SUMMARY OF RECOMMENDATIONS
Many of our recommendations make reference to the
way we have organised therapies into three separate groups in
the Report. These groupings are outlined in detail in Chapter
2 but for ease of reference a short synopsis of our grouping system
is as follows:
- The first group embraces
what may be called the principal disciplines, two of which, osteopathy
and chiropractic, are already regulated in their professional
activity and education by Acts of Parliament. The others are acupuncture,
herbal medicine and homeopathy. Each of these therapies claims
to have an individual diagnostic approach and are seen as the
'Big 5' by most of the CAM world.
- The second group contains
therapies which are most often used to complement conventional
medicine and do not purport to embrace diagnostic skills. It includes
aromatherapy; the Alexander Technique; body work therapies, including
massage; counselling, stress therapy; hypnotherapy; reflexology
and probably shiatsu, meditation and healing.
- The third group embraces
those other disciplines which purport to offer diagnostic information
as well as treatment and which, in general, favour a philosophical
approach and are indifferent to the scientific principles of conventional
medicine, and through which various and disparate frameworks of
disease causation and its management are proposed. These therapies
can be split into two sub-groups: Group 3a includes long-established
and traditional systems of healthcare such as Ayurvedic medicine
and Traditional Chinese medicine. Group 3b covers other alternative
disciplines which lack any credible evidence base such as crystal
therapy, iridology, radionics, dowsing and kinesiology.
Introduction (Chapter 1)
2. More detailed quantitative information is required
on the levels of CAM use in the United Kingdom, in order to inform
the public and healthcare policy-makers, and we recommend that
suitable national studies be commissioned to obtain this information
Evidence (Chapter 4)
3. Diagnostic procedures must be reliable and reproducible
and more attention must be paid to whether CAM diagnostic procedures,
as well as CAM therapies, have been scientifically validated.
We agree that this is an issue that should always be kept in mind
when doing research in this area (para 4.16).
4. In our opinion any therapy that makes specific
claims for being able to treat specific conditions should have
evidence of being able to do this above and beyond the placebo
effect. This is especially true for therapies which aim to be
available on the NHS and aim to operate as an alternative to conventional
medicine, specifically therapies in Group 1. The therapies in
our Groups 3a and b also aim to operate as an alternative to conventional
medicine, and have sparse, or non-existent, evidence bases. Those
therapies in our Group 2 which aim to operate as an adjunct to
conventional medicine, and mainly make claims in the area of relaxation
and stress management, are in lesser need of proof of treatment-specific
effects but should control their claims according to the evidence
available to them (para 4.18).
5. We recommend that if a therapy does gain a critical
mass of evidence to support its efficacy, then the NHS and the
medical profession should ensure that the public have access to
it and its potential benefits (para 4.37).
Regulation (Chapter 5)
6. We recommend that, in order to protect the public,
professions with more than one regulatory body make a concerted
effort to bring their various bodies together and to develop a
clear professional structure (para 5.12).
7. We recommend that each of the therapies in Group
2 should organise themselves under a single professional body
for each therapy. These bodies should be well promoted so that
the public who access these therapies are aware of them. Each
should comply with core professional principles, and relevant
information about each body should be made known to medical practitioners
and other healthcare professionals. Patients could then have a
single, reliable point of reference for standards, and would be
protected against the risk of poorly-trained practitioners and
have redress for poor service (para 5.23).
8. It is our opinion that acupuncture and herbal
medicine are the two therapies which are at a stage where it would
be of benefit to them and their patients if the practitioners
strive for statutory regulation under the Health Act 1999, and
we recommend that they should do so. Statutory regulation may
also be appropriate eventually for the non-medical homeopaths.
Other professions must strive to come together under one voluntary
self-regulating body with the appropriate features outlined in
Box 5, and some may wish ultimately to aim to move towards regulation
under the Health Act once they are unified with a single voice
(paras 5.53 and 5.55).
9. We recommend that each existing regulatory body
in the healthcare professions should develop clear guidelines
on competency and training for their members on the position they
take in relation to their members' activities in well organised
CAM disciplines; as well as guidelines on appropriate training
courses and other relevant issues. In drawing up such guidelines
the conventional regulatory bodies should communicate with the
relevant complementary regulatory bodies and the Foundation for
Integrated Medicine to obtain advice on training and best practice
and to encourage integrated practice (para 5.79).
