4.1 How might a TCM registration board be constituted?
Under the Victorian model for the constitution and powers of health practitioner registration boards, discussed in section 3.3 and outlined in detail in Appendix 7, registration boards are established under a statute of Parliament. Victorian health practitioner registration boards have a maximum of twelve members, and for smaller professional groups, around seven members is considered satisfactory, comprising a majority of practitioners from the profession, a qualified lawyer, and two lay persons with no professional qualifications or pecuniary interest in the profession.
Members are appointed by Governor-in-Council on recommendation from the Minister for Health. The normal procedure is for advertisements to be placed in newspapers inviting interested parties to apply for appointment to practitioner, lay or lawyer positions on the board. President and deputy president are also appointed. Practitioner members of a TCM board would require expertise in one or both of the two key TCM modalities, that is Chinese herbal medicine and acupuncture.
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What are your views? This review seeks comments on a suitable size and composition for a registration board for TCM. |
4.2 What powers might a TCM registration board have?
Appendix 7 outlines the powers and functions of a health practitioner registration board in Victoria. These include the power to:
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What are your views? This review seeks comments on the powers required for a TCM registration board. |
4.3 What modalities of TCM might be regulated?
Towards a Safer Choice noted that TCM is as diverse in its practice as western medicine. It is employed in both acute and chronic illnesses and it includes:
The majority of TCM practitioners in Australia are trained primarily as acupuncturists, and a significant number have knowledge of Chinese herbal medicine. Towards a Safer Choice identified that these are the two practices that present significant risks to the public and therefore require regulation. Other traditional therapeutic approaches such as acupressure, Chinese therapeutic massage, exercise and diet therapy, which are used considerably less in Australia than China, are unlikely to pose a serious risk to the public and therefore may not warrant government regulation.
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What are your views? This review seeks comments on the modalities of TCM that should be regulated. |
4.4 Protection of title versus protection of practice
The Victorian model and that recommended for TCM by Towards a Safer Choice is based on 'protection of title'. This means that use of certain titles is restricted to those who have the accredited qualifications and are registered practitioners under the relevant registration Act (24). The Victorian model does not provide for a definition and restriction of practice, leaving unregistered people free to undertake the practices associated with the registered occupation. However, if unregistered people use the protected title or lead members of the public to believe they are registered, they may be prosecuted under the registration Act.
In some professions, such as optometry and dentistry, the legislation prohibits unregistered people from practising certain procedures. This is known as 'protection of practice'. There are differing views on whether occupational regulation for TCM should include restrictions on the use of certain procedures known to carry risk. Some parties, for example, believe that only trained and registered practitioners should be able to use acupuncture. Others believe that certain procedures, such as direct needling of children, or needling certain areas of the body such as the chest or around sensory organs, should be restricted to trained and registered practitioners. In Chinese herbal medicine, prescribing of certain herbs known to be toxic has been restricted to registered medical practitioners, via State and Commonwealth Drugs and Poisons legislation (see section 4.9).
The majority of health practitioner registration Acts in Victoria, including those for medical practitioners, nurses, osteopaths and chiropractors, are based on 'protection of title' only. While 'protection of practice' would prevent unqualified practitioners from offering TCM services to the public and prevent untrained practitioners from entering the profession, Towards a Safer Choice suggests that, given that the risks of TCM are not more significant than those encountered in the practice of medicine, the same level of regulation is appropriate. Restrictions on practice are difficult to support in the current deregulatory environment. In addition, practice restrictions may deny the right to practice to those who may have been practising safely for many years but without formal qualifications.
In the context of TCM, under protection of title legislation, unqualified practitioners would be able to continue their practice of acupuncture or Chinese herbal medicine, but they would not be able to use certain titles associated with the profession, or to lead the public to believe that they were qualified and registered. If additional restrictions on practice are required, for example on the use of acupuncture or certain toxic herbs, then other forms of regulation, for example skin penetration regulations or provisions within State and Commonwealth Drugs and Poisons legislation, may provide a more suitable mechanism.
