Training for Medical Practitioners

6.86 It has been almost universally agreed by our witnesses that the undergraduate medical curriculum should only familiarise students with CAM and not teach them how to practise it. Although several submissions have suggested that CAMs with a proper evidence base should be subsumed into conventional medical practice, this has met with scepticism and occasional frank opposition from the CAM bodies. Therefore, medical practitioners who wish to incorporate CAM therapies into their own practice need to seek specific training in these therapies at a post-graduate level.

6.87 Historically there are many cases of medical practitioners delivering CAM alongside conventional medicine. For example, the Royal London Homeopathic Hospital, which has been part of the NHS since its inception and provides a range of CAM therapies (P 193), has a clinical staff who are "all statutorily-registered health professionals with additional training in Complementary and Alternative Medicine". There is much controversy about whether doctors who want to train in a specific CAM modality need to undertake the same training as a non-medically qualified student of that therapy. Many doctors assert that their previous medical training should allow them to take a much shorter course, as they do not need to learn the basics of anatomy and physiology in the way that non-medically qualified students would. It has also been suggested that the practice of doctors who are delivering an integrated approach is likely to be different from the practice of therapists delivering a complementary or alternative approach, and therefore the emphasis of their training should be different.

6.88 In the Glasgow Homeopathic Hospital (which the Chairman and a member of Sub-Committee I visited in August 2000 - see Appendix 6) medical students are regularly attached to the Homeopathic Hospital on an elective basis. Here they are taught how to use homeopathic remedies of all types but whenever appropriate, and particularly in serious disease, they are trained to use conventional medical treatment. In essence, therefore, they are trained in the practice of integrated medicine.

6.89 FIM has suggested that "it is important that the standards of training and skills of orthodox western medicine practitioners in CAM disciplines is the same as that approved by the appropriate CAM regulatory body" (P 89). We have received evidence from several bodies that have been created to train and support doctors wishing to practise certain CAMs. These bodies tend to have their own training courses, open only to previously qualified healthcare practitioners. There is often limited communication between medically-based and non-medically based CAM bodies. A case in point is the communication between the two homeopathic bodies, the Faculty (see para 5.91) and the Society which represents non-statutory registered homeopathic practitioners.

6.90 The Faculty of Homeopathy accredit postgraduate doctors, dentists, veterinarians and other healthcare professionals who wish to practise homeopathy (P 82). They have developed a specialist examination, and issue qualifications which they say are internationally recognised (P 82). They told us that they are currently working towards a core curriculum which "provides a framework of training requirements for safe and effective homeopathic practice and defines the syllabus for the Faculty's examination. The core curriculum sets out three levels of training for practitioners working in different settings and at different levels of expertise - Introductory, MFHom and Higher Specialist Training. It includes minimum specifications for the subject matter, the time scale of the study and the assessment procedure or "exit criteria" at each level of training" (P 83).

6.91 The Faculty told us that there is very little co-operation between themselves and the Society of Homoeopaths over a core curriculum for training homeopaths. Although the Faculty worked on the development of National Occupational Standards in homeopathy they do not train according to the National Occupational Standards. This is because the Faculty believe the training needs of medically qualified homeopathy students are very different from the training needs of those not medically qualified. There are several reasons for this. The Faculty told us: "In a sense we are not training the same people so a core curriculum for someone starting from scratch to become a homeopath is a completely different training pathway from the core curriculum for a doctor that has done undergraduate training and then postgraduate training" (Q 672). The Faculty's training therefore assumes that people who come to them for training "know what the basic foundation of medical science is and know the structure and function of the body and the mechanisms of disease" (Q 667). The Faculty also believe that medically qualified homeopaths "do not do the same jobs as people who have not had a medical training" (Q 652). "The kind of people who come to a homeopathic hospital will probably of necessity be different from those seeking help in a place where there is no local homeopathic medical provision". Therefore it would make sense for them to have a slightly different training.

6.92 The Society of Homoeopaths agree that "…medical practitioners who have done full medical training do not need to study anatomy, physiology and pathology again" (Q 685). However they assert that "…to achieve full homeopathic competence — and we are talking here of a philosophical shift of perspective on human health and illness — there is a large block of learning and knowledge to be done which is quite different from conventional medical training and, therefore, we would maintain that to be fully competent homeopathically requires full education and training in the same homeopathic knowledge and understanding that the non-medically qualified homeopaths have". We are not convinced that this body of knowledge is derived from a firm evidence base.

