Chiropractors

Meeting report

HEALTH PORTFOLIO COMMITTEE
30 October 2000
PUBLIC HEARINGS: CHIROPRACTORS, HOMEOPATHS AND ALLIED HEALTH SERVICE PROFESSIONS SECOND AMENDMENT BILL [B 66B-2000]

Chairperson : Dr A S Nkomo

Relevant documents
Chiropractors, Homeopaths And Allied Health Service Professions Second Amendment Bill [B 66b-2000]
Chiropractic Liaison Committee submission (see Appendix 1)
SA Association of Herbal Practitioners submission (see Appendix 2)
Massage Therapy Association (see Appendix 3)
Integrated Health Professions Liaison Committee (see Appendix 4)
The Chiropractors, Homeopaths And Allied Health Service Professions Council Of South Africa (see Appendix 5)

SUMMARY
During the all-day hearings, the Committee heard submissions from the Chiropractors, Homeopaths and Allied Health Service Professions Council of SA, the Chiropractic Liaison Committee, the SA Association of Herbal Practitioners, the Integrated Health Professions Liaison, the Ayurvedic Liaison Committee and the Homeopathic Association of SA, the Complementary Medicine Association of South Africa, the Herbal and Naturopathic Liaison Committee, the Chinese Medicine and Acupuncture Liaison Committee and the Homeopathic Liaison Committee.

The recurring issue was voluntary registration. It was argued that to leave the choice of registering to the therapist or practitioner does not adequately protect the public from inadequately trained health therapists. Other issues were:
- The level of training required by the various professions
- The practitioner vs. therapist issue
- Whether to grant the Interim Council an extension of time
- Unequal representation on the Council

MINUTES
Chiropractors, Homeopaths and Allied Health Service Professions Council of SA
Mr M O'Brien, Council Chairperson, focused his submission on the Interim Council and, most emphatically, the distinction made by the Bill between practitioners and therapists. Practitioners are empowered by the Bill to "prescribe and dispense medicine" whereas therapists are not. This means that, for example, an acupuncturist or ayurveda yoga practitioner will be able to prescribe and dispense medicine (what kind of medicine is not specified. Ironically, aromatherapists, therapists who deal in medicines, are not empowered by the Bill to prescribe or dispense medicine.

Discussion
(Q) Dr Rabinowitz (IFP): Can you establish a "Code of Practice" to distinguish between those who provide "professional" and "cosmetic" services. Can you monitor this? Can you compare professionals and new holistic practitioners? Even prostitutes can be considered to be health workers. How can we distinguish between "quacks" and quality practitioners and police their work?

(A) Yes, monitoring and a "Code of Practice" are possible. Our Council is very professional. As for your allegations that some practitioners are "quacks", I find this unacceptable and arbitrary.

(Q) Ms Kalyan (DP): You say you want the Council to be extended. For how long?

(A) At least two months.

Chiropractic Liaison Committee
Dr R Engelbrecht, Acting Chairperson of the Chiropractic Liaison Committee, said they were happy with the proposed amendments to the Act, but agreed with the problem raised by the first group, that the distinction between practitioner and therapist empowers practitioners, but not therapists, to prescribe and dispense medicine.

Discussion
(Q) Dr Rabinowitz: Yes, the public are not linguists. Is it fair a therapist can choose whether or not to be registered? How is the public to tell the difference between a registered practitioner and a non-registered therapist? Registration should be mandatory.

(A) Yes, it is confusing although the public does not see it this way but only thinks of the individual professionals they visit. Each profession must prove itself in order to gain recognition.

(Q) Dr Rabinowitz: How can a practitioner choose whether or not to be regulated? And how can we monitor something with the scope this Bill allows for?

(A) Chairperson Nkomo: We have no magic wand. There are limits to what we can do.

SA Association of Herbal Practitioners
Ms C Meyer, Association Chairperson, informed the Committee about what herbal practice is and the training needed to be qualified.

Discussion
(Q) Ms Kalyan (DP): What kind of education or training does an herbal practitioner require?

(A) The minimum criteria is four years. I myself trained for four years in the UK. The course is not yet available in South Africa so most herbal practitioners here were trained elsewhere.

(Q) Ms Kalyan: Whose responsibility is training?

(A) It is the responsibility of each profession.

(Q) Dr Mbulawa (ANC): How many herbal practitioners are there in South Africa?

(A) We are now around ten, be we are re-opening a register. Our association has around 80 members, not all of whom are practitioners. It is a growing profession.

(Q) Dr Rabinovitz: I want to know if people with less education in their profession will influence the standards for people who have more education. I mean, lower the standards.

(A) This question is unanswerable as I can only speak for our profession.

Integrated Health Professions Liaison Committee
This was a "cluster" presentation by Ms Hart, their Chairperson, Ms Graham (reflexology), Ms Nye (aromatherapy) and Mr Hooper (massage therapy). They each explained the work they do and how it contributes to overall health.

Discussion
(Q) Ms Kalyan (DP): How many of the professions under this Bill do you represent?

(A) We represent only three: aromatherapy, massage and reflexology.

(Q) Dr Rabinovitz: Isn't it fair to say that at least some aromatherapists are "quacks"? What percentage of practitioners are registered? Isn't it odd that a practitioner can choose to be regulated or not? How is the public to know the difference?

(Q) Dr Mbulawa (ANC): What is the real difference between a "practitioner" and a "therapist" Isn't it elitist to make this distinction?

(A) We don't know how many therapists are registered and how many are not. A practitioner can look at a client's dietary needs and actual treatment delivery whereas a therapist cannot. Their work is completely different from that of a practitioner.

Ayurvedic Liaison Committee
Ms Vassen discussed ayurvedic therapy, its different modules and how they work.

