believes that any registered practitioner who chooses
to practise complementary therapies within their own sphere of
practice should do so in accordance with the standards expected
of that practitioner, and that is within the Code of professional
conduct and by the principles laid out in the scope of professional
practice. They indicate that if somebody is going beyond what
their initial training encompassed, they should actually look
at those principles to guide any further development" (Q
565). The UKCC do not issue specific guidelines on what training
courses they consider are of an appropriate standard for nurses
who want to learn about specific CAM therapies, but they did say
that if a nurse practised a therapy for which they had "not
sought the appropriate training" (Q 566) this could be considered
a breach of the code of conduct.
5.74 The UKCC's emphasis is on nurses practising
self-regulation and they offer very little specific guidance on
which therapies are safe or appropriate or on where to train in
specific therapies. Considering nurses are a group known often
to practise CAM, especially those therapies in our Group 2, this
seems to be an area where clear guidelines would be beneficial.
However the UKCC did tell us: "We are responsive to the needs
of people on our register and if we do receive a large number
of enquiries from nurses etc. about this particular aspect…that
is how we develop new guidance in response to their needs. So,
yes, we would be prepared to consider guidance if the need was
evident" (Q 585).
5.75 We also heard evidence about the regulation
of veterinary surgeons wishing to practise CAM. The Royal College
of Veterinary Surgeons pointed out that the Veterinary Surgeons
Act 1966 limits the treatment of animals to qualified veterinary
surgeons although others can treat animals under the direction
of a veterinary surgeon who has examined the animal and prescribed
the treatments (p 193). Thus they told us: "The underlying
position is...that complementary and alternative treatments which
amount to veterinary surgery are already subject to statutory
regulation" (p 193). We also heard from the Association of
British Veterinary Acupuncture which represents veterinarians
who wish to practise acupuncture. They told us: "We believe
that veterinary surgeons are the only people sufficiently qualified
to really fully assess the health of any animal, to make a diagnosis
about conditions, to formulate a treatment and to present a prognosis.
This applies to conventional or complementary medicine. The principles
of this are embodied in the Veterinary Surgeons Act, which gives
us a rather nice monopoly to look after the welfare and health
of animals in our care" (Q 807). Although the Association
of British Veterinary Acupuncture is in a good position to advise
veterinarians wishing to practise acupuncture, we heard no evidence
that the Royal College of Veterinary Surgeons or any other veterinary
body has issued formal guidelines for veterinarians wishing to
practise CAM, or on relevant training courses, but informal guidelines
are emerging.
5.76 The General Dental Council (GDC), the statutory
body for the regulation of dentistry, told us that: "Dentists
may be involved in complementary and alternative medicine in a
number of ways. The Council would expect that at all times dentists
would act in accordance with those sections of the Council's ethical
guidance which have a bearing on these matters" (p 75). The
ethical guidance to which this quotation refers is published in
the Council's document Maintaining Standards which deals
with issues such as acting in the patient's best interests, providing
a high standard of care, the obligation to obtain patient consent
and the seriousness of making misleading claims in relation to
any treatment. However, it does not explicitly refer to complementary
medicine at any time. The GDC told us: "The Council does
not consider that this guidance needs amendment although it anticipates,
in the light of greater public interest in complementary and alternative
approaches, more discussion on these matters particularly in relation
to the exercise of its jurisdiction" (p 76).
5.77 The evidence we have heard from the conventional
medical, nursing, dental and veterinary regulatory bodies makes
it clear that they all take quite a passive position on their
members practising CAM. None of them has promulgated clear guidelines
for their members who may be practising CAM. This means that the
position of those working in these professions who wish to practise
CAM is not very clear.
5.78 However, one body that has issued guidelines
in this area is the BMA. In their document New Approaches to
Good Practice they state: "Medically qualified practitioners
wishing to practise any form of non-conventional therapy should
take recognised training in the field approved by the appropriate
regulatory body, and should only practise the therapies after
registration"[41].
This is not at present practicable.
5.79 We recommend that each existing regulatory
body in the healthcare professions should develop clear guidelines
on competency and training for their members on the position they
take in relation to their members' activities in well organised
CAM disciplines; as well as guidelines on appropriate training
courses and other relevant issues. In drawing up such guidelines
the conventional regulatory bodies should communicate with the
relevant complementary regulatory bodies and the Foundation for
Integrated Medicine to obtain advice on training and best practice
and to encourage integrated practice.
