Appendix 1:
Executive Summary of Towards a Safer Choice: The Practice of Traditional Chinese Medicine in Australia in Australia

Why a review?

In December 1995, the Victorian Department of Human Services commissioned a report into the practice of Traditional Chinese Medicine (TCM). The New South Wales and Queensland health departments subsequently contributed funding to the study. The research was directed and undertaken by Mr Alan Bensoussan of the University of Western Sydney Macarthur, with Dr Stephen Myers of Southern Cross University.

The aim was to form a national picture of the practice of Traditional Chinese Medicine, to identify benefits and risks, and make recommendations to help governments decide policy on regulation.

This booklet presents the key findings and recommendations.

What is Traditional Chinese Medicine?

Traditional Chinese Medicine includes a wide range of therapies.

It is best known for the practices of acupuncture and Chinese herbal medicine, but also includes techniques such as massage, moxibustion, dietary advice and breathing exercises. Traditional Chinese Medicine consists of a large body of knowledge which includes a long history of clinical use.

The first recorded material on Traditional Chinese Medicine is traced back to the third century BC. It is used extensively in public hospitals in China for both inpatients and outpatients, and in acute and chronic care.

An Australian snapshot

Popularity

Traditional Chinese Medicine has existed in Australia since the influx of Chinese migrants to the Australian goldfields in the 19th century. By 1911, Chinese herbal remedies were available with English labels and directions.

Traditional Chinese Medicine accounts for an increasing percentage of total health care services. It is estimated there are at least 2.8 million consultations each year, representing an annual turnover of over $84 million.

Its popularity is growing strongly, as reflected in the fourfold increase in the importation of Chinese herbal medicines since 1992, and the proliferation of Traditional Chinese Medicine practitioners, training courses and professional associations during the last decade.

The profession

Traditional Chinese Medicine is practised as a principal health occupation and as an adjunct to other health care practices.

Currently, there are over 1,500 primary practitioners (whose principal health occupation is Traditional Chinese Medicine), and 3,000 non-primary practitioners, (who practise other disciplines such as medicine, nursing, osteopathy, and physiotherapy). By the year 2000, the number of primary practitioners is forecast to almost double, when over 1,100 students will graduate from Traditional Chinese Medicine qualifying programs.

There are now 23 professional associations representing different segments of the profession. However, there is no peak body covering the entire profession, and the proliferation of groups makes it difficult to achieve uniform practice standards.

Regulation of the profession

No provisions directly govern the practice of Traditional Chinese Medicine, although practitioners are regulated in part by provisions in various State and/or Federal legislations and guidelines. The dispensing of raw Chinese medicinal substances is not adequately regulated by current legislation.

Education

There has been a recent expansion of Traditional Chinese Medicine education in universities and private colleges. However, there is significant variation in the delivery of education with award and nonaward course lengths ranging from 50 hours to over 3000 hours. This results in a very unevenly qualified workforce. Traditional Chinese Medicine courses for qualified medical practitioners range from 50 to 250 hours.

The academic component of education (which includes both acupuncture and Chinese herbal medicine) offered at some institutions appears similar to that in China, but clinical training in Australia is less substantial due to the lack of access to public hospitals for clinical experience.

The patients

Traditional Chinese Medicine is provided to patients of all ages, including infants. Two in three patients are female, 50% are tertiary educated, and over 80% have English as their first language.

A wide range of illnesses is treated, with 44% of cases being rheumatological or neurological in origin. Over 75% of patients are being treated for a recurrent complaint of at least three months' duration.

On average, the cost of a consultation is $30, with the cost of a full course of treatment about $670, including Chinese herbs.

Overseas trends

A number of overseas administrations have recently reviewed regulations concerning Traditional Chinese Medicine practice, with the result that some have introduced occupational regulation.

Regulatory approaches vary from country to country, from a high degree of regulation where practitioners are licensed and supervising boards are established to maintain
standards and oversee qualifications, to a virtual absence of regulation.

