Application for Western herbal medicine
to be regulated under the
Health Practitioners Competence Assurance Act 2003
May 2015
New Zealand Association of Medical Herbalists (1983) Inc.
2
Application for Western herbal medicine
to be regulated under the
Health Practitioners Competence Assurance Act 2003
1. Introduction
The New Zealand Association of Medical Herbalists (NZAMH) proposes that
Western herbal medicine (hereafter referred to as herbal medicine) be included as a
profession within the scope of the Health Practitioners Competence Assurance Act
2003 (HPCAA).
The NZAMH is the professional organisation that represents educated and trained
medical herbalists in New Zealand. Medical herbalists formulate and dispense
herbal medicines to clients. NZAMH is an independent self-governing body that sets
its own educational standards, has an established code of ethics, and issues annual
practising certificates to professional members.
The NZAMH strongly believes it is in the safety interests of both practitioners and
consumers of herbal medicine for the profession of herbal medicine to be statutorily
regulated. The profession was originally approved for inclusion under the HPCAA in
2007 by the then Minister of Health Pete Hodgson; however changes to regulation
criteria have necessitated this reapplication.
1.1 The Profession of Herbal Medicine
1.1.1 History
Herbal medicine is one of the oldest forms of medical treatment known. The
medicinal use of plants is common to all cultures and peoples of the world and
evidence of the use of plants as a source of medicine dates back to at least 60,000
BC1 . There is archaeological evidence of the utilisation of medicinal plants2 and
many ancient documents contain references to plant medicines including the
Chinese Nei Ching c. 2600 BC3 the Egyptian Ebers Papyrus c.1550 BC and the
Indian Atharva Veda c.1200 BC2.
Ongoing use of Western herbal medicines has been extensively documented and
includes works from authors such as Dioscorides, Avicenna, Gerard, Culpeper,
Withering, Grieve and others1. Such texts have provided a fundamental basis for
medical thought and consequently such knowledge has been included within both
contemporary orthodox and complementary medicine practices to varying degrees.
In recent times herbal medicines have provided the basis for many pharmaceutical
drugs in their traditional form or as isolated, active constituents4.
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Western herbal medicine has its roots in the indigenous practices of the British Isles,
North America and European and Graeco-Roman traditions. It is practised today in
New Zealand and in many other Western countries including the United Kingdom,
United States, Canada and Australia5.
Western herbal medicine in New Zealand dates back to the first European settlers
who brought seeds of European plants with them for medicines6. Many of these
plants grew and flourished in New Zealand and remedies were prepared using water
or alcohol based preparations. When there was no ready access to European herbs
early herbalists through observation of Maori remedies substituted with New Zealand
native plants. A tincture of koromiko was included in Martindale’s Extra
Pharmacopeia4 for many years. Many great proponents of herbal medicine were
evident in early New Zealand history including Mother Aubert7 and Dr James Neil8.
1.1.2 Western Herbal Medicine
Members of NZAMH practice Western herbal medicine and as such this document
seeks to define and discuss only this discipline. Throughout this document the terms
‘medical herbalism’ and ‘herbal medicine’ are used as synonyms for ‘Western herbal
medicine’. These terms are distinctive and distinguishable from other forms of
traditional medicine that employ herbs, namely rongoā Maori, traditional Chinese
medicine, Ayurvedic medicine and traditional Tibetan herbal medicine.
Western herbal medicine is a traditional system of medicine based on the
fundamental principle of ‘Vis medicatrix naturae’, that is the “body’s inherent ability to
establish, maintain and restore health”9 . Western herbal medicine utilises plants for
healing and is based on observation and experience passed down over thousands of
years. Contemporary herbal medicine practice includes knowledge in medical
sciences (anatomy, physiology, biochemistry, pathophysiology, and pharmacology),
use of clinical information (derived from case taking, physical and laboratory
examination) and research in phytomedicine and phytopharmacology, as well as the
sciences of botany and nutrition.
Western herbal medicine is founded in a traditional philosophy of holistic practice. It
is characterised by a patient centred approach, so that the patient rather than the
disease or an isolated part of the body is the focus of the practitioner’s treatment.
The practitioner works at all times to create an environment of trust, shared
responsibility and decision-making within the therapeutic relationship. On
presentation to a practitioner the background to a patient’s condition is investigated
through a thorough case history that takes account of family, personal health history
and lifestyle choices. Physical examination and laboratory tests may be undertaken.
Assessment of the patient is made based on understanding the significance of the
patient’s presenting signs and symptoms, their age, vitality or constitution and any
New Zealand Association of Medical Herbalists (1983) Inc.
