Thursday, 15 November 2018

Possible Amendments to UK Legislation to control Quackery

The UK approach to regulating non-medically qualified practitioners has revolved around trying to increase professionalism, educational standards and encourage voluntary self-regulation. It also resulted in the Professional Standards Authority (PSA) Accredited Registers scheme.

This is all well and good and works well for certain professions and sectors but it does not deal with the worst type of quack. Quack here is meant as a non-medically qualified practitioners who pretends special knowledge and skill in medicine (healing or whatever other terms they use) above and beyond that of the ordinary lay person. Whether they deliberately set out to mislead or are deluded is irrelevant. What matters is that they pose potential risk.

(Medically qualified practitioners can get up to all sorts of "quackery" but they are subject to specific regulation. Quacks are not.) 

There have been suggestions regarding protecting specific groups from quacks and their claims especially regarding autism (see this petition) but protecting one vulnerable group is not sufficient.

It is suggested that the most effective way to to deal with quackery is by amending the law to make quacks criminally liable for their (in)actions.

1. Exemptions
As discussed in a previous post, introducing legislation that impedes the functioning of a vast proportion of health and social care provision in the UK would not be a good idea. It is also the case that impinging on the ability of lay persons to come to the aid of person in distress would not be a good idea either.

1.1 Delegation
None of this is intended to exclude medically unqualified lay persons carrying out activities as instructed by (named) medical professionals. There is a liability on medical professionals to ensure that ensure that are correctly instructed in carrying out an activity. There is also a duty on employers to ensure lay persons are competent and correctly trained.

This would also apply to residential homes and the like. Treatment plans are devised by doctors but may be carried by care professionals who are employed by the home. In this case there is a duty both on the doctor and the employer to ensure care assistants are competent.

1.2 Self/carer-administered treatment
Obviously, any law would not prohibit a person taking medicine orally that was prescribed by a doctor. Nor would it prohibit a family member giving such medicine to a dependant. But there are other treatments that are invasive that could potentially could fall foul of poorly framed laws.

For example, type 1 diabetics need to inject insulin. Modern delivery systems are minimally invasive. No-one would have an issue with a carer (as opposed to a care professional) administrating an insulin injection. But other types of injection can involve big needles, are intravenous and so on. They come with more risks.

Which treatments can be self/carer administered by is beyond the scope of this post but it is suggested to a large degree, it would be the judgement of health professionals as to whether a lay person was competent to do so. As this treat is not carried out under the notional supervision of a medical professional, they can not be held liable.

1.3 First Aid and Good Samaritan acts
Obviously, no-one would want to stop trained lay persons from performing first aid in life-threatening or serious situations. Not all jurisdictions explicitly recognise the principle of "Good Samaritan acts although case law implicitly does. Some jursidictions do require persons to come to the aid of those in distress. It is said that sometimes people do not act in certain situations because of a fear of litigation.

2. Criminal Acts
Whilst case law does prohibit certain acts by quacks, there is no clarity in law. It is often the case that charges are brought that do not relate directly to act and that the penalties do not match the crime (see later parts of this).

Whilst consumer protection law effectively forbids marketing of certain acts, the offer to treat in any form should be illegal.

It is not suggested that all the below should be implemented, more than they represent potential models.

2.1 Controlled Acts
Canadian Provinicial legislation in the form of various Regulated Health Professions Acts contain a list of acts that are forbidden to medically unqualified lay persons and even to some regulated professions. To quote from the Ontario Act -

(2) A “controlled act” is any one of the following done with respect to an individual:

1. Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the diagnosis.
2. Performing a procedure on tissue below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth, including the scaling of teeth.
3. Setting or casting a fracture of a bone or a dislocation of a joint.
4. Moving the joints of the spine beyond the individual’s usual physiological range of motion using a fast, low amplitude thrust.
5. Administering a substance by injection or inhalation.
6. Putting an instrument, hand or finger,
i. beyond the external ear canal,
ii. beyond the point in the nasal passages where they normally narrow,
iii. beyond the larynx,
iv. beyond the opening of the urethra,
v. beyond the labia majora,
vi. beyond the anal verge, or
vii. into an artificial opening into the body.
7. Applying or ordering the application of a form of energy prescribed by the regulations under this Act.
8. Prescribing, dispensing, selling or compounding a drug as defined in the Drug and Pharmacies Regulation Act, or supervising the part of a pharmacy where such drugs are kept.
9. Prescribing or dispensing, for vision or eye problems, subnormal vision devices, contact lenses or eye glasses other than simple magnifiers.
10. Prescribing a hearing aid for a hearing impaired person.
11. Fitting or dispensing a dental prosthesis, orthodontic or periodontal appliance or a device used inside the mouth to protect teeth from abnormal functioning.
12. Managing labour or conducting the delivery of a baby.
13. Allergy challenge testing of a kind in which a positive result of the test is a significant allergic response.
14. Treating, by means of psychotherapy technique, delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual’s judgement, insight, behaviour, communication or social functioning. 1991, c. 18, s. 27 (2); 2007, c. 10, Sched. L, s. 32; 2007, c. 10, Sched. R, s. 19 (1).

Not all of this is compatible with UK law. For example, in the UK psychotherapy is not regulated (although there are arguments that it should be). It would also outlaw lay practitioners from offering colon hydrotherapy although it would not prevent a healthcare assistant etc being delegated the task of giving an enema or performing manual evacuation by a medical professional. Obviously this does not relate to consensual sexual activity either but "intravaginal manipulation" is known in some manual therapies, including quack ones.

The restriction on lay persons offering diagnosis is particularly important. One obvious area where this could well apply is in fictional conditions such as adrenal fatigue and vaccine damage

The Dutch Wet op de beroepen in de individuele gezondheidszorg als restricts certain acts to by profession. Google translate doesn't do a good job with Dutch but the acts and associated professions -
  • Surgery - Doctors, Dentists, Midwives, Physician Assistants and Specialised Nurses - the latter four are restricted in scope.
  • Midwifery procedures - Doctors and Midwives
  • Endoscopy - Doctors, Physician Assistants and Specialised Nurses - the latter two are restricted in scope
  • Catheterisation - Doctors, Midwives, Physician Assistants and Specialised Nurses - the latter three are restricted in scope.
  • Injection - Doctors, Dentists, Midwives, Physician Assistants and Specialised Nurses - the latter four are restricted in scope.
  • "Punktie" biopsy etc - Doctors, Midwives, Physician Assistants and Specialised Nurses - the latter three are restricted in scope.
  • Anaesthesia - Doctors and Dentists - the latter are restricted in scope.
  • Radiology and Radiography (ionising radiation) - Doctors and Dentists - the latter are restricted in scope.
  • Cardioversion - Doctors, Physician Assistants and Specialised Nurses - the latter two are restricted in scope.
  • Defibrillation - Doctors, Physician Assistants and Specialised Nurses - the latter two are restricted in scope.
  • Electroconvulsive therapy - Doctors.
It also deals with prescribing rights. Physician Assistants are called Physician Associates in the UK but to be clear they are not statutorily recognised but they are in the Netherlands. Specialised Nurses means Advanced Practice Registered Nurses (APRN) - the UK differs in detail.

