6.3 The study on the CAM professional organisations, referred to in paragraph 1.16, examined each organisation's training standards[42]. This was carried out first in 1997 and repeated in 2000. The study was based on a questionnaire designed to elicit the "current status, activities and aspirations" of professional associations in the CAM fields and included questions on the entry and educational requirements for each CAM professional body. With regard to educational standards four questions were asked:

(i)  whether a formal accreditation procedure was used to screen the membership;

(ii)  whether the members were required to graduate from an accredited and/or recognised college;

(iii)  whether members were required to participate in Continuing Professional Development;

(iv)  what minimum length of study was required to be eligible for membership.

6.4 The following pages refer to the data extracted from the responses to these questions. Mills and Budd, the authors, note that in the absence of formal regulatory structures for CAM very little of the information is independently accredited. They also advocate caution about interpreting these data. In response to the first question, if an organisation claims to have a formal accreditation procedure to guide entry it may imply little more than the existence of certain procedural requirements that their members must fulfil. Organisations that do not have such mechanisms may have a 'default' route for members who have graduated from a specific institution to which the organisation is linked. If this is the case the organisation should answer positively to question two. If they do not respond positively to question (i) or (ii) this may mean they do not operate rigorous membership requirements.

6.5 Mills and Budd also note that if an organisation answers positively in response to question two, this may mean they have a close link to the training establishment out of which they were founded, and may not yet have managed to become independent of that establishment. This is common in some CAM disciplines because training courses were often established before a professional body existed; graduates from particular colleges often then started a professional body and operated it as a facility for students from that institution.

6.6 The provision of Continuing Professional Development could be regarded as a sign of a discipline's maturity. A positive answer to the third question, however, would not necessarily indicate how much Continuing Professional Development the organisation advocates, or whether it is a mandatory requirement for membership: the Exeter authors' experience indicates the latter is rare.

6.7 Finally Mills and Budd express concern over interpreting data given on "minimum hours required for training"; the answers provided are not the result of an accreditation process and, thus, can only provide a sketchy idea of the range of requirements across organisations; hence such figures as are available are unreliable.

6.8 Using the Exeter Report and the evidence made available to us by several witnesses we have attempted to illustrate the variations in training provision in the CAM sector.

Training in Statutorily Regulated CAM Therapies

6.9 Osteopathy and chiropractic, the two CAMs with professional bodies established by statute, have clear guidelines on education set by their respective regulatory councils (the General Osteopathic Council, GOsC, and the General Chiropractic Council, GCC). The GOsC and the GCC also have the advantage that by law all those practitioners calling themselves osteopaths or chiropractors must abide by the training standards set by the respective regulatory bodies. Practitioners of mainstream osteopathy, chiropractic, acupuncture, medical homeopathy and herbal medicine now recognise their limits of competence and will refer patients whose problems do not lie within those limits, for conventional medical treatment. It is worth reflecting on how the GOsC and the GCC have implemented the validation of their training standards.

6.10 The GOsC explained that they have been working on improving and validating the training courses for future osteopathic students and on validating the training and competence of existing osteopaths who wish to continue to practise and so have to register with the new GOsC (Q 456). They explained that they had embarked on a "recognised qualification process as laid down in the Osteopaths Act". This involved asking each training provider to "map their provision, their profile and their resources, and in particular their clinical education provision". Of the thirteen educational providers that existed at the beginning of the process, seven have been deemed satisfactory.

6.11 The GOsC also explained that the Osteopaths Act allows them to raise the standard of proficiency required to graduate as an osteopath. Their current standard of proficiency, which provides minimum standards of competence through which to assess students, was developed by the King's Fund Working Party on Osteopathy, chaired by Sir Thomas (now Lord) Bingham. They have now consulted with the osteopathic training providers and these standards are currently in the process of being upgraded. They are developing a number of quality assurance mechanisms to ensure that training remains at a high standard and will use external examiners to monitor the final assessment of students; they are also continually monitoring standards.

6.12 In assessing the training and competence of existing osteopaths who wished to register with the GOsC, they concluded that "…it was not appropriate to rely on the retrospective recognition of qualifications in osteopathy as a means test of entry to the statutory register for practising osteopaths" (p 99). This was partly due to training in the area having previously been delivered in a wide variety of ways with no common curriculum, and partly because many institutions that had provided osteopathic qualifications now no longer exist (Q 444). As a consequence of this the GOsC have developed a comprehensive standard of proficiency and a strict registering system whereby all existing osteopaths have to provide evidence that they were sufficiently trained by submitting to scrutiny a "Professional Profile and Portfolio".