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other contributing physical and mental and lifestyle factors such as diet. The choice
of therapeutic herbal substances in any prescription is based on thorough
assessment and is directed at the individual contributing factors or causes of the
complaint, not merely the presenting symptoms or disease. As a result,
prescriptions may vary substantially between patients presenting with an apparently
similar condition.
New Zealand and Australian herbal medicine practice are similar. A national survey
of medical herbalists in Australia found that the predominant prescription by Western
herbal practitioners was individualised herbal formulae consisting of highly
concentrated fluid extracts in ratios of 1:1 or 1:2, rather than use of single herbs.
Traditional preparations of herbals such as teas and powders are used as are pre-
formulated tablets/capsules made by herbal manufacturers although individualised
liquid herbal formulas are most commonly dispensed10.
Herbal treatment is commonly reinforced with appropriate advice on healthy lifestyle
choices, particularly nutrition, stress management and exercise. Many practitioners
incorporate a naturopathic approach within their practices, often, but not always,
supplementing concomitant holistic methods such as nutritional medicine, body
therapies such as massage, and other techniques aimed at improving the overall
health and well-being of the patient. A 2011 survey of NZ medical herbalists found
76% practised multiple modalities11. Some naturopaths and other health
professionals also practice medical herbalism.
Western herbal medicine works within a traditional philosophical and therapeutic
framework that is increasingly supported by scientific research. The fundamental
purpose of treatment is to facilitate resolution of symptomatology and improve
outcomes in ill patients, as well as to enhance wellness and prevent ill health. This is
achieved primarily through recommendation and dispensing of herbal medicine
treatments individualised according to the patient’s situation. Such treatments also
support and activate the innate healing processes of the body itself and strengthen
mind, body and spirit. In this way treatment aims to have long-term efficacy.
1.1.3 Distinguishing Features of Herbal Medicine
Herbal medicine is a clearly identifiable health profession. An obvious and
fundamental point of difference is the form of medicines used. Medical herbalists
rely on the use of herbs, generally the crude or whole plant or plant part, rather than
pure, isolated chemicals refined from plants.
A “herbal remedy” is defined under the Medicines Act 198112 as being:
“a medicine (not being or containing a prescription medicine, or a restricted
medicine, or a pharmacy-only medicine) consisting of:
New Zealand Association of Medical Herbalists (1983) Inc.
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a) any substance produced by subjecting a plant to drying, crushing, or any
other similar process, or
b) a mixture comprising two or more such substances only, or
c) a mixture comprising one or more such substances with water or ethyl
alcohol or any inert substance.”
The MedSafe Consultation Paper (2004), Regulation of Herbal Substances in a Joint
Australia New Zealand Therapeutic Products Agency 13 suggests a different
definition, namely:
A herbal substance for the purpose of inclusion in a Class 1 medicine means:
a) a traditional preparation of crude herbal material:
i) obtained by the methods traditionally used to prepare that herb for
therapeutic application, for example: drying, crushing, comminuting, cooking
(charring, baking or frying), steeping in wine and frying in vinegar, honey, oil
or other herbal substances, traditional fermentation, or other processes
identified and justified by the sponsor as being used traditionally to prepare
crude herbal material; or
ii) obtained by a traditional extraction method such as infusion, decoction,
maceroexpression, percolation, expression or distillation.
b) a non-traditional preparation of crude herbal material:
i) not obtained using a chemical transformation process; and
ii) justified as phytochemically equivalent to a preparation of a crude herbal
material currently included as an active ingredient in a product listed in the
ARTG.
A further significant difference between orthodox medicine and traditional medicine
systems, such as herbal medicine, is philosophical. In traditional systems health and
disease are seen as a continuum15. A person can move from a state of health to ill-
health and/or to some extent from ill-health to health. The healing process can be
supported, facilitated and augmented by identifying and removing obstacles to health
and recovery and by supporting and nurturing the body’s innate self healing capacity
and external environment. Western herbal medicine can also be used to support
health maintenance and disease prevention; it can also be used in palliative care to
assist in relief of some symptoms and to provide comfort. The traditional therapeutic
framework that underpins Western herbal medicine practice provides a sophisticated
approach to treatment.
Medical herbalists promote health and well-being. They provide primary health care
based on Western herbal medicine, biomedical science and evidence-based
medicine and traditional therapeutic philosophy. They utilise diagnostic and
assessment techniques for the identification of dysfunction, disorder and disease,
and treatment techniques for the maintenance and restoration of health and the
New Zealand Association of Medical Herbalists (1983) Inc.
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prevention of disease14. Medical herbalists encourage the inherent self-healing
processes and homeostatic balance within each individual patient15,16.
