Healthcare of the Nation

The Role of the CAM Practitioner in the Future Healthcare of the Nation - a Personal Perspective for a Practical Solution by Edith Maskell

INTEGRATION

The idea of integrating CAM into orthodox medicine was initiated by the Prince of Wales around 1999. It has been a pipe dream for practitioners for many years. Despite what, sometimes, seems like insurmountable obstacles remaining in the way. I believe there are solutions if only those involved would just take a peek outside of the box. I believe my vision and perspective offers practical solutions.

Keeping in mind the dream of CAM practitioners to participate, contribute, be respected and hence make a difference to the health of the nation for eons, do we deserve it and have we properly prepared ourselves?

A TELLING TALE

If there is any truth in the myth that CAM and its practitioners are dangerous or that there is no hard evidence that it works – why is it becoming so popular? As far as I am aware, we aren't witches, capable of casting spells over the public.

At a recent conference I attended, in a homeopath's presentation he related a story of telephoning calling the DoH one day and in introducing himself said "I think homeopathy should be available for all patients". The response was "don't say that – they'll all want it"!

At the same conference, a GP (who has incorporated CAM into his practice since the mid eighties) stated that the outcome of a study he conducted, concluded that 75% of his patients want to be referred to a CAM practitioner.¹ The public are nobody's fools. They're learning fast … and this is borne out in my own practice … it's clear that their needs aren't being met by the NHS and CAM is filling the gap.

MUTUAL RESPECT

As a multi disciplined CAM practitioner, in my dream, I want to be fully integrated into medicine as a respected member of a healthcare team but not necessarily working within the health service environment or by being employed by them.

I want to have :

• CHOICE for the patient, client, user. (The new terminology). By choice, I mean that I do not wish for the doctor to be the "gatekeeper". I want to have responsibility for the care of those people. Choice also means that patients too can take responsibility by choosing how they want to be treated without fear that their doctor will disapprove. The same GP I mentioned earlier also stated that 50% of his patients seeking CAM "don't want their GP to know". Are afraid he/she will disapprove.
• RECOGNITION of my hard work and investment, in terms of time, effort and finance over the last 15 years (the specialist skills, knowledge and professional development gained through experience and training over that period).
• On a personal level, as a multi disciplined practitioner, the training has never stopped. I find it insulting to lump everyone into the same category and continue making assumptions that we are not trained properly.
• In my vision, we must also be paid for our contribution and not feel guilty about it - just like everybody else is paid, a fair wage for a fair day's work. One of my biggest "hang ups" is CAM practitioners remaining unpaid for work which is clearly acknowledged as valuable by the sick and others who care for them.² I understand all the reasons why so much of our work is carried out on a voluntary basis but whilst we continue to do it for nought, we devalue that work and it will continue to be taken for granted. I am also intrigued at the same time fears are publicised about the safety of CAM and the professionalism of the people who carry out the work, we continue to be allowed to work in what I consider to be the most vulnerable areas of medicine, ie palliative care. There seems to be something about not paying for CAM that somehow deems it safe? This fact remains a mystery to me.
• HIERARCHY and INTEGRATION go hand and hand for me. It has been estimated that there are in excess of 120 000 CAM qualifications in the UK, not all at the same level. Until differentiation is established - the myths will continue in terms of doubt as to our ability and professionalism. Hence, I believe, CAM practitioners don't have a hope when it comes to integration – regulated or not. The standards required to be regulated are National Occupational Standards (NOS) which are low – it's designed to be inclusive rather than exclusive. However, I believe that low standards will do nothing to evoke confidence by the medical profession. Thus we need to be highlighting our specialist skills and higher level qualifications. To stand proud and demonstrate the difference between the work of the serious health practitioner and leisure therapist. Both of which have a role in society.

OBSTACLES are many and varied. So what is it that stands in the way of my dreams?

