ANPA Submission for the Terms of Reference to The Natural Therapies Review 2019

Introduction

The ANPA is a national association that has represented Naturopaths since 1975 to State and Federal agencies. The ANPA supports formal registration for the naturopathic profession. That we have the ‘potential’ to cause harm has been established by Lin et al (2009). Unfortunately registration and inclusion in the NRAS has not yet been enacted by the State health ministers. We have been advocating for more than 15 years for the highest form of registration which will also ensure a minimum education standard as well as a formal external complaints mechanism. The ANPA offers continued professional education for members and ANPA members are required to adhere to a strict code of conduct as well as code of ethics. ANPA members are nowadays a minimum of a bachelor’s degree in Naturopathy with many members having higher levels of education. The ANPA regularly contributes to media coverage on issues related to the naturopathic profession. We place significant focus on all sectors of our membership especially students and the professionalisation of new graduate naturopaths. The ANPA is eligible to join the World Naturopathic Federation, and are presently reviewing this possible membership. For all the years private health insurance rebates were available for ANPA members naturopathic services, ANPA has worked closely with the Private Health Insurance Sector supplying member information regularly and meeting all criteria when audited.

The comments in this document are meant to be constructive and supportive to inform the Minister for the upcoming review process as well as panel member selection. Much has been learnt from the inadequacies of the previous process that can guide and be implemented for this new 2019- 20 Review. Naturopathy is a professional practice that goes back more than one hundred years. It is based on a unique philosophy and principles that continue to be effective today for acute and chronic conditions. Naturopathic philosophy and approaches are different from mainstream medical approaches. Treating both symptoms as well as underlying causes is why naturopaths often have outcomes for health complaints where gaps in mainstream approaches seem to have no answers. Naturopaths are primary care providers. The public often seeking naturopathic care first want a more natural approach for their health condition. Naturopaths treat both chronic and acute health conditions. Naturopathy is suited to all ages from pre-conception to end of life support. Naturopathy is lifestyle medicine. There is significant focus on empowering the patient to take responsibility for proactive daily health and wellness self-care.

The ANPA looks forward to submitting the relevant updated evidence for the upcoming 2019-20 Review.

As a significant stakeholder for Naturopaths as well as an active participant in the previous review, we are pleased to provide the following constructive feedback.

NTREAP Panel Selection:

  • All panellists ought to be supporters of Private Health Insurance and Extras coverage.
  • Consumer Representatives must be unbiased and not members of Friends of Science or Sceptics associations but bone fide consumers who use natural therapies.
  • NTREAP to include consultant researchers as well as others who have expertise in CAM and the profession or modality under review.
  • The NTREAP panel tasked to review the additional evidence supplied for each in-scope therapy.
  • The reviews of the updated evidence should not be tasked to external reviewers but conducted by the experts on the NTREAP with subject experts for each therapy.
  • Full disclosure and transparency naming who the reviewers are of each therapy.
  • If representatives from other professions not under review for example GP, pharmacist, physiotherapist – must have additional formal qualifications and expertise in natural therapies to fully contribute to the review process.
  • The NHMRC to support the process of review, but not the co-ordinator of the reviews.
  • Where conflicts of interest may apply, those panel members are managed appropriately.
  • Confidentiality agreements strictly adhered to by NTREAP members until the final recommendations are publicly released.

Terms of Reference Considerations:

The process of the 2014- 15 had numerous flaws. The ultimate outcomes of this flawed 2014-15 Review had very serious ramifications for the profession of Naturopathy. These consequences were for other in-scope therapies that received a negative review, not only the naturopathic profession.