The contemporary Western herbal medicine practitioner treats an individual patient
in a holistic manner17. Treatment predominantly takes the form of a blended mixture
of concentrated herbal extracts (commonly called ‘tinctures’) such that the medicine
is specific to the person being treated18.
Most patients who visit medical herbalists seek care for chronic conditions, some
acute health conditions as well as for maintaining health19. Most chronic conditions
have been medically diagnosed and patients generally continue to consult a general
practitioner23. More than half of all breast cancer patients and up to 90% of people
with chronic benign conditions such as arthritis use complementary and alternative
medicine (CAM)20. Many patients are taking herbal and pharmaceutical medicines
concurrently21.
Medical herbalists are educated in orthodox medical treatment of conditions
alongside herbal medicine components of their training. Particular attention is paid
to potential herb-drug interactions. Due to this educational focus most herbal
practitioners support a blend of both scientific and traditional values, thereby placing
them in a unique position within the healthcare sector.
1.2 Professional Organisations
The New Zealand Association of Medical Herbalists is the major professional
organisation representing medical herbalists in New Zealand. The NZAMH was
formed by a group of practising herbalists in the early 1900s and first applied for
statutory registration in 191022. In 1983 the NZAMH became an incorporated society
and in 2000 amalgamated with The Aotearoa Herbalists Inc (TAHI) to form a unified
national body. NZAMH is an independent body which is self-governing, sets its own
educational standards and competencies (Appendix 2), has a Constitution (Appendix
1), Code of Ethics (Appendix 3), Scope of Practice (Appendix 4) and Complaints and
disciplinary process (Appendix 1), and issues its own annual practicing certificates.
There are four classes of membership of the NZAMH: Professional Members,
Student Members, Associates, and Fellows. There are currently 235 professional
members of the NZAMH, although there are many more practitioners who don’t
currently belong to a professional body who choose to prescribe and dispense herbal
medicines.
Most NZAMH medical herbalists are also qualified naturopaths, and could be eligible
to join a naturopathic association. However, not all naturopaths are qualified as
medical herbalists. Some medical herbalists are trained nurses or general
New Zealand Association of Medical Herbalists (1983) Inc.
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practitioners. Other professional organisations to which medical herbalists may
belong include:
Naturopaths of New Zealand
New Zealand Society of Naturopaths
Natural Health Practitioners of New Zealand
Nursing Council of New Zealand
New Zealand Medical Association
Pharmaceutical Society of New Zealand
A medical herbalist is a health practitioner who prescribes, formulates, manufactures
and dispenses herbal medicine as a therapeutic agent to a patient for the purpose of
treatment. Therefore, for the safety and protection of individuals any person carrying
out this act should be deemed a medical herbalist and as such should be considered
within this application for registration.
1.3 Public Perceptions of Medical Herbalists
Herbal medicine has a long and rich history; it is not only cost effective but also
provides holistic care and is efficacious. However it is not exclusive of other healing
paradigms. The general public extensively choose to consult medical herbalists to
enhance their health and well-being23.
The choice to utilise herbal medicine occurs for various reasons. Motivations may
include the inadequacies or limitations of orthodox treatment, concern over drug
safety and costs and/or the desire for a more holistic approach to illness24. Many
patients view herbal medicine as a critical aspect of self-care25. Social forces,
consumer critique, economic factors, increased research validation and a paradigm
shift with regard to view of illness are all involved in the increased use of
complementary and alternative medicine (CAM) modalities by the general
public26,27,28,29,30.
Patients in New Zealand increasingly consult CAM practitioners. The 2006/7 NZ
Health Survey found 1 in 5 adults reported that they had consulted a CAM
practitioner in the past 12 months23. Of those who saw a CAM practitioner 6.5%
consulted a herbalist23 (up from 1 in 4 visits to CAM providers and 1.8% for
herbalists in the 2002 survey31). The public consult medical herbalists for many and
varied health concerns although chronic, complex and serious illnesses tend to
predominate within the clinical setting. Musculoskeletal, digestive, respiratory, skin
and non-specific illnesses are relatively commonplace as are psychological or
psychiatric conditions and cancer28,32,33,34,35. The marked growth in use of herbal
medicine is mirrored worldwide36,37,38.
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A 2007 Australian survey39 on complementary medicine found 16.3% of Australians
had visited a Western herbal medicine practitioner in the past 12 months and 10.7%
a naturopathic practitioner (who also prescribe herbal medicine) compared with
16.1% who had visited a chiropractor, 4.6% visited an osteopath and 9.2% had
visited an acupuncturist. Currently chiropractors and osteopaths are statutorily
regulated professions in New Zealand.
A UK postal questionnaire undertaken by General practitioners of 400 consecutive
patients attending six Scottish medical practices found 36% of patients reported
concurrent use of complementary medicine remedies with 18% combining CAM
therapies40.
