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The Health Professions Council (HPC) is yet another regulatory quango.

 The HPC’s strapline is “Working with health professionals to protect the public”

At present the HPC regulates; Arts therapists, biomedical scientists, chiropodists/podiatrists, clinical scientists, dietitians, occupational therapists, operating department practitioners, orthoptists, paramedics, physiotherapists, prosthetists/orthotists, radiographers and speech & language therapists.

These are thirteen very respectable jobs. With the possible exception of art therapists, nobody would doubt for a moment that they are scientific jobs, based on evidence. Dietitians, for example, are the real experts on nutrition (in contrast to “nutritional therapists” and the like, who are part of the alternative industry).  That is just as well because the ten criteria for registration with the HPC say that aspirant groups must have

“Practise based on evidence of efficacy”

But then came the Pittilo report, about which I wrote a commentary in the Times, and here, A very bad report: gamma minus for the vice-chancellor, and here.

Both the Pittilo report, the HPC, and indeed the Department of Health itself (watch this space), seem quite unable to grasp the obvious fact that you cannot come up with any sensible form of regulation until after you have decided whether the ‘therapy’ works or whether it is so much nonsense.

In no sense can “the public be protected” by setting educational standards for nonsense.  But this obvioua fact seems to be beyond the intellectual grasp of the quangoid box-ticking mentality.

That report recommended that the HPC should regulate also Medical Herbalists, Acupuncturists and Traditional Chinese Medicine Practitioners. Even more absurdly, it recommended degrees in these subjects, just at the moment that those universities who run them are beginning to realise that they are anti-scientific subjects and closing down degrees in them.

How could these three branches of the alternative medicine industry possibly be eligible to register with the HPC when one of the criteria for registration is that there must be “practise based on evidence of efficacy”?

Impossible, I hear you say.  But if you said that, I fear you may have underestimated the capacity of the official mind for pure double-speak.

The HPC published a report on 11 September 2008, Regulation of Medical Herbalists, Acupuncturists and Traditional Chinese Medicine Practitioners.

The report says

1. Medical herbalists, acupuncturists and traditional Chinese medicine practitioners should be statutorily regulated in the public interest and for public safety reasons.

2. The Health Professions Council is appropriate as the regulator for these professions.

3. The accepted evidence of efficacy overall for these professions is limited, but regulation should proceed because it is in the public interest.

But the last conclusion contradicts directly the requirement for “practise based on evidence of efficacy”.  I was curious about how this contradiction
could be resolved so I sent a list of questions.  The full letter is here.

The letter was addressed to the president of the HPC, Anna van der Gaag, but with the customary discourtesy of such organisations, it was not answered by her but by Michael Guthrie, Head of Policy and Standards   He said

“Our Council considered the report at its meeting in July 2008 and decided that the regulation of these groups was necessary on the grounds of public protection. The Council decided to make a recommendation to the Secretary of State for Health that these groups be regulated.
http://www.hpc-uk.org/assets/documents/100023FEcouncil_20080911_enclosure07.pdf
“.

This, of course, doesn’t answer any of my questions. It does not explain how the public is protected by insisting on formal qualifications, if the qualifications
happen to teach mythical nonsense. Later the reply got into deeper water.

“I would additionally add that the new professions criteria are more focused on the process and structures of regulation, rather than the underlying rationale for regulation – the protection of members of the public. The Council considered the group’s report in light of a scoring against the criteria. The criteria on efficacy was one that was scored part met. As you have outlined in your email (and as discussed in the report itself) the evidence of efficacy (at least to western standards) is limited overall, particularly in the areas of herbal medicines and traditional Chinese medicine. However, the evidence base is growing and there was a recognition in the report that the individualised approach to practice in these areas did not lend themselves to traditional RCT research designs.”

Yes, based on process and structures (without engaging the brain it seems). Rather reminiscent of the great scandal in UK Social Services. It is right in one respect though.

