This report of the Victorian Ministerial Advisory Committee on Traditional Chinese Medicine completes the second stage of the review of the practice of Traditional Chinese Medicine (TCM). The review, which commenced in August 1995, has been undertaken by the Victorian Department of Human Services on behalf of all States and Territories, in response to a rapid expansion of the practice of and demand for TCM in this country and concerns expressed by consumers, practitioners and professional groups.
The first stage of the review was a major research project to collect information on the risks and benefits of TCM and the nature of the TCM workforce, and to consider the need, if any, for registration of the TCM practitioners and regulation of Chinese herbal medicines. The research was carried out by the University of Western Sydney (Macarthur) and Southern Cross University. It resulted in the report Towards a Safer Choice: The Practice of Traditional Chinese Medicine and the recommendation to the Australian Health Ministers Advisory Council (AHMAC) and all State and Territory governments that occupational registration of the profession of TCM proceed as a matter of urgency.
AHMAC accepted the recommendation that Victoria take the lead in exploring the feasibility of occupational registration of TCM, and the Ministerial Advisory Committee was formed. Its report, this document, completes the second stage of the review and contains recommendations to the Victorian Minister for Health on a proposal for regulation of TCM. The Minister will advise AHMAC and the Australian Health Ministers Conference on steps required to achieve a suitable regulatory framework for TCM, and implementation will constitute the third stage.
The review takes place in the context of:
- Mutual Recognition as set out in the Commonwealth Mutual Recognition Act 1992. Australian Health Ministers have agreed that mutual recognition is an important first step towards agreed national standards for each health occupation.
- National Competition Policy: Any new regulatory measure that might restrict competition must demonstrate first, that the benefits of the restriction to the community as a whole outweigh the costs and second, that the objectives of the legislation can be achieved only by restricting competition.
Towards a Safer Choice recommended occupational registration by statute. Victoria provides a legislative model for such health practitioner legislation, whereby the main privilege of registration is the right to use the relevant title ('protection of title'). The practice of the profession is not protected in this model. The main purpose of this model is to protect the public rather than to protect and promote professional interests.
The report found that the practice of acupuncture and Chinese herbal medicine carry risks, both inherent in the practice itself and associated with poor practitioner training. A significant number of serious adverse events have been reported, and the risks are likely to increase with the expanding use of TCM. Self-reported adverse incidence rates are linked to length of training in TCM. In Australia, the standard of training varies widely, and the profession has no power to enforce standards. The report concluded that on balance, the benefits of promoting public safety through occupational regulation clearly outweigh its potential negative impacts.
Self-Regulation, Co-Regulation, and Statutory Regulation
The Ministerial Advisory Committee on TCM approved the release of a Discussion Paper in August 1997. The first question addressed was: should there be legislative regulation of the occupation of TCM, or should less restrictive self-regulatory approaches be adopted?
Difficulties identified in the discussion paper in applying self-regulation to the TCM profession included fragmentation within the profession, lack of agreement on standards, deregulation of education, and the difficulty of creating incentives for voluntary certification.
An extensive public consultation demonstrated that statutory-based occupational registration of TCM practitioners has widespread support from TCM organisations and others, including universities, government and health care complaints bodies. The only dissent came from AMA Victoria, the Australian Medical Acupuncture Society, and the Australian Traditional Medicine Society.
The Committee is of the view that the most effective method of protecting the public is to apply to the profession of TCM the same models of regulation that apply to medicine, nursing, optometry, physiotherapy, and many other apparently less risky and less intrusive health occupations. (See Recommendation 1).
State Versus National Approaches
Options proposed in Towards a Safer Choice for administration of a regulatory scheme for TCM practitioners were: a national registration board, State and Territory based registration boards, or a national accreditation body. That report quoted widespread support for a national approach to setting standards of practice. Public submissions confirmed this, but given the constitutional barriers to formation of a single national board, supported State–and Territory–based registration boards.
To achieve a national approach in conjunction with State–and Territory–based boards, standards might be set by either a group of practitioner representatives from the majority of professional associations, or a Victorian Board with interstate practitioner representation. The Committee recognised the constitutional and political barriers to implementation of occupational regulation at a national level, but supported a national process for standard setting. It believes that responsibility for developing standards rests with the profession, and that any initiative to bring together representatives from a broad cross-section of the profession should be supported. (See Recommendations 2, 3, 4 and 5).