1.4 Primary Care Practice
Medical herbalists are used by the public as primary health care providers. It is
crucial to the health of the public that practitioners provide safe care. They must
have knowledge of, and the ability to respond to a medical emergency and know
when it is appropriate to refer a patient to a general practitioner or other healthcare
specialist. Medical herbalists fulfil this role. They are trained in comprehensive case
history taking, are competent in the clinical assessment of vital signs and symptoms,
understand pathology and diagnostic tests and have the ability to assess patient
health. A postal survey of 649 herbalists in Australia found that 99% indicated that
they referred patients to other health care professionals with 93% reporting that they
regularly referred patients to medical practitioners41.
As can be seen from the Practice Analysis (Appendix 5), patients may present with
complex health conditions, and could be taking several medications prescribed by
their general practitioner or medical/surgical specialist. Patients may also be using
self-prescribed nutritional supplements and herbs. Some of these supplements may
be either inappropriate and have a relatively low evidence basis for usefulness in
their situation, or provide an inappropriate dosage, or the product may be of
questionable quality. Medical herbalists are the experts in advising on such products
and are required to take details of all medications used by patients. They also have
up-to-date knowledge of phytopharmacology and potentially dangerous as well as
advantageous herb-drug or herb-nutrient interactions.
In current medical practice secondary referrals are also made to naturopaths and
medical herbalists by mainstream health care practitioners. A 2006 survey of NZ
GPs showed that the rate of referral from GPs to naturopaths was 12.3% and the
rate of referral from GPs to herbal medicine practitioners was 9.7%42.
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HPCAA PRIMARY CRITERIA
2. Criterion A
Does the profession deliver a health service as defined by the Act?
Herbal medicine is a health service as defined by the Act: “a service provided for the
purpose of assessing, improving, protecting, or managing the physical or mental
health of individuals or groups of individuals”.
Herbal medicine is a clearly identifiable health profession providing primary health
care. Medical herbalists rely on the use of plant medicines, derived predominantly
from the whole crude plant rather than specific chemicals refined from plant material.
Patients consult medical herbalists on a wide range of health concerns within the
clinical setting, predominantly chronic and complex illnesses. The 2006/07 New
Zealand Health Survey found 25.8% of participants had visited a
naturopath/homoeopath and 6.5% had visited a herbalist at least once in the past 12
months23. Naturopaths and herbalists commonly prescribe herbal medicines.
2.1 International Recognition
Herbal medicine is recognised as a valid healthcare modality in many countries
around the world38. Furthermore, many studies suggest the level of usage of herbal
medicine by consumers in many countries is increasing markedly.
In Germany 70% of GPs favour herbal medicine use over pharmaceuticals43. Fifty
two countries including Argentina, Australia, Canada, France and the United States
of America have taken steps to regulate herbal medicines37,44. The World Health
Organisation (WHO) has acknowledged that over three quarters of the world’s
population rely on herbal medicine for their primary health care and they have
strongly encouraged regulation of these medicines to “protect and promote public
health”. The World Health Assembly (1991) resolutions resulted in the WHO
developing a Traditional Medicine (including Herbal and Complementary Medicine)
[T&CM] programme44 and then later a 10-year strategy for the period of 2014 to
202345 to promote its cohesive integration into national health care in all member
states. Within several Western countries there are now moves towards statutory
regulation of Western herbal medicine practitioners.
2.1.1 United Kingdom
Under long standing United Kingdom regulations, anyone could be a herbalist with
little or no training. Therefore new proposals were sought to limit the use of legally
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protected titles to those practitioners on a statutory register. Such legally protected
titles would enable the public to determine who is a properly qualified practitioner
and enable practitioners contravening agreed codes of ethics or practice to be struck
off such a register, thereby losing use of the protected title.
In 2000 the ‘House of Lords’ Select Committee on Science and Technology’ report
on CAM was published46. This report recognised the growing use of complementary
medicine, including herbal medicine, and the risk posed by CAM practitioners with
inadequate training as well as from the supply of unregulated herbal medicines. It
also stated that herbal medicine had a well-organised professional base and that
research into its effectiveness had begun and was “likely to prove of benefit”.
The Government responded in 2001 to the Select Committee Report recommending
that herbal medicine practitioners should seek statutory regulation under the Health
Act 1999 to benefit both practitioners and patients47. This was then followed in 2002
by the Department of Health establishing an independent committee, the Herbal
Medicine Regulatory Working Group (HMRWG) to consider how statutory regulation
of herbal practitioners and their medicines could best be achieved.