These kind of restrictions would be largely compatible with UK legislation. 

2.2 Scope of Practice
For a particular profession, a specific list of what acts are permitted. It's impossible to do for doctors but not so for other professions. It can be argued that in the case of UK osteopaths and chiropractors there is a good case for introducing amendments to legislation to explicitly control what they can do. What is not in the scope of practice is not permitted. This is a side issue though.

There are issues with some medical professionals who have a side line in self-employed quackery whilst being (self-)employed elsewhere. This is a complex area but in short, practising outside of even a notional scope of practice means that they can not use a protected title in that context and they have no more qualification/entitlement than a medically unqualified lay person yet would be held to a higher level of accountability by a Court for harms done (they should know better etc). 

2.3 Restricted Groups/Conditions
This concept exists in a number of jurisdictions. In Sweden, the Patientsäkerhetslag states lay persons can not.
1. treat such infectious diseases as according to infectious diseases (2004: 168) are notifiable diseases, 
2. treat cancer and other malignant tumours, diabetes, epilepsy or conditions in connection with pregnancy or childbirth; 
3. examine or treat another person during general anaesthesia or during local anaesthesia by injection of anaesthetics or under hypnosis, 
4. treat someone else with radiological methods, 
5. Without personal examination of the person seeking him or her, provide written advice or instructions for treatment; 
6. examine or treat children under eight years; or 
7. try out contact lenses.
The Norwegian Lov om alternativ behandling av sykdom mv (Law on Alternative Treatment etc) prevents lay persons from -
  • Performing treatments or interventions that carry a serious health risk
  • Treatment of communicable diseases (although it does permit treatment to alleviate symptoms there of or side effects of conventional treatment - but only a medical professional can treat the disease itself.
  • Treatment of serious conditions and diseases (although, again, alleviation etc are permitted)
Alleviation can be defined as a reduction in intensity of symptoms. Pain relief is one obvious example.

There are strong arguments for prohibiting quacks from treating those who can not legally consent to treatment. Children are the obvious example but it also applies to some with learning disabilities, mental health conditions and those suffering from dementia. UK law case is clear where parental wishes conflict with medical opinion - the rights of the child to appropriate medical treatment come first. Preventing quacks going near anyone who can not give consent would be consistent with that.

Prohibiting the treatment of pregnant women is justified in terms of protecting the unborn child from quackery. However, the status of the foetus in English (and even European) law is unclear. That doesn't mean that such a prohibition would be impossible - it's more that it could be argued that it is an infringement of a woman's human rights.

As for a list of conditions - yes, there are some very obvious candidates that quacks should not claim to treat but coming up with an exhaustive list is beyond the scope of this post.

The question of alleviation of symptoms is tricky. Arguably it is incompatible with the philosophy of certain forms of quackery that treat "the whole person" or "root causes". Making those kind of statements and offering to alleviate the side effects of chemotherapy such as nausea? Treating foot conditions that result from diabetes? No. 

In the case of herbal quackery, there is the risk that nostrums may interact with medicines and/or have other adverse effects. It is suggested that such treatment should only be allowed if permission is granted by the patient's medical practitioner. This is what happens with use of CAM (often by volunteers) in palliative care settings. Hospices and NHS Trust (should) have very clear policies in place to mitigate risk.

Outside of those controlled settings, the offer to "alleviate" or "help with" symptoms of conditions etc can disguise the intention to treat said conditions, hence why restrictions on marketing claims are insufficient.

2.4 Mandatory Referral etc
The Norwegian Law on Alternative Treatment etc regards a patient not seeking proper treatment as the fault of the quack as well as making ignorance of putting a patient at danger inadmissible as a defence. Some of the Canadian Provincial Colleges (which are regulated) have as part of their Code of Ethics etc a duty to refer patients to real medical professionals if they present with certain conditions.

One issue with mandatory referral is that with undiagnosed conditions, it depends on the ability of the quack to recognise the symptoms of a potentially serious condition. As the example of CEASE therapy clearly demonstrates, some quacks would not recognise them and indeed would seem them as positive signs.

2.5 Medical Tests and Medical Devices
There has been a large growth in both private testing clinics and direct to consumer medical tests. For some types of tests, it is no longer necessary to visit a doctor (NHS or private) to arrange for tests.

Some types of medical tests require interpretation by a professional. It is often the case that a test on its own is insufficient to diagnose a particular condition. It is also the case that tests for certain conditions do require pre/post-diagnosis counselling.

There are some tests on the market that are completely useless or that have limited uses but are widely abused and misrepresented by quacks but arguably, restrictions on diagnosis would curtail this.

Obviously, what applies to tests also applies to diagnostic devices. But therapeutic devices? In theory, the controls on medical devices should prevent quacks getting their hands on anything potentially dangerous. Marketing claims by manufacturers are one thing but the claims made by quacks are another. 

2.6 Contracts, Waivers and Consent forms
Making certain acts illegal has an impact on any contracts etc that might be signed. Generally, seeing a practitioner involves filling in various forms that may or may not be considered to be a contract. A contract that involves illegality can be ruled as void.

Sometimes quacks will ask clients to sign what are essentially liability waivers - the legality of these is questionable. This may or may not take the form of a consent form.

Informed consent is a difficult issue with quackery. There are two elements to this - the inability/unwillingness of the quack to explain the risks/benefits of the treatment in clear (and truthful) terms and secondly, the ability of the client to understand what is said and evaluate the risks/benefits. Can someone give informed consent to an act that is explained into fictional or allegorical terms? Can someone give informed consent based on incomplete or erroneous information?

