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Making the case for registration of naturopaths

Should naturopaths be registered? It’s a controversial debate that’s hit the headlines again recently, following the near-death of a baby in Sydney.

Dr Jon Wardle, from the Australian Research Centre in Complementary and Integrative Medicine at the University of Technology Sydney, who has been taking plenty of media calls on this question, argues below that registration of naturopaths would help protect the community.

Updated: See this 17 July statement from the Public Health Association of Australia (PHAA) which says:

“Every government report since 2000 looking into the regulatory requirements of naturopaths has said the same thing, the risks associated with this profession are significant enough to warrant registration.

“It’s time to take these reports seriously and look at actually regulating naturopaths.”

 ****

Jon Wardle writes:

The debate on whether naturopaths should be registered has been reignited by the recent case of a Sydney naturopath being charged by police after providing questionable treatment advice that nearly resulted in an eight-month old infant’s death.

Undeniably tragic, in an unregulated major health profession like naturopathy this unfortunate event was, however, both preventable and predictable.

So would registration of naturopaths have helped in this case? It’s difficult to judge in hindsight, but there are several reasons why I believe it could have protected the public in this instance.

The client had specifically sought this person for naturopathic advice, and the practitioner’s claims specifically targeted people seeking a qualified naturopath. But in fact she had no naturopathic training – she was previously a registered nurse and midwife and had a massage certificate. She was not a naturopath at all, though her patients had no way of knowing this.

Although registered with the Australian Traditional Medicine Society, she was registered as a massage therapist only. However, the fact that she was able to use the term naturopathy whilst a member of this association for 26 years does show the severe failings of self-regulation.

Many complaints against naturopaths are for practitioners who have no naturopathic qualifications (a survey conducted for the Victorian review found that 10% of people calling themselves naturopaths had no formal training at all), people who have faked naturopathic qualifications, and sometimes deregistered practitionersresurfacing as naturopaths.

And it is its use as an alternative medicine ‘dumping ground’ that makes naturopathy so dangerous. Naturopaths are used by around 10% of the Australian population, up to 16% in some conditions (such as cancer). Naturopathy is what advertisers would call a ‘recognised brand’ – and it is an unprotected one. This results in a free-for-all co-option of the term by all sorts of fringe therapists. Any reader of this article could legally set themselves up as a naturopath tomorrow, if they wanted to.

The recent private health insurance review, for example, did note that while naturopathy had evidence of effectiveness in chronic conditions (and the naturopathic community is increasingly active in researching their therapies), the variability of standards among Australian naturopaths made this difficult to translate across all practitioners. Lack of regulation has been identified as the major factor in this variability.

Even if this person had managed to be registered (unlikely given the absence of qualifications), more minor indiscretions in her practice could have been picked up. Minor complaints that had been made would not have been ignored, as they often are in self-regulatory environments, either deliberately or due to lack of resources to adequately handle them.

While not being registered as a naturopath would not have stopped this person from practising at all – as a healer, for example – restricting her from the use of a title claiming services she was not qualified to provide would have identified her as an untrained practitioner (which may still be amenable for some people, but it would at least allow them to make an informed choice).

Some have expressed concern that registration of naturopaths would infer unwarranted legitimacy on naturopaths. The AMA is one group using this argument, with President Dr Brian Morton arguing that it would “send a message of acceptability and validity” to naturopaths. Yet there is not one skerrick of evidence that registration results in increased recognition.

Given the high use and recognition of naturopaths in Australia, one could say that naturopaths already enjoy this legitimacy in the eyes of the public, they are merely able to enjoy it without any accountability or responsibility to go with it.

In fact, the use of regulation as a tool of monopoly, recognition and legitimacy has been expressly forbidden since the Hilmer Report in the mid-90s. To ensure that health practitioner regulation was only done in the public interest, a set of criteria (now known as the ‘IGA criteria’) was established to ensure that the benefits of any registration outweighed any disadvantages.

Naturopaths are currently the only profession with a formal assessment against this criteria showing that they require registration who are not currently included in the National Scheme.

The costs of extending registration to naturopaths have also been expressed as a concern, yet the National Registration and Accreditation Scheme is user-pays, meaning that professions need to pay the costs of their own regulation. Not only does this absolve tax-payers from the financial responsibility of regulation, it sends a very clear incentive to the profession to get its own house in order.

This compares to the implementation of a statutory Code of Conduct for unregistered practitioners (currently being rolled out nationally), of whom naturopaths and counsellors form the largest groups, which will have minimum maintenance costs of $1 million per year.

It has also been held that ‘negative licensing’ (or a statutory code of conduct for unregistered practitioners – as currently exists in New South Wales and South Australia) model of regulation negates the need to extend registration to new professions. It is an argument which was also been used by other State and Territory ministers during the consultation process for the national roll-out of the Statutory Code of Conduct.