Discussion
(Q) Dr Rabinovitz: Should people be able to choose whether or not to register?

(A) We believe all students should register.

(Q) Dr Mbulawa: Which South African universities offer ayurveda degrees?

(A) The University of Natal has taken the initiative to develop a course there.

(Q) Dr Mbulawa: So all ayurveda therapists in South Africa are foreign-qualified?

(A) As I said, the University of Natal is developing a course.

(Q) Dr Mbulawa: How many hours of training is required for a minimum qualification in ayurveda?

(A) It depends on the category, but the minimum from all categories is 1000 hours. For example, qualification in yoga therapy requires 1050 hours of training.

Homeopathic Association of South Africa
Dr Pillay said the Interim Council was a failure. He said registration was important but that it was being undertaken in the wrong way. He asked why homeopathic practitioners were regarded as a "minority" when they were many in South Africa. He thought they were misrepresented. He added it was absurd that the Interim Council does not look into training but leaves that to the professions themselves to determine and regulate. He said the public trusts the Council whereas there is not adequate reason for this trust. He asked the Committee to reconsider the passing of the Bill.

The Association's Legal Counsel said they did not support equal representation of all professions on the Council, saying unequal representation can also be democratic. He said they also do not support voluntary registration since it is the responsibility of Parliament to protect public health standards. He said the drafters had not received enough input before drafting the Bill.

Discussion
Ms Baloyi (ANC): These comments on our process are disturbing. We thought there had been thorough consultation in the drafting of this Bill. These comments present serious problems for our Committee. We must analyse and discuss this presentation. It distorts the work of our policy.

Ms Kalyan (DP): I agree with Ms Baloyi. Voluntary registration is unacceptable. We are failing in our duty to the public.

Chairperson Nkomo: Registration must cover people so that anyone who is not registered cannot practice. This must be absolutely clear.

Ms Kalyan: But people are practising without registering.

Chairperson Nkomo: This is a matter for the police.

Dr Mbulawa: I'm perturbed. How can you formulate criteria for your own further registration? And how can the extension of the Interim Council help with this?

Dr Pillay: It is not necessary to extend the Interim Council. We want to know what will be the minimum standards for registration.

Chairperson Nkomo: Alright, there has been consultation but not total agreement Our duty is to listen to the majority.

Complementary Medicine Association of SA
Dr D Nye dealt with the issue of the level of training required for admission to the professions represented. He stated that although standards are high, many practitioners had been admitted to the profession under the grandfathering clause. In terms of this clause, persons were recognized as being qualified to practice by virtue of their years of experience, as opposed to their qualifications. He however stressed that this did not mean that members with inadequate training were allowed to practice.

He stated that they were eagerly awaiting the Act and that there had been too many obstacles to date. It was important that the Interim Council be granted an extension of time, as lots of work would be undone if things were rushed. On the issue of registration, he stated that all practitioners who had passed the required standard should register or be prevented from calling themselves 'practitioners'

Discussion
A member asked for Dr Nye's opinion on the issue of unequal representation and the fact that there were such a vast number of medical practitioners represented.

Dr Nye did not think that unequal representation would unbalance the council as one profession could not dictate to another. He also stated that the numbers game was just based on fear.

Ms Baloyi (ANC) asked how people who chose not to register will be monitored.

Dr Nye replied by using an example of a massage therapist who chooses to de-register saying that such person will then not be allowed to refer to herself as a massage therapist but will have to use the term masseuse. He said that it would therefore be necessary to educate the public, as they would have to find out whether such a person is registered or not. The public would have to be informed that they would only be afforded protection against such person if the person has been registered.

Ms Baloyi asked how the grandfathering clause worked in the case of their profession.

Dr Nye replied that only a small number of practitioners were grandfathered .There were those who had received a French or British qualification which enabled them to practice. A minority was accepted under the grandfathering clause, in terms of which they needed at least ten years experience in order to practice.

A member asked how the decision was taken as to who qualified under the grandfathering clause i.e. was it decided on an individual or group basis.

Dr Nye replied that the majority of cases were dealt with as a group although a few cases required individual scrutiny.

Dr Cwele (ANC) asked how the actions of a person who was not registered would be monitored.

Dr Nye replied that the same principle applied as in the medical profession i.e. that a person gets away with a transgression until he is reported. One therefore would have to wait for complaints to be registered before any action can be taken.

The Chairperson pointed out that in the Medical and Dental Council it is practice for inspectors to visit the rooms of practitioners as a means of monitoring the profession.

Herbal and Naturopathic Liaison Committee
Dr Webber gave a brief explanation of the practice of Naturopathy. He described it as a practice of using nature to heal disease. He said it was not aligned to a cultural philosophy but is based on the principle of self-healing.

Although Naturopathy has been on the Council since 1975 they have not enjoyed any effective representation. The first problem was that there was no training available in South Africa even though the profession was increasing rapidly abroad.

He stated that this profession has been advising patients against smoking and a high intake of red meat and has recommended a high fibre diet to patients already since 1839. The medical profession has only accepted these facts very recently. The public needed information regarding natural remedies. For example, most people are unaware of the fact that patients treated with cholesterol lowering drugs have a high mortality rate due to the side effects of the drugs. Dr Webber submitted that vitamin B has the same effect on one's cholesterol without having the negative side effects.

Dr Webber stated that many people wanted to study Naturopathy but were unable to do so because of the fact that the register is closed. He stated that once the register is reopened, they would be able to meet public demand. He concluded that it was necessary that the bill be passed as soon as possible.

Discussion
Ms Njobe (ANC) asked how many practitioners Dr Webber is referring to (taking into account the fact that the profession is closed). She also wished to know where most of them currently receive their training.