It should pointed out that the client signing a waiver or a consent form does not remove liability from a quack. Here is an example of a consent form (plus guidance) from the Society of Homeopaths (SoH( regarding homeoprophylaxis. The guidance says -
Homoeopaths may supply or prescribe homoeopathic medicines for prophylactic purposes only if they have been specifically requested by the patient. Practitioners should always document sign and date all discussions, advice and treatment with the patient. Such documentation should be kept for a period of at least 6 years. Members may wish to use a consent form, but we need to remind members that use of such a form will not offer any protection against liability in the event of legal action: it is never possible to exclude liability for injury caused by negligence.
As this post points out the supply of the products used in homeoprophylaxis by quacks is largely illegal and they have no prescribing rights but as the SoH points out this sort of form offers no protection against liability.

3. Penalties etc
Arguably, any of the above amendments to law could have the effect of making it easier to secure conviction of quacks. Whether this is sufficient to deter the more larcenous/deluded is moot. And among the more extreme there can be a martyr complex - some homeopaths have made noises to the effect that they would rather be referred to Trading Standards and face potential prosecution than withdraw marketing claims re autism and in particular CEASE therapy.

Quackery is generally not lucrative. Fines on conviction and legal costs may act as a deterrent for some but possibly not in all cases. Custodial sentences would likely have more of a deterrent effect. What maximum penalties should be is difficult to say. In the case of serious physical harm or death it is likely that quacks would be convicted for different offences. 

Bear in mind for regulated medical professionals, loss of registration means loss of their livelihood. They can no longer practice and would face criminal sanctions if they did and misrepresented themselves. They could set themselves up as quacks though. Conviction of a quack itself (barring custodial sentences and licence conditions of parole) does not prevent them returning to their bad ways. 

The case of Errol Denton was mentioned in the last post. Part of the ruling against him was a Criminal Behaviour Order (CBO) restraining him from making further misleading medical claims until further order of the court. This falls far short of actually stopping his activities. 
The Anti-social Behaviour, Crime and Policing Act 2014 grants courts to power to restrict the activity for an indefinite period. A law that made it illegal for quacks to diagnose disease as per the Ontario Regulated Health Professions Act combined with an indefinite CBO would put the likes of Denton out of business or face jail.

4. Advertising Restrictions etc
Obviously prohibiting the advertising of illegal acts is one thing but some jurisdictions go further.

In some jurisdictions there is an absolute prohibitions on certain professions advertising beyond simple listings but this tends to be for historical reasons. Traditionally, professions did not advertise - it was seen as uncouth for one thing - and arguably they did not. There was one doctor and one lawyer in a small town etc and those able to afford them would likely have social connections.

In Norway, quacks are only permitted factual advertising as to the existence of a service. Beyond that, no claims can be made. 

In some jurisdictions, quacks have to reveal to clients the nature of the qualifications before even attempting to treat them ie that they are not medical professionals. 

5. Opposing Arguments
There are some very obvious arguments that could be made against any of these suggestions. Some are not discussed as they have no merit whatsover (eg conspiracy theories)

5.1 Suppression of Free Speech
This is easily dealt with. These proposals would not in any way limit free speech, they would limit commercial speech. The distinction between the two is discussed here

5.2 Autonomy
It could be argued that making the offer of certain acts by quacks reduces patient autonomy.

If a person with mental capacity wishes to treat their own condition, with products that are legally marketed and obtained and it results in harm or even death, this is basically permitted. It is possible to "section" someone under the Mental Health Act 1983 if they are assessed to be suffering from a severe mental disorder but the criteria are set very high (partly due to a lack of psychiatric facility beds).  If that course of action also places others at risk of harm can also be a consideration.

Case law does recognise the right of a person with mental to refuse treatment - Do Not Resuscitate are one obvious example. Others include cancer patients who have had multiple rounds of chemotherapy/radiotherapy/surgery and the cancer still progressing. Heroic measures are not as common in the UK as the US.

When others become involved, things are more tricky. Taking an extreme example, assisting suicide is an offence under the Suicide Act 1961. In English law they could be charged with voluntary manslaughter (culpable homicide in other jurisdictions). The point was made above but to restate in different words - a person cannot lawfully consent to anything more than the infliction of minor injury and that the person inflicting the injury can be charged with assault. That an act carries a high risk of harm is a consideration even if it does not necessarily result in actual harm.

But the patient autonomy argument involves the question of whether quackery is actually medical treatment. 

5.3 Parental Rights
In reality, under UK law there is no such concept. There are children's rights and there are parental responsibilities. Of course, parents as adults have their own human rights but these do not supersede children's rights. In most jurisdictions, law limits parental power over children.
Parents do not have absolute power over their children. Parents are subject to criminal laws against abandonment, abuse, and neglect of children. International human rights law provides that manifestation of one's religion may be limited in the interests of public safety, for the protection of public order, health or morals, or for the protection of the rights and freedoms of others.
Children may well have rights under law but from B. (R.) v. Children's Aid Society of Metropolitan Toronto -
While children undeniably benefit from the Charter, most notably in its protection of their rights to life and to the security of their person, they are unable to assert these rights, and our society accordingly presumes that parents will exercise their freedom of choice in a manner that does not offend the rights of their children.
To be clear, those who often shout loudest about "parental rights" are often seeking sanction for behaviour that offends the rights of their children. 

Comments and Corrections
It is likely that this post contains a number of errors, especially on finer points of the law. The ideas expressed here need further development and refinement.

Tuesday, 13 November 2018

Why is Quackery Legal in the UK?

Firstly, a slight diversion.

Guardian story on CEASE therapy
As previously mentioned, the Guardian printed a story about CEASE therapy on 28/04/2018. The online version can be found here. The Daily Mail published a version of this story on their website on 29/04/2018 which appears to be lifted entirely from the Guardian story and contains no original reporting.

Social media reaction was largely one of horror. Many made statements along the lines of CEASE therapy being child abuse. This thread on Mumsnet is illustrative. Many asked how this kind of thing was legal. The answer lies in history and poorly framed legislation.

Common Law
English Common Law (ECL) forms the basis of the legal system of many countries. The US (with the exception of the State of Louisana) and the many current and former Commonwealth countries are common law jursdictions (although the Canadian Province of Quebec is an outlier). Some current/former Commonwealth countries mix common law with other legal systems that ultimately derive from Roman Law.