10. We encourage the bodies representing medical
and non-medical CAM therapists, particularly those in our Groups
1 and 2, to collaborate more closely, especially on developing
reliable public information sources. We recommend that if CAM
is to be practised by any conventional healthcare practitioners,
they should be trained to standards comparable to those set out
for that particular therapy by the appropriate (single) CAM regulatory
body (para 5.83).
11. We recommend that the MCA find a mechanism that
would allow members of the public to identify health products
that had met the stringent requirements of licensing and to differentiate
them from unregulated competitors. This should be accompanied
by strong enforcement of the law in regard to products that might
additionally confuse the customer with claims and labelling that
resemble those permitted by marketing authorisations (para 5.93).
12. We strongly recommend that the Government should
maintain their effective advocacy of a new regulatory framework
for herbal medicines in the United Kingdom and the rest of the
European Union, and urge all parties to ensure that new regulations
adequately reflect the complexities of the unregulated sector
13. We are concerned about the safety implications
of an unregulated herbal sector and we urge that all legislative
avenues be explored to ensure better control of this unregulated
sector in the interests of the public health (para 5.97).
14. We support the view that any new regulatory regime
should respect the diversity of products used by herbal practitioners
and allow for simplified registration of practitioner stocks.
Nevertheless, any such regime must ensure that levels of quality
and assurance of safety are not compromised (para 5.98).
Professional Training and Education (Chapter
15. 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 (para 6.20).
16. 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 (para 6.33).
17. 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
18. 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 (para 6.40).
19. 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 (para 6.43).
20. We recommend 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 (para 6.49).
21. 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 (para
22. 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 (para 6.54).
23. We conclude that there should be flexibility
for training institutions to decide how to educate practitioners.
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
24. We 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 in paragraph 6.55 (para 6.62).
25. We recommend that therapies with a fragmented
professional organisation work with Healthwork UK to develop National
Occupational Standards, and we encourage the Department of Health
to further support Healthwork UK's activity with such therapies;
we believe that this would be of long-term benefit to the public
26. We recommend that familiarisation should prepare
medical students for dealing with patients who are either accessing
CAM or have an interest in doing so. This familiarisation should
cover the potential uses of CAM, the procedures involved, their
potential benefits and their main weaknesses and dangers (para
27. We recommend that every medical school ensures
that all their medical undergraduates are exposed to a level of
CAM familiarisation that makes them aware of the choices their
patients might make (para 6.79).
28. We recommend that Royal Colleges and other training
authorities in the healthcare field should address the issue of
familiarisation with CAM therapies among doctors, dentists and
veterinary surgeons by supporting appropriate Continuing Professional
Development opportunities (para 6.85).
29. The General Osteopathic and Chiropractic Councils,
and any other regulatory bodies, should develop schemes whereby
they accredit certain training courses aimed specifically at doctors
and other healthcare professionals, and which are developed in
conjunction with them. Similar schemes should be pursued by dentists
and veterinary surgeons (para 6.95).
30. We recommend that the UKCC work with the Royal
College of Nursing to make CAM familiarisation a part of the undergraduate
nursing curriculum and a standard competency expected of qualified
nurses, so that they are aware of the choices that their patients
may make. We would also expect nurses specialising in areas where
CAM is especially relevant (such as palliative care) to be made
aware of any CAM issues particularly pertinent to that speciality
during their postgraduate training. The Royal College of Nursing
and the UKCC, as they do not provide CAM training themselves,
should compile a list of courses in CAM that they approve, in
order that nurses who wish to practise in this field can obtain
guidance on appropriate training (para 6.106).
Research (Chapter 7)
31. To conduct research into the CAM disciplines
will require much work and resources, and will therefore be time-consuming.
Hence, we recommend that three questions should be prioritised
and addressed in the following order:
- To provide a starting point for possible improvements
in CAM treatment, to show whether further inquiry would be useful,
and to highlight any areas where its application could inform
conventional medicine does the treatment offer therapeutic benefits
greater than placebo?
- To protect patients from hazardous practices
- is the treatment safe?
- To help patients, doctors and healthcare administrators
choose whether or not to adopt the treatment - how does it compare,
in medical outcome and cost
with other forms of treatment? (para 7.7)
32. We recommend that CAM practitioners and researchers
should attempt to build up an evidence base with the same rigour
as is required of conventional medicine, using both RCTs and other
research designs (para 7.26).