The evidence base is indeed growing, But it is almost all negative evidence. Does the HPC not realise that? And what about “at least by Western standards”?   Surely the HPC is not suggesting that UK health policy should be determined by the standards of evidence of Chinese herbalists?  Actually it is doing exactly that since its assessment of evidence was based on the Pittilo report in which the evidence was assessed (very badly) by herbalists.

One despairs too about the statement that

“there was a recognition in the report that the individualised approach to practice in these areas did not lend themselves to traditional RCT research designs”

Yes of course the Pittilo report said that, because it was written by herbalists! Had the HPC bothered to read Ben Goldacre’s column in the Guardian they would have realised that there is no barrier at all to doing proper tests. It isn’t rocket science, though it seems that it is beyond the comprehension of the HPC.

So I followed the link to try again to find out why the HPC had reached the decision to breach its own rules. Page 10 of the HPC Council report says

3. The occupation must practise based on evidence of efficacy This criterion covers how a profession practises. The Council recognizes the centrality of evidence-based practice to modern health care and will assess applicant occupations for evidence that demonstrates that:

• Their practice is subject to research into its effectiveness. Suitable evidence would include publication in journals that are accepted as
learned by the health sciences and/or social care communities
• There is an established scientific and measurable basis for measuring outcomes of their practice. This is a minimum—the Council welcomes
evidence of there being a scientific basis for other aspects of practice and the body of knowledge of an applicant occupation
• It subscribes to the ethos of evidence-based practice, including being open to changing treatment strategies when the evidence is in favour
of doing so.

So that sounds fine. Except that research is rarely published in “journals that are accepted as learned by the health sciences”. And of course most of the good evidence is negative anyway. Nobody with the slightest knowledge of the literature could possibly think that these criteria are satisfied by Medical Herbalists, Acupuncturists and Traditional Chinese Medicine Practitioners.

So what does the HPC make of the evidence?  Appendix 2 tells us. It goes through the criteria for HPS registration.

“Defined body of knowledge:  There is a defined body of knowledge, although approaches to practice can vary within each area.”

There is no mention that the “body of knowledge” is, in many cases, nonsensical gobbledygook and, astonishingly this criterion was deemed to be “met”!.

This shows once again the sheer silliness of trying to apply a list of criteria without first judging whether the subject is based in reality,

Evidence of efficacy. There is limited widely accepted evidence of efficacy, although this could be partly explained by the nature of the professions in offering bespoke treatments to individual patients. This criterion is scored part met overall.

Sadly we are not told who deemed this criterion to be “part met”. But it does say that “This scoring has been undertaken based on the information outlined in the [Pittilo] report”. Since the assessment of evidence in that report was execrably bad (having been made by people who would lose their jobs if
they said anything negative). it is no wonder that the judgement is overoptimistic!
Did the HPC not notice the quality of the evidence presented in the Pittilo report?   Apparently not.  That is sheer incompetence.

Nevertheless the criterion was not “met”, so they can’t join HPC, right?   Not at all. The Council simply decided to ignore its own rules.

On page 5 of the Council’s report we see this.

The Steering Group [Pittilo] argues that a lack of evidence of efficacy should not prevent regulation but that the professions should be encouraged and funded to strengthen the evidence base (p.11, p. 32, p.34).

This question can be a controversial area and the evidence base of these professions was the focus of some press attention following the report’s publication. An often raised argument against regulation in such circumstances is that it would give credibility in the public’s eyes to treatments that are not proven to be safe or efficacious.

This second point is dead right, but it is ignored. The Council then goes on to say

In terms of the HPC’s existing processes, a lack of ‘accepted’ evidence of efficacy is not a barrier to producing standards of proficiency or making decisions about fitness to practise cases.

This strikes me as ludicrous, incompetent, and at heart, dishonest.

There will be no sense in policy in this area until the question of efficacy is referred to NICE.  Why didn’t the HPC recommend that?  Why has it not been done?

One possible reason is that I discovered recently that, although there are two scientific advisers in the Department of Health,. both of them claim that it is “not their role” to give scientific advice in this area.  So the questions get referred instead to the Prince of Wales Foundation. That is no way to run a ship.