Wales and Northern Ireland effectively use ECL (although Welsh law is a relatively new innovation - to a large extent England and Wales are still the same jurisdiction). Scotland is different. The Scottish legal system is based on Civil Law - that ultimately derives from Roman law. Much is made of the differences between English and Scottish law but there aren't huge differences when it comes to areas such as commercial law, consumer protection and health and safety regulations. It is also the case that compared to European civil law jurisdictions, common law is much more important. Historically, ECL has had a profound effect on Scottish law.

The differences between ECL and Civil Law are multiple and can be technically quite complex but in short - Civil Law is a codified system where written laws have primacy. By contrast, Common Law places a lot more emphasis on decisions, on the interpretation of the law by judges. Precedent plays a great role in common law jurisdiction - not that is it is ignored in Civil Law jurisdictions, it just has less of a role. Case-based reasoning is a phrase often used to prescribe how common law works - a concept that will be familiar to computer scientists.

Although a gross simplification, it is often said that in Civil Law systems what is not permitted in law is forbidden whereas as in Common Law what is not forbidden is permitted. This is particularly relevant to the practice of medicine.

Quackery and Common Law
Being most familiar with homeopathy, during research I have encountered all sorts of bizarre notions of ECL dating back to the Druids and there be some magical right to practice homeopathy associated with this. What legal systems existed in pre-Roman Britain is unknown - likely widely varying customary law - but it is very likely that Roman Law would have had some influence pre-Invasion due to trading links. ECL really starts to take form after the Norman conquest as it started to supplant Anglo-Saxon law (the Norman invasion had less effect than one might think). Henry II's legal reforms are particularly important.

In ECL, the practice of medicine is not forbidden to anyone per se. There are certain acts that are forbidden except by certain legally recognised professions. There are certain titles that can only be used by certain legally recognised professions but beyond that any member of the public has considerable to freedom to do all manner of things to another person that would prohibited in a Civil Law jurisdiction. Interestingly, this is also true for many legal matters - it is possible for a member of the public to represent themselves in Court.

It is worth pointing out that this is not the case for veterinary medicine. Other than owners (or their employees) treating their own animals, treatment of animals is confined to veterinary surgeons. Members of the public are forbidden in law from treating animals that do not belong to them. 

However, as might be expected, things are a bit more complicated and there is also the business of Scotland.

History of Medical Professions Recognition and Regulation
Ideas of distinct medical professions date back to Antiquity and Ancient Greek ideas held great sway over a long period of time. At the time that the professions stated to become legally recognised (if not regulated) were -
  • Surgeon
  • Physician
  • Apothecary
Although nursing and midwifery were known - and certainly some midwifes were held in very high regard for their skills - they were not regarded in the same way. Although much is made of the idea of the "wise woman" and an associated folk-medicine tradition, a lot of this is bound up with the witch-cult hypothesis. And homeopathy has nothing to do with it. 

The history is fascinating (would recommend this on the development of regulation in England - and this text goes into depth on the development of medicine in Scotland), the notion of quackery in a modern sense only comes into existence as modern scientific medicine does. There are several key drivers at work - the decline in costs of printed material, increases in education and literacy and later on the advent of advertising and mail order. Arguably, the advent of the internet has lead to an explosion in quackery but these past developments likely had a similar (if more slow acting) impact.

This has to be viewed in the context of as modern scientific medicine has evolved, as professionalism has grown, some of what previously fell in it canon has been discarded and now belongs to the realm of quackery. This is particularly true for ideas about causation of disease. Miasma theory, vitalism both long discarded - germ theory denialism is seen very much as quackery now.

The past isn't perfectly recorded and is subject to interpretation. For one thing, commonly understood definitions of words, professions and so on, can change.

The past explains the why but not the what.

Medical Act 1983
This act does various things but grants the General Medicial Council various powers. It restricts certain roles to registered medical professionals -
47 Appointments not to be held except by fully registered medical practitioners who hold licences to practise
    (1) Subject to subsection (2) below, only a person who is fully registered and who holds a licence to practise may hold an appointment as physician, surgeon or other medical officer]—
        (a) in the naval, military or air service,
        (b) in any hospital or other place for the reception of persons suffering from mental disorder, or in any other hospital, infirmary or dispensary not supported wholly by voluntary contributions,
        (c) in any prison, or
        (d) in any other public establishment, body or institution,
or to any friendly or other society for providing mutual relief in sickness, infirmity or old age.

(2) Nothing in this section shall prevent any person who is not a Commonwealth citizen from being and acting as the resident physician or medical officer of any hospital established exclusively for the relief of foreigners in sickness, so long as he—
    (a) has obtained from a foreign university a degree or diploma of doctor in medicine and has passed the regular examinations entitling him to practise medicine in his own country, and
    (b) is engaged in no medical practice except as such a resident physician or medical officer. 
(3) None of the suspension events mentioned in subsection (4) below shall terminate any appointment such as is mentioned in subsection (1) above, but the person suspended shall not perform the duties of such an appointment during the suspension. 
(4)The suspension events are—
    (a) the suspension of registration of a person by a Fitness to Practise Panel—
        (i) following a finding of impairment of fitness to practise by reason of deficient professional performance or adverse physical or mental health under section 35D above, or
        (ii) under rules made by virtue of paragraph 5A(3) of Schedule 4 to this Act;
    (b) an order for immediate suspension by a Fitness to Practise Panel under section 38(1) above; or
    (c) an interim suspension order by an Interim Orders Panel or a Fitness to Practise Panel under section 41A above (or such an order as extended under that section).
 It also makes it a criminal offence to pretend to be registered -
49 Penalty for pretending to be registered.
(1) Subject to subsection (2) below, any person who wilfully and falsely pretends to be or takes or uses the name or title of physician, doctor of medicine, licentiate in medicine and surgery, bachelor of medicine, surgeon, general practitioner or apothecary, or any name, title, addition or description implying that he is registered under any provision of this Act, or that he is recognised by law as a physician or surgeon or licentiate in medicine and surgery or a practitioner in medicine or an apothecary, shall be liable on summary conviction to a fine not exceeding level 5 on the standard scale. 
(2)Subsection (1) above shall not apply to anything done by a person who is a national of any EEA State for the purposes of or in connection with the lawful rendering of medical services by him without first being registered under this Act if he has previously complied with the requirements of subsection (2) of section 18 above or subsequently complies with its requirements as modified in respect of urgent cases by subsection (3) of that section. 
(3) Any penalty to which a person is liable on summary conviction under subsection (1) above may be recovered in Scotland by any person before the sheriff or the district court who may, on the appearance or the default to appear of the accused, proceed to hear the complaint, and where the offence is proved or admitted the sheriff or court shall order the accused to pay the penalty as well as such expenses as the sheriff or court shall think fit.