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What are your views? This review seeks comments on whether the practice of acupuncture and the prescribing of certain herbs should be restricted via legislation to only those practitioners with an acceptable level of training, or whether 'protection of title' only should apply. |
4.5 Which titles might be protected?
When a title is protected, no practitioner, unless exempted under the legislation or registered, is able to use that title on their publications, shopfront, advertising etc. If 'protection of title' legislation is recommended, it will be necessary to determine which titles should be protected; that is, which titles would be identified in the legislation to be used only by registered practitioners. A number of options are available:
The last approach would distinguish between those qualified in acupuncture only and those with a qualification in Chinese herbal medicine adequate to allow them to prescribe certain scheduled herbs. Those acupuncture practitioners without such training might continue to prescribe unscheduled patent medicines, but would be unwise to go beyond their level of competence and training in prescribing of herbal medicines. A registration board might issue guidelines for practitioners to assist in clarifying what constitutes safe practice for practitioners with different levels of training.
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What are your views? This review seeks comments on which titles should be protected; that is, which titles might be identified within a statute regulating the practice of Chinese herbal medicine and acupuncture, and therefore restricted to use only by registered practitioners. |
4.6 How might standards be set?
Towards a Safer Choice outlines a range of approaches through which accreditation of courses and standards for professional practice might be established and enforced, from self-regulation to statutory approaches. State education authorities are proceeding with initiatives to establish standards for accreditation of educational courses at degree level. Regardless of whether occupational regulation via statute proceeds, it is important for the profession to formalise and achieve consensus on standards of training for primary care practitioners of TCM.
If occupational registration proceeds, then it becomes the role
of the registration board to accredit courses and determine the
standard of training required for registration. To
assist registration boards in this process, it would be valuable
to have available standards that have broad support from the majority
of professional associations.
Automatic registration might be granted to graduates of educational courses that meet the required standard and have been accredited by a registration board. Graduates of courses that have not achieved accreditation might still be eligible to sit examinations set by a registration board. Standards set by a registration board would provide incentives to administrators of unaccredited courses to upgrade the courses they offer.
The existence of occupational regulation via statute does not diminish the need for complementary self-regulatory activities by professional groups.
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What are your views? This review invites comments on how the profession might develop suitable standards of practice and what these standards might address. |
4.7 What grandfathering arrangements would be made?
'Grandfather' practitioners are defined as existing practitioners in a professional discipline which is unregistered and unregulated, who do not hold qualifications newly prescribed by a regulatory authority, be this a statutory board or professional self-regulating body. Grandfather practitioners tend to have diverse backgrounds and levels of competence.
The workforce survey published in Towards a Safer Choice identified that among primary TCM practitioners, 15% had received an apprenticeship in TCM and approximately two thirds of these had received no further formal TCM education.
The report concluded that almost 10% of primary TCM practitioners practise on the basis of apprenticeship training alone. Apprenticeship took various forms, but in some cases consisted of up to six years full time work.
Among non-primary TCM practitioners, about 9% received an apprenticeship, with the majority receiving no other formal TCM training. In some cases this apprenticeship was reported as training at national or international conferences.
If occupational regulation is to be introduced, a process is needed from the start for determining which practitioners are eligible for registration.
The following models proposed by Prof. Andy Kleynhans from RMIT are based on experience with grandfathering of practitioners with the introduction of first Victorian Chiropractors and Osteopaths Act 1978.
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What are your views? This review seeks comments on the above approaches to grandfathering of practitioners on introduction of occupational registration. Which method or combination of methods is preferable? |
4.8 What about non-English speaking practitioners?
All health care practitioners who are registered via statute in Victoria are required to be fluent in the English language. Arbitrary application of such a standard, however, could discriminate against the significant proportion of TCM practitioners in Australia from non-English speaking (usually Chinese) backgrounds. Options include the following:
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What are your views? This review seeks comments on what issues face non-English speaking practitioners of TCM and what standard of English might be required for registration. |
4.9 How should access to and prescribing of scheduled herbs be regulated?
There is considerable variation in the extent of toxicity of different Chinese herbs. TCM practitioners argue that consumer choice is constrained because prescription of certain herbs traditionally used by TCM practitioners is restricted by the Standard for the Uniform Scheduling of Drugs and Poisons (SUSDP). The SUSDP complements the operation of the Therapeutic Goods Administration and is administered by the AHMAC Drugs and Poisons Scheduling Standing Committee. Herbs listed in schedules 1 to 4 of the SUSDP may only be prescribed by registered medical practitioners, dentists or veterinarians and may be dispensed only by registered pharmacists.
There may be a need to classify herbs according to the extent to which they can be used safely by the general population, untrained practitioners, and trained herbalists. One function of a registration board, in consultation with the TCM profession, the Drugs and Poisons Schedules Committee and the Therapeutic Goods Administration, might be the classification of Chinese herbs and the determination of regulations regarding their use.