However, analysis of the legislation’s first five years in New South Wales shows that while it certainly fills some gaps in public protection, it is no substitute for statutory registration of new professions. This is because it is primarily reactive, not proactive. It can ban a practitioner from re-entering the health workforce once something egregious has happened, but it does nothing for ensuring or enforcing standards beyond this.

It is for this reason the same report that resulted in the development of negative licensing in New South Wales explicitly called for the investigation of naturopathic registration in addition to the development of broader arrangements for unregistered practitioners.

Naturopaths have been registered previously – in the Northern Territory until the Mutual Recognition Act 1992 required their removal, given that no other State or Territory registered them. Victoria investigated the registration of naturopaths in 2003, and began the process of developing a regulatory scheme in 2006. New South Wales and South Australian governments identified that naturopaths may have additional regulatory requirements than most unregistered practitioners, though wished to observe developments in Victoria first.

However, with the advent of national registration, all State and Territory schemes were ceased, and handed over to the national body. The Victorian work on registration of naturopaths has been tabled there since.

There also seems to be broad support for registration of naturopaths. Naturopaths themselves support it, though there are some vested interests (usually those providing inadequate or unaccredited training) who oppose it.

Whilst the AMA opposes it, this may not reflect the opinion of practising medical practitioners (the association does represent less than 25% of medicos after all), as a survey of medical practitioner attitudes towards naturopathic regulation conducted for the Victorian government in its review of naturopathy found 73% support for the idea, as well as support of health insurers and government agencies.

In New South Wales, Jillian Skinner, the current New South Wales health minister, also expressed her support in parliament (in opposition) for the potential registration of naturopaths in the interests of public protection.

Whilst naturopathy is a controversial health profession, it is one of the largest unregistered professions in Australia, and has significant utilisation by the public. However, refusing to regulate just because it’s controversial is not appropriate. The public interest reasons for regulation are pretty clear.

However, opposing a public protective mechanism known to be effective in complementary therapy practitioners based solely on principle is absurd, most certainly not evidence-based, and definitely not in the public interest.

• Jon Wardle has  a naturopathic background and qualifications in public health and law. He is a member of the PHAA’s special interest group in complementary and alternative medicines.

 

 

 

Comments 3

  1. Chris Hartwell says:

    It’s not controversial – it’s just not based on evidence.

  2. Claire Hewat says:

    This is an interesting article but I must dispute the assertion that ‘there is not one skerrick of evidence that registration results in increased recognition.’ Oh yes there is! All the well recognised evidence based professions which because they are not considered ‘dangerous’ and are therefore not registered such as speech pathologists, dietitians, audiologists etc have suffered constant and ongoing discrimination from the public who think being registered makes you better, right through to government departments who continually ignore or disregard these important professions because they are second class citizens in the regulation world. So would registration give naturopaths greater validity – yes it would. That said good robust self regulation can work and many of us have demonstrated that over many years. Perhaps a full analysis of the issue rather than concentrating on one profession or one sensational case would be of greater value.

  3. Jon Wardle says:

    Hi Claire, thanks for your comments. I would be legitimately interested in evidence of this discrimination. I’m not suggesting that it doesn’t exist, but it is a hypothesis that hasn’t been formally tested, though it definitely should be (in fact, we have done pilot work and have a grant proposal under assessment on this very issue). In relation to naturopaths, there is in fact some research showing the public already *think* they’re regulated, which could make it even more complicated – in fact, I was once referred by a state (which will remain unnamed) health complaints commissioner’s office to get some information for one of our projects from that state’s naturopathic board, as even they had assumed it was a regulated profession! What hope do the public have of navigating it!

    I focused on this single issue of naturopaths solely because the reports and assessments showing that naturopaths need to be regulated have been tabled at COAG since 2008. It really is unforgivable form a public health perspective that they’ve not moved on this for various reasons. And really this whole fiasco could have been avoided if they hadn’t sat on their hands.

    In fact, I agree with you on the other points you’ve raised as well. Self-regulation can work – but only if there is professional unity and a strong accreditation incentive (for dietitians and speech pathologists hospital accreditation to some extent serves as this), but in many professions this is not the case (including many of those in NRAS). One thing to consider too is that the health system is changing, and profession not registered may need to be reconsidered. One of the arguments against dietitians, for example, was that they worked under registered practitioners. But as more dietitians begin to increasingly work in non-supervised private practice this may need to be reassessed. Scope expansions and task substitution is another issue (particularly relevant to speech pathologists) as unregistered professions are increasingly asked to perform tasks once restricted to registered professions on safety grounds. We have a paper on this coming out soon. Would love to discuss more, I agree this issue goes beyond this case and beyond this profession, but am running out of characters!

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