(4) Any sum of money arising from conviction and recovery of penalties as mentioned in subsection (3) above shall be paid to the treasurer of the General Council.
And also 
49A Penalty for pretending to hold a licence to practise 
(1)If a person who does not hold a licence to practise—(a)holds himself out as having such a licence; or(b)engages in conduct calculated to suggest that he has such a licence,he shall be liable on summary conviction to a fine not exceeding level 5 on the standard scale. 
(2)Any penalty to which a person is liable on summary conviction under subsection (1) above may be recovered in Scotland by any person before the sheriff or the district court who may, on the appearance or the default to appear of the accused, proceed to hear the complaint, and where the offence is proved or admitted the sheriff or court shall order the accused to pay the penalty as well as such expenses as the sheriff or court shall think fit. 
(3)Any sum of money arising from conviction and recovery of penalties as mentioned in subsection (2) above shall be paid to the Treasurer of the General Council.

Level 5 on the standard scale is £5,000.

There have been cases of people masquerading as doctors and even getting jobs in the NHS but this is very different from the kind of quackery that is of concern and is better prevented by locum agencies and NHS bodies doing more thorough checking.

Arguably, it is very difficult to define what medical practice is because what doctors do is so wide ranging. 

Opticians Act 1989
The Opticians Act 1989 differents from the Medical Act 1983 in one key area. It restricts certain activities purely to opticians.

But the Act 1989 does not necessarily restrict what opticians can do but the General Optical Council (GOC) does.

The case of Ian Jordan is informative - he was struck for a number of reasons. It is important to distinguish between ophthalmologists (doctors who specialise in diseases/disorders of the key) and opticians. Opticians do play a role in screening for signs of certain eye diseases.

Dentists Act 1984
This falls somewhere between the previous two. The definition of dentistry is somewhat circular.
... the practice of dentistry shall be deemed to include the performance of any such operation and the giving of any such treatment, advice or attendance as is usually performed or given by dentists; and any person who performs any operation or gives any treatment, advice or attendance on or to any person as preparatory to or for the purpose of or in connection with the fitting, insertion or fixing of dentures, artificial teeth or other dental appliances shall be deemed to have practised dentistry within the meaning of this Act.
The Act goes onto regulate associated professions such dental nurses, hygienists and technicians.

It is a criminal offence for unqualified lay persons to practice dentistry or hold themselves out as dentist. The General Dental Council (GDC) has prosecuted a number of individuals/companies for offering teeth whitening.

Something that is curious is the position on Botulinum toxin injection. Both the GDC and British Dental Association (BDA) state that it is not part of any dental training yet it is not prohibited. Whilst not strictly relevant to this post, it raises questions.

Protected title
Statutory recognition can grant a profession exclusive use of a particular title (or suffix) but because of the history of English qualifications, "doctor" isn't one of them. It's not helped that different medical schools have different names for their qualifications unlike the US where MD is universal (although in India, there is an MD (homeopathy) qualification).

There's also a different between stating you obtained a qualification and that you are practicing. For example, there are former nurses who practice homeopathy - they can mention their degree but can't claim to be a Registered Nurse (RGN).

Some professions with protected title are more aggressive than others in pursuing breaches - curiously the General Chiropractic Council (GCC) have employed private investigators. To quote from a Professional Standards Authority (PSA - although at the time they were still called the Council for Healthcare Regulatory Excellence) report of 2012 -
The GCC has reported 55 potential illegal uses of protected title to the police since 2002. Registered chiropractors are the initial source of information in most cases. There have been 17 prosecutions for title misuse. The GCC used private investigators to gather evidence before notifying the police in the 55 instances they have recorded. The GCC suggests that to ensure individuals do not continue using a title, after not retaining registration or voluntarily removing themselves from the register, they could be subject to an investigation. 
The report is particularly informative - and not just about prosecution for misuse of protected title. The Executive summary is very clear.

In short
If a lay practitioner avoids certain activities, does not use a protected title or claims to be registered then in theory, there is nothing to stop them practicing.

This blog makes much of medicines regulations that prevent unqualified lay practitioners obtaining or supplying certain medicines but not all "therapies" use medicines or the like. Consumer protection legislation does prevent certain types of claim being made but it does not prohibit activities per se.

Cancer Act 1939
This article is well worth reading. In essence, it is illegal for anyone to advertise treatments for cancer although it is (rarely) used to prosecute quacks offering bogus treatments rather than anyone else.

It may be useful to examine the case of Errol Denton. Denton was prosecuted back in 2014 under the Cancer Act. In 2018 after still continuing in his ways, he was prosecuted again (ASA response chosen because it mentions their rulings against him).

The difficulty of obtaining a conviction under the Fraud Act 2006 is proving that the accused knowingly made "any representation as to fact or law ... express or implied" which is untrue or misleading. It would appear that the Court did not believe that Denton deliberately set out to mislead customers - the implication being that Denton actually believed in what he was doing.

But this relates more to the marketing and taking of money for a practice, not the practice itself. If Denton had made no claims, had taken no money, it is unclear what he could have been charged with except supplying a food product unfit for human consumption.

Assault and Negligence
Certain physical acts by lay practitioners might be considered assault but English law is complicated to say the leastAdministering quack nostrums can also be considered assault if they result in harm - think of poisoning. But the definitions used of harm are wide ranging and include emotional and psychological harm. 

Intention is important but is extremely unlikely that most practitioners would set out to harm anyone (but there are obvious examples such as Paida-Lajin and certain types of exorcism - "beating the Devil out" etc - that are clearly physical harm). 

The role of consent is also important but that an act is consensual does not automatically mean that an act is not assault. There have been various cases involving consensual sado-masochism and body modification that have resulted in prosecutions.

When harms result due to negligence, there is a test of reasonableness. Whether Courts treat lay practitioners as medical professionals varies by individual case. It is about the level of duty of care that is assumed. Whereas the test of reasonableness for a medical practitioner is whether other medical practitioners would carry out such an act, with lay practitioners, the test maybe against a ordinary member of the general public. This is different from assault though. Compare murder to manslaughter. 