The fact of the matter is that the HPC, like so many other regulatory agencies, fails utterly to protect the public from fraudulent and incompetent practitioners. In fact it actually protects them, in the same way that the financial ‘regulators’ protected fraudulent bankers.  They all seem to think that ticking boxes and passing exams is an effective process. Even if the exams require you to memorise that amethysts “emit high Yin energy so transmuting lower energies and clearing and aligning energy disturbance as all levels of being”.

## 25 Responses to Health Professions Council ignores its own rules: the result is nonsense

• I wonder what the individuals in professions currently under the HPC would think of the inclusion of TCM and Herbalism. Do they get a say?

I would have thought that a lot of the people in the professions you mention above work in the NHS and are directly employed by trusts and are thus subject to control and discipline via their employer? If the services of individual practitioners is comissioned directly by PCTs – aren’t they subject to all sorts of SLAs, etc.?

• These people aren’t scientists; they’re politicians who strive to please all of the people all of the time, especially the people who pay their wages.

In a real world, they would be removed and sent to remedial school.

• So David, how does all this fit with the vaunted Complementary and Natural Healthcare Council? That has been dismally ineffective in getting `professions’ (I use the word advisedly) to sign up. Are they more likely to want to sit alongside real professionals?

• It’s interesting that page 5 of the HPC report mentions the following,

“The Steering Group [Pittilo] argues that a lack of evidence of efficacy should not prevent regulation but that the professions should be encouraged and funded to strengthen the evidence base (p.11, p. 32, p.34).”

because a test which was designed to find out whether the regulation of the UK osteopathic and chiropractic professions had any impact on their research activity in the areas of efficacy and safety reached this conclusion:

“[These] data do not support the hypothesis that regulation of a healthcare field will increase research in that area.”

Canter P and Ernst E., The effect of statutory regulation of osteopathy and chiropractic on research activity in the UK, Physical Therapy Reviews Volume 10, Number 2, June 2005, pp. 67-68(2)

That seems to suggest that other CAM therapists, once regulated, will also be disinclined to place much emphasis on research. (I think we can guess why.)

• Fantastic article, great discussion of this farcical issue. I’ve just begun the process of applying for HPC registration (clinical scientist) and this absolutely infuriates me. To get my registration, I entered a training scheme which requires you to already have a high quality science degree and preferably a postgraduate qualification. I’ve then spent four years in tough professional training in the NHS and completing an MSc. Before the HPC will have me I have to submit a large portfolio to the Association of Clinical Scientists describing in minute detail (and with documentary evidence) how I have fulfilled every required HPC competence for clinical scientists. E.g:

3a.1p: “Understanding the science that underpins the specialty (modality) and the broader aspects of medicine and clinical practice”

3a.2p: “Awareness of the evidence base that underlies the use of the procedures employed by the service”

2b.1p: “Ability to critically appraise results in the light of existing knowledge and the hypothesis developed and to formulate further research questions”

2b.1p: “Evidence of presentation of scientific material at meetings and in the literature”

2b.1p: “Ability to develop an experimental protocol to meet the aims and objectives in a way that provides reliable and robust data (i.e. free of bias)”

All the healthcare professions listed in the article above have similar procedures and they all secretly believe that their training is the toughest.

What on earth is the point in insisting on all this if any bunch of delusional new age charlatans can call themselves HPC-regulated professionals? How can anyone at the HPC seriously reconcile this?!

• Prion. That is a very good point. I had no idea that you had to jump through all those hoops. What could possibly be the equivalent for a TCM practitioner? A portfolio of make-believe?

• I’ll have one more go at that link: HPC competencies for clinical scientists in biochemistry.