6.93 The Faculty and the Society agree that previous medical training negates the need for doctors to complete some parts of the course that would be required of non-medical students. It also seems logical that medically qualified individuals may benefit from teaching specifically on how to integrate their two areas of knowledge, conventional and homeopathic. They also agree on the need for an in-depth understanding of the philosophy and practice of homeopathy itself. However, despite what seems to be considerable common ground, the two bodies have had very little communication over what a curriculum needs to include to provide students with no previous knowledge of homeopathy, with an in-depth understanding of the practice and philosophy of homeopathy. This lack of communication between medical bodies and non-medical bodies providing a specific therapy seems quite common. For example, a similar trend was found between the British Acupuncture Council and their medical counterparts, the British Medical Acupuncture Society.

6.94 As the best use of the same therapy for the benefit of patients is the aim of both the medical and non-medical bodies in each of these cases, it would seem sensible for them to communicate on the best ways of achieving this aim; it may even be sensible to encourage inter-disciplinary learning in some modules.

6.95 The GOsC has managed to find a way of satisfying FIM's idea that the training of medically qualified CAM practitioners should be approved by the appropriate CAM regulatory body. The GOsC approve a college which provides training in osteopathy exclusively for doctors and takes into account their previous training, experience and expertise (p 113). As a well-organised statutory body the GOsC are well-placed to do this, and in fact if doctors want to use osteopathic techniques and call themselves osteopaths they need the approval of the GOsC, so they have an incentive to co-operate. 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.

Nurses, Midwives and Health Visitors

6.96 Like doctors and dentists, nurses are often used to provide an information service on healthcare by patients and, therefore, they also need to be aware of the variety of other treatment modalities their patients may be accessing either through CAM practitioners or through health food shops and other outlets. The practice of nursing often incorporates some form of complementary therapy, as a way of relaxing patients or as a part of palliative care. The Royal College of Nursing have suggested that "the therapies that nurses use most often are therapies like reflexology, aromatherapy and massage" (Q 532).

FAMILIARISATION

6.97 We were concerned to hear that, unlike the medical schools, there seems to be little or no evidence of a trend within nursing schools to ensure that student nurses come into contact with the main issues connected to the practice of CAM therapies. This is despite the fact that nurses are probably the most likely of all conventional health practitioners to use CAM techniques in their day-to-day practice. The Royal College of Nursing explained that "At present there is no formal facility for awareness-raising of complementary therapies within the core curriculum. However in many courses it is in fact happening, because it happens naturally in some modules. A module that is focusing on chronic illness will introduce an awareness of complementary therapies, because it is that section of the public who are mostly accessing complementary therapies. Nurses, by virtue of their role of working alongside patients and helping them to gain information, need to understand that this is a choice patients are exercising" (Q 534). Although this suggests that some nurses are made aware of CAM in their training, the Royal College of Nursing were unable to give a clear picture of how common this is because they have not achieved any systematic monitoring of the teaching of CAM within the nursing curriculum.

6.98 The UKCC, the regulatory body responsible for nursing training, said they do not set the curricula for schools of nursing; just the profession's competencies (Q 572). At present an understanding of patients' interest in CAM and its benefits and shortfalls is not considered as a specific competence required of nurses. The nearest they get to issuing such advice is requiring an "understanding of the roles of other practitioners" (Q 570) and they believe this is "equally applicable to the understanding of therapists as it is to the role of the medical practitioner or physiotherapist". But CAM therapists' roles are not explicitly mentioned. It is worth noting that the UKCC does have a role beyond setting competencies in that they support the work of the National Board of Education Providers in determining how their standards will be met (Q 565). They also set the standards for post-registration education.