The HMRWG rejected an independent Herbal Council as an option for the
registration of herbal practitioners. The HMRWG observed that while this might be
perceived as giving herbal medicine a clear identity, the need to work across
professional boundaries to deliver integrated healthcare was better achieved through
shared arrangements among CAM professions. In addition, the HMRWG noted, the
cost of a single Herbal Council was likely to be prohibitive to practitioners,
particularly for those practicing both acupuncture and herbal medicine. For these
reasons the HMRWG favoured the adoption of a shared council (to be called the
CAM Council), to include at this stage, both herbal medicine and acupuncture, with
the possibility of including other CAM disciplines at a later stage.
The consultation document proposed a number of significant changes to that part of
the 1968 Medicines Act that regulated one-to-one prescription of herbal medicines.
In particular, it proposed that the use of some herbal medicines should be limited to
herbal practitioners on the new Statutory Register. It also proposed that herbalists on
the Statutory Register have access to specific formulations manufactured to their
specification without the need for a full medicines license. This exemption from
licensing would also be granted for individual formulations made up by the herbalists
on their own premises. The consultation document also suggested that regulated
herbalists should use herbs on a broad list agreed upon by their regulating body in
consultation with the profession.
In March 2004, the U.K. Medicines and Healthcare Products Regulatory Agency
published a consultation document proposing significant changes to the U.K.
Medicines law in relation to the one-to-one prescription of herbal medicines48.
Consultation with interested organisations (including from both CAM and orthodox
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medicine) and the public on the statutory regulation of both herbal medicine and
acupuncture proceeded in 2005. A positive response was received from 98.5% of
respondents.
Political delays meant that a steering group for regulation did not begin until 2006
and they reported in 2008 to the Minister of Health. Their main recommendations
were49:
statutory regulation proceed without delay for the public safety and to also
allow the public to make an informed choice
that supplies of herbal medicine by third parties should not change due to
regulation
that in accordance with section 12(1) of the 1968 Medicines Act only statutory
registered practitioners should be allowed to use herbal medicines without
marketing authorisation for individual patients
that regulation should be carried out by the Health Professions Council
The group also approved standards of education and ethics as provided to them and
encouraged research to verify the practice of herbal medicine.
In 2011 the UK government announced that they intended to statutorily regulate
medical herbalists and tasked the European Herbal and Traditional Medicine
Practitioners Association (EHTPA), an umbrella body of professional herbal medicine
associations from eastern and western traditions, with the interim responsibility for
accreditation of courses of herbal medicine. The intention was that in due course the
Health Professions Council would assume the task of both accreditation and
registration of practitioners.
The right of herbalists to prescribe unlicensed herbal medicines following one-to-one
consultations, granted in 1968 and called “herbalists’ exemption” was incorporated
into the 2012 Human Medicines Regulations.
Despite the above and that the statutory regulation of herbalists was supported by
two select committees50 this has not occurred possibly due to complexities within the
European Union. Instead there has been a focus on self-regulation and development
of national accredited registers for various practitioners. Each accredited register
sets and oversees education standards, continuing professional education and
complaints51.
Such regulation may be appropriate for low risk complementary therapies as
recommended in the NZ Ministerial Advisory Committee on Complementary and
Alternative Health (MACCAH) in 200452. However this approach does not address
all the safety concerns of high risk modalities (such as osteopathy, chiropractics,
herbal medicine, naturopathy, acupuncture, traditional Chinese medicine, Ayurvedic
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medicine) that MACCAH recommended are regulated by the Health Practitioners
Competence Assurance Act 2003.
2.1.2 Ireland
Ireland had decided on the statutory regulation of complementary and alternative
health practitioners; however as in the UK the progression of herbalists to statutory
regulation has been stalled by moves from within the European Union. A survey of a
number of European countries by O’Sullivan described how these countries were
moving ‘very cautiously’ towards regulation53.
In May 2003 a working group was established by the Health Minister to look into and
recommend steps towards statutory regulation of complementary therapists54.
Their report published in December 2005 again cited that statutory regulation would
satisfy the need for the public to be able to make an informed choice. They
particularly recommended that herbalists be considered for statutory regulation
because of the issue of public safety surrounding the use of herbal medicines and
also the fact that herbalists are more likely to be a first port of call in primary health
care compared to other complementary therapies. They also suggested that
herbalists, due to their extensive training, be given continued access to herbal
medicines for making complex medicines on an individualised basis.
2.1.3 Australia
The Expert Committee on Complementary Medicines in the Health System
commissioned by the Federal Government has made significant recommendations
regarding the regulation of Western herbal medicine practitioners including that state
governments should move quickly to statutory regulation where appropriate55. As a
consequence both the New South Wales and Western Australia governments asked
for submissions on the registration of traditional Chinese medicine practitioners
although the expert committee did recommend that herbalists and naturopaths also
be regulated.