Dr Webber replied that there are 134 duly registered practitioners and 45 professionals (with overseas training) who are currently applying for registration. Training took place in Germany, the UK and the USA. In addition some of them had applied to be accepted under the grandfathering clause.

Dr Mbulawa asked whether the interests of the herbalists would be represented by the Naturopathists to which Dr Webber replied that dual representation is preferable.

Ms Kalyan asked whether new concerns regarding training would be raised once the register is reopened.

Dr Webber replied that they have taken into account international training standards. A four year curriculum which includes individual therapy, an examination and naturopathy diagnostics has been formulated. They have already received communication from the University of the Western Cape which has expressed interest in their program.

Chinese Medicine and Acupuncture Liaison Committee
Dr Adams stated that this committee had been brought into operation in 1999. With regard to the Grandfathering clause he stated that their approach had been generous rather than exclusionary as they believed that there would subsequently be sufficient opportunity to upgrade ones qualification. The overriding principle however is that the practitioner should not be a danger to the public.

Within the committee there are various sub-groupings, the primary one being those who have attained a degree or diploma in this field. At the other end of the spectrum, he referred to the dry-needlers, whom they wish to exclude from the Council because they feel that this group lack adequate training in the field of Chinese medicine and acupuncture.

Dr Adams expressed concern that people without adequate training have been slipping through the system and they now realize that they may have been too generous in their approach. This is evident in the fact that family members of practitioners were allowed to practice without having received the proper training.

Dr Adams continued that communications with the Council had not always been without mishap but that it was important to take a balanced view and not just focus on the negative aspects.

Discussion
Ms Kalyan requested clarity on the accreditation process and Dr Mbulawa asked whether, in the light of the fact that family members had been allowed in without the necessary qualifications, their final product was trustworthy.

Dr Adams responded that it was precisely this problem that he had been pointing out.

Dr Mbulawa asked why physiotherapists, as dry needlers, were excluded from the Council.

Dr Adams responded by identifying the dry needlers as a group of physiotherapists with minimal qualifications in acupuncture and that the practice in which they engaged, did not form part of accepted oriental practice. As a result, he argued that they should not be part of the board representing acupuncturists. He also stated that they aimed to be as inclusive as possible but had been forced to become more exclusive as the process came about.

A member asked what the guiding principles were when determining whom to exclude and Ms Rabinowitz(IFP) asked him to comment on voluntary registration.

Dr Adams responded that the Education Subcommittee of the Chinese Medicine and Acupuncture Liaison Committee dealt with the accreditation process. It appears as if doctors and members with higher qualifications did not wish to be grouped with those members with few qualifications. He stated that it was unsatisfactory that members with 80 hours of training should be grouped with members with 1000 hours of training. He stated that it was unsatisfactory that everyone be referred to as 'practitioners'. In determining who is a practitioner, one should have regard to public safety.

Homeopathic Liaison Committee
Dr Tsotetsi, an Interim Council member, argued that there needs to be a distinction in the health profession as the members' levels of experience and qualifications differ.
She stated that she found the presentation by the Council very disturbing and criticized their tone and content, especially when dealing with Professor Gumba.

Firstly, she argued that it had not been the Department's intention to be exclusionary but that the safety of the public had to be taken into account. She criticized the argument that a masseuse who chose not to register could still practice but could not use the term 'therapeutic masseuse'. This offered no protection to the public who are ignorant on the subject and would not even understand the meaning of the term 'therapeutic'

In addition she stated that regulations with regard to accreditation criteria had never even been discussed or debated by the Council and wanted to know how there could be criteria determining accreditation when the regulations had never been discussed with the whole Council.

She accused Mr O 'Brien of having implemented regulations without any consultation with the rest of the Council members and without the rest of the members having had insight into the regulations.

She recommended that the Interim Council not be granted an extension of time, that it be dissolved and a new Council put in its place.

Discussion
Ms Njobe stated that Dr Tsotsetsi had made very serious allegations and asked whether it was not appropriate for the Chairperson of the Interim Council to respond at this stage. The rest of the committee did not support this proposal.

Ms Baloyi stated that the fact that the Council was experiencing problems should not jeopardize the functioning of this Committee and their duty of getting the Bill passed.

The Chairperson concluded that criticism accompanied public office and that it should not result in acrimony, but instead be seen as part of a democratic system.

The meeting was adjourned.

Appendix 1:
Chiropractic Liaison Committee

30 October 2000

Dr Abe Nkomo, Honorable Members of the Committee:

Thank you so much for affording us the opportunity of addressing you this morning on the proposed Chiropractors, Homeopaths & Allied Health Service Professions Second Amendment Bill.

The Chiropractic profession has indeed experienced its' own long journey starting way back in the 60s - in a struggle for acceptance and recognition. We have known rejection, disappointment false promises, and a variety of frustrations. But all of these challenges, culminating in the achievement of Act 63 (amendment Act 1985 - which reopened the Chiropractic Register) have moulded our profession into a worthy and now recognised health care service. Today we are in general, fairly content with the amendments to the Act as now proposed. It still provides for appropriate standards, protection of the public and the regulation of health care workers and the services they provide.

Four new disciplines, Chinese Medicine & Acupuncture, Massage Therapy, Aromatherapy and Reflexology - are now being catered for. There is a worldwide swing towards the utilisation of natural therapies and to this end we believe that our country has done well in identifying and regulating such services in an orderly manner.
In the public interest we believe that all professions or services rendering any form of health care should be regulated through legislation.