6.13 The professional profile and portfolio asks each individual to "…provide evidence to support his or her claim to have practised to an adequate level of safety and osteopathic competence within the prescribed timeframe of the Act" (Q 444). Ms Sarah Wallace, Acting Chairman of the GOsC education committee, believes that the professional profile and portfolio offers individual applicants from diverse backgrounds "the means to make realistic and verifiable claims" that they meet the standard of proficiency. She also explained that the portfolio required each individual to reflect in detail on their training and practice as well as on their future training, practice and intentions for engaging in Continuing Professional Development.

6.14 The GCC have approached the validation process in a slightly different way (and because of the later enactment of the Chiropractors Act their progress is slightly behind that of the GOsC). Like the GOsC, the GCC have Standards of Safe and Competent Practice for Chiropractors as well as published Standards of Education (Q 478). They have an accreditation process for chiropractic training providers consistent with that of other professional groups, in that it requires certain documents to be presented and site-visits to each institution to talk to staff and students (Q 493). In terms of validating the training of existing practitioners, the GCC differ from the GOsC in relying on the retrospective recognition of qualifications. To this end they ask each applicant for a detailed Curriculum Vitae. They also check the applicant's insurance history, and search for any evidence of a criminal record, etc. (Q 477).

6.15 However the GCC are currently working on developing their educational structure in two other important areas. Firstly they are looking into establishing a pre-registration year of practice after training, before students become fully registered (Q 485). Secondly they are consulting the profession and the public on what form a scheme of Continuing Professional Development should take. Their Act allows them to specify that a certain amount of Continuing Professional Development should be undertaken and they will be exercising that power in due course (Q 505).

6.16 The GCC is less advanced along the path of developing educational standards than the GOsC are, and the two bodies have taken different routes towards educational validation. It is too early in the respective lives of these Councils to judge the relative success of their approaches to educational validation. However, both bodies have interesting elements in their requirements which look promising. We are interested in the GCC's moves towards establishing a supervised pre-registration year of practice, similar to the pre-registration year of medical training under supervision, which may be considered as a model for other therapies, specifically those in our Group 1.

Training in Non-Statutorily Regulated CAM Therapies

6.17 Training standards in the non-statutory regulated CAMs vary widely, usually in proportion to the level of professional development within the particular CAM discipline. Those therapies which are closest to achieving a single regulatory body to represent all therapists in the field are most likely to have clearly defined training standards. A number of therapies' training standards are reviewed below, by way of example, to illustrate the variations that exist. Those disciplines which are not reviewed here have very variable, often limited, training programmes.

CURRENT STATUS OF TRAINING

6.18 Acupuncture - We received evidence from the British Acupuncture Council. The Exeter Report[43] describes the British Acupuncture Council as the largest group representing acupuncturists in the United Kingdom and as having 'led the way among complementary professions in establishing verifiable standards of education for their profession.' The British Acupuncture Council has been involved in the formation of an Independent Accreditation Board for Educational Standards. This was established to ensure that no college or course would be advocated by the Council without being scrutinised by an independent board, which has an independent Chair and 16 members from a range of professions (pp 28 & 29). The Council explained why establishing the Accreditation Board was such an important step: "When the British Acupuncture Accreditation Board was first created the profession was quite fragmented. There were five professional associations. Although they met in the Council for Acupuncture and were able to agree some things together, like a common code of ethics and a code of practice, they were not able to agree a core curriculum for educational standards. This was partly because, at the time, schools which were working as commercial private enterprises emphasised their differences more than the common features they shared. Therefore, that was one of the most difficult things for us to establish: a dialogue and agreement over educational standards. We felt that creating an independent board was the best way to overcome these difficulties. The board has been immensely useful in helping facilitate the process of peer review, which the profession at the time was fairly nervous about. Also, it helped to develop a consensus producing a common core curriculum" (Q 765).

6.19 The British Acupuncture Council are already looking at ways to move forward by "...looking at a change in the relationship between the Board and the British Acupuncture Council, partly as a result of discussions with the Department of Health, who are recommending that accreditation should be managed by an accreditation committee which reports directly to the governing body. The British Acupuncture Council must be fully accountable for all its educational processes. This is in line with what has been established for the osteopaths and chiropractors. So we are now looking at setting up this kind of structure. We believe the processes and procedures of accreditation have been exemplary and we would not like to change these" (Q765).

6.20 The problems highlighted by the British Acupuncture Council, which show why it was important for them to set up an independent accreditation board, are ones we have found to be common across the CAM professions. Fragmentation, disagreement between groups and concentration on differences rather than common aims are frequent problems. Establishing an independent accreditation board along the lines of the British Acupuncture Accreditation Board is a positive move. Other therapies with fragmented professional representation may wish to use this as a model.