Six categories of herbs have been identified:
Guidelines for prescription and dispensing need to be developed for substances in categories 1, 3, and 4. Similar guidelines and schedules for prepared medicines may also need to be developed.
With the passage of the Victorian Optometrists Registration Act 1996, a model has been established which:
This model may be applicable to TCM, where a list of toxic herbs and herbal preparations might be included on Schedules under Drugs and Poisons legislation, and suitably trained practitioners might be eligible to seek an endorsement of their registration certificate to allow them legally to prescribe this approved list of substances.
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What are your views? This review seeks comments on mechanisms for controlling the prescribing and labelling of a range of herbs that are considered a risk to public health if incorrectly prescribed or administered. |
4.10 Should dispensing of raw herbs be regulated?
The Register of Acupuncture and Traditional Chinese Medicine Inc. has identified the following problems with the current unregulated dispensing of raw herbs:
Options for regulation range from no change to the current situation for dispensing, through to requirements for licensing of all dispensers of raw herbs, including wholesalers, practitioners and retailers. In the current deregulatory environment, it may be difficult to achieve support for the regulation of dispensing as a separate activity or profession, particularly where a cost/benefit analysis of the impact of regulation of this area has not yet been undertaken.
Some have advocated a role for registered pharmacists in dispensing Chinese herbs; however, pharmacy training is unlikely to have addressed this area.
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What are your views? This review seeks comments on the need, if any, for mechanisms to control dispensing of raw herbs, and what role, if any, registered pharmacists should have in the dispensing of herbs. |
4.11 How might a regulatory system be funded?
In Victoria, registration boards are independently incorporated bodies that are self-funding. They receive no funds from Government. The range of costs of registration of health care practitioners in Victoria is given in the table below.
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Profession |
Registration fee per annum |
Numbers registered |
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Nurses |
$35 |
72,000 |
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Medical practitioners |
$95 |
14,500 |
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Physiotherapists |
$29 |
3,600 |
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Optometrists |
$208 |
700 |
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Chiropractors & Osteopaths |
$352 |
720 |
The most significant costs facing a registration board relate to legal fees for the conduct of inquiries and appeals arising from inquiries. These costs vary considerably from profession to profession.
Based on findings from the workforce survey, Towards a Safer Choice concluded that:
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What are your views? This review seeks comments on whether the profession is prepared to finance, via registration fees, the operation of a registration board, and what is seen as an acceptable fee level. |
4.12 Generalist health care practitioners who are already registered
Increasing numbers of generalist health care practitioners are offering complementary medicines, particularly acupuncture. Generalist health care practitioners are defined as those whose primary form of practice is in another discipline (registered or unregistered). They include medical practitioners, nurses, physiotherapists, osteopaths, chiropractors, massage therapists and naturopaths.
Towards a Safer Choice documented concerns that practitioners registered to practice in other health care disciplines may not necessarily have adequate training or expertise in TCM, particularly where acupuncture or Chinese herbal medicine has been learned in isolation, without a sound education in the broader principles of TCM, and may be practised part-time:
The Workforce Survey suggests that in Australia, the rate of adverse events associated with TCM is higher for registered than unregistered health practitioners. It seems likely that this disparity is related to a combination of factors:
The British Medical Association's policy is that medical practitioners who wish to offer therapies outside western medicine should first ensure they are fully trained in the relevant discipline (30). Some Australian registration bodies and professional associations are in the process of addressing issues of standards of practice for their members who practise acupuncture and TCM:
The main thrust of registration is to protect the public by establishing standards of practice for registered practitioners, and to provide an avenue for aggrieved consumers to have their complaints addressed. Where practitioners are already registered, complaints mechanisms exist via the registration board, regardless of the type of treatment the individual practitioner provides.
There are concerns, however, about whether a generalist health practitioner registration board without access to appropriate TCM expertise will adopt and enforce suitable standards of practice in relation to complementary therapies. Options to ensure that generalist health care practitioners practice to an acceptable standard include the following:
In Victoria, where a registered practitioner's activities falls within the domain of a number of registration boards, the respective boards have been encouraged to meet and develop mutually accepted guidelines for practice.
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What are your views? This review seeks comments on mechanisms for setting and monitoring standards of practice in TCM for practitioners registered under another health practitioner registration Act. |
4.13 Practitioners of other complementary therapies
Questions have been raised concerning the scope of the current
review and whether occupational groups practising other forms
of complementary medicine should be registered. Given the imperatives
created by National Competition Policy and AHMAC
agreements, any occupational group pursuing statutory-based registration
must satisfy rigorous criteria concerning the need for regulation
and the benefits to the public. This involves a comprehensive
analysis of risks and benefits such as the one undertaken in Towards a Safer Choice.