There are however some areas of concern relative to the bill, and we trust that reason will eventually prevail:

The first issue is that of the composition of the Proposed New Council. The CH & AHSP Council together with several stakeholders have work shopped this item quite thoroughly and have motivated a new Council represented by one member from each profession. The C & H Council will no doubt present their case on this issue in more depth. The Council's proposal for one member per profession to be represented on the new Council, is democratic and the Chiropractic Association supports this proposal without any reservations (the establishment of Professional Boards representing each of the respective disciplines - all resorting under the "mother" Council can work). We must however express our concern in that there seems to have been a very serious communication gap between the C & H Council and the Department, which has apparently submitted a different version of the Bill - or at least with changes of which we were not aware.

The second issue is that of the apparent distinction being made between Practitioners & Therapists: (Refer to Practitioners vs Therapists)

Members of the Committee - thank you for your time and allowing us to present this submission.
__________________________________________________________________
Practitioner vs Therapist
The debate on the allocation of the terms "practitioner" and "therapist" to specific professions should be approached rationally and with extreme wisdom. First of all it must be taken into account that these are generic terms descriptive of health care groups.

Various dictionaries describe "practitioner" as one who practices an art or a profession. Especially a doctor. Other sources refer to a practitioner as a graduate professional who has complied with all aspects of his/her education and who is legally entitled to practice his/her discipline. Yet another definition simply states that a practice is the business of a professional person, a practitioner.

These definitions are widely accepted internationally and it should be noted that no reference is ever made pertaining to a health practitioner's "right to dispense". It has been inferred that Chiropractors do not dispense. This statement is based upon serious misinformation. Chiropractic practitioners do dispense a variety of over the counter remedies such as nutritional supplements, vitamins, minerals, topical applications etc.. Most prefer to simply advise or prescribe such items, but I do not think we can support the false conception that chiropractors "do not dispense". This argument is not fair to other practitioners either - i.e. homeopathic practitioners etc.

Therapist - is derived from the word Therapeutist: The internationally accepted definition for therapist is "one skilled in the treatment and cure of diseases" Once again, no reference to method or dispensing! We can't re-invent the English Language and to apply either or both of the above terms to specific professions will be most unusual when taken into account that either term could apply to virtually anyone entitled to practice what he/she has been trained to do at an accredited institute.

Thus, we believe that any GRADUATE PROFESSIONAL who is entitled to the title DR and who is legally registered to practice according to his/her training and is capable of a differential diagnosis should retain the right to be referred to as a "practitioner" in his/her specific discipline.

We concur that it is perhaps more appropriate to refer to Massage Therapists, Reflexology Therapists and Aromatherapy therapists. I don't think such practices would have any objection.

However, in the interests of objectivity, this Association supports the CH & AHSP Council in that unnecessary distinctions be avoided.

The Chiropractic Association of SA, wishes to express its' deepest concern about this issue. We must be as objective as possible without constraining any profession through an unconstitutional or misdirected implication.

Dr Reg Engelbrecht
Secretary-General

Dr Nkomo, members of the committee, thank for your time and for listening.

Appendix 2:
SA Association of Herbal Practitioners

Address to the Parliamentary Portfolio Committee on Health : Monday 30^th October 2000

· Thanks for the opportunity to work together in a transparent and democratic way by having this meeting.

· Special thanks to Minister Tshabalala Msimang for her support for Complementary Medicine, Dr Nkomo, Lauretta Jacobus and the Gauteng Legislature for their support and input.

· Our Association is in agreement with the Council on the various issues being debated. Michael O'Brien and Leonie MacDonald deserve thanks for their hard work.

· We are grateful for the opportunity to be heard and to make representation for our Profession. We have all worked hard at getting new regulations and criteria together for our Profession

· We object to the unilateral changes made to the Bill by Dept of Health:

· Unilateral decisions have been one of the major problems to plague our profession in the past:

· Closure of the register: There has been no recognition of Herbalism, arguably the oldest profession, no education, no development.

· It has been an unhealthy situation to exclude phytotherapists, leaving a situation where the public thinks a practitioner of any other complementary medicine is a homoepath

· There is no education in place as a result of this exclusion, and it has not been seen as a career option.

· We are far behind other countries with respect to numbers of professionals in practice

· Opening of the register to include Phytotherapy will be a triumph for SA - putting us ahead of UK, Australia etc.

One of the problems is the number of persons from each profession represented on the new Council:

· Equal representation of each profession on the new Council is essential. Even if the numbers of practitioners are small at present, this is due to the exclusion of Phytotherapy in the past, and does not allow for exclusion now.

· There are important issues to be discussed,
· plans to be made for education, and we do not want a perpetuation of what happened in the past.

· Especially as many people/professions do not understand the philosophies of other professions.

· Some homeopaths have publicly stated that they do not want to be on the same board as phytotherapists. This is not an acceptable attitude when we are all in the business of healing.

Title of practitioner

· The term practitioner is the most suitable for all complementary health care professionals. Practitioner of herbal medicine. No room for confusion

· We see this as a dispute which is ego-based, and could jeopardise the re-opening of the register.

· Hours have been spent on arguing these issues before, and agreement was reached. Last minute changes only delay important progress.

· The Medical profession/complementary medical profession needs to recognise the need for co-operation. AIDS, cholera, TB, cancer, no one profession can claim a cure - co-operation is essential.

· This is another reason why unilateral decisions are unacceptable. Serving public health means we need to work together

· It is for these reasons that it is essential that the Bill goes through on time, and without any further hitches.

Appendix 3:
REPORT ON THERAPEUTIC MASSAGE THERAPY TO THE PARLIAMENTARY PORTFOLIO COMMITTEE ON HEALTH
30^th OCTOBER 2000
PRESENTED BY: BRIONY ESTERHUYSEN
FROM THE MASSAGE THERAPY ASSOCIATION (SA)

INTRODUCTION
Massage is an ancient form of therapeutic treatment, and because of public demand, the time has come to clearly define the role and place of "therapeutic massage" as a health profession. It is more than ten years since we first lobbied to have therapeutic massage recognised as a legitimate health profession. We would like to express our gratitude and thanks to Mike 0' Brien, Leonie Mac Donald and their team for all the support, guidance and hard work that has contributed to us arriving at this point.