For example, in the United States, 27 states have specific legislation to regulate the practice of acupuncture. A small number of states have adopted regulation similar to that applied to medical practitioners in Australia, restricting use of title to those with full Traditional Chinese Medicine qualifications. In these states, medical and other health practitioners are required to obtain full Traditional Chinese Medicine qualifications in order to be able to call themselves Traditional Chinese Medicine practitioners or acupuncturists.

Does Traditional Chinese Medicine work?

The report reviews international trials and studies the efficacy of Traditional Chinese Medicine.

• There is a sufficiently strong case for the use of acupuncture to manage pain, nausea and vomiting. Acupuncture also shows significant promise in other clinical areas, such as in hypertension and other cardiovascular disorders, digestive disorders, neurological problems, and drug addiction.
• There are hundreds of clinical trials on Chinese herbal medicine, the majority of which have been undertaken in China. While these generally report favourable outcomes, they do not meet a sufficiently high methodological standard for broad acceptance in the west. However, there is some limited evidence in western countries for the efficacy of Chinese herbal medicine in a small number of clinical disorders.

What are the risks?

Although Traditional Chinese Medicine may be relatively safe compared to western medicine, it is not riskfree, and fatalities have occurred. Interestingly, it appears to pose greater risks than some regulated health care practices, like chiropractic and osteopathy. On average, practitioners experience one adverse event every eight months. These arise from:

• The consumption of Chinese herbal medicines, leading to toxicity and allergic reactions.
• The application of acupuncture, leading to infection, physical injury, fainting and convulsions.

A key finding is that the risk of adverse events is linked to the length of education of the practitioner. Practitioners graduating from extended Traditional Chinese Medicine education programs experience about half the adverse events experienced by practitioners graduating from short programs.

Key recommendations

The study recommends an integrated reform package across the industry, with the key aim being the need to minimise risks to the public that may arise from inadequate education and unsafe practice.

The main recommendation is to introduce appropriate regulation to ensure adequate public safety, while minimising any restriction on competition in the health care marketplace.

The need for regulation

The study found that existing regulatory mechanisms are inadequate to protect the public, and that statutory occupational regulation be introduced in the form of a restriction of title.

Regulation could be based on one of three options, consisting of State and Territorybased registration, or a National Accreditation Board with State and Territory registration, or a National Registration Board.

Regardless of the option adopted, the regulations should provide for:

• Protection of the public by ensuring practitioners have adequate qualifications for safe and competent practice.
• Accreditation of education courses that meet a satisfactory standard.
• Effective disciplinary policies and procedures to enable appropriate responses to consumer complaints.

Recommendations for education

• Review of Traditional Chinese Medicine education to set an acceptable minimum standard for practice.
• Educational institutions to review their course content and ensure adequate training is available to minimise specific adverse events and promote the ability of practitioners to deal with adverse events.
• Review and upgrade, where necessary, basic medical and clinical sciences for nonmedical practitioners.

Recommendations for herbal medicines

• Introduce education of importers and/or monitoring of imported raw Chinese herbs to ensure protection against the risk of contamination.
• Improve labelling of raw herbal medicines which are mixed by practitioners.
• Reassess controls on Chinese medicinal substances and identify those substances that are too toxic for use in Australia, those that are safe and appropriate for wide use, and those that should be available for use only by adequately educated practitioners.

Other recommendations to minimise risk

• Professional associations and relevant government agencies to identify and promote a centralised location for reporting and recording adverse events.
• Relevant funding bodies to allocate funds for new research, and the translation of Chinese research, on the interactions between Chinese herbal medicines and western pharmaceutical drugs.

Recommendations for professional associations

• Strengthen the selfregulatory mechanisms of professional associations, whether or not Statebased occupational regulation proceeds.
• Professional associations to cooperate to standardise course requirements, continuing education requirements, codes of conduct, disciplinary procedures and other matters related to standards of clinical practice.

What would these changes mean?

Members of the public will be assured that the practitioners they choose will have adequate education. This will ensure that health care choices remain as wide as possible while delivery remains as safe as possible.

For the Traditional Chinese Medicine profession there will be legislation within which the profession can set and enforce standards of practice. This will mean increased responsibility for the improved delivery of TCM.