Credible scientific evidence of clinical effectiveness should underpin the delivery of health care. Satisfactory health outcomes and cost effectiveness require this approach. In Australia however pseudoscience flourishes as regulatory bodies fail to protect consumers from health care fraud.
Health practitioners can be divided into those that are “registered” with the Australian Health Practitioner Regulation Agency (AHPRA) and those who are not. Most unregistered practitioners offer unconventional non-evidence based “alternative” approaches to health care. Naturopaths, iridologists, reflexologists and homeopaths fall into this category. The last Labor government became interested in their activities when it was realised that as private health insurers (with the exception of the “Doctor’s Fund”) paid for care from alternative practitioners, so were Australian taxpayers via the government subsidy to the industry.
The National Health and Medical Research Council (NH&MRC) was asked to evaluate the 17 most common alternative modalities asking if they were supported by “credible scientific evidence of clinical effectiveness”. They reported to the coalition government that none met that criteria. Sussan Ley was urged to withdraw taxpayer support for these modalities as millions of dollars could be saved and the public would receive a clear message about the importance of evidence based care. Private insurers were asked to stop paying for these alternative services. Neither request met with success. The private health industry maintains that they must give their insured what they want! Hard to believe (maybe not) that despite the NH&MRC reporting no value at all in homeopathic preparations the government still subsidises the fees required of students studying to become homeopaths.
This brings us to an examination of the potential harm involved when relying on non-evidence based care. In the early eighties I was caring for many patients with HIV infections with as yet no anti-viral drugs available to arrest the progress of their disease I saw how easy it was for the unscrupulous or misguided to prey on understandable vulnerability and offer, often at great expense, false hope. Patients went to the Philippines to see “faith healers” who said they could offer a cure. Some became convinced that massive doses of Vitamin C offered a cure, as could a process where one’s blood was heated to dangerous levels. Patients were robbed before they died, suffered the psychological consequences of having false hope banished and experienced a worse than necessary death away from skilled palliative care.
In less dramatic circumstances harm associated with a delay in getting an accurate diagnosis and timely treatment must be added to the harm that should be considered when looking at consumer protection. I emphasise this as governments and their regulatory bodies such as the TGA and AHPRA use a “risk stratification” approach that sees them focus almost entirely on direct physical harm to the consumer.
There are some agencies that have the ability to examine and react to complaints about care from unregistered health practitioners e.g. the Health Care Complaints Commission in NSW, but in general they are seriously under-resourced and so slow to act that consumer protection is unsatisfactory. Of course all reactions to harm reflect a failure of strategies to protect one from harm in the first place.
Perhaps the most serious and very current concern about consumer protection from health care fraud has arisen, ironically, from a well-intentioned decision by government to add chiropractors, osteopaths and Traditional Chinese Medicine partitioners to the list of health professionals who must seek national registration. A Board under the AHPRA umbrella oversees the activities of all registered health care providers. All three professions, emboldened by national registration status, have moved to expand the scope of the services they offer (the problems they say they can treat) way beyond any evidence base. To illustrate the problem one has only to look at the much-publicised problems associated with chiropractic care.
Based on an absurd anti-science concept they call “subluxation” literally thousands of chiropractors are claiming to be able to help with problems such as autism, asthma, bedwetting, colic and pregnancy complications to name but a few. Subluxation theory holds that there is an invisible but vital energy force running up and down our spines the integrity of which is essential for whole of body health. Any slight distortion of the spinal anatomy can disrupt this force and cause disease remote from the spine.
Chiropractors are targeting children and pregnant women for the expansion of their clinical roles. More than 600 chiropractic clinics involving more than 1200 chiropractors have been reported to AHPRA as they have advertised care for conditions they are not trained to treat based on the above concept. There are many more related concerns we could discuss but as we are discussing consumer protection we must look at a troublesome dangerous anomaly.
The Chiropractic Board has issued instructions to the profession telling registrants that they may not advertise services for which there is no evidence that chiropractic techniques can help. Here is the consumer rub however. Current legislation does not provide Boards with the authority to restrict the scope of treatments offered, only the advertising of same. Any “pub test” would surely have Australians agreeing, “If you can’t advertise it because the claims are fraudulent then you can’t do it”.
Many of us interested in consumer health care are urging the COAG health council to address this problem that is also prominent when looking at the advertising and practices of many osteopaths and Chinese medicine practitioners.
Ultimately effective consumer protection must involve a marked improvement in the health literacy of Australians. Such literacy embraces “educated scepticism” and therefore comfort in challenging one’s health care provider to discuss the evidence supporting their treatment plans. A number of studies show that only 40% of Australians have a satisfactory level of health literacy. How to achieve that is certainly a topic worthy of further exploration in this cyberspace.
John Dwyer is Emeritus Professor of Medicine, UNSW, and Foundation President of Friends of Science in Medicine.