The therapeutic massage practitioner plays a valuable role in primary health care and lifestyle education. It would be sad if at this point our right to practise as independent practitioners is compromised by classifying us as therapists and not practitioners. Although we form part of a dynamic multi-disciplinary health care team, many of the clients using the services of our practitioners are not referred. Also our level of training enables the therapeutic massage practitioner to competently assess a client to determine the best treatment plan, be it to treat, refer or to play a role within the multi-disciplinary approach.

DEFINITION OF THERAPEUTIC MASSAGE THERAPY
A therapeutic massage practitioner's:
· training takes place within a therapeutic environment i.e. in normal and abnormal pathological situations
· application is specific - with the aim to improve, restore, maintain and / or manage health
· training in anatomy and physiology enables an understanding of normal structure and function
· training in pathology enables the practitioner to identify abnormal structure and function and to constructively refer where necessary
· training in a healthy lifestyle enables the practitioner to promote health in a primary health care capacity through education within their practice

ROLE OF THERAPEUTIC MASSAGE PRACTITIONER
A therapeutic massage practitioner:
· maintains and I or promotes health
· is able to play a role in the early detection of disease for referral
· provides emotional support for the client i.e. the benefit of touch transcends all barriers
· provides recuperative care after disease and I or operation

SUPPORT FOR THERAPEUTIC MASSAGE THERAPY
The need for therapeutic massage as part of the health programme is demonstrated by:
· the number of therapeutic massage practitioners in full-time practice
· inter-professional referrals to and from currently recognised health professionals
· the high number of therapeutic massage practitioners practising within multi-disciplinary teams i.e. alongside General Practitioners, Physiotherapists, Chiropractors, Psychologists, Homeopaths and in Sports Science Centres

WHOM DO WE TREAT?
Situations where a therapeutic massage practitioner would provide beneficial service:
· health promotion and I or maintenance and lifestyle education
· within the corporate environment where stress management is an integral part of employee motivation to enhance morale / productivity and reduce absenteeism / human suffering
· post-operative care for speedy elimination of anaesthetic and to reduce the recovery period
· emotional and psychological health care by providing a safe, non-judgmental, nurturing environment
· terminal illness patient comfort, to reduce suffering and / or isolation and family support
· chronic pain reduce medication and it's side effects and pain management through touch
· care of the disabled - maintains tissue health, slows degeneration/ contractures
· sports massage performance enhancing, injury prevention/ recovery
· post traumatic stress touch therapy transcends communication barriers and reduces long term effects of PTSD

REASON FOR REGISTRATION
The registration of Therapeutic Massage provides:
· public protection public freedom of choice in health care with ensured safety
· practitioner integrity - an enforced Code of Ethics and Scope of Practice ensures
* safe hygiene practices (prevention of disease spread)
* practise within Scope of Practice and Limitations
* enforced national training standards and continued professional development
· protection of the referring practitioner enables all health professionals to select and refer to a therapeutic massage practitioner with peace of mind
· the legal practice of therapeutic massage as a profession within the health structures and within the parameters of existing legislation which supercedes this Allied Health
Professions Bill
· a distinction between the therapeutic aspects of massage, superficial pamper massage and the sex workers who use the terms massage and massage parlour

CONCLUSION
Many other countries such as America, Canada, Australia and Germany have recognised the need to register and regulate Therapeutic Massage as a profession, whilst the United Kingdom is in the process of registering and regulating the profession.

We in South Africa have entrenched the philosophy of Primary Health Care as the most effective way to manage health in our country. Many South Africans have embraced Therapeutic Massage as part of their health management programme. Regulated, registered Therapeutic Massage Practitioners will ensure the public's choice of practitioner is informed whilst protecting the good name of our profession.

Appendix 4:
ADDRESS BY INTEGRATED HEALTH PROFESSIONS LIAISON COMMITTEE
TO THE PARLIAMENTARY PORTFOLIO COMMITTEE ON HEALTH - MONDAY 30TH OCTOBER 2000

Petitioning for statutory registration by the professional associations representing therapeutic aromatherapy, therapeutic massage and therapeutic reflexology commenced in 1988.

Application was made by these three modalities to the Interim Council. The vision of Council for the future identified the potential for delivery within the field of primary health care. Council, having satisfied itself that the professions all had an acceptable educational criteria, the support of their constituencies, and spoke with one voice at a national level, accepted the applications for the opening of statutory registers. The commonalities shared across these three professions in terms of education and therapeutic delivery led to the proposal from Council that a unified grouping under the guidance of the Council be formed, known as The Integrated Health Professions Liaison Committee.

Council has consistently demonstrated an open, transparent, democratic and consultative manner, and for this we would like to record our thanks, Stakeholder groupings have been consulted, and have participated in all decision making regarding the Bill. The modalities were party to the first submission of the Amendment Bill in November 1996 as well as the presentation of the Bill, and the three modalities, to the Parliamentary Portfolio Committee on Health in June 1998.

Council has included the three modalities in all the stakeholder workshops around the Bill and its Regulations. Council's commitment to democratic change ensured that all stakeholders were represented and able to participate in the process.

The final stakeholder workshop organised by Council was held on 24/25 June 2000 to discuss the distinction between "practitioner and therapist" and was attended by representatives from all ten stakeholder professions seeking registration under the Act. A unanimous decision was taken that all health workers to be registered under the Act, would be called "practitioners", regulated and controlled by their specific scope of practice. This clearly defines what treatments practitioners may perform and is accepted to be in accordance with their professional training. The Chief Director of the Department of Health, also a member of Council, attended several of these meetings and concurred with Council's decision on this section of the Act.