• The lack of knowledge from a variety of perspectives. There is a level of CAM practitioners where there is a huge font of knowledge and expertise but it tends to be coupled with inertia and general lack of confidence within the profession. There is also a reluctance to get involved in research. Negative assumptions concern me, that there is no point, regulation will never happen, for instance. Insufficient backing from academics, lack of funding and support with training in how to carry out appropriate research studies.
• Another level of inertia with CAM practitioners is the resistance to change. Even a requirement to carry out continual professional development (CPD) like simple reflective practice is often bemoaned to me. CPD is a subject (in my experience) which causes most unrest among practitioners. "I can't afford to do courses" is one I hear most.
• As far as credibility is concerned, CAM practitioners don't help themselves when they bury their heads about what's happening within their profession. We owe it to our profession to keep abreast of news.
• Constant complaints that practitioners only work part time or as volunteers and therefore can't afford to pay to be regulated, only serves to publicly confirm doubts about our professionalism.
• Other myths with which we have to contend with and I believe, must overcome, are concerned with the safety of CAM and those who practice it. Our training is not understood; has been too varied with no recognisable or common standards in the past; professions have taken too long to get their act together in regulating themselves; are disparate; not accountable to anyone.
• It is not understood what we do behind closed doors in our therapy rooms; I once called a major corporate and spoke to the head of HR. When I mentioned that I would like the opportunity to meet to discuss offering "On Site Massage" to the employees. I was greeted with "oh we don't do anything like that here". As if massage was something to be frowned upon. This isn't helped by the fact that we sometimes work in darkened rooms with candles (poor image and worse still a major safety concern). We often play inappropriate music; other concerns are that we practice outside of our scope in isolated environments; particularly with the young and vulnerable adults without carrying out appropriate protocols; it is not understood that we work to specific codes of ethics; we are perceived as making promises of cure; that we mix therapies when each is powerful in its own right. Some even dress inappropriately; practice without insurance or membership to a professional association. I have heard logic for this expressed as "I we only have one or two clients a month, so it's not worth it"; then there is the old chestnut that there is no evidence that CAM works; we don't know when to make appropriate referrals; we're charlatans because we take money from vulnerable people when they're ill. Last year there was the newspaper article from 13 Professors who claimed that there are insufficient funds within the NHS for seriously ill patients to receive orthodox medicine never mind investing in CAM.
• And the one which is guaranteed to press my buttons is - CAM is only helpful because of the placebo effect or when given as a "nice hand or foot massage" to make people feel better
• Last but not least : politics and fears from pharmaceutical companies?

EVIDENCE

So what can we do to dispel the myths? Much has already been done. In the past 5 years, evidence has been mounting that the use of CAM within the NHS provides credible savings ³, so much so, the studies more than paid for themselves and had very interesting outcomes.

• Savings in GP time enabled more facilities to spend with those who were terminally or acutely ill
• It transpires that 10% of patients utilise 90% of NHS resources.
• Less drugs administered, less diagnostic/investigative tests carried out and less surgical procedures deemed necessary
• Question. Might utilisation of CAM services have a lasting effect on economy?
• GP's admitted they are empty handed. Have nothing to offer patients with chronic conditions (persistent and mystery illnesses where symptoms present for more than 12 months). Felt these areas are where CAM is most effective.
• All of this is not a surprise to the CAM profession. Our aim has never been to cure. We work with complex problems which are not symptom related. Our objectives are to deal with prevention (bringing about awareness of what it means to be healthy), dysfunction (the bit between when symptoms first present and disease/ degeneration is eventually diagnosed by the medical profession); and maintenance of well being, once it is achieved. In other words, a truly holistic approach to healthcare.
• Better quality of life – the GP I mentioned earlier, reported that he and his partners were
• Happier and "less burnt out"
• The community as a whole was healthier

I believe that if GP's referred patients to CAM it would give them and their patient's choice …. not just about which treatment they receive, but whether to pay for it or not, whether to wait for it (or not); to be provided on the NHS.

With scarce funding and appointments available say, to see a physiotherapist, I believe some patients would happily pay privately rather than wait 6 weeks or longer, if their GP were to give them the choice and "rubber stamp"/approve a local reputable CAM practitioner. This would mean more availability for those who could not afford or did not want to pay privately. Their health outcome would improve too. It is common knowledge that for best results, particularly with muscular and skeletal problems that there is a 3 week window between the onset of symptoms and when treatment should begin. So attention could be sought before the problem became "locked" in.