When children and other vulnerable persons are involved, Courts will take a much harsher line. 

Human Medicines Regulations 2012
As this blog has mentioned multiple times, the supply of prescription only medicines (including unlicensed medicines) to and by lay practitioners is a criminal offence - see above as well. The classification of some of the nostrums handed out 

General Regulatory Council for Complementary Therapies

The General Regulatory Council for Complementary Therapies (GRCCT) is very strange and the guy behind it, Barry Tanner is somewhat of a mystery. The website does seem to have been updated in several years. It's not clear if the GRCCT is active in any meaningful way.

If were not for the GRCCT being mentioned by the Society of Homeopaths (SoH) in various board minutes, being referred to Freedom4Health (run by Scientologist Martin Weightman) and Tanner's involvement with Homeopathy International (HINT), this would be of little initial interest. But what investigation has revealed is something very bizarre indeed. Something that raises more questions than it answers.

What is the GRCCT?
It is difficult to be sure.

It claims to be a "federal" regulator. The theory is that many small trade associations are simply to small to deal with regulation. They have few members who probably don't make a lot of money, can't afford to employ many, if any, staff. Some trade associations are just one person looking after a membership list, collecting fees and sending out a newsletter. Much is made of "ethical standards" by some of the larger trade associations but they can afford permanent staff and so forth. The idea of a federal or umbrella regulator is that they can deal with this. There's also something about such a regulator being able to "get a seat at the table" when it comes to engagement with the authorities.

The GRCCT isn't the only organisation like this. The Complementary and Natural Healthcare Council (CNHC) which is accredited by the Professional Standards Authority  (PSA) works is roughly the same idea. There is some history involved which will be explained later.

Where the GRCCT varies from the CNHC is that it purports to "certify" advertising and in some places is presented as an alternative to the Advertising Standards Authority (ASA) although this seems only have been going on since 2014.

It has said on its website for quite some time that the intentional is set up a community interest company but no such company or charity exists but as per previous post on Homepathy International, it is possible that GRCCT is effectively a limited by another name or an incorporated association but...

Who are the GRCCT?
There is a staff list here but it is very curious. None of the mentioned trustees, lay panel leads or staff make mention of the GRCCT online. It is the kind of thing that people do put on the LinkedIn profile. The only person associated with GRCCT who gets any mention anywhere is Barry Tanner.

A lot of the organisation involved in attempts at introducing some sort of regulation of Complementary and Alternative Medicine (CAM) in the UK have disappeared and even when they have not, records going back to the late 1980's aren't available or organisations don't want to share them.

This article from the Federation of Nutritional Therapists is very interesting (and wrong in places) and to quote -
The first steps on the road to a robust regulatory process for complementary medicine were taken in 1987 with the formation of the British Complementary Medicine Association. This new association recognised the necessity for a ‘Therapy Council’ to act as a centralised knowledge base for each therapy with an overarching administrative process performing the regulatory role. This ground-breaking regulatory structure developed by Barry Tanner and Sir John Hopson was called the ‘Pyramid Structure’.
John Hopson is a name that been encountered during research. The only "Sir" John Hopson that can be found would appear to be associated with the infamous Medicina Alternativa diploma mill that operates out of Sri Lanka which was mentioned in a previous post.

The British Complementary Medicine Association (BCMA) still exists but unfortunately, the website doesn't tell us anything about its history. The BCMA is like the GRCCT an umbrella group for small trade associations.

The article mentions the NHS Alliance which has changed somewhat in the past few years. It has rebranded itself as the "New NHS Alliance" probably to distinguish itself from the previous Dr Mike Dixon influenced incarnation. Although consigned to history, one of the things did was foist a directory of CAM lay practitioners on GPs. Dixon is well known for his involvement with the disastrous Prince's Foundation for Integrated Health and its successor the College of Medicine.

It's known that Tanner did have various meetings with various people at which he positioned the concept of the GRCCT but it isn't clear whether he was ever taken seriously.

What came out of all of this was the formation of the CNHC with considerable funding (and government bailouts). The "adventures" of the CNHC (aka "OfQuack") are well documented elsewhere including at the Quackometer blog.

The article stops before the remit of the PSA was expanded to cover voluntary registers.

Who is Barry Tanner?
Well, he looks like this.

Image result for "barry Tanner" "grcct"

But difficult to say. It's likely that he is related to Renee Tanner (some sources say he is her son), author of a number of books of reflexology and chair of the International Federation of Reflexologists (IFR). The IFR has an interesting document mentioning the GRCCT. Some reflexologists mention being trained at a "world famous" Renbardou Institute by both Tanners and there is also mention of them being examiners for Morley College. There is no indication that Barry Tanner is a practicing reflexologist.

What the internet turns up on Tanner is mostly him going to meetings with trade associations (the photo is from such a meeting). There are no photos of any other person from the GRCCT.

A puff piece from a trade association conference flyer -
Project Director GRCCT. Broadcaster & lecturer. Campaigner on Rights Of Complementary Medicine. Former NHS Project Manager, Teacher, Examiner, University External Verifier, Professions Rep, Parliamentarian, Participant Of Prince’s Foundation Federal Regulatory Group. Talking ‘From his years of experience as Over 30 years as a complementary therapist and over 25 years experience in regulatory processes as diverse as the London Stock Exchange, the employment sector, and education, as well as orthodox and complementary medicine.’
Similar claims can be found here. Parliamentarian? In the UK that means MP and Tanner has never been an MP. University external verifier? Unlikely. Claims that he was a paramedic have also been seen but in the UK paramedics are regulated and the title is protected and can be searched for here. The history of paramedics in the UK is discussed here.

Regulation and registration of complementary therapists in the UK is voluntary self-regulation. This means that there are no laws in place to protect the public from unqualified or incompetent therapists. For the past ten years and in accordance with recent government recommendations, the various professional associations in each therapy have been working together to agree standards and requirements for each type of complementary therapy. 
When these criteria had been set the next stage was to put in place an overarching independent regulator to establish a national register and protect the public by validating the status of all registered therapists. This is a role of the General Regulatory Council for Complementary Therapies (GRCCT).
OK. Clear enough, in some ways but in reality, how does the GRCCT validate the status of therapists? By membership of a trade association? This list of therapy organisations whose members are eligible for membership makes for dismal reading (the healing one is worse). GRCCT makes mention of National Occupational Standards (NOS). NOS for homeopathy were discussed here and the point was made only lip service is paid to them. NOS do not exist for the majority of therapies covered. And even where they exist, the trade associations do not necessarily require members to demonstrate that they meet them.