The fact the Department of Health decided to make unilateral changes to the Bill without consultation with Council or the stakeholders is cause for concern, particularly when taking into account the large amount of time and finance that have been invested in multiple collaborative meetings with Council.

The passage of the Bill has been particularly protracted, taking some 6 years to have reached this point. This Liaison Committee applauds the actions and dedication of the Hon. Minister of Health in seeking finalisation as soon as possible.

It is requested that very careful consideration be given to the proposed changes and the effects they will undoubtedly have on the new professions to be governed under the new legislation. These will be highlighted in the modality specific presentations. The Integrated Health Professions Liaison Committee supports Council in the proposal that one category of health worker, namely "practitioner", as contained in the amendments to the Act proposed by Council, should be adopted.

The delay in bringing the Amendment Bill to parliament for debate has disrupted the entire time-frame for the outgoing Council to organise the necessary election for the new Council. This could necessitate Council having to abandon the democratic, bottom-up process of electing members onto the professional boards and nominating from there to Council. The election process may instead have to be an election of Council members first, with a second election for professional board members.

The Liaison Committee believes it is necessary for the term of office of the Interim Council to be prolonged after the Act has been signed off to allow for current activities to be completed. This would ensure a democratic electoral process. Representatives elected to Council for therapeutic aromatherapy, therapeutic massage and therapeutic reflexology should automatically sit as members of our professional board to ensure continuity.

We would like to extend our thanks to Dr Nkomo and committee, Ms Lauretta Jacobs (NCOP Social Welfare Committee) and the legislature of provinces, who collectively ensured that each profession has representation on the new Council to be elected in 2001.

Ms Briony Esterhuysen will now represent therapeutic massage. She will be followed by Ms Sharon du Raan who will represent therapeutic reflexology and finally to Ms Sandi Nye who will represent therapeutic aromatherapy.

Thank you, Jessica Hart
Chairperson Integrated Health Professions Liaison Committee.

Appendix 5:
THE CHIROPRACTORS, HOMEOPATHS AND ALLIED HEALTH SERVICE PROFESSIONS COUNCIL OF SOUTH AFRICA

30 October 2000

PRESENTATION TO THE PARLIAMENTARY PORTFOLIO COMMITTEE ON HEALTH ON THE CHIROPRACTORS, HOMOEOPATHS AND ALLIED HEALTH SERVICE PROFESSIONS AMENDMENT BILL

Dr Abe Nkomo and honourable members of the Committee,

Our Interim Council thanks you for this opportunity to address you on our Amendment Bill.

As you well know, our Interim Council was inaugurated on 12 February 1996. We were the first of the Interim Councils to submit our Amendment Bill in November 1996. It was then lost to sight as far as our Council was concerned in spite of many requests to both the previous Minister and the Department of Health as to its progress. In 1998 we and our stakeholders were requested to present the contents of our Bill to the Portfolio Committee which we did successfully in June 1998. In spite of further requests to the Department of Health on the way forward, no response was received. Council then decided to initiate a further series of stakeholder workshops in 1999 to bring our Bill and Regulations from 1996 up to date.

When Minister Tshabalala-Msimang assumed office in 1999 we took our plight to her. She responded immediately and vigorously including apologising to our Council for the foot-dragging that had occurred not only with regard to our Amendment Bill but also for the inordinate delays by the MCC in implementing a registration system for Complementary Medicine. As a result the Department requested us to submit the new version of our Bill, which we did in October 1999.

The oversight of the Department of Health in not extending the lifespan of our Interim Council, although we had questioned this on a number of occasions, led to Parliament in August this year having to retrospectively extend the life of the Interim Council until 12 February 2001 and the threat that this would not be extended has subsequently put huge pressure on the Department of Health to ensure that our Bill is placed before Parliament this year. The result of this time pressure is that instead of the Interim Council having time to carry out the democratic and bottom up election structure of the ten professions electing their Professional Board members and then the Board members nominating a member per profession onto Council, this has had to be removed from the Bill. Boards will now only be created by the Minister later, which is most unfortunate.

In addition, serious unilateral changes have been made by Professor Gumbi's department which we believe change the whole character of the new Council and its ability to function effectively and harmoniously. We have objected most strongly to this action:

It went against the carefully and extensively workshopped structure unanimously agreed upon by all Council members and nine out of the ten professions.

Two of the main changes, to the composition of the Council and the introduction of a "practitioner/therapist" distinction, we believe are not democratic and equitable, and will re-open old wounds which the Interim Council has been at pains to heal.

It was done not only unilaterally but with the absolute minimum of communication and consultation, often leaving the Council in the dark as to what was occurring; a number of instances of this can be quoted.

Because of this unseemly haste and the lack of communication and consultation many serious errors were contained in the Bill as presented by the Department. Some we believe have still not been corrected. This would not have happened had the Department followed its own policy and consulted appropriately with the Council.

Council finds it extremely strange that the self-centred "protecting of own turf" proposals of certain members of the Homoeopathic Liaison Committee have been taken up verbatim in the major changes made by the Department. I say certain members because no full meeting of the Homoeopathic Liaison Committee was called to make the submission to the Department - certain crucial members and organisations were not informed of the document and therefore could not participate in the submission made in the name of the Liaison Committee. It would appear that certain members of the profession have had the ear of the Department over the years in a way that the Council has never succeeded in having. These same members have in a most immature, unprofessional and destructive way, threatened to discredit and "bring down" the Council at various times.

In direct contrast, Council would like to congratulate the professions of Chiropractic and Ayurveda, who have been most professional, democratic and considered the good of all in their submissions on the Bill. This applies indeed to all the nine other professions on our Council, where unanimity around the common good has prevailed.