My general conclusions therefore, are that CAM is a valuable "add-on" service so that it would not be a burden on the NHS. On the contrary, the provision of CAM or referral to a CAM practitioner could actually provide additional funding for the medical profession to spend on other vital services for patients who need expensive, possibly life saving drugs.

SO WHAT CAN CAM PRACTITIONERS ACTIVELY DO IN THE IMMEDIATE FUTURE TO DISPEL THE MYTHS AND PROVIDE RESOLUTIONS?

It's seems to me that with some evidence already in place, we need to ensure it continues :

CAM practitioners must get involved in research. Particularly in studies for chronic conditions for which the medical profession have no drugs or literally run out of services to offer. GP's I have spoken to have suggested that their "worst nightmare" is when patients arrive with a list of symptoms and there is nothing to offer them. Some chronic conditions mentioned were ME, Osteoarthritis, IBS and other what I term as general "mystery" illnesses. The patients who have been everywhere, seen everyone and done everything. Been told there is nothing wrong yet are clearly unwell; and by now, depressed as well. These patients have had their symptoms for well over a year and are getting progressively worse physically; and eventually, on an emotional level. When they arrive, they are feeling abandoned and desperate.

With the regulation of CAM practitioners drawing closer (estimated to be by the Spring of 2008; if the CAM specialists are highlighted and are properly marketed to the medical profession and to the public, I believe the old beliefs and myths will begin to fade. A good analogy is to look at what happened to plumbers and electricians.

The best analogy is to look at Corgi Registered Plumbers. Today, the public are more likely to choose from this register than anyone else. New laws are now in place where property owners must provide evidence of Gas and Electricity safety when putting their house on the market. This is the result of public safety measures, which is the basis of regulation of any industry/profession. The same will happen to the CAM profession but …

COMMUNICATION IS KEY

• Practitioners must take responsibility and help themselves by actively participating in research studies to build the library of evidence.
• Professional associations have a duty to foster and encourage research and support the practitioners in this work by promoting the results.
• There is a movement and acknowledgement towards qualitative research that it is more valid and valuable with the CAM profession than random controlled or double blind trials and I am aware of work taking place by academics in this field.
• There needs to be an acknowledgement that it is the role of the professional associations not the Regulator to promote registered practitioners to the public and the medical profession. Does the GMC promote GP's to the public? How many of the public check whether their GP is on the register before joining a particular surgery?

It is going to be an uphill struggle to get past all the myths and so practitioners must continue to invest in themselves – be prepared to take risk, be focused and make clear decisions to :

• Continue to hone skills already acquired and continue to develop by gaining new skills and specialise in the areas CAM is acknowledged
• Reflect on a regular basis. Am I going in the right direction? What can I learn or have I learned from this or that experience?
• Be prepared to build a career and be business like. We must lose the "buff and shine" image. Prove that we are responsible.
• Consider CAM as a profession instead of something that's done for pin money or a hobby when the children leave home or something to give back to society after a mid life crisis. CAM is a serious profession offering skills which are a valuable and vital commodity.
• This doesn't necessarily mean spending vast sums of money on attending numerous workshops and courses which give no proper qualifications.
• Change attitudes and perceptions – our own and others. Value ourselves and our work – demand to be paid.
• Learn to put aside all our own fears, myths and beliefs, especially when it comes to regulation and the potential costs/perceived risks.
• Register when the time comes. We must all take risks if we want to go forward. The journey of a thousand miles begins when we take that first step.

A COMPARATIVE PERSPECTIVE

Chiropractors were statutorily regulated about 6 years ago. I'm told there are less than 4,000 in the UK. It is illegal for them to call themselves chiropractors unless they are registered with the General Chiropractic Council. The GCC is not a professional association – it is the body that regulates Chiropractic.

The first year they register it costs them £1 250. Renewal drops to £1 000 per year plus they have to prove that they have done CPD; some, specific to Chiropractic.

Additionally, most join a professional association – not obligatory but the majority join because membership demonstrates professionalism, it plays a supporting role. For example, if the GCC were to notify a registrant that a complaint was made against them. Professional association membership keeps them informed of what is going on within their profession on all levels. For that - they pay in the region of an additional £530 – each year. On top of that is insurance. Like any insurance, where there is more risk, the cost of insurance increases and in the case of chiropractors the risk is deemed (by brokers) to be higher and consequently, the cost is in proportion to the risk. £500 every year.