33. To achieve equity with more conventional proposals,
we recommend that research funding agencies should build up a
database of appropriately trained individuals who understand CAM
practice. The research funding agencies could then use these individuals
as members of selection panels and committees or as external referees
as appropriate (para 7.45).
34. We recommend that universities and other higher
education institutions provide the basis for a more robust research
infrastructure in which CAM and conventional research and practice
can take place side-by-side and can benefit from interaction and
greater mutual understanding. We recommend that a small number
of such centres of excellence, in or linked to medical schools,
be established with the support of research funding agencies including
the Research Councils, the Department of Health, Higher Education
Funding Councils and the charitable sector (para 7.57).
35. Bodies such as the Departments of Health, the
Research Councils and the Wellcome Trust should help to promote
a research culture in CAM by ensuring that the CAM world is aware
of the opportunities they offer. The Department of Health should
exercise a co-ordinating role. Limited funds should be specifically
aimed at training CAM practitioners in research methods. As many
CAM practitioners work in the private sector and cannot afford
to train in research, we recommend that a number of university-based
academic posts, offering time for research and teaching, should
be established (para 7.67).
36. We recommend that companies producing products
used in CAM should invest more heavily in research and development
37. We recommend that the NHS R&D directorate
and the MRC should pump-prime this area with dedicated research
funding in order to create a few centres of excellence for conducting
CAM research, integrated with research into conventional healthcare.
This will also help to promote research leadership and an evaluative
research culture in CAM. Such funds should support research training
fellowships and a limited number of high-quality research projects.
This initiative should be sufficient to attract high-quality researchers
and to enable them both to carry out large-scale studies and to
continue to train CAM researchers in this area within a multi-disciplinary
environment. We believe ten years would be sufficient for the
pump-priming initiative as, for example, in the case of some MRC
programme grants and various training and career development awards
available in conventional medicine. The Association of Medical
Research Charities may also like to follow this example (para
Information (Chapter 8)
38. We recommend that the NHS Centre for Reviews
and Dissemination work with the RCCM, the UK Cochrane Centre,
and the British Library to develop a comprehensive information
source with the help of the CISCOM database, in order to provide
comprehensive and publicly available information sources on CAM
research, and that resources be made available to enable these
organisations to do so (para 8.21).
39. We see the NHS as the natural home in the United
Kingdom for reliable, non-promotional information on all types
of healthcare; providing such a home is particularly important
for CAM, where the diversity of opinion and organisations make
it almost impossible for individuals to gain an overview. Consequently
we support the plans of the Department of Health to make information
on CAM available through NHS Direct, and we urge that they be
carried out in the very near future. We recommend that the information
should contain not only contact details of the relevant bodies
and a list of NHS provision of CAM in each local area, but also
some guidance to help patients (and their doctors) evaluate different
CAM therapies (para 8.31).
40. We are aware that the National electronic Health
Library and NHS Direct Online plan to have information available
about CAM in the future and we support these plans and recommend
that they are carried forward (para 8.48).
41. We recommend that CAM regulatory bodies, whether
statutory or voluntary, remind their members of the laws concerning
false claims in advertisements and take disciplinary action against
anyone who breaks them. Information leaflets produced by such
bodies should provide evidence-based information about a therapy
aimed at informing patients, and should not be aimed at selling
therapies to patients (para 8.57).
Delivery (Chapter 9)
42. We recommend that those practising privately-accessed
CAM therapies should work towards integration between CAM and
conventional medicine, and CAM therapists should encourage patients
with conditions that have not been previously discussed with a
medical practitioner to see their GP. We also urge CAM practitioners
and GPs to keep an open mind about each other's ability to help
their patients, to make patients feel comfortable about integrating
their healthcare provision and to exchange information about treatment
programmes and their perceptions of the healthcare needs of patients
43. We recommend that all NHS provision of CAM should
continue to be through GP referral (or by referral from doctors
or other healthcare professionals working in primary, secondary
or tertiary care) (para 9.37).
44. We recommend that only those CAM therapies which
are statutory regulated, or have a powerful mechanism of voluntary
self-regulation, should be made available, by reference from doctors
and other healthcare professionals working in primary, secondary
or tertiary care, on the NHS (para 9.46).