Major Unresolved Issues

Composition of the Council
Council has worked hard with its stakeholders to create a structure where powers have been appropriately delegated downwards to the four Professional Boards and underlying them the ten Professional Liaison Committees, one for each profession. All matters concerning the day-to-day running of each profession will be handled by its Liaison Committee under its Professional Board. Hence every profession will have an appropriate measure of autonomy to conduct its own affairs without fear of domination or control by any other profession, and with appropriate checks and balances.

We believe, therefore, that each profession having one elected member on the new Council ensures that no profession may dominate any other; that each profession's concerns can be voiced in Council; and that this will free Council members to be Council members first and foremost and thus avoid sectarian strife.

The Homoeopathic and Department of Health proposal of weighted representation for certain professions and no representation for others will, Council believes, create animosity and power struggles on Council and lead to great dissatisfaction and discord.

The Homoeopathic statement that they should have more members because of their education and training is fallacious in that the Chiropractors who have the same training, do not accept this necessity. Both Ayurvedic doctors, who have a university 5 ½ year degree equivalent to an M.B.Ch.B., and Doctors of Chinese Medicine, who will have the same training, have at least equivalent education and training. Naturopaths, Osteopaths and Phytotherapists will all have four year degrees.

The other Homoeopathic point is that they have greater numbers. There will be many more Reflexologists and at least as many Aromatherapists and Acupuncturists. Should there be more Reflexologists than Homoeopths on Council following this argument?

However, Council believes that following the good work done by Ms Lauretta Jacobus and the NCOP Social Services Committee, who have accepted the proposal of the Gauteng legislature that the Bill should return to the original equitable and democratic Council proposal of one Council member per profession, that this Portfolio Committee will also vote on the democratic structure of one Council member per profession.

Practitioner and Therapist Distinction
Our Interim Council together with all the stakeholder groups debated this issue intensively during the course of many workshops held in formalising the Bill. It was decided that all health workers registered with the Council should be called "practitioners" and that their scope of practice as laid down in the Act and regulations would be the definition of what the practitioner may do and the distinction between them. This was decided on for a number of reasons:

Although there is nothing essentially inferior in the term "therapists" the distinction was initially introduced by the South African Homoeopathic Association in 1997 in such a way that it indicated a "better then"/"inferior to" connotation to the distinction. This rationale was only much later changed to one of "protecting the public" by the Homoeopathic Liaison Committee. This superior/inferior attitude has created a split in the ranks of our stakeholders which threatens to carry over into unnecessary animosities in the new Council, which we believe should be avoided.

This distinction was first unilaterally introduced into the Bill by Professor Gumbi in May of this year. On 5 June 2000 our Registrar wrote to Professor Gumbi requesting that the distinction not be made and outlining the many problems attached to the distinction from a very practical point of view due to the very diverse nature of our professions. She also requested that nothing be done until after our stakeholder workshop and Council meeting on 24/25 June. This letter, as usual was never acknowledged or replied to by Professor Gumbi and many of the problems relating to this distinction contained in the letter are, in fact, now facing us in the Bill. I might mention that at that final stakeholder workshop and Council meeting it was unanimously decided that only the word "practitioner" be used for our health workers.

These practical difficulties caused by the distinction and the definitions contained in the Bill have been put to our Council attorney. His legal opinion is that certain of the definitions presently in the Bill will lead to an untenable situation and that it is foreseen that the Council could become embroiled in Supreme Court cases. This may occur when practitioners registered on the various levels of registration are prevented by Council from performing acts which are not in their scopes of practice, but they are permitted to do so in terms of the Act, leading to requests to the courts to interpret our Act. For example:

In Section 1(q)(2)(a) (pg 4, line 14) "a practitioner may -
diagnose, treat or prevent, physical and mental disease, illness or deficiencies in humans;
prescribe or dispense medicine; and
provide or prescribe treatment for such disease, illness and deficiency in humans."

In Section 1(j) (pg 3, line 33) "a practitioner means a person registered as an acupuncturist, ayurveda practitioner, chiropractor, homoeopath, naturopath, osteopath or phytotherapist in terms of this Act."

This means that:
an acupuncturist who is registered on any level of acupuncture registration may in terms of the Bill do all of the above (for example, a physiotherapist or chiropractor registered as an acupuncturist may in terms of his/her scope of practice only do acupuncture, but will now be permitted to prescribe/dispense, which are not in their scope of practice;
an ayurveda practitioner who is registered on any level of ayurveda registration may in terms of the Bill do all of the above (for example, a remedial yoga therapy teacher or Panchakarma technician may in terms of his/her scope of practice not diagnose or prescribe/dispense, but will now be permitted to diagnose and prescribe/dispense);

It is not stated what categories of medicine a practitioner may prescribe/dispense, e.g. allopathic, homoeopathic, Chinese medicine, etc. It should be defined further (pg 4, line 17):
"(ii) prescribe or dispense the medicines contained in the scope of practice of the relevant profession."

In Section 1(q)(2)(c) (pg 4, line 25) it is stated: "(c) any reference in this Act, except in Section 16(3), (4), (5) and (6), to practitioner includes a therapist." This section deals at length with the relationship of this Act and Act 101 of 1965, The Medicines and Related Substances Control Act, and deals specifically with how a practitioner may compound or dispense medicines. As we have pointed out above, this means that, as presently defined two registered categories of acupuncturists and three registered categories in ayurvedic medicine may compound and dispense medicine even though they may not do so, and are not trained to do so, under their scope of practice.

There is a further anomaly in that aromatherapists, as therapists, may not prescribe aromatherapeutic substances, their medicines, to their clients. All aromatherapy substances will be defined as medicines under the new MCC registration system for complementary medicine.