Constitution and Powers of a TCM Registration Board
Under the Victorian model, registration boards are established under a statute of Parliament, and have a maximum of twelve members. The Committee and the majority of submissions support this model. Registration board membership of approximately seven was the most popular option, although size should reflect workload. The majority of board members should be practitioners. (See Recommendation 6).
Modalities to be Regulated
Both Towards a Safer Choice and submissions identified acupuncture and Chinese herbal medicine as the two key modalities to be regulated, as they present significant risks to the public. The Committee believes that further work is needed to determine whether Chinese orthopaedics and manipulation (which includes traumatology) should be added to this list. While this modality has not been as widely practised in Australia, spinal and joint manipulation carries demonstrated risks and, when carried out by other practitioners such as chiropractors or osteopaths, is regulated by at least protection of title legislation. The Committee does not believe that Chinese therapeutic massage presents sufficient risks to the public to warrant regulation via registration. (See Recommendations 7 and 8).
Protection of Title Versus Protection of Practice
Under 'protection of title', recommended for TCM by Towards a Safer Choice, use of certain titles is restricted to practitioners who have the accredited qualifications and are registered under the relevant Act. The majority of health practitioner Acts in Victoria (including those for medical practitioners, nurses, osteopaths and chiropractors) are of this nature.
Under this model, practice is not protected, and such protection may be difficult to support under National Competition Policy. In the context of TCM, protection of title only would mean that unqualified practitioners would be able to continue their practice of acupuncture, Chinese herbal medicine and/or Chinese orthopaedics or manipulation, but would not be able to use the titles associated with the profession or lead the public to believe that they were qualified and registered.
The Committee, in agreement with most submissions, believes that protection of title is sufficient for TCM, but it sees no practical difficulties should any State or Territory government decide to implement protection of practice via a core practices model.
Complementing protection of title legislation, the Committee believes that:
- prescribing of identified toxic herbs should be restricted to practitioners qualified in Chinese herbal medicine, and a national process should exist for identifying such herbs
- Skin Penetration Regulations should apply only to unregistered practitioners. (See Recommendations 9, 10 and 11).
Prescribing of Scheduled 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) and State and Territory legislation. Submissions argued the importance to TCM practitioners of scheduled herbs, and the widespread flouting of the law regarding the use of these herbs; the need to involve those with TCM expertise in identifying and classifying the toxicity of herbal medicines for the purpose of scheduling; the availability of toxic herbs to medical, dental and veterinary practitioners unskilled in their use; and the lack of scientific or policy logic in the way herbs are categorised in the SUSDP. Most supported access to scheduled herbs for suitably trained practitioners; this did not include those trained only in the use of patent medicines and/or acupuncture.
The Committee believes that the current restrictions on access to herbs by trained Chinese herbal medicine practitioners should be reviewed and amended, and that a satisfactory model for regulating limited prescribing rights for scheduled drugs can be found in the Victorian Optometrists Registration Act 1996. The Committee recommended application of that model to TCM and recommended review of the scheduling arrangements as they relate to herbal medicines, with the involvement of suitably qualified Chinese herbal medicine practitioners. (See Recommendations 12 and 13).
Regulation of Dispensing of Raw Herbs
At present, raw herbs (other than scheduled herbs) can be dispensed over the counter with no requirements regarding instructions to the user, labelling, age or source of the prescription, or other related safety issues. While herbs are usually dispensed by the practitioner who prescribes them, dispensing is also emerging as a skilled and independent profession, and the Committee believes this development should not be hindered. A TCM registration board could include a mechanism to ensure that dispensers who dispense scheduled herbs are appropriately trained, and could establish standards for dispensing of Chinese herbal medicines. (See Recommendations 14, 15 and 16).
Which Titles Should be Protected?
There continues to be disagreement as to whether the official descriptor of the profession should be 'Traditional Chinese Medicine' or 'Chinese Medicine'. The Committee's view is that both options should be available, and practitioners seeking TCM registration should be able to nominate which they prefer on their registration certificate.
The Committee believes that sufficient titles should be protected to adequately identify the profession and to ensure that a practitioner qualified in one protected modality but not in another cannot use a title that suggests qualifications in both. (See Recommendations 17, 18, 19 and 20).