There is no doubt that risks exist in most forms of complementary therapy. However, the most significant risks that arise with the majority of complementary therapies appear to relate to practitioners who:
Apart from western herbal medicine, which involves ingestion of potentially toxic substances, it appears unlikely that other forms of complementary therapy where practitioner registration is not required pose the same range and scale of risks to the public as those posed by TCM. A self-regulatory approach may therefore be sufficient to protect the public from such risks.
The focus of this review is TCM, and any recommendations arising from it will apply only to practitioners who use TCM modalities, that is, acupuncture and Chinese herbal medicine. There is no intention at this stage to examine the need for regulation or registration of other forms of complementary therapy, such as naturopathy and western herbal medicine. However, there are practitioners of other forms of complementary therapy, such as massage therapy, naturopathy, and shiatsu, who use modalities of TCM, particularly acupuncture, as part of their practice. If registration is introduced, these practitioners may seek registration under the same conditions as all primary TCM practitioners. If their qualifications are considered unsatisfactory for registration, they would have similar options to those outlined under the grandfathering section ( 4.7).
If unsuccessful in achieving registration, then under a restriction of practice model (where the practice of acupuncture would be restricted to practitioners registered with either a TCM registration board or some other health practitioner registration board), they would be unable to practice acupuncture. If protection of title only applied, then these practitioners would be able to continue to use acupuncture but would not be able to use the title 'Registered Acupuncturist' and would not be able to advertise themselves as if they were qualified to practice acupuncture.
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What are your views? This review seeks comments on a suitable approach to the regulation of unregistered practitioners of other forms of complementary medicine, such as naturopathy, massage therapy etc., who use TCM modalities such as acupuncture. |
4.14 Other traditions of acupuncture
Forms of traditional medicine other than TCM use acupuncture as
part of their practice. One such form is Ayurvedic Medicine. The
International Association of Suchi Karma Inc. has written raising
concerns as to how their practice of acupuncture might be affected
by statutory regulation of TCM, particularly if legislation prevents
them from using the title 'Acupuncturist'. They state that their
system of acupuncture is different to the Chinese system and has
been practised in India, Sri Lanka and Tibet for over 3000 years.
A registration board consisting of practitioners trained in Chinese
acupuncture may not be sufficiently qualified to regulate practitioners
of 'Ayurvedic Acupuncture'.
Options under a protection of title system of registration include the following:
The Australian Veterinary Acupuncture Association (AVAA) has written raising issues affecting their members. The Association represents qualified veterinary surgeons who are registered under the Veterinary Surgeons Acts in each State and have undergone further training in animal acupuncture. The AVAA is proposing that if registration of TCM Acupuncturists proceeds, then veterinarians with post-graduate training in veterinary acupuncture to a standard set by the AVAA be granted an exemption under the legislation and therefore continue to have the right to use the titles 'Veterinary Acupuncturist' or 'Veterinary Acupuncturer'.
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What are your views? This review seeks comments on what provisions should be made for 'Ayurvedic Acupuncturists' and 'Veterinary Acupuncturists'. |
Copies of this discussion paper are available from:
Ms Adriana Lilla
Health Care Evaluation Section
Public Health Branch
Department of Human Services
Tel: 03 9637 4237
Fax: 03 9637 4744
Further information on the review is available from:
Anne-Louise Carlton
Executive Officer
Ministerial Advisory Committee on
Traditional Chinese Medicine
Public Health Division
Department of Human Services
Tel: 03 9637 4230
Fax: 03 9637 4744
Email: Anne-Louise.Carlton@dhs.vic.gov.au
Parties interested in commenting on the above proposals may put in a written or taped submission. Submissions should be forwarded to:
Mr Robert Doyle, MP
Parliamentary Secretary to the
Minister for Health (Victoria)
Chair, Ministerial Advisory Committee
on Traditional Chinese Medicine
C/O Dept Human Services
GPO Box 4057
Melbourne VIC 3001
Departmental staff are available to meet with groups to discuss the model for legislative reform and the implications for the practice of TCM. Arrangements for meetings can be made by contacting Ms Carlton on the above number.
Submissions should be received by the Victorian Department of Human Services no later than:
Friday 24th October, 1997.