  • The most damaging result for the naturopathic profession was the ‘perception’ created as a result of ‘insufficient’ evidence. For many of the other therapies/professions, a finding of ‘no evidence’ was just as damaging.
  • The disjoint between ‘absence of sufficient evidence’ findings and clinical efficacy experienced by end-users of naturopathic services, created significant damage to the perception of the Health Ministry as well as the Private Health Insurance sector.
  •  Patients could not make sense of how a therapy they were benefitting from was now being targeted and how the Ministry of Health was now claiming ‘insufficient’ evidence.
  • There was no indication from the Ministry of Health or Private Health Insurers for the public or health practitioners what the precise criteria for ‘sufficient’ evidence was. How many pieces of research evidence were required for ‘sufficient’ evidence?
  • Patients who chose ‘Extras’ in their Private Health Insurance memberships were discriminated against, penalised and worse, denied a choice in how their health dollars are spent. Many PHI members have not renewed their memberships. This is disastrous for the PHI sector. Members of PHI paying for extras take, a burden off the health budget.
  • If PHI shared their data on their payouts for services for those on ‘Extras’ compared with their members who do not have ‘Extras’ coverage, it would not be surprising that the ‘Extras’ members cost them less, are more proactive about their health, resulting in less health expense to both PHI and the government.
  • Through the process of the 2014 – 15 Review meetings were held behind closed doors by Health Minister Ley and PHI without all stakeholders (natural therapy associations) who would be directly impacted by the decisions in those meetings and recommendations. We strongly advocate that in meetings where stakeholders are affected, all stakeholders are included in those meetings.
  • The Health Ministry’s management and messaging to the media was less than adequate. Whilst we understand what various media convey in their messaging is out of the control of the Health Ministry, much of the messaging was used to misinform and denigrate natural therapies to the public and health professionals beyond those in the scope of the review.
  • Natural therapies have been in damage control continuously with negative misinformation regularly being conveyed to consumers ever since the 2014-15 Review.
  • Australia is not isolated in the health landscape. International perceptions of the outcomes of the first review have been scrutinised and reviewed by many overseas experts. How this upcoming review is managed will be under very close scrutiny again. This is a good reason for practical stakeholder recommendations to be adopted.

NTREAP is to be responsible for the direct oversight of the review process with Subject Matter Experts either on the panel or invited to the panel as each in scope profession/therapy is reviewed.

The Natural Therapies sector that receives the least government funding for research was targeted to supply evidence for these reviews when this kind of review process has not been conducted for any registered health profession in Australia.

Methodological Flaws of the Reviews

  • Inconsistencies reviewing the evidence. Naturopathy was the only therapy singled out with issues of generalisation of research findings from the country of the research to Australia. No other therapy in the 2014-15 Review was scrutinised in this way. The vast majority of research evidence for other therapies was performed in overseas countries.
  • “Health practice” reviewed – excluding tools of trade – A naturopath as part of clinical practice uses a variety of modalities in creating a treatment plan. None of these tools of trade were admissible as evidence. For example: herbal medicine evidence, nutritional medicine evidence, lifestyle evidence, physical activity evidence, dietary evidence. It would be unacceptable to review a GP without automatically including their ability to prescribe various drugs or other measures as part of their holistic practice for each patient. This significant flaw in relation to the practice of Naturopathy needs to be addressed in the upcoming review with all tools of trade commonly used included.
  • No clear cut-offs for what was deemed ‘sufficient’ evidence. How many pieces of evidence were admissible? This was never properly established prior to the reviews being conducted by external review consultants.
  • The models of research design deemed appropriate for the 2014-15 Review were not the ideal to assess the evidence for Naturopathic practice. Overviews were least accurate or appropriate to fully and comprehensively reflect the practice of naturopathy. This extends to the Meta-analysis and Systematic Review models.
  • Naturopathic practice is best and most comprehensively explained by a Whole Systems Practice Design.
  • Mixed Methodologies are acceptable in public health research and include both Experimental as well as Naturalistic lines of enquiry to answer the research question.
  • N of 1 Design is also deemed acceptable as high level evidence.
  • Randomised Controlled Trial models are not always ideal in assessing the whole practice of Naturopathy. However, they may be applicable to the tools of trade used by naturopaths: herbal medicine, nutritional medicine and other modalities used by naturopaths.
  • Outcome research is also suited to explain the efficacy of Naturopathic practice.
  • Traditional evidence must be included and deemed as valuable and as important as current forms of research evidence.
  • There needs to be flexibility in what is deemed quality research that is admissible for Naturopathy.
  • Research evidence in other languages beyond English must be included. Therapies originating in countries where the language is not English that hold vast bodies of research knowledge must be included to allow that therapy a fair representation.

The ANPA is committed to support the Ministry of Health’s focus on an improved process for this upcoming Natural Therapies Review 2019-20.