It is further undermined by -
Registration Fee £35 for initial therapy plus £5 for each subsequent therapy
That suggests that if an applicant belongs to a particular trade association they can "bolt on" almost anything without need for any validation.

How does a trade association sign up with GRCCT? This gives some clues (as well as providing another insight into history) but it isn't entirely clear what criteria the GRCCT assess any approach. But it looks as if some of the trade associations never applied to GRCCT and that GRCCT just decided to accept members from them if this newsletter from the British Association for Applied Nutrition & Nutritional Therapy (BANT) is correct. This from 2008 doesn't take a favourable view of the GRCCT.
There are two bones of contention, firstly, this organisation is neither recognised nor sanctioned or has any connection with the Dept. of Health or its funded body The Foundation for Integrated Health despite clever wording implying a connection. Secondly and more concerning is that this organisation has used the name of the LCSP Register in its information, as it has other Societies, without permission or consultation. We have written to the GRCCT asking for our name to be withdrawn from their information with immediate effect.
Some of the trade associations don't seem to exist (online) either or have become part of something else.

There's also possible for those not on any list to apply for registration but there is apparently a verification process and it costs extra. 

Certified Advertising
As mentioned before this seems to have started to be offered in 2014.
Advertising Certification is a formal procedure by which the UK Federal Regulator for Complementary Therapies – The General Regulatory Council for Complementary Therapies (GRCCT) assesses and verifies advertising in the sector of Complementary and Alternative Medicine. 
Advertising which is seen to meet stringent industry and legal requirements of the profession and applicable UK law is issued with a GRCCT Unique Certification Mark. Certification is valid for a period of one year and is subject to random audit.
This is obviously not the case as even cursory examination of some of the advertising reveals multiple breaches of consumer protection law and in some cases medicines regulations.
Each submission is considered by a panel composed of:
  • Legal expertise
  • Profession expertise (for each discipline appearing)
  • Regulatory expertise
  • Academic expertise (Research)
  • Lay representation
Details of how the decision-making process is structured are available here: The Certification Process

The certification process is just a flow chart. The GRCCT also helpfully tells us about "relevant" legislation and fails to mention medicines regulation or the role of the ASA.
The Profession Support Guarantee is applied to any advertisement displaying a valid GRCCT Advertising Certification Unique Identification Mark. 
The Guarantee undertakes that GRCCT will supply free of charge and without limit expert report and expert witness in defence of any legal claim on the validity of the advertisement.
There is a problem with this statement - "expert". The GRCCT does not obviously demonstrate any expertise in the area of consumer protection and advertising law and offering an "expert witness" is all they offer. If an advertiser finds themself in court, they will have to bear the rest of their legal costs and their lawyers may well advise against using GRCCT's expert witness. Even if they don't, the Court may well choose to disregard the expert witness.
To summarise, an expert witness is an also an expert, but one whose specialist knowledge supports considered opinions which may be placed before a court (or other judicial or quasi-judicial body – for example, a tribunal or arbitration).

Fundamentally, the role of the expert witness is to provide technical analysis and opinion which will assist the court in reaching its decision. The opinion evidence put forward by the expert witness is based on evidence of fact.
And the GRCCT will charge a variable annual fee for certification between £55 and £285. What the GRCCT would do if that annual fee is not paid and their symbol still used is unknown. Would they pursue through the courts? Ditto with those mentioning GRCCT registration after it lapses?

It is worth pointing out that the Committees of Advertising Practice (CAP) do provide lots of guidance, some therapy specific. They also offer free copy advice as well as an express (four hours) paid for service.

The ASA ruled against Elle Fox trading as Bubbling Life. Interestingly, her advertising purports to be certified by the GRCCT. Whilst it is possible that Fox did not request help from the GRCCT, there would seem little point in her paying for certification if this is the case. Fox has not complied and it is likely that there will be a referral to Trading Standards (ASA are alarmed by CEASE therapy).

Taking a look at a few websites that have have GRCCT "certification" -

Medical Thermal Imaging was subject to a very clear and damning ASA ruling in July 2015. Archived versions of the website reveal that GRCCT "certification" happen between June 2015 and October 2015.

Spherical Living is extremely strange and makes mention of Universal Medicine. It it offers among other things "esoteric breast massage".

Wendy Hooper and Bushey Colonic Hydrotherapy are enema providers. The International Association and Register of Integrative Colon Therapists and Trainers (RICTAT) is a trade association of enema providers. CAP has provided very clear guidance on colonic hydrotherapy.

The irony of an organisation that claims both regulatory and legal expertise having a website that is non-compliant with consumer protection legislation is probably lost on those who have signed up the GRCCT.
Practitioners who hold current registration with the GRCCT will be seen to meet the NHS National Cancer Action Team criteria in relation to Patient Safety.

‘We are happy to be working with, and guided by, the lead bodies in CAM for the benefit of patient care and safety.’ – Acting National Coordinator, Cancer Peer Review, Ruth Bridgeman
There is also a "press release" that has turned up in a number of other places. It is not the case. For one thing, although there is guidance (which suggests CAM practitioners who belong to PSA accredited registers) it is down to individual NHS Trusts to decide what is safe. There is a lot more to this but readers are unlikely to be terribly interested in NHS workforce policies.
The Federal Regulatory Council (FRC) is central to the operation of GRCCT and makes all regulatory decisions. In the same manner as the statutory Health Professions Council (HPC), the FRC is composed of a practitioner from each of the regulated professions and an equal number of lay members. The Council is chaired by a Lay Chair rendering it majority lay.
Really? From the only FRC minutes (15/09/2015) that are available -
Chair: Barry Tanner (BT) 
Ian McDougal (IM) Colonic Hydrotherapy 
Michael Lingard (ML) Buteyko Breathing 
Sue Knight (SK) Healers 
Sheila Hicks Balgobin (SHB) Essence Therapy 
Barbara Reeves (BR) Classical Manipulation 
Ann Whittle (AW) Upledger Cranio Sacral Therapy 
Robert Jefford (RJ) Reiki 
Nina Barbora (NB) Hirudotherapy 
Frances Smith-Williams Kinesiology 
Muddassar Raja (MR) Hijama 
Jacqui Footman (JF) EFT 
Geof Evans (GF) Orthopathy