In Section 1(q)(2)(b) (pg 4, line 20) "a therapist may -
treat or provide treatment for diagnosed disease, illness or deficiencies in humans; and
prevent such disease, illness or deficiencies in man."

This means (and it was so stated by Professor Gumbi in the Department's response to a question from the NCOP Social Welfare Committee) that a therapist may only see a patient who has been referred by a medical doctor or a practitioner. Therapists (the three professions who are provided for in the Bill and referred to as therapists) do see referred patients, but these form a negligible proportion of patients seen. Our legal advice is that limiting them to referrals will be infringing on an existing right as they have been seeing, for many years, patients who have not been referred. This will effectively be removing their source of income.

The term "diagnosis", we believe, has become something of a holy cow in this context. Any health worker, especially when not part of a greater therapeutic team, must "diagnose" their patient in terms of their particular profession and scope of practice. A clinical psychologist, a physiotherapist, an optometrist each diagnoses in terms of their education and training, otherwise they would not be able to commence any treatment. So too with a reflexologist or aromatherapist. This does not mean that they diagnose in the sense of a medical differential diagnosis, but that is only one, albeit important, meaning of the term.

Our Interim Council has on a number of occasions made it clear that it is following the principles of the Primary Health Care approach of non-discrimination, flattening of hierarchies and mutual respect amongst health workers who should operate as a team. We would like to point out that this is Department of Health policy. In its official policy document, "Restructuring the National Health System for Universal Primary Health Care" in section 4.3.5.1 "The PHC Team", it states: "In general the PHC team should function as an integrated unit, with each member playing a role in providing comprehensive and effective care. It is obvious that the model of interaction between PHC nurses and medical practitioners, and of the integrated PHC team, is neither a static nor a fixed one, and may vary in different practice settings."

For those members of this committee who are ANC members I would like to remind you of the same principles contained in the 1994 "Green Book", A National Health Plan for South Africa" (pg 7):
"All legislation, organisation and institutions related to health have to be reviewed with a view to attaining the following: emphasising that all health workers have an equally important role to play in the health system and ensuring that team work is a central component of the health system."

This egalitarian principle of the equality of all health workers has emerged also in the Bargaining Chamber. Dr Steven Hendricks, Chief Director of the Department, has assured us of this. Dr Hendricks is the Department's representative on our Council, has been at most of our stakeholder workshops and Council meetings in preparing this Bill and has concurred with the Council's unanimous decision. His input has apparently been ignored by the Department.

The Department has said that it is protecting the public by insisting on this distinction. The public, we believe, is not uninformed; people go to brain surgeons for brain surgery, clinical psychologists for psychotherapy, acupuncturists for acupuncture, reflexologists for reflexology. They do not go to "practitioners" or "therapists" and would be hard pressed to know the distinction.

The Department has said that it would be unfair for "therapists" to get the same share of the medical schemes pie as "practitioners". The Council has made enquiries into how payment is made by medical schemes to general practitioners and therapists. Our advice has been that this may be the same in some cases and differ in other cases depending on a range of factors concerning any procedure.

It is obvious that if the Act is to be passed with this distinction, unilaterally decided upon by the Department and imposed upon our Council, wholesale complex changes will be necessary to address the issues raised above. Our Council maintains for the above reasons that the simple and elegant description of one class of health worker, namely "practitioner" regulated and defined by their scope of practice, as contained in the Council's version of the Bill, should be retained. In addition to all the advantages noted above it makes it much easier for the future Council, especially in dealing with multi-tiered levels of registration in a number of the professions, to abide by the SAQA principle of different portable units of education and training with different entry and exit points. This, together with the PHC principle of allowing health workers to practice to the upper limits of their education and training, will help us to encourage all registered professionals to continuously expand their education, training and skills levels so they can better serve the public. This will be hampered and complicated by this unnecessary distinction imposed by the Department.

Lack of Clarity Concerning Lifespan of Interim Council
The Interim Council was originally told that the reason for the disruptive rush to get the Bill through Parliament was because the life of the Interim Council would not be extended past 12 February 2001 when the new Council must be inaugurated. We have since been told by a number of people that once the Amendment Act has been promulgated the Interim Council will remain in place until the new Council is elected, due to the first Amendment of the Bill earlier this year falling away. We have not been able to obtain clarity on this issue. If it is in fact the case then the Interim Council will have enough time to run elections for the new Council appropriately for all ten professions.

If it is not the case and the lifespan of the Interim Council ends before 12 February 2001, then it will be virtually impossible to run elections at all given that the Regulations public comment period and final publication will only be at the end of November at the earliest. If we presume that the Act will only be implementable by the middle of December this leaves very little time indeed for elections before 12 February, given it is holiday season. Council has not been able to obtain clarity on this issue from the Department of Health.

Council envisaged the Professional representatives of Council also being members of the Professional Board. With the election of Council members now preceding that of the Professional Boards it is necessary to ensure that the Council member is also a member of the Professional Board to ensure seamless communication and co-operation between Boards and Council.

As of Thursday 26 October, Council, and therefore it's professions, have not been able to access a revised copy of the Bill with the relevant changes which have already been made from the Department. Hence we tend to be working in the dark in terms of this submission, which we find to be unacceptable.

Finally, we would like to thank Minister Tshabalala-Msimang and her Special Advisor, Advocate Patricia Lambert, for their commitment to ensuring that our Act is finally processed. We would also like to thank Dr Abe Nkomo and Ms Lauretta Jacobus for their help in ensuring that democratic principles prevail. Also Dr Ayanda Ntsaluba for his intervention in responding to the difficult situation that the Council has found itself in with the Department. And finally, our thanks go to you the members of the Portfolio Committee in enabling our constituency to address you.

Michael O'Brien
(Chairperson)