Select Committee on Science and Technology Sixth Report

CHAPTER 6: PROFESSIONAL TRAINING AND EDUCATION

Validation of Training

6.35 The accreditation and validation of training courses by the appropriate professional body is vital in ensuring their adequacy. It is important to note that a distinction exists between academic qualifications on the one hand and the ability either to practise or to register as a practitioner on the other.

6.36 The increasing availability of CAM training within higher educational institutions is an encouraging development, as it provides externally validated educational achievements. However there is some concern that even courses within universities, designed to train students to practise, are often not accredited by a professional regulatory body of the therapy being studied.

6.37 The Committee of Vice Chancellors and Principals (CVCP) explained, in relation to undergraduate qualifying courses, the difference between academic qualifications in a discipline and a license to practise that discipline: "In any area where a qualification is giving a licence to practise, whether in health or outside health, the university does not have the authority to award the licence to practise…Therefore, in those professions where there is an existing regulatory body such as the GMC, the Council for Professions Supplementary to Medicine or the UKCC…the universities do work very closely with the regulatory body that has the authority in the end to confer the licence to practise. The quality assurance regimes which underpin the programmes are commonly now run as an integrated set of activities with the universities' own quality assurance, with the academic stream or the academic qualification being integrated, in so far as it is possible, with the regulatory body's inspections of its interests…It follows from that situation that [even] where there is no regulatory body with the authority to give a license to practise the university cannot award the licence to practise" (Q 275). This statement does not, however, take into account the common position where universities have to work with the non-statutory regulated registering bodies which generally represent CAM therapies.

6.38 Many of the main CAMs now taught at university level have reasonably well-developed voluntary self-regulatory bodies with which the universities should liaise when setting standards. This is already happening in some cases. For example, the University of Westminster Centre for Community Care and Primary Health offers BSc degrees in several of the most popular CAM therapies. One of their objectives is "to collaborate with training organisations and professional bodies in developing educational programmes." This is a principle that we believe all CAM training courses should accept (P 235).

6.39 The Department of Health also share this view. They told us that "…in the most established of the CAM professions the regulatory body is responsible for the accreditation of training for the purposes of a licence to practise. Through its support for initiatives in relation to integrated medicine, the Department is encouraging developments in the accreditation of training systems throughout the whole of the CAM field" (Q 2).

6.40 We consider that it is imperative that higher educational institutions and any regulatory bodies in CAM liaise in order to ensure that training is adequate for registration. If extra training is required after academic qualification to ensure fitness to practise, this should be defined by the appropriate professional body, which should then implement appropriate mechanisms in order to see that this objective is achieved. One good example of this principle is that of the chiropractors who propose a pre-registration year of clinical practice which will be supervised. This is a principle which the main CAM therapies may wish to consider.

What Should CAM Training Courses Include?

BASICS OF BIOMEDICAL SCIENCE

6.41 It was a recommendation of several witnesses including FIM, the University of Westminster and the BMA, that CAM practitioners should be taught basic principles of anatomy and physiology as provided in orthodox healthcare training. The BMA stated that "all practices claiming therapeutic benefits should include in their training courses a foundation in the basic medical sciences" (P 45).

6.42 Most CAMs within our Group 1, which have established core curricula, include in their courses such basic knowledge as requirements set by their professional bodies.

6.43 We recommend that training in anatomy, physiology and basic biochemistry and pharmacology should be included within the education of practitioners of therapies that are likely to offer diagnostic information, such as the therapies in Groups 1 and 3a. Although it may be useful for other therapists to understand basic biomedical science, there is no requirement for such in-depth understanding if the therapy being practised is to be used as an adjunct to conventional medicine. This requirement should be tailored depending upon the limits of competence of each discipline

RESEARCH METHODS

6.44 A theme that has repeated itself throughout this Inquiry is the lack of research into complementary medicine. The Research Council for Complementary Medicine (RCCM) referred to some evidence to support this perception: "Smaller studies carried out by a large number of independent clinics and units do not hide the fact that as yet there is only a limited research ethic among CAM practitioners in the UK" (P 180). Common reasons we were given for this were lack of understanding of research ethics and methodology among many CAM practitioners, a lack of willingness to evaluate evidence in order to change practice and a shortage of resources.

6.45 One reason for the poor research ethic among many CAM therapists is that many have never been trained in research methods or the importance of evidence-based practice. As a result, many CAM therapists are unable to take the opportunities of practice-based research and even fewer consider the opportunity of becoming an active researcher. Most medical and health-related research is undertaken by conventional healthcare practitioners or scientists with priorities that primarily emanate from the conventional medical domain. It is our opinion that until CAM undergraduates and practitioners become familiar with what research can offer and with the methods used to investigate processes and health outcomes, difficulties will continue to arise between those who will only accept CAM practice if it conforms to the rigours of conventional research requirements, and those in the CAM world who regard such scrutiny as irrelevant.