It doesn't take a brain surgeon to work out that Chiropractors pay between £2 030 and £2 280 each year for the privilege of protection of

Title, i.e calling themselves Chiropractors. No wonder they work their socks off to ensure their practices are successful and most charge around £30 for 10 minutes! I have worked with many Chiropractors over the years and never met one who feels guilty about charging and I don't consider them to be charlatans and neither do their loyal patients. They provide a vital service. Additionally, I have never met any who do voluntary work.

They're merely earning a living which equates to the hoops they jump through in training and continually developing their professionalism. What's the difference between them and us – their commitment to a "profession" and I suspect the annual bills they face tend to focus the mind somewhat!

Alternatively, bearing in mind, there are said to be in excess of 120 000 CAM qualifications in the UK. The cost of regulation for us will be in proportion to how many practitioners decide to register. Again, it doesn't take a brain surgeon to work out that by comparison registration for CAM practitioners should be considerably lower than £1 000 per annum. However, the important point is t to remember that cost is dependent upon how many register; plus we are talking about voluntary, not statutory. This means that CAM practitioners will be allowed to continue to work whether they choose to register or not. For the moment, that is. This may well change in the future.

If we have a desire to be fully integrated and considered as part of the healthcare team in the UK and to be viewed as serious practitioners of integrity and professionalism – it is my personal belief that we would be well advised to act responsibly.

Because of the lack of complaints and the low risk of harm – insurance is considerably cheaper for CAM practitioners; there are very few complaints, if any. Most are about suspect behaviour of the practitioner than the safety of the therapy. Another reason we need to "act and look the part". Likewise, membership of a professional association is also considerably cheaper for us. It isn't decided yet, the precise model that will regulate CAM practitioners, so there can be no guarantees.

However, we do know the majority of CAM practitioners are multi disciplined and those I have communicated with, have shared with me, that they don't want to choose to register in one therapy only (me included); hence in order to encompass the majority of CAM practitioners, the objective of a regulatory body must be to keep the process simple, cheap and to enable practitioners to register smoothly. As I see it, one of the purposes of this regulatory process, is inclusivity. Whilst I acknowledge believe there some more skilled than others (and they should be recognised for their specialisms), there are none more equal than others. Above all, everyone deserves not to have their right to work taken away from them. I see a valid role for all.

It is estimated that on average, multi disciplined therapists are qualified in 3 therapies. If the cost of regulation was in the region of £25 - £50 with a small additional fee for every therapy within which a practitioner is qualified and may wish to be acknowledged as regulated; the total cost, including insurance, regulation and continued membership to a professional association could be in the region of £150 - £200p.a. Quite a different story to that of the chiropractors! I believe if that is the cost of credibility, then it's good enough for me.

TRUST AND CREDIBILITY

If that's what it takes for CAM practitioners to earn respect and be trusted outside of the NHS or to gain employment within the medical profession, the cost could very quickly be recovered by the practitioner. I appreciate it's a risk but I like to think of it as more of an investment. Unless that risk is taken CAM practitioners will be left out in the cold because when the public start to realise there is a multi disciplinary Register which gives them a level of re-assurance – if marketed appropriately - than that will be the register from which they will choose their practitioner. Regrettably, those who remain unregistered – for whatever reason, because they feel can't afford it or simply refuse to pay because this is a voluntary system – could find themselves earning even less and the poor reputation of our profession, will persist.

It's probably a fair guess for me to suggest that the majority of us, if not all, are in this profession because we're passionate about our work and we know from our professional and personal experience, that we can have a positive effect on the future healthcare of the nation.

So in order for my vision to come true – may I urge other CAM practitioners that if you too have a dream and a desire to be truly integrated into the healthcare team which is our medical profession, in your own right and to make a real difference to society ………….in the words of the song ….

TAKE YOUR PASSION AND MAKE IT HAPPEN

References :
¹ Dr Michael Dixon – Complementary and Alternative Medicine Seminar – 5/10/06
² House of Lords – Science and Technology – Sixth Report
³ Christopher Smallwood Report – The Role of Complementary and Alternative Medicine in the NHS : October 2005

Thursday, 25 January 2007

© 2007 Bromley Health Management