6.21 Homeopathy - In Mills & Budd's survey four organisations representing non-medically qualified homeopaths were identified. Only one of these used a formal accreditation process to screen membership, although all required members to graduate from a professional college and all required continuing professional education. The Exeter study found that the minimum educational criteria used by these organisations ranged from three years of full-time to three years of part-time study. The largest homeopathic professional organisation, the Society of Homoeopaths, told us about their work with "the other smaller bodies which also represent homeopaths in this country" to develop National Occupational Standards in homeopathy with the assistance of Healthwork UK (see paras 5.56 - 5.63). The Society of Homoeopaths explained how they have used these to enhance their education policy: "We almost immediately began to use the National Occupational Standards in several areas. Throughout our educational policy document we refer to the National Occupational Standards when we are examining the criteria presented by the course providers who meet our recognised criteria for our educational policy" (Q 681). The merits of National Occupational Standards are discussed in paragraphs 6.63 - 6.70.

6.22 The development of National Occupational Standards has benefited the Society. The joint work involved in developing the standards has had other benefits in developing the professional structure of homeopathy. The Society and the other smaller bodies "…have recently got together to form a common council and our objective is to move forward using these competencies to establish a national register for homeopathic practitioners with all the requisite infrastructure for that. When we have achieved that stage of development we will then carefully consider the next possible option which will be that of statutory self-regulation" (Q 676).

6.23 The Society told us that they felt their educational requirements were progressing well. "There has been quite a development in education…things have evolved in the last 22 years quite dramatically; during that time we have seen the introduction of full-time courses equivalent to undergraduate degree training. We now have two university degrees, BSc (Hons) degrees in homeopathic education. The interesting thing about these degrees is that the conventional medical part of the education, which contains basic anatomy, physiology, pathology, research methodology etc., is part of the curriculum which has been written by doctors" (Q 677).

6.24 Herbalism - We heard evidence from the European Herbal Practitioners Association (EHPA) which was established in 1993 to unify the herbal medicine profession. It has been working towards bringing herbal practitioners from a variety of different backgrounds under one body with a common core curriculum (P 78). They explained that their core curriculum lays down basic standards of training and is 'science based', in that it teaches the basics of conventional medicine and points out the limits of competence of trained herbalists. To reflect the growing number of BSc degree programmes available in this subject, the core curriculum is aimed at a four-year university course. However at the time of their giving evidence, the core curriculum was not yet in force although they had just launched an independent accreditation board to make sure educational providers measure up to this standard (QQ 705-711). Mills and Budd's study found that the educational requirements for membership in the herbal medicine organisations ranged from 4 years of full-time study to 2 years of part-time study. The EHPA's desire to undergo statutory regulation may provide a future body which can reconcile such differences.

6.25 Nutritional Therapy - The Nutritional Therapy Council (established in 1999) is an umbrella body for the nutritional therapists, which focuses particularly on educational standards and on developing National Occupational Standards for the profession. The largest nutritional therapy organisation is the British Association of Nutritional Therapists. They believe that the Nutritional Therapy Council will be able to co-ordinate training colleges. Currently educational requirements for membership of the different nutritional therapy bodies range from 4 years full-time to 2 years part-time. All bodies require members to graduate from a recognised college, and over half use the formal accreditation process to screen membership. However, fewer than half require Continuing Professional Development for their members.

6.26 Aromatherapy - We heard from the Aromatherapy Organisations Council who told us that they represent the 'majority of professionally qualified aromatherapists' who work in the field of complementary medicine, through their 12 professional member associations. The therapists recognised by the Council have trained to standards defined in that body's core curriculum (P 9). Mills & Budd identified 12 organisations that represented aromatherapists, but all came under the umbrella body of the Aromatherapy Organisations Council, and were working towards the same core curriculum. The Aromatherapy Organisations Council's minimum educational requirement for membership is nine months part-time which adds up to 180 hours, plus 50 supervised treatment hours.

6.27 Massage - Mills & Budd's study emphasised that there are many types of massage, some of which fall within the spectrum of beauty therapy; those they surveyed emphasised the health effects of massage. The study identified nine organisations representing massage therapists but noted that many massage therapists may also be members of aromatherapy organisations as the two therapies are often practised together. The proportion of massage therapists in organisations that use a formal accreditation process to screen membership was found to be small but all required members to graduate from a recognised college and almost all required continuing professional education. For membership the time committed to educational requirements ranged from 1600 hours to 100 hours.