5.80 Although the main conventional regulatory bodies
are not providing guidance for their members on CAM practice,
there are some bodies which represent conventional practitioners
who practise certain CAM therapies. The Faculty of Homeopathy
is one such body representing medical practitioners who wish to
incorporate homeopathy into their practice. The British Medical
Acupuncture Society is a similar body representing medically qualified
acupuncturists. These bodies provide an information resource for
doctors interested in this area; they also run training courses
specifically designed for medically qualified people wishing to
train in the therapy in question. These bodies have a valuable
role in promoting and regularising the position of CAM in the
conventional medical world; however, it is not compulsory for
conventional practitioners who practise CAM to be members of these
bodies and they are not regulatory bodies (as their members are
already regulated by the GMC or the UKCC).
5.81 One weakness in the current situation is the
lack of communication between those bodies representing conventional
medical practitioners who also practise specific CAM therapies
and the CAM bodies representing individual therapies. This leads
to little agreement on educational standards, little collaboration
on research and, most worryingly, no clear agreement on information
policies within a therapy to help the public understand their
options when wishing to consult a practitioner of a particular
therapy. For example, the British Medical Acupuncture Society
told us that, although they are beginning to try and build bridges
with the British Acupuncture Council (which represents non-medical
acupuncturists), their meetings are at an "embryonic stage",
and although they hope to discuss a way of helping the public
understand their options this had not happened yet (Q 1021). In
fact they told us that a member of the public might only distinguish
between a medically qualified acupuncturist and a non-medical
acupuncturist by "careful inquiry" and even then there
may "still be some confusion" (QQ 1026 & 1027).
Similarly the Faculty of Homeopathy told us there have not been
any planned or significant discussions with the Society of Homoeopaths
on giving the public clear advice on choosing a homeopath (Q 673).
5.82 We also heard from the bodies representing statutory
regulated health professionals practising CAM about their attitude
towards the level of training required of medically qualified
personnel who wish to practise CAM therapies, in comparison to
the level of training that should be required of non-medically
qualified persons. The Faculty of Homeopathy told us that their
core curriculum for training in the specialism of homeopathy has
been developed independently of that of the Society of Homoeopaths
because "we are not training the same people so a core curriculum
for someone starting from scratch to become a homeopath is a completely
different training pathway from the core curriculum for a doctor
that has done undergraduate and postgraduate training" (Q
672). When we questioned them on which group was given more in-depth
training on the principles of homeopathy itself (as opposed to
physiology, research methods etc.) they said: "I think the
membership exam in homeopathy in terms of homeopathic training
for the homeopathic remedies, analysis and skill is probably similar
to the Society of Homoeopaths" (Q 671).
5.83 We would encourage the bodies representing
medical and non-medical CAM therapists, particularly those in
our Groups 1 and 2, to collaborate more closely, especially on
developing reliable public information sources. More collaboration
on developing core curricula would be valuable, as it is important
that both medically qualified and non-medically qualified practitioners
are trained to the same level of skill in the therapy in question;
sharing the knowledge of how to do this and spreading training
resources will benefit both groups. We recommend that if CAM
is to be practised by any conventional healthcare practitioners,
they should be trained to standards comparable to those set out
for that particular therapy by the appropriate (single) CAM regulatory
body
5.84 The indemnification of medical practitioners
and other health care professionals who wish to practise CAM is
also an important issue. We were made aware of the guidance of
the Medical Protection Society to its members on the use of CAM.
This guidance is as follows:
"The Society recognises
the benefits from bona fide complementary techniques and does
not wish to inhibit members from providing treatments proven to
be beneficial to patients.
"Practitioners should only undertake procedures
which are in the patient's best interests and for which the practitioner
has the requisite skill, training and facilities.
"In the event of any claim, complaint or other
legal challenge the practitioner must be able to demonstrate that
he or she was acting in accordance with recognised medical practice,
and that experts in the field would support that form of management.
"The Society's Council considers it improper
for practitioners to employ unproven or speculative techniques,
and will not usually provide an indemnity in such circumstances.
Council expects members of the Society to participate in continuing
medical education to ensure that they remain fully up to date
in their chosen areas of practice and participate in audit.
"Practitioners offering alternative forms of
medicine should notify the Society of the technique employed within
their practice and answer any supplementary questions. Withholding
information or providing false or misleading answers, will usually
disqualify the practitioner from any benefits of membership for
incidents arising from any form of medical practice."
5.85 Under the Dentists Act, individuals are restricted
as registered dentists to undertaking the business and practice
of dentistry. Therefore in providing CAM as registered dentists
this must only be done in conjunction with the practice of dentistry.
Should a dentist offer CAM treatment outside the scope of the
practice of dentistry, then he would not be providing it as a
registered dentist and such treatment would not be covered by
any indemnity offered by a protection organisation.
40