The National Herbalists Association of Australia (NHAA), the Australian equivalent of
NZAMH, was one of five CAM modality organisations to be granted $500 000 by the
Department of Health and Aged Care in 2002. This money was granted to assist in
working towards national registration systems and the retention of GST-free status.
The New South Wales Chief Health Officer released a discussion paper in October
2002 offering various models for regulation of CAM practitioners56.
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In 2003 the Department of Human Services of the State of Victoria funded a major
review of the risks, benefits and regulation of naturopathic and Western herbal
medicine57.
In 2006 a single national register of all professional health practitioners was
proposed58 and it lead to the establishment of the Australian Health Practitioner
Regulation Authority (AHPRA), whose remit is to protect the public and set standards
with which all registered practitioners must comply. AHPRA’s operation is governed
by the Health Practitioner Regulation National Law in force throughout Australia
since 1 July 2010. The AHPRA initially covered 14 health professions that were
already regulated such as medical practitioners and pharmacists. In 2011 partially
registered professions were added to the register such as traditional Chinese
medicine practitioners. A third round was due to review the addition of unregulated
professions including Western medical herbalists but this has not yet transpired,
although it is still expected to happen in the next few years59. In the meantime the
independent Australian Register of Naturopaths and Herbalists (ARONAH) has been
established to protect the public. It functions according to the same criteria as
AHPRA and should enable the transfer of these professions to statutory regulation in
due course. This register became operational in July 201360.
Support for statutory registration of complementary medicine in Australia is
widespread and includes the Australian Medical Association61,62, the general
public63, some government reports63,64, and the professional organisation, the
National Herbalists Association of Australia58.
2.1.4 United States of America
Financial support by way of reimbursement for the use of herbal medicine in the
United States is determined by each state’s Health Maintenance Organisation
(HMO) and is at this stage limited65.
Herbalists are able to practice without a licence or under exemption laws. The United
States of America White House Commission on Complementary and Alternative
Medicine report recommended that the effects of different regulatory guidelines be
investigated in terms of consumer choice and consumer protection66. The
Commission’s extensive report recommended that the:
“States should consider whether a regulatory infrastructure for CAM practitioners is
necessary to promote quality of care and patient safety and to ensure practitioners'
accountability to the public. The Federal government should offer assistance to
states and professional organisations in developing and evaluating guidelines for
practitioner accountability and competence, including regulation of practice and
periodic review and assessment of the effects of regulations on consumer protection.
New Zealand Association of Medical Herbalists (1983) Inc.
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When appropriate, states should implement provisions for licensure, registration, and
exemption that are consistent with a practitioner's education, training, and scope of
practice.
Nationally recognised accrediting bodies should evaluate how health care
organisations are using CAM practices and develop strategies for the safe and
appropriate use of qualified CAM practitioners. In partnership with other public and
private organisations, they should evaluate the present use of CAM practitioners in
health care delivery settings and develop strategies for their appropriate use in ways
that will benefit the public. Current standards and guidelines should be reviewed to
ensure safe use of CAM practices and products in health care delivery
organisations.”
Numerous authors have investigated CAM modalities within the USA67,68,69,70, 71
including examination of regulatory policy72,73,74,75.
Consumer use of herbal medicine in the USA is high; a reported 20% of the adult
population had used herbal medicine according to a National Health Interview
Survey in 200276. In fact of all complementary therapies used in the USA, herbal
medicine is the most commonly used77. The only regulation at present is through the
American Herbalists Guild which is a peer-review self regulated organisation that
specifies training standards and maintains a register of herbalists who meet these
standards. Practitioners of herbal medicine are also found amongst physicians,
osteopaths and naturopaths78.
2.1.5 Canada
Although herbal medicine is widely used in Canada it is unregulated65. A survey by
the Fraser Institute in 1999 estimated herbal medicine use at 17% with insurance
payments covering less than 10% of cost of herbal medicine therapy79. Canadian
herbalists are currently self-regulated77.
The Health and Human Resource Strategies Division has examined CAM in the
Canadian health system since 1998. This division has produced the document
Perspectives on Complementary and Alternative Health Care: a collection of papers
prepared for Health Canada which discusses the regulation of CAM practitioners,
including herbalists80.
Health Canada’s Advisory Group on CAM have released a paper that discussed in
some depth the ethical issues surrounding regulation of CAM modalities and how
these impact on regulatory processes81.
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Health regulation review, public support and protection have been identified as
drivers for regulation of complementary and alternative practitioners in the Canadian
context82,83. Better integration of CAM with conventional medicine and legitimacy of
these professions would be achieved by regulation and even though the health
regulators in the various provinces have shown an interest in CAM there has been
very slow progress in responding to the demands of CAM representatives for
regulation84.