6.46 This is a view supported by many witnesses from whom we have heard. For example, in their written evidence to us the BMA state that: "Active support is needed for therapists embarking on research projects, including appropriate training in research techniques…Core curricula for undergraduate training establishments should include components on research methodology, information technology, and statistics" (P 44). They suggest "…training in clinical audit should also be provided, so that the practice and management of patients are evaluated rigorously at regular intervals" (P 45). Many submissions, including that from the University of Westminster (P 236), have highlighted the need for this problem to be addressed through incorporating research methods and statistics modules into CAM undergraduate courses. The CVCP indicated that they would expect any CAM courses taught in universities to include research methods: "Any university course worth the name nowadays has to have an evidence-based, self-critical, reflective element within it" (Q 280). Therefore they would "take it as given" that university courses should include proper research training within their curricula.

6.47 The RCCM supported the view that such education would help improve the overall picture of CAM research. They stated that "...a programme of research awareness for practitioners of complementary and alternative medicine would help improve the quality of research" (P 180).

6.48 If research training is incorporated into the curriculum of all CAM training courses, as we hope it will be, this should eventually lead to a new cadre of research-aware CAM practitioners, but such a development will take time. For a more immediate solution it would seem wise for existing practitioners to gain some research training. This would require initiatives to help practitioners cover the costs, and incentives to make them aware of the need. We asked the Department of Health if they had any initiative relating to making available training in research methods for practitioners who are keen to improve the evidence base of their profession; one of the Department of Health officials responded in the affirmative: "To give an example, until May of last year I was Regional Director of Research and Development (R&D) for Trent region. We had within our regional R&D budget a substantial proportion of funding going into the provision of training for research work, most of it directly through the Trent Institute. That provided courses for practitioners in any field who wished to acquire skills, for example in statistics, epidemiology, research design and so on, which are the common tools, as it were, of research" (Q 18). This is quite a limited initiative but is a good example of how, at a regional level, it is possible to encourage practitioners to become interested in research. It is important that such initiatives are made more widely available and are publicised well. Informing the appropriate professional bodies of such initiatives and encouraging them to pass on the information to their practitioners would be a step in the right direction.

6.49 We recommend that that every therapist working in CAM should have a clear understanding of the principles of evidence-based medicine and healthcare. This should be a part of the curriculum of all CAM therapy courses. An in-depth understanding of research methods may be even more important for those therapies that operate independently of medical supervision, and which attempt to make a diagnosis and to cure complaints rather than for those which offer relaxation or aim to improve the general quality of life of patients. Therefore training in research and statistical methods may be particularly appropriate for practitioners of therapies in Groups 1 and 3a. But we consider that an understanding of research methods and outcomes should be included in the training of all CAM practitioners. It is important that all of those teaching these courses should understand these principles. Chapter 7 considers research training for CAM professionals in more detail.

LIMITS OF COMPETENCE

6.50 A number of witnesses have emphasised the importance of CAM practitioners being aware of the limits of their competence and of when it is in the best interests of the patient to refer to other health-care professionals who are better qualified to deal with specific problems. The BMA stated that this should be an element of training: "Limits of competence must be established for each therapy during the training process. Patients suffering from conditions not amenable to treatment must be identified and referred to the appropriate agency. This is particularly important in cases where medical attention is needed" (P 45).

6.51 Many therapies do already consider the limits of their practitioners' competence in their training and in their code of ethics. For example the Society of Homoeopaths told us that bounds of competence "…is an issue we have taken to heart and have addressed in our code of ethics and practice. It is also an issue we have addressed with our member practitioners and an issue that has been taken into homeopathic colleges" (Q 868).

6.52 It is possible to argue that until more research on the efficacy of each therapy is done, it is hard to define the limits of competence of that therapy. We recommend that all CAM training defines limits of the particular therapist's competence as clearly as possible in the state of current knowledge. Training should also give students clear guidance on when a patient should be referred to a primary care physician or even directly to secondary hospital care.

FAMILIARISATION WITH OTHER CAM THERAPIES

6.53 Evidence from many CAM associations has highlighted the importance of CAM practitioners being given CAM familiarisation courses so that they are aware of the other forms of treatment their patients may be accessing. However, few of our witnesses have suggested that such familiarisation should cover the whole spectrum of CAM. It is quite likely that patients accessing one type of CAM may also be accessing another and, as we have discussed previously, there is such a wide range of CAM professions that it is not necessarily true that a practitioner trained in one CAM discipline will know about all the others. An example emerged in the GCC's evidence when they explained that "…the position of complementary and alternative therapies has not been built into our training… other than as how to conduct oneself as a professional with other people who may be co-operating in the treatment: therapies like aromatherapy or crystal therapy and meditation are not things that crop up to any degree. I think there is a limit to what one can do within chiropractic education" (QQ 490 & 491).

