This chapter reviews the background to recent policy developments in relation to the registration of Chinese medicine, naturopathy and western herbal medicine (WHM) and discusses what factors have shaped policy development, and might shape future policy. In doing so, the chapter illustrates that health policy is often not a single decision but a series of actions that affect a set of institutions, services, and the community. Policy development then reflects the continued engagement of a range of actors in a process of policy debate, who represent different interests, and who respond to changing social, economic, and political contexts.

COMPLEMENTARY AND ALTERNATIVE MEDICINE DEFINED

The umbrella term CAM encompasses a large array of health practices and occupations generally considered alternative or complementary to the mainstream health system. The term CAM can be problematic, as it groups together divergent practices, but has been adopted as a policy terminology of convenience. The nature of CAM practices and its increasing adoption by biomedical practitioners (known as integrative medicine) means the boundary between CAM and biomedicine is not always sharply defined or fixed. While Table 10.1 lists some of the major CAM systems in Australia, our focus on Chinese medicine (including acupuncture), naturopathy and WHM means this chapter relates to a limited, albeit significant, number of CAM practices.

In terms of the three practices of concern to this chapter:

With underlying philosophies and principles quite different from those underlying biomedicine, the differences among CAM professions, in worldviews, in the diversity of practices, and the practitioners’ desire for autonomy of their particular CAM domain, increasing the challenge of regulating CAM professions (Canaway 2007).

AUSTRALIAN POLICY FRAMEWORK FOR HEALTH WORKFORCE REGULATION

The difference in level of regulation of the same profession generally reflects historical and institutional arrangements, rather than objective assessments of risk to public health and safety (Australian government 2006b). Concerns about the level of regulatory differences across Australia and the impact this has on enterprise and competition, in all areas, not just health, led to the Commonwealth Mutual Recognition Act 1992, relating to the free movement of goods and services (Australian government 2000).

Further, in 1995 the National Competition Policy (NCP) committed all governments to review legislation and remove unnecessary regulation which might impede competition. Around the same time, the Australian Health Ministers’ Advisory Council (AHMAC) established criteria for assessing the regulatory requirements for unregulated health professions. All six criteria must be satisfactorily met for the consideration of statutory registration. These criteria are:

• the Mutual Recognition Act 1992
  
• the NCP
  
• the AHMAC criteria for occupational registration.

In 2006, the Council of Australian Governments (COAG) adopted the recommendation of the Productivity Commission’s health workforce report for a national approach to the registration and course approval of health professions. This further signifies the trend towards nationally defined standards and a common regulatory approach to all health professions (see also Chs 3, 4 & 9).

Table 10.2 lists the main regulatory models for all health professions. Self-regulation of CAM is currently the norm in every state and territory. The Victorian Chinese Medicine Registration Act 2000, legislating for reservation of title, is the only statutory regulation of a CAM profession in Australia, excluding chiropractic and osteopathy. Reservation of title is the most common approach used for regulation of health professions and in the case of Chinese medicine in Victoria, outlaws the use of such titles as acupuncturist, Chinese medicine practitioner, Chinese herbal practitioner, Chinese herbal dispenser, and so on, by anyone other than a registered practitioner. This model of regulation does not prohibit other people from offering similar practices, but does make it an offence to do so and use these titles. The July 2007 adoption of the Health Professions Registration Act 2005 in Victoria repealed all profession-specific registration Acts and further reinforced the common approach adopted for health workforce regulation.

Table 10.2 General models for regulation of health professions
1. Self-regulation 2. Negative licensing 3. Co-regulation 4. Reservation of title only 5. Reservation of title and core practices 6. Reservation of title and whole of practice

A LONGSTANDING PROBLEM: THE HISTORICAL BACKGROUND TO POLICY DEVELOPMENTS FOR CAM

Throughout the 20th century in Australia, the impetus for professional registration had come from within the ranks of CAM practitioners (see Table 10.3). In the 1920s, the threat of ‘anti-quackery’ laws with the potential to outlaw or limit practice motivated herbalists and chiropractors to seek registration as a means of gaining greater institutional and professional recognition (Bentley 2005, Martyr 2002). Public support and arguments for freedom of choice and the benefits of competition, quelled the early legislative threats to herbalists and other ‘irregular’ medical practitioners (Bentley 2005, Martyr 2002).

While inquires in the 1960s and 1970s led to practitioner registration for chiropractors and osteopaths, the same was not recommended for naturopathy or other natural therapies (Table 10.3). The 1986 Victorian Parliamentary inquiry was the first to acknowledge that ‘alternative medicine practitioners represent primary contact healthcare providers for a significant proportion of the Victorian public’ (Social Development Committee [SDC] 1986a p 179). Once again, however, registration was not recommended, on the grounds that naturopaths presented little concern for causing public harm, and because registration would imply government endorsement of the body of knowledge that supported alternative medicine (SDC 1986a p 181).

Changing ideologies have impacted on policy development relating to CAM. By the 1980s, banning or restricting medical practices, even when their knowledge was based on philosophy and practices divergent from orthodox medicine, had come to be regarded as an unacceptable ‘relic of medical paternalism’ (National Health and Medical Research Council [NHMRC] 1989 p 76). Perhaps of greater impact in bringing CAM to the attention of government, the medical profession and policy makers, has been the increasing usage of CAM that has led to it becoming a multi-billion dollar industry, through increased use of CAM products as well as adopting of CAM practices (MacLennan et al. 2006).

Reasons for consumers seeking care by CAM practitioners include finding that conventional healthcare has not relieved symptoms, preferring longer and more supportive consultations, wanting lifestyle counselling alongside illness treatment, or generally seeking holistic or proactive approaches to healthcare (Lin et al. 2006). CAM practitioners are sought for treatment of a wide range of complaints including the alleviation of side effects from orthodox medicine, and particularly for help with chronic conditions (Lin et al. 2006). For many consumers, negotiating across parallel primary care systems of the GP and the CAM practitioner has become the norm.

Changes in the attitude of medical professionals towards CAM also have a bearing on shifting attitudes that might ultimately inform policy relating to CAM. Changes in attitude from medical professionals reflect not only responsiveness to consumer demands but also increasing reports of the effectiveness of CAM practices. Some GPs now refer patients to CAM therapies (Pirotta et al. 2000), some report that they use CAM themselves, or offer CAM therapies to patients (Leach 2004, Lin et al. 2006, Wilkinson & Simpson 2002). Some clinicians trained in conventional healthcare (e.g. nurses, physiotherapists or pharmacists) take a further step by training to become a CAM practitioner. Medical practitioners have sufficiently embraced acupuncture for it to now have a presence within the Royal Australian College of General Practitioners (RACGP) and gain Medicare rebates for these services, which is something denied non-medical establishment acupuncturists.

RECENT POLICY RESPONSES

The policy developments in the last decade, as outlined in Table 10.4, occurred against this background of increasing consumer usage and interest from medical practitioners.

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