As of 2005 four of the Canadian states had regulated naturopaths, who are providers
of herbal medicine65. However the professional associations of medical herbalists
are not required by law to be self regulated but have taken on the responsibility of
monitoring standards of training and practice65.
3. Criterion B
Do the health services concerned pose a risk of harm to the health and safety
of the public?
The risks of herbal medicine are sufficient to warrant regulation and are comparable
to those of regulated professions. Of 148 articles published about herbal or
complementary and alternative medicine in the Medical Journal of Australia
(Australia’s primary medical journal) from 1966 to 2008, 42% of articles referred to
adverse reactions or events and 30% referred to the risk of the
herbal/complementary and alternative medicine therapy or practitioner85.
The Western herbal medicine profession was originally approved for inclusion under
the HPCAA (2003) in 2007 by the then Minister of Health Pete Hodgson who
recognised there to be enough risk to the public to warrant regulation.
Herbal medicine practice poses a risk of harm to the health and safety of the public
through the prescription of herbal medicine itself as well as poor decision making
and actions of the practitioner. In addition, because herbal medicine practice sits
outside statutory regulation potentially risky referral practices are taking place. The
patient is the go between the medical practitioner and CAM practitioner, with
referrals done through word-of-mouth86. Such practice raises safety concerns and is
unsatisfactory in modern health care.
3.1 Clinical interventions with the potential for physical and mental harm
Physical risks specifically associated with the use of herbal medicines include:
New Zealand Association of Medical Herbalists (1983) Inc.
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risks associated with the potential toxicity of some herbal medicines, including
inappropriate use and overdose;
potential interactions between herbal medicines;
potential adverse interactions between herbal medicines and prescribed or
OTC pharmaceutical drugs;
potential for hypersensitivity or allergic reactions including anaphylaxis;
potential for inappropriate use due to physiological factors e.g. pregnancy;
risks associated with misidentification or substitution of plant species;
risks associated with use of incorrect plant part;
risks associated with poor product quality or product adulteration;
risks associated with self-prescription of inappropriate herbal medicine.
3.2 Clinical decision-making and its potential impacts for harm
Risks associated with poor clinical judgement of the herbal medicine practitioner
include:
misdiagnosis and poor patient management;
inappropriate, unnecessary or ineffective treatment;
aggravation or progression of a condition due to inappropriate treatment;
failure to refer to another practitioner when warranted;
inappropriate removal of allopathic medication;
failure to explain instructions, precautions, and contra-indications;
failure to identify adverse reactions and take appropriate remedial action;
practitioner impairment, professional misconduct and poor ethical decision-
making
unethical or misleading advertising
inappropriate internet prescribing
3.3 Establishing risk of harm
A risk assessment of the practice of herbal medicine needs to consider not only the
documented incidence of harm, but also the potential for harm inherent in both the
use of plants as therapeutic tools, and in the actions of practitioners inappropriately
educated and trained, and operating outside an apposite professional body. In New
Zealand the NZAMH are the only professional body specifically representing medical
herbalists, however there are an undetermined number of naturopaths, not
registered with the association, who also use herbal medicine as their primary tool of
trade.
3.3.1 The nature, frequency, severity and likelihood of harm to the consumer
New Zealand Association of Medical Herbalists (1983) Inc.
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Few adverse physical reactions to herbal medicines are reported. Whilst this
possibly reflects the reduced risks of taking herbal medicines in comparison to
pharmaceutical medicines, other factors may include the possibility that adverse
reactions to complementary therapies are not well recognised or that there exists a
lack of awareness by practitioners and the public that adverse reactions can be
reported to the Centre for Adverse Reactions Monitoring (CARM)87. Commenting on
a similar analysis of the situation in Australia, Wardle suggested that fear of having
therapeutic tools taken away and non-disclosure of use of complementary medicines
may also play a part in under-reporting89.
As part of the workforce survey in 2004 of naturopaths and herbal medicine
practitioners in Australia frequency of adverse events were reported14. In Australia
herbal medicine is an essential modality in both herbalist and naturopathic training
although in New Zealand a naturopath may qualify with little or no herbal medicine
education and yet practice herbal medicine.
The workforce survey analysed responses from 489 practitioners who identified
herbalism as one of their practice descriptors (62% of the total sample), and 604
practitioners who identified naturopathy as one of their practice descriptors (76% of
the total sample). The survey participants were asked questions related to adverse
events. Practitioners were asked to indicate the number of times each adverse event
had occurred during their practice lifetimes. The most common adverse events
reported in herbal medicine were mild gastrointestinal symptoms (n = 1952),
headaches (n = 870), menstrual irregularities (n = 322), significant skin reactions (n =
307) and severe gastrointestinal symptoms (n = 296).