Note, no lay members. And those minutes reveal some interesting things.
3.1. Registrations – BT reported that registrations currently stand at 17,780 individuals which represents one of the slowest periods of growth for GRCCT since inception. Previous meetings had discussed a probable ceiling for significant registration rise at about 24,000 to 28,000 registrants depending largely on what happens with the 4,000 to 5,000 CNHC registrants.  
3.2. Growth for the next 36 to 48 months is predicted to be slow in comparison to previous years. With a prediction of hitting 20,000 registrants around 36 months.
BT confirmed that GRCCT currently list between 5,000 and 6,000 practitioners or Reflexology on the National Register and that the extent of input by a regulator into an award consultation would usually be limited to the requirements for employment.
Compare this to -
The Complementary Therapies regulated by GRCCT are practised by in excess of 50,000 practitioners in the UK
Is that a misleading statement? It is difficult to determine the exact number of registrants from the website (the search facility is shockingly bad) but research suggests 200. There would appeal to have been a massive decline in numbers which would suggest a massive decline in income too. 
4.5. The management team of GRCCT are of the view that we have lost traction in practitioner marketplace over the last twelve to eighteen months. GRCCT has been enormously successful in recruiting registrants and profession bodies. Whilst retention remains strong market awareness has diminished. We feel we have relied too heavily on the numbers and the profession association communication route.4.6. Several major sites and a number of less major sites have dropped GRCCT referral as they are not ‘seeing GRCCT’. The Admin Team is now chasing hard on all of which we are aware. Please tell us of any sites of which you become aware that are not listing GRCCT.
Market awareness?
Financial report – Year to date is £736K income v £674 outgoings representing an annualised increase in turnover of approaching 18%. 
3.15. The two primary impacts on these are figures. The annual registration fee was increased at the end of last year. We targeted to cover 750K over three years so to hit 736K within twelve months is very positive. 
3.16. Advertising Certification is now coming online very well and will be reported more accurately at the next meeting.
That is an awful lot of money and the absence of an obvious limited company is troubling. At that level of income VAT registration is required. No mention is made of it but it is not necessary to display it on a website - only on invoices.
3.21. Since the last meeting senior teams have met or been in specific communication with: 
3.21.1. The GMC to discuss changes in advice to GPs 3.21.2. The BMA to discuss issues around insurance relating to the advice given to GPs3.21.3. Skills for Health to discuss awarding body status and development of new framework awards. 3.21.4. HCPC in relation to instruction from Privy Council 3.21.5. Delegation from Hong Kong in connection with ongoing discussion for the regulation and education of CAM practitioners in the China 3.21.6. Delegation from Kingdom of Saudi Arabia.3.21.7. The Irish Department of Health and Children on implementation of regulation and insurance.3.21.8. QCF re government proposals to amend framework level descriptors to more closely match European levels. It was noted that the majority of awards in the CAM sector are not on the framework. 3.21.9. Dept. of Health procurement team to facilitate understanding of requirement
"Specific communication"? That might mean the GRCCT sent an email. Most of the bodies mentioned would be extremely unlikely to engage because the CNHC exists etc. QCF stands for Qualifications and Credit Framework which is looked after by OfQual in England.
3.22. AGORED – Welsh awarding body who are seeking award consultation in Reflexology. The usual route for consultation on a framework award is for the proposer to demonstrate industry consultation. Often they will come to the regulator seeking a list of profession bodies. A Level 5 award was proposed by AGORED; the consultation for which would usually be directed by GRCCT to the LB (in this case the Reflexology Forum) and the proposer also supplied with a list of any know profession bodies outside of the regulatory process. In this case AGORED had mistakenly approached CNHC and ended up with a consultation panel including only discipline representation from the proposing education provider, the CNHC Profession Specific Body rep and Margaret Coats from CNHC. GRCCT was able to step in and administer the correct procedure to ensure that the submission would receive a proper consultation. 

Because of the nature of some of the claims, a complaint has been made to the ASA. It seems very unlikely that the GRCCT will respond.

Also from the minutes -
7. Advertising Standards Authority  
7.1. Legal actions – The meeting discussed the legal defence process and considered how GRCCT provides the Profession Guarantee to cover witness and profession report. 7.2. There are currently two certified sites initiating legal action against ASA. The cost of libel action in the UK is very high but so are the awards for successful outcome. 7.3. Advertising Certification – The advertising Certification process is now fully functional for all disciplines. 7.4. BT provided the meeting with a history of ASA communication and overview of the types of applications being received. 7.5. The FRC instructed that GRCCT continue to communicate with ASA with a view to having appropriate expertise consider complaints against practitioners. 7.6. Another invitation to appear before the FRC is to be issued. 7.7. RJ queried the term co-regulation as quoted by ASA. 7.8. BT advised that in in 30 years of work in regulation he had never before encountered the term co-regulation in this context and could not provide an interpretation as to how co-regulation would function. Regulation in healthcare is either Statutory or Voluntary, the two cannot be mixed. 7.9. SHB asked if there was specific advice available. She was directed to the discipline advertising descriptors on the GRCCT website.
Legal action against the ASA could take one of two forms. The serving of an injunction (average cost £500, but would be very difficult to obtain, see this case involving Matthias Rath) to prevent publication of an adjudication or post-publication libel action. Pursuing the ASA for libel would be unlikely to succeed given i) the number of legitimate defences and ii) breach of CAP Codes is also likely to be a breach of  consumer protection law and in some cases medicines regulation.

Searches of legal databases reveal no court action against the ASA by registrants of the GRCCT or persons with "certified" advertising but this may be a case of omission.

GRCCT at one point had a limited company in Ireland which is now defunct. It also had a website which is archived. Obviously, the GRCCT's attempt to expand into Ireland was a failure.

Questions, questions
Short of seeing audited accounts, audited membership numbers, etc, to be certain of anything that they GRCCT has said. Research has made it clear that the GRCCT/Banny Tanner has consistently overstated the importance/role of the GRCCT.

Have the trade associations involved with GRCCT ever seen audited figures? In the light of some of the information above, would they wish to continue their association? What about registrants?

Are there any real links between Freedom4Health and GRCCT or are they just "fellower travellers"?

Surely the GRCCT is not financially tenable any more? Has the formation of HINT anything to do with this?