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This emerged from a recent study conducted in Middlesex University, London. The study examined patient's attitudes, concerns and needs in seeking acupuncture and Chinese practitioners in an unregulated environment. It investigated how patients perceive and evaluate their treatments, the practitioners who deliver them, and if the lack of regulation impacts on their behaviour or the clinical relationship in any way. This was a two centre qualitative study conducted in both London and Dublin during which both patients and practitioners took part in face-to-face narrative interviews and were encouraged to speak freely without prompting. Interviews were recorded with consent and transcribed verbatim so that the study data could speak for itself.

Acupuncture Needling Shoulder Compressed

 
Results of the study showed that the lack of government regulation, guidance or a single approved register of Acupuncturists and Chinese medicine practitioners has significant impact on the clinical relationship, from both the patient and practitioners point of view. Patients are obliged to become informed consumers and conduct their own ad hoc research into a practitioner before consulting. They are then obliged to evaluate their treatments by result. Nevertheless there is a certain anxiety reported by patients in sourcing the 'right' practitioner, and the need for them to rely on a recommendation and rely on their own judgement as the treatment progresses to evaluate benefits to them.

Practitioners who comply with all professional requirements find themselves having to justify their treatments to sceptical patients. Nevertheless despite this, study data showed that patients will continue to seek out Acupuncturists and Chinese medicine practitioners to help with their conditions because they find the treatments effective.[1]

Patients – Informed Consumers

The assumption of naivety of patients, who seek acupuncture and Chinese Medicine, variously reported, is inaccurate and is not sustained by the findings of this study. Those interviewed continue their treatments only because they benefit from them, and all reported in both countries they will continue regardless of regulation, because they benefit from the treatments. Patients interviewed for this study in both countries had already consulted their doctors for the conditions they sought acupuncture treatments.

Many of them had been prescribed various medications, and in some case other medical treatments such as physiotherapy. Dominant throughout the study was that it was only when patients could not get relief or when the side effects of the prescribed medication were unacceptable to them and effected their lifestyle, did they consider acupuncture and Chinese medicine treatments.

Patients seek acupuncture and Chinese medicine treatments because the conventional medical structures fail to treat their conditions effectively

Patients spoke about the benefit they received from their acupuncture treatments and throughout patient interviews in both countries they spoke of satisfaction with their treatments. Many patients spoke of difficult conditions which they had suffered from and their doctors were unable to help them.

Patient Sarah  UK said
"I had got nowhere with my GP because it is very hard for the GP to know anything about a musculoskeletal condition. He was just going to have to refer me, and I was left in the dark, nowhere to go, nothing, so I was desperate to find something."

Data was similar in patient interviews in Ireland.  The patients themselves have no difficulty with consulting their doctors and at the same time having acupuncture treatments. As far as they are concerned they are simply opting for another method of treatment which they evaluate by it results.

This current generation of people, regardless of income have much more access to information and are much better informed than previous generations. They want freedom of choice of treatments that they find effective for conditions which currently cannot be treated effectively and to their satisfaction within the conventional medical structures, in both the UK and Ireland. This does not mean that they have rejected the conventional medical structures, as all patients reported they continue to consult their general practitioners and will take prescribed medication for some conditions. 

This study has identified an aspect of the provision of healthcare which seems to have been ignored by decision makers in that patients use their considered judgement when it comes to their healthcare. They are in fact informed consumers of all of the healthcare options, whether that is the doctor's advice, a medication regime or an acupuncture treatment. Limitation of treatment options available to patients does not work. They want access to a treatment which works for them, and it is essential this access be provided from a controlled safe source. If it is not available from a safe source they will continue to seek it anyway.

This situation is potentially harmful to patient safety as unknowingly they could opt for treatments from inadequately trained or rogue practitioners who do not have any oversight on their practice by any of the professional associations.

No Government Register of Approved Practitioners in Either the UK or Ireland

One of the main concerns of patients who seek acupuncture and TCM treatments in both the UK and Ireland is the lack of a single approved register of Acupuncturists and Chinese Medicine practitioners with a single uniform standard of training and practice that are accountable to a single regulation body.

This would enable patients to source safe practitioners and would mean patients would have the ability to identify if the therapist they choose has been adequately trained and is operating within agreed standards of best practice. In the absence of such a single regulatory body and register, patients are obliged to look for recommendations, do their own research on practitioners, or just 'ask around' in order to source a practitioner.

Acupuncture Needling leg Compressed

Analysis of data from patient interviews in this study shows that patients try to find someone who has had a previous experience with an acupuncturist or TCM practitioner as some sort of recommendation.

Patient 3 Nora (Ireland) commented "I had worked in a hospital and one of the nurses had been to ........and recommended her, and I would trust her judgement."

This was a recurring theme throughout patient interviews both in the UK and Ireland.

Patient 1 Alan UK
"I approached it (the treatment) on a week to week basis, I thought I would try it and see if something was happening and as I got some improvement I came back."

Data was similar from patient interviews in Ireland. This current situation is potentially a healthcare time bomb in terms of public safety.

The Therapeutic Relationship

Much has been written about the doctor / patient relationship and CAM practitioner / patient relationships. There is a perception that one of the reasons that patients seek out complementary healthcare treatments is the time the practitioner spends with the patient, and the empathy and listening skills the practitioner uses in discussing the patient's condition. This has often been given as a reason that patients 'feel better' after their treatment. Many articles have been written on the 'Placebo Effect' - the belief of the patient that they will feel better following their treatment, and good results from successful acupuncture treatments are often dismissed as the placebo effect. This is addressed in the Lewith and White 2005 study at the University of Southampton.[2]

In this Southampton University study, scientists Dr George Lewith and Dr Peter White of the University's Complementary Medicine Research Unit, the study succeeded in distinguishing between the placebo effects produced by a patient's expectation and the real effects of treatment in a group of patients with painful osteo-arthritis, by monitoring specific responses in the brain during treatment, by measuring the difference in brain activity between sham needle intervention and actual acupuncture needling with using sophisticated Positron Emission Tomography (PET) scans.

