Wednesday, 27 January 2021

Consultation on the future shape of the Accredited Registers programme

 Below is my response to the Professional Standards Authority consultation. A future post will discuss the Accredited Registers scheme in more depth. It helps to read this first.

Question 1: Do you agree that a system of voluntary registration of health and social care practitioners can be effective in protecting the public?

For certain occupations, yes. It really depends on how committed occupations, individual registers and their members are to public protection. If (most) registrants are employed or contracted, the ethos of their employers can have a strong influence on the occupation and associated registers.

However, experience suggests that some registers, at best, pay lip service to public protection whilst some of their members undermine public health etc. Experience suggests that even when this is pointed, some registers fail to take concrete steps to address problems. In some cases, it may be due to the register itself, in other cases it has to do with the nature of the occupations they represent.

Question 2: How do you think the Authority should determine which occupations should be included within the scope of the programme? Is there anything further you would like us to consider in relation to assessing applications for new registers?

There is a need for more concrete definitions of what health and social care are. Legislation is somewhat vague and may need to be changed. There are arguments that some existing registers cover occupations that are not health care, even if registers and practitioners represent their occupation as such.

There can be problems with occupations that are vaguely defined and/or whose members practice adjunctive therapies yet see them as part of their occupation. Ideally, an occupation should have a clearly defined scope of practice or at least there should be a strong consensus within the occupation as to what it is.

Some Complementary and Alternative Medicine (CAM) occupations are particularly problematic in terms of vagueness; they use aphoristic and even metaphysical (vitalistic) language to describe themselves. Plain english it is not. This can also apply to some fringe psychological therapies.

Colonic hydrotherapy likely should not have been included for various reasons. Whilst enemas are used in clinical settings by clinicians, the clinical indicators are very clear and limited. However, non-medically qualified practitioners can not make the determination. Carried out by non-medically qualified practitioners, they are often associated with the discredited autointoxication theory. Klismaphilia is also a concern. In some jurisdictions, colonic hydrotherapy by non-medically qualified practitioners is prohibited. In others, the sale of equipment to them is prohibited.

That a therapy has a legitimate clinical use can not be the sole reason for it to be regarded as a health care occupation for non-medically qualified practitioners.

There are questions about massage therapy as well. Massage therapy can be used in a physiotherapy context, especially in rehabilitation, but it can also be used for pleasure/relaxation. It is understood that from the view of existing registers, admission is based on education and training.

Yoga therapy is questionable too. Structured exercise programmes are a core part of physiotherapy and there are physiotherapists who use yoga but they tend not to invoke “chakras” etc.

Some of the procedures used by non-medically qualified practitioners of non-surgical cosmetic treatments may be used by clinicians for justifiable medical reasons, although those reasons are often not cosmetic. For example, Botox injections can be used to control muscle spasticity.

The legality of supply of substances/devices used in some occupations is concerning. Whilst regulators like the MHRA may be indifferent to the supply of unlicensed medicines or the use of unapproved medical devices by non-medically qualified practitioners, they are concerned about the supply of prescription only medicines, medical devices of certain classes and the marketing of services involving such. Official tolerance of the legally questionable activities of some occupations should not be seen as providing a reason for recognition.

It is interesting to note that there are no Herbalism registers, nor are they accepted by either of the CAM umbrella registers.

Question 3: Do you think that moving from an annual to a longer cycle of renewal of accreditation, proportionate to risk, will enable the Authority to take a targeted, proportionate and agile approach to assessment? Do you think our proposals for new registers in terms of minimum requirements are reasonable?

A move to a longer cycle of renewal does make sense for certain well run ARs, as long as the Authority retains capacity to deal with any major developments that might occur with these registers.

Obviously, the Authority will maintain “in cycle” monitoring of such ARs. It may be sensible to require these ARs to supply some sort of annual update to the Authority. The “Share Your Experience” process may need to be changed.

There is a concern that it could lead to uneven income for the Authority. Uneven income could lead to an uneven approach to risk. This could be mitigated by a phased introduction and aligning renewal dates in such a way as to guarantee a regular income stream as well as potentially building reserves.

Minimum standards for new ARs are not unreasonable but there are concerns that some potential ARs might move very slowly and 12 months may be insufficient for them to potentially enact radical change. Of course, introducing pre-application assessment etc might mitigate some of that. Ideally, prospective ARs should think long and hard about applying for AR status and initiate a programme of change to align with Standards well before making a formal application. Unfortunately, not all registers have good strategic planning and direction.

Question 4: Do you think accreditation has been interpreted as implying endorsement of the occupations it registers? Is this problematic? If so, how might this be mitigated for the future?

It’s not even a question of “endorsement”. Accreditation is recognition of certain occupations as health and social care occupations. It is recognition of registers as being related to health and social care. For fringe occupations, the recognition that accreditation gives is a big deal. This is probably even more so for ARs that represent a single occupation and see promotion of the occupation as a major part of their role.