• Or you could try the Skills for Health competence in spiritual healing. That’s easier. You are allowed to make it up,

• Blue Wode – the Canter and Ernst article is unfortunately paywalled ($48 gets you in). Do you know if it is gratis anywhere. I am sure Dr Aust will be on here soon berating this paywalling ! The future is online… but not necessarily open • At least they have their website server (and presumably their database) within the UK, unlike OfQuack, which has theirs in the USA, despite telling the Information Commissioner that they do not transfer the personal details of their quacks outside the EU. http://www.thinkhumanism.com/phpBB3/viewtopic.php?f=14&p=50963#p50963 • @ John Hooper Unfortunately, the Canter and Ernst article doesn’t appear to be gratis anywhere online. However, if you register at the JREF forum, or the UK Skeptics forum, you could PM me with your email address and I could send you a scanned copy of it. • Amazing isn’t it. You can download terabytes of quack nonsense online including some of the most risible garbage imaginable. You want to download an academic article which (hopefully) criticises this rubbish and you have to cough up$48 for the privilege.

Not exactly symmetrical warfare is it.

This is £33 at todays FX and for this you could go to Amazon and buy “Trick Or Treatment”, “Snake Oil Science” and “Suckers” and still have some spare change for a coffee.

So three excellent books and a refreshing caffeine based beverage or one academic article which the paywallers never paid for in the first place.

Decisions, decisions.

• Blue Wode – that is really very kind of you.

I did post my true email address (and mobile phone number) on here once (by accident – they were embedded in a letter to the HSE complaining about plutonium based sugar pills) and rather lived to regret the unwarranted attention.

So this time I will use my junk email account which is:

johnhooper2000@hotmail.com

• Thank you David.

An interesting argument and somewhat pithy.

I would probably have been doubly aggrieved at forking out \$48 for what is really a one pager.

Now I can spend the money on books (or, more likely, wine).

• Excellent article, DC, and one which should have all RDs like myself frustrated and angry in equal measure that the HPC is not upholding the standards of its predecessor,the CPSM, but aping the ‘any professional as long as you don’t kill someone’ approach of OfQuack.

Its a heartsink thought but wonder if we could expect the alignment of less rigorous criteria for awarding registration to herald the way ‘for a natural merger’ of the two bodies. After all, wasting £800K of DH monies has to be accounted for somewhere.

It is appalling that HPC are considering this – surely not the plan when the HPC rose phoenix-like from the ashes of the CPSM with its restricted number of specialist practitioners agreed under the original 1960 Act There should be an open vote by all its registrants with regards this lax and louche prostituting for business and in doing so debasing the sterling qualifications of its current registrants.

For quite a while now I’ve marvelled at how there’s been an influx of new UK RD registrants with initial degrees from South America applying for NHS jobs. This despite the fact that in their home countries dietitians are a mere footing ahead of diet cooks, and nutrition is handled by the gastroenterologists. I’ve wondered how on earth they’ve acquired the skills and medical competencies that their own countries fail to teach, given the nature and status of the job over there – to enable them to become registered over here. Its all making sense now – they’ve obviously relaxed the criteria for registration.

Absolutely APPALLING

• Thanks for posting the Canter & Ernst article, DC.

I am not as “Open Access Gung-Ho” as some people. Scientific publishing requires a publishing industry, publishers have to make a profit somewhere, and I am suspicious of “author pays” models since they assume that everyone publishing research has funding to pay the charges (which is not true). There is also the point that full open access would decimate the finances of many scientific learned societies that generate their income from their journals.

Personally I think the “limited time exclusive access” models, with something like six months embargo from initial publication, is a workable compromise. But a corollary would be that publishers should give instant full-text open access to ANY paper about which they have put out a press release.

The thing that most annoys me,as I alluded to in the blog post John Hooper linked to above, is the pay-walling of OLD content, which is think is completely indefensible, and almost certainly totally counter-productive as well.

• UK Dietitian:

With a nod to the Supreme Patron of UK Quackery, I think your sign-out lline should be:

“It really is quite appalling”

• Dr Aust. There has been some interesting stuff about open access at MIT.

I have been getting quite close to wondering whether we need journals at all. Almost everything, however poor, can get published in a ‘peer reviewed’ journal. The review process does little more than maintain a hierarchy of journals. Would things be really much worse if we all published on the web, with comments allowed? The advantages would be huge -no more vast payments to Elsevier, and an end to the absurd business of everyone trying to publish in the same two journals,

The biggest argument against this would be the loss of income to learned societies.

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