The brain activity in the group of patients receiving 'real' acupuncture showed that real acupuncture elicits a demonstrable physiological effect over and above a simple skin prick. In addition, the response of the second group of patients who received the sham acupuncture treatment indicates that the expectation of and belief in the treatment also has a physiological effect on the brain. The expectation appears to mediate a potentially powerful although non-specific clinical response to acupuncture

This is only a very small part of the whole therapeutic picture. Maciocia[3] states that the nature of the Chinese Medicine assessment of the patient, from the initial case history taking, to observation of the patient, the assessment of the physical and emotional condition could lend itself to the building of the therapeutic relationship.

While some suggest such a holistic assessment creates a 'placebo effect' this is not the primary goal of the professional practitioner, which is to inquire, listen, palpate, assess and probe in order to establish a holistic diagnosis and treatment plan. The reasons for the inquiry and probing are not unlike the initial biomedical testing a doctor will carry out with a patient presenting with a condition.

The practitioner aims to gather information to treat the condition, and in the acupuncturist's case to probe the underlying causative factors and any other relating conditions, including emotional and mental, which can be woven into the treatment plan.[4]

The Middlesex University study research shows that patients report actual physical improvements and changes in their condition, in addition to "feeling better" about their conditions which previous medication strategies could not achieve. There is no doubt that the holistic practitioner, listening to the patient and delivering a focused one-to-one treatment in a pleasant environment could contribute to the overall treatment benefit; however this cannot account for dramatic physical improvements reported by several patients in this study, such as bleeding of several days which stopped after treatment. Chronic pain relieved, digestive function improved, irregular menstrual cycle regulated, respiratory function improved are just some of the examples reported by patients in this study.

Study data showed that patients feel that the feel good factor or 'placebo effect' of a one-to-one treatment is a bonus of acupuncture treatment, rather than the reason for positive results.

The one-to-one treatment and the 'treatment room' atmosphere does create a feel good factor or 'placebo effect' according to patient reports, and may improve the treatment outcome, but patients discount it as being the sole reason for physiological changes and actual improvements in physical conditions reported in both countries.

Current Status of Regulation in the UK and Ireland

In the UK, following several initiatives over many years to investigate the regulation of Complementary Medicine, The Department for Health issued a report to the ministers from The Department of Health Steering Group on the statutory regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine and other traditional medicine systems practised in the UK in May 2008. The report under the chairmanship of Professor Michael Pittilo, Vice-Chancellor of the Robert Gordon University, Aberdeen stated that it was in the public interest to regulate Acupuncture and Herbal Medicine in the UK.[5]

The proposals and recommendations have not been implemented, and the Minister has recommended another period of consultation. A new round of sector consultation in the UK was launched on August 3rd - November 2009. The Department for Health (UK) is currently collecting and analysing data from this latest round of public consultation. Industry experts expect very little in terms of implementation of recommendations.

Similarly in Ireland following several initiatives investigating a mechanism for the regulation of Complementary therapists, a National Working Group representing all stakeholders in the CAM sector was put in place to investigate the regulation of CAM therapists.

In 2005 The National Working Group report on the regulation of CAM therapists was published.[6] The report recommended the statutory regulation of Acupuncture, Herbalism and TCM, as "Category 1" therapies in terms of risk exposure to the patient, also in the interests of public safety.

To date none of the recommendations have been implemented either in Ireland or the UK. The sector is again undergoing another period of consultation. Acupuncturists and CAM therapists remain unregulated and unregistered by statute with no immediate prospect of further progress. No further initiatives have been announced by the DOHC. (Department for Health and Children Ireland).

In conclusion, this study has found that the continued absence of government regulation and registration of Acupuncturists and Chinese Medicine practitioners does affect the clinical relationship from both the patient's and the practitioner's point of view in both the UK and Ireland. Data from both countries showed similar results, and patients from both countries are obliged to source practitioners in an unregulated environment. Practitioners who avail themselves of the best available professional training and voluntarily adhere to professional standards find themselves outside the official healthcare tent. They are not included in any decision making in their own sector, and although they deliver thousands of healthcare treatments to thousands of patients safely and effectively each week in both the UK and Ireland, they are still not considered to be healthcare professionals.

References

1. Ward B. The absence of government regulation of acupuncturists and Chinese medicine practitioners affects the clinical relationship. Middlesex University, London. 2009.
2. Lewith and White. Acupuncture: beyond the placebo effect University of Southhampton website. Available at www.soton.ac.uk/mediacentre/news/2005/may/05_71.shtml 2005.
3. Maciocia G. The Foundations of Chinese Medicine. Churchill Livingstone Edinburgh. UK. Page 143. Reprinted 1998.
4. Maciocia G. The Foundations of Chinese Medicine. Churchill Livingstone, Edinburgh .UK Pages 311 - 327. Reprinted 1998.
5. DH Report to Ministers from the Department of Health Steering Group on the Statutory Regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine and Other Traditional Medicine Systems Practised in the UK. P 12. Viewed at www.rchm.co.uk/FINAL_SG_MASTERREPORT-11JunOnlineJM1.pdf  2008.
6. DOHC (Department for Health and Children) Report of The National Working Group on Regulation of Complementary Therapists to the Minister for Health and Children  Online Available at www.dohc.ie/publications/pdf/complementary_therapists.pdf?direct=1 2005.