6.54 We recommend that all CAM therapists should be made aware of the other CAM therapies available to their patients and how they are practised. We do not think it should be assumed that CAM practitioners competent in one discipline necessarily understand the others. When we visited the Southampton University Medical School we noted that the CAM familiarisation course available to medical undergraduates was also open to nurses and to students from the Anglo-European College of Chiropractic in Bournemouth. This enabled students to become familiar with CAM while meeting practitioners involved in different fields, sharing resources and encouraging interdisciplinary understanding and co-operation.

A Core Curriculum?

6.55 Some of our witnesses consider that a common core curriculum for all CAM training courses is needed to ensure that all therapies have a common awareness of the issues central to all forms of practice in healthcare. The BMA, FIM and the University of Westminster propose a core that embraces some or all of the following themes:

  • Fundamentals of conventional medical diagnosis and guidelines of patient referral;

  • CAM therapies and their potential uses, including the principles of diagnosis and practice;

  • Research methodology and the application of results;

  • Holistic models of healthcare;

  • Professional ethics;

  • The therapeutic relationship;

  • Clinical audit of outcomes;

  • Impact of social, cultural, economic, employment and environmental factors on health;

  • Counselling skills;

  • Principles of quality management and audit;

  • Organisational skills including record keeping;

  • Technical skills including IT management etc.

6.56 This requirement may well depend on increasing partnerships being developed between medical schools and the newer universities.

6.57 If each of the principal complementary therapies develops one professional regulatory body responsible for supervising all training in that discipline, as we hope they will, this should result in core competencies being defined. These competencies will vary according to the extent to which the therapy claims to make independent diagnoses or is independent of medical supervision. Nevertheless, an understanding of the ethical aspects of healthcare, clinical audit and the therapeutic relationship should be part of all such training.

6.58 The University of Westminster, which offers several CAM courses, suggests that the advantages of a core curriculum are that it establishes the generic field of knowledge and skills required by such CAM practitioners, while also promoting inter-disciplinary learning and multi-disciplinary practice (P 236).

6.59 Although many witnesses have supported a core curriculum with similar components, there is less consensus over the professions to which it should extend. FIM's outline for a core curriculum is one which they see extending to the training of all healthcare professionals in all institutions (P 88). They promote a core curriculum applicable to all types of CAM, as well as to conventional practice because they see there being "a core body of knowledge that both CAM and orthodox practitioners need to understand" (Q 101). Their proposals are supported by others including the British Complementary Medicine Association (P 34).

6.60 However, several witnesses have objected to the idea of core curricula and their objections have mostly followed one of two arguments: either they believe that the range of CAM disciplines is so diverse that to envisage a common body of knowledge useful for them all is too difficult, or they disagree, a priori, on theoretical grounds with the concept of core curricula. The second objection was typified by the CVCP who told us: "It would not be the Committee of Vice Chancellors and Principals' position to advocate that a national core curriculum should be prescribed in any particular field of any sort. That is not something that the Committee of Vice Chancellors and Principals would embrace" (Q 277). They went on to suggest that it is the role of each therapy's regulatory body to prescribe outcomes of training: "In these particular areas both of western medicine and CAM it is clearly the case that the activity of the professional and regulatory bodies does prescribe something which may look more or less like a core curriculum, depending on the discipline". But although the CVCP support the idea of the regulatory bodies prescribing outcomes in this way they also support the need to "…give some flexibility to the individual universities to decide how to educate that practitioner so as to arrive at those desired outcomes".

6.61 We conclude that there should be flexibility for training institutions to decide how to educate practitioners. To introduce one formal core curriculum across healthcare would be a Herculean task; there is no obvious body available to tackle such a task which, in any case, would no doubt meet with much opposition. We endorse the view of the CVCP (shared by many other witnesses) that it is the relevant professional regulatory body of a specific CAM therapy that should set objectives of training and define core competencies appropriate to their particular discipline, and we so recommend. We do not advocate a blanket core curriculum.

6.62 However, we do recommend that, whether subject to statutory or voluntary regulation, all healthcare regulatory bodies should consider the relevance to their respective professions of those elements set out above in paragraph 6.55.