TRAINING

6.99 We do not have precise figures on the proportion of nurses who practise CAM. The Royal College of Nursing has a Complementary Therapies Forum, which brings together nurses with an interest in CAM. The Forum has a membership of 11,400, which is a rough guide to the number of nurses in the United Kingdom who have expressed an interest in this area of practice (Q 513). Among nurses the popularity of CAM is increasing; this is reflected in the trend in membership of the Forum which was established in 1994, and which in 1997 had a membership of 1600 nation-wide (Q 524). (Its size has more than quintupled in the last 3 years.) However, these figures cannot be used as anything other than a guide to nurses' interest in CAM. Nurses who want to join this group neither have to be practising CAM nor do they have to show any evidence of training in the area; similarly nurses who wish to practise forms of CAM do not have any obligation to become a member of the Forum (QQ 516 & 517).

6.100 There is also no mechanism through which the UKCC can trace how many of their members practise or have received training in CAM therapies. They explained that in the past they "recorded qualifications that would have been recognised by the National Boards" but they found "inherent problems in doing this" and they no longer note any extra qualifications that nurses hold (Q 587). They stated they would "look to other bodies to undertake that, rather than ourselves".

6.101 Having received written and oral evidence from the Royal College of Nursing and the UKCC we are concerned about their passive approach to CAM and the lack of work being undertaken by these bodies in relation to nurses' use of CAM and their training in the awareness of CAM practices. There is a concern that nurses may be exposed to inferior or superficial training programmes and may practise without adequate supervision of this component of their work.

6.102 The Royal College of Nursing's Complementary Therapies Forum has produced some guidelines for nurses wishing to practise CAM. They have produced a leaflet for nurses which sets out questions they should ask before commencing a CAM course; they have also produced a leaflet on the types and levels of courses run in complementary therapy education. However, outside the Forum there seems to be little movement within the Royal College of Nursing or the UKCC towards making sure that all nurses are aware of CAM and that those who practise CAM as a nurse are properly trained to do so. Even for members of the Forum who practise CAM there is no requirement for them to demonstrate completion of training. When asked if nurses in the Forum should logically have had to demonstrate appropriate training, the Royal College of Nursing responded by saying that it was not something they were actively looking into at present (Q 519).

6.103 If neither the Royal College of Nursing nor the UKCC are paying active attention to this field it means there is almost no guidance for nurses who are trained, or want to train in CAM. The Royal College of Nursing did state that it "...seeks to uphold certain standards of practice in specific areas like complementary therapies by engaging in activities like standard setting, trying to promote ideas about the core curriculum when considering the preparation of nurses and by encouraging research activity" (Q 520). However, they had produced a patient information leaflet which encourages patients to ask questions of those people who are offering them complementary therapies.

6.104 The Royal College of Nursing stated that they felt themselves and the UKCC should be responsible for core curricula for nurses wishing to train in this area (Q 537). One of the reasons for this is that the Royal College of Nursing have expressed a belief that the training of nurses in CAM therapies needs to have a different emphasis - one which concentrates on enabling nurses "safely and efficaciously to integrate this therapy in the context of clinical work" (P 118). "The Royal College of Nursing does not aspire to own any core curricula that are developed; although, in the context of complementary therapies, our Forum would seek to have an influence in the development of the core curricula" (Q 537). The Royal College of Nursing's Forum has already begun to do some work in the area of developing curricula for CAM training courses specifically aimed at the needs of nurses: they explained: "I think we need to make it clear that discussions about the development of elements of the core curriculum are at a developmental stage within the Steering Group of the Forum. Those standards are not entirely established" (Q 535).

6.105 The Royal College of Nursing did express concern that there was a variation in the quality of CAM training to which nurses may be exposed: "One of our concerns is that, by advising individual nurses to undertake appropriate training, it is leaving things too much in the open...Until fairly recently, the training that people could access was private and independent, it was of variable standard and often quite expensive, and not focused to the needs of nurses using complementary therapies in clinical practice. This is an area where we feel it appropriate for the Royal College of Nursing to do some work looking at educational standards so we can offer some guidelines to nurses" (Q 531).

CONCLUSION

6.106 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. This is something which the Royal College of Nursing indicated was already beginning (Q 534), a move we find encouraging. We have no expectation that training in the use of any CAM therapy should be a standard part of a nurse's undergraduate training and would therefore expect that nurses who wish to practise CAM therapies would take up such training post-registration. 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.