6.28 Reflexology - Mills & Budd's study identified ten bodies representing reflexologists. Most practitioners were in organisations that used a formal accreditation process to screen membership, all requiring members to graduate from a recognised college; but fewer than half such organisations required Continuing Professional Development. Educational requirements for membership ranged from 60 to 100 hours of training. Recently all the reflexology organisations identified have agreed to work together within a new reflexology forum, launched in September 2000, towards identifying new National Occupational Standards for the discipline.

6.29 Shiatsu - Mills & Budd's study identified five organisations representing Shiatsu practitioners in the United Kingdom. This was considered to be a retrogressive step as in 1997 nearly all practitioners had been represented by one body. However, all the organisations identified used a formal accreditation process and required members to graduate from a recognised college. They also found that most required some form of Continuing Professional Development. The educational requirements for membership varied between 150 to 500 hours of training.

6.30 Healing - Mills & Budd's study identified twelve organisations representing registered healers; most, but not all, of these have accepted the authority of the Confederation of Healing Organisations. The educational requirement for that Confederation is either 2 years' full-time training or one year part-time. However it does not use a formal accreditation process to screen for membership, it does not require members to have graduated from a recognised college nor does it require continuing professional education. For those practitioners in groups outside the Confederation most use a formal accreditation process to screen membership and most require Continuing Professional Development. The educational requirements of these other bodies vary enormously from 2 days' to 2 years' part-time training.

6.31 Alexander Technique - Mills & Budd's study identified three Alexander Technique associations. However, unlike other groups within the complementary and alternative sector, the Alexander Technique professionals consider themselves as teachers rather than healthcare practitioners. Each of these groups uses a formal accreditation process to screen membership but does not require members to have graduated from a recognised college. Continuing Professional Development is usually required. The educational requirement for membership ranges from 3 years' full-time to 4 years' part-time training.

GENERAL CONCLUSIONS

6.32 FIM has used Mills and Budd's report to draw conclusions about the status of CAM education in the United Kingdom: "The report by the University of Exeter suggests that the CAM professions should engage in vigorous attempts to reassure the public that their training courses are sound, validated and consistent and that they incorporate modern experience of health and illness, as well as more established teaching techniques. It is important in this context that CAM practitioners, teachers and researchers also understand the advantages of more systematic audit and rigorous research within their practice" (P 88). Currently it is legal for anyone in the United Kingdom to practise any CAM therapy without having ever had any relevant training, except in the cases of osteopathy and chiropractic (which are protected by statute). This is disquieting; fortunately this does not seem to be a common problem but it does remain a possibility for all the therapies that are not so protected.

6.33 We recommend that CAM training courses should become more standardised and be accredited and validated by the appropriate professional bodies. All those who deliver CAM treatments, whether conventional health professionals or CAM professionals, should have received training in that discipline independently accredited by the appropriate regulatory body. This was the view expressed by the Department of Health, and we agree (P 111). This would protect the public who use CAM and would improve the transparency of the organisations and make understanding what practitioners' qualifications mean easier. It is clear to us that the quality and degree of standardisation of training within each therapy are closely linked to how successful each individual therapy has been in overcoming internal divisions and coming together under the auspices of a single body that agrees core objectives for education and regulation. The efforts of organisations such as the British Acupuncture Council to form an independent accreditation board must be commended and could be used as an example in related CAM fields. Improving training through the appropriate self-regulating body is an expressed aim of the Department of Health: "The Government's overall concern is to ensure that all those who deliver CAM treatments, whether orthodox health professionals or CAM professionals, should have received training in that discipline independently accredited by the appropriate CAM self-regulatory body" (P 111). We agree.

Continuing Professional Development

6.34 Continuing Professional Development is uncommon in all CAMs. The public interest demands a better structure in the principal CAM disciplines. Even those from whom we have received evidence in the professions we included in Group 1 have uneven Continuing Professional Development requirements. Continuing Professional Development is vital if professionals are to keep up with new developments in their field; it is also a mechanism that can be used to encourage research understanding and inter-professional collaboration. We recognise that developing a coherent Continuing Professional Development structure to cover a whole profession requires the body in charge of such a scheme to devote considerable time and resources which some of the smaller CAM therapy professional bodies may find hard. However, there does seem to be a lack of keenness in some therapies to try to overcome such problems. We suggest that the CAM therapies, particularly those in our Groups 1 and 2, should identify Continuing Professional Development in practice as a core requirement for their members.

43   Mills, S. & Budd, S. (2000) (Op. cit.). Back