There is also the problem of recognition of an occupation being seen as recognising all the practices (bar adjunctive ones) carried out by that occupation even if they are questionable. Whilst the Authority may insist that (prospective) ARs prohibit such practices (CEASE therapy, anti-vaccination and gay conversion therapy are obvious examples), that will not be immediately apparent to the public.

Question 5: Do you think the Authority should take account of evidence of effectiveness of occupations in its accreditation decisions, and if so, what is the best way to achieve this?

This is a complex area. The criteria discussed in 4.11 could form a reasonable basis for accepting occupations without the need for copious evidence of effectiveness. However, two items are of concern -

d. The occupation or role is used independently by the public to support their health and wellbeing

If the occupation does not meet any of the other criteria, greater evidence of efficacy should be required. Again, CAM and certain fringe psychological therapies are the main source of worry.

f. Government and/or other public authorities support its inclusion in the programme.

On the face of it, this is not unreasonable. However, there are concerns that Government might ask the Authority to recognise an occupation that has no/little evidence of efficacy because it is seen as politically popular. Government might also view Accreditation as an alternative to legislation and statutory regulation when they might be warranted.

It is noted that the evidence of efficacy of occupations may vary considerable in its form. Social care is not amenable to RCTs and “placebo” social care would be unethical even if possible. But there is much academic literature, benchmarking of services and so on.

There can be a gap between claimed efficacy and evidence of efficacy. The bigger the gap, the greater the risks posed to the public.

Requiring some (prospective) ARs to submit a report outlining the evidence base for an occupation would be preferred over a “knowledge base”. It may prove a useful exercise for ARs anyway. There are concerns that some ARs lack the ability to understand let alone evaluate evidence. This can be seen in the cherry picking of favourable evidence (generally of poor quality) and the select ignoring of evidence of lack of efficacy.

It is suggested that the Authority use an external panel of experts to evaluate the evidence base presented. Unless the Authority anticipates many new applications, developing in-house resources may be wasteful.

It is anticipated that if the Authority chooses to evaluate evidence of efficacy, regardless of how it chooses to do so, if ARs and their members do not like the results, there will be accusations of bias, mention of “Big Pharma” conspiracies and so on. Some CAM practitioners take the view that only practitioners understand the occupation and sometimes state that others are unqualified to make judgments about efficacy. This is a ludicrous assertion.

Evidence may also have a role to play in defining scope of practice. There is for example NICE guidance on the use of specific therapies for certain conditions. For example, Vega Machine (a “bioresonance” machine), Hair Mineral Analysis and Applied Kinesiology are all do not do for the diagnosis for allergies. Whilst NICE guidance is not mandatory, completely ignoring it should be viewed in a negative light.

Question 6: Do you think that changing the funding model to a ‘per-registrant’ fee is reasonable? Are there any other models you would like us to consider?

One problem with a per-registrant fee structure is that it does not reflect “work done” by the Authority in terms of dealing with an AR and it is known that some ARs necessarily create more work and cost than others. Larger/less problematic ARs would be, in effect, subsidising other ARs - but that would like apply to most other potential fee structures as well. A move to longer renewal cycles for less problematic ARs might mitigate that to an extent, if charged a renewal fee rather than an annual fee.

Any fee structure that the Authority implements must be transparent. Some ARs are very small and have limited budgets. A move to per-registrant fees would benefit them but even so, they likely still need to have a good idea of costs. A per-registrant fee might encourage some smaller registers to apply for accreditation.

It is noted that the Authority has mentioned pre-assessment fees that takes into account register size and number of professions covered.

A fee structure that was partly based on occupation sector could be justified if a particular sector, say CAM, generates more work for the Authority compared to others.

Question 7: Do you think that our proposals for the future vision would achieve greater use and recognition of the programme by patients, the public, and employers? Are there any further changes you would like us to consider? 

Possibly but it will take some time and unless there are changes to legislation, some elements of the vision can not be realised.

It may also be the case that some occupations currently included in the programme would have to undergo radical transformation or be excluded. The Authority may end up de-recognising the certain CAM occupations for example.

There is also the risk that Government may choose to statutory regulate counselling and psychotherapy.

Question 8: Do you agree that to protect the public, the Accredited Registers should be allowed to access information about relevant spent convictions?

This would require a change to legislation. There are concerns that some existing ARs are very amateur and may not have sufficient data protection measures in place.

Question 9: Are there any aspects of these proposals that you feel could result in differential treatment of, or impact on, groups or individuals with characteristics protected by the Equality Act 2010?

Not really. It is possible that some practitioners might feel that changes may impinge on their belief systems but those belief systems do not have the status of religious beliefs. Nor is there any occupation or AR that is tied to a particular religious belief. Membership of the UK Board of Healthcare Chaplaincy is open to all religions and even the non-religious. The Association of Christian Counsellors is non-denominational.

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