Approaches to Standard Setting
If occupational registration proceeds, the registration board will be responsible for determining the standard of training required for registration and accrediting courses that meet this standard. Many submissions favoured degree level training as the minimum standard. The Committee anticipates that the forum and process facilitated by the Australian Acupuncture and Chinese Medicine Association may achieve consensus on draft comprehensive standards that can be used as a basis for the accreditation process. In the absence of consensus, it should be the responsibility of a TCM registration board(s) in cooperation with the profession to determine standards of practice and accredit educational courses. (See Recommendation 5).
Grandparenting Arrangements
Where existing practitioners do not hold the qualifications newly prescribed by the registering authority, recognition could be based on membership of an existing professional association, assessment of qualifications, competency-based assessment, further education and training, or standard examination. The Committee believes that a combination of these is appropriate for TCM. Responsibility for determining and implementing guidelines for grandparenting will rest with the TCM registration board(s). (See Recommendation 21).
Non-English Speaking Practitioners
Arbitrary application of a standard of English fluency in the registration of TCM practitioners could discriminate against the significant proportion of TCM practitioners in Australia from non-English speaking backgrounds. These practitioners have argued their safe practice record and important community service.
It is imperative that clients be able to communicate the history and nature of their complaints, and that practitioners be able to understand the information, question the client, and communicate advice and intentions. The Committee believes that legislation for TCM registration should include the power to refuse registration to an applicant whose competency in English is insufficient, but retain the flexibility to recognise and support to continuing safe practice of NESB practitioners. (See Recommendation 22).
Funding of a Regulatory System
Existing registration boards in Victoria are independently incorporated and self-funding. Submissions and the Committee support self-funding. There is every indication that a sufficient number of practitioners are willing to pay registration fees to support the operation of a registration board. A seeding loan from Government may be required for establishment. (See Recommendation 23).
Regulation of Practitioners Registered with Another Board
Complementary therapies, particularly acupuncture, are being offered by increasing numbers of health care practitioners whose primary form of practice is in a discipline other than TCM and who are registered by another board. There is widespread support among health care professional organisations (other than the AMA and AMAS) for their practitioners who use TCM to be required to register with a TCM board. The Committee's view is that:
- Registered medical practitioners have the necessary skills to use the title 'Medical Acupuncturist' without registration with a TCM board, given that an agreement between the AMAS and the Health Insurance Commission can be expected to set a reasonable standard of education for these practitioners.
- Other registered health professionals should be exempted from requirements to register with a TCM board provided that they meet education and practice requirements set down by their own registration board, that these standards have been endorsed by the TCM board, and that where a generalist health practitioner registration board investigates a complaint of unprofessional conduct involving the practice of TCM, it has access to TCM expertise. (See Recommendations 24 and 25).
Regulation of Practitioners of Other Forms of Complementary Therapy
Where modalities of TCM are used by practitioners of other complementary therapies for which practitioner registration is not required, these practitioners may, if TCM registration is introduced, seek registration under the same conditions as all primary TCM practitioners. This view is supported both by submissions and by the Committee.
The Committee believes that further work is required to establish whether there is a need for statutory registration of practitioners of Western herbal medicine, including the need for a mechanisms for access by suitably trained practitioners to certain scheduled Western herbal medicines. (See Recommendations 26 and 27).
Regulation of Other Traditions of Acupuncture
Ayurvedic acupuncture (practised in India, Sri Lanka and Tibet) uses a system different from the Chinese.
The Committee believes that TCM registration should be required for Ayurvedic acupuncturists who wish to use the word 'acupuncturist' as part of their title and that, to assist in regulating this practice, the TCM registration board should have the power to co-opt people with relevant expertise from Ayurvedic medicine associations.
Some veterinary surgeons are trained in, and practise, animal acupuncture. They have proposed that practitioners calling themselves 'veterinary acupuncturists' be exempted from registration requirements where they are registered veterinary surgeons, and the Committee sees no problem in this. (See Recommendations 28 and 29).
The Need for Research
The Committee is of the view that there is a need to develop dialogue between researchers in TCM and in Western medicine, in order to explore opportunities to improve the health status of the Australian community through the application of TCM in concert with Western medicine, to ensure adequate protection of the public, and to determine the place of TCM within the health care system. (See Recommendations 30, 31 and 32).
The report draws extensively on the publication Towards a Safer Choice: The Practice of Traditional Chinese Medicine in Australia prepared by
Mr Alan Bensoussan and Dr Stephen Myers.
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last updated 16/7/98