National Occupational Standards

6.63 Setting training standards is an important step in protecting the public from inadequately trained practitioners and, as we have discussed, setting such standards is a role for each appropriate professional body. The Department of Health stated that the Government's position is that a pre-condition of membership of any professional register should be to meet recognised and appropriate standards of training set by the respective registering body. This is an integral part of professional regulation (P 110). However, considering that many of the CAM professions are fragmented, an outside body could work with the various CAM bodies to develop appropriate core training standards that would apply across each discipline.

6.64 In 1998, the Government approved the establishment of Healthwork UK, a new National Training Organisation set up to work with the Government and the healthcare sector in the field of education and training. The Department of Health see Healthwork UK's role as being to promote the development of individuals and to "assist in delivering Government training and development policies" (P 110). They state that one of the specific functions of Healthwork UK is to "support the needs of CAM practitioners by helping members of professions to work together to set standards of practice, education and training" (P 100).

6.65 We have heard evidence about the experience of working with Healthwork UK in developing National Occupational Standards from the homeopaths, one of the CAM groups to have recently developed National Occupational Standards. The National Occupational Standards for homeopathy were developed in collaboration by the Society of Homoeopaths, the Faculty of Homeopathy and several other homeopathic bodies. Both the Society and the Faculty told us that they felt the National Occupational Standards were a major leap forward (QQ 676 and 663). Undertaking this exercise with an independent organisation like Healthwork UK has helped to bring the various fragmented and disparate homeopathic associations together. Mr Stephen Gordon, Director of Political and NHS Affairs at the Society of Homoeopaths, said: "For us this marks a watershed and I am pleased to say that through the joint work involved in developing the National Occupational Standards, the Society, together with the other smaller bodies which also represent homeopaths in this country, has recently got together to form a common Council and our objective is to move forward these competencies to establish a single national register for homeopathic practitioners with all the requisite infrastructure for that" (Q 676). The Society also explained that they see the National Occupational Standards as having a key role in all three levels of training, registration and practice (Q 681).

6.66 The Faculty of Homeopathy, representing statutory registered doctors, point out that its members are not subject to the training requirements prescribed by the National Occupational Standards but they were still involved in their preparation. The Faculty echoed the Society's sentiments by saying that National Occupational Standards have "enabled the emerging profession of the homeopathic practitioner, which is currently unregulated, to define much more clearly what their job is and what their skills are. I think this will lead to a single register and maybe then consequently to statutory regulations" (Q 665).

6.67 We also asked Healthwork what benefits they saw for CAM therapies in developing National Occupational Standards under their guidance. They echoed the homeopaths' belief that they can help professions come together and defined this as a key role they play: "One of our roles is that we bring stakeholders together, we bring the educationalists together, the practitioners, we bring people offering courses together with those that need them, we bring members of the public into the debate. It really is useful to be able to say that at the end of all this effort you can say you have kite mark qualifications, you have kite mark standards behind them, the public safety is something demonstrable, the value for money associated with Government public funds going into this is demonstrable. The workforce which develops is evidentially a workforce which is developing with a view to patients getting better outcomes" (Q 1456).

6.68 Healthwork also told us that they felt they could be of particular benefit to CAM bodies not only as an outside unifying force but also because they themselves have a good system of support both in terms of regulation and finance, which much of CAM lacks: "We are supported by the Education Act regulatory authorities. We have access to funds as a National Training Organisation. We have a special access that some other bodies cannot gain for certain funds. We have expertise and competence in this area" (Q 1455).

6.69 As well as highlighting the advantages they see of their work, Healthwork UK also identified an obstacle they have encountered in their efforts to develop National Occupational Standards with the CAM professions: "…we have struggled over finance because it is time-consuming, because we have to build consensus so that time is well invested. We need a funded work programme that can last perhaps 3 to 5 years at a time before you begin to see concrete products. Complementary medicine does not appear to us to be a priority from the Department of Health's point of view. It is very hard to help them to put finance aside for this. We have been funded to develop work in public health, in breast cancer, in nursing. The Department of Health is willing and able to apply funds in order to develop National Occupational Standards and their application. It has been much harder for us to achieve funding for CAM. We are quite worried at the moment that we will lose the benefit of the momentum that has been generated" (Q 1146).

6.70 National Occupational Standards are most likely to benefit therapies whose professional organisation is still fragmented and which have not, as yet, managed to agree training standards and objectives. Healthwork UK's support structure and access to funding is also likely to help the smaller CAMs which have fewer resources and less access to funding from their members. The therapies in Group 1 have probably developed beyond a stage where Healthwork can be of maximum help, but for therapies such as those in Group 2 Healthwork UK's clear structures and resources are likely to be beneficial. We recommend that therapies with a fragmented professional organisation move in this direction and we encourage the Department of Health to support further Healthwork UK's activity in this field; we believe that this would be of long-term benefit to the public.