Serious adverse events reported in herbal medicine included CNS effects (n = 17),
hepatotoxicity (n = 9) and significant respiratory disturbance (n = 9). Eighty-two
adverse event cases were significant enough to refer to a medical practitioner or
hospital, although no deaths were reported.
The most common adverse events reported in regard to use of nutritional medicines
were mild gastrointestinal symptoms (n = 1023), headache (n = 434) and severe
gastrointestinal symptoms (n = 150). Serious adverse events reported included CNS
effects (n = 1), significant respiratory disturbance (n = 8), renal toxicity (n = 1) and
one death. Fourteen adverse event cases were significant enough to refer to medical
practitioners or hospital.
Data suggested that practitioners will experience 2.3 adverse events for every 1000
consultations (excluding mild gastrointestinal events). The researchers estimated
that 1.9 million consultations were conducted annually in Australia and they
suggested that there was a need to re-examine whether statutory regulation of
New Zealand Association of Medical Herbalists (1983) Inc.
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herbal medicine practitioners was required to better protect the public14.
In June 2003, the Victorian Department of Human Services, Australia contracted with
the School of Public Health, La Trobe University, to coordinate research on the
benefits, risks, and regulatory requirements for the professions of naturopathy and
Western herbal medicine57. The aim of the project was to investigate and understand
the practice of naturopathy and Western herbal medicine in Australia, and to make
recommendations on the need, if any, for measures to protect the public.
The methodology adopted in the study included: (i) literature reviews (including
systematic reviews); (ii) reviews of documents and reports; (iii) reviews of
administrative data; and (iv) primary data collections through surveys and focus
groups.
This research examined the effectiveness of herbal and nutritional medicine and
showed a substantial increase in the publications devoted to examining efficacy of
these CAM therapies with 152,925 entries found between 1966 and 2003. There was
also evidence to support the use of herbal and nutritional medicine in the treatment
of all body systems.
Risks associated with CAM use were assessed to be due overall to one of two major
areas.
a) the clinical judgement of the practitioner including:
incorrect prescribing
lack of knowledge of contra-indications
inappropriate dosage
inappropriate duration of treatment
inadequate skills
failure to recognise the need to refer to other practitioners
b) inappropriate intake of herbal or nutritional medicines causing problems due to:
overdosing
interaction with pharmaceutical drugs
allergic reactions
idiosyncratic reactions
The researchers suggested that reporting of adverse reactions was likely to be
understated because of the method used to collect such data, but that there was
nonetheless a wide range of adverse events reported in the literature for both herbal
and nutritional medicine.
New Zealand Association of Medical Herbalists (1983) Inc.
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The research team’s review of coroners’ records, reports from professional
associations, data from the health services commissioner and media reports showed
that:
• there had been some deaths related to inappropriate clinical advice
• there were some common concerns about interaction between orthodox medicines
and herbal medicines.
General practitioners also reported high numbers of perceived adverse events,
estimated to be one for every 125 consultations. In order, chiropractic, herbal
medicine and naturopathy were responsible for the highest number of adverse
events of the CAM modalities surveyed. General practitioners attributed adverse
events to a number of causes, including ineffective treatment, wrong diagnosis,
allergic reaction, drug interaction, and profit-motive over-riding clinical judgement.
The study also indicated that 34% of those taking herbal medicine were taking
pharmaceuticals concurrently which in the light of increasing reports of such
interactions between the two was a cause for concern.
Data from the surveys and focus groups suggested that many people who used
complementary health care also used conventional medical services. There was also
a smaller number who did not wish to use conventional medicine unless necessary.
Patients have had to navigate two systems and this process has difficulties and
potential dangers when consumers do not feel they can inform all practitioners of
their use of particular services, or when they do not choose to inform all practitioners.
Poor communication between general practitioners and Western herbal medicine
practitioners was particularly concerning as a majority of patients were seeking care
for chronic conditions and were, therefore, frequent and routine users of both types
of medical care.
In summary, the evidence from this report suggested that the risks of Western herbal
medicine arise from both the primary care practice context as well as ‘tools of the
trade’.
More recently, the NHAA submission as part of the Review of the Australian
Government rebate on private health insurance for natural therapies, identified 1462
articles published on the PubMed database on the safety/toxicology of herbal
medicine and over half of these were published in the last 5 years (Table 1)89.
New Zealand Association of Medical Herbalists (1983) Inc.
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Table 1: The increasing publication of herbal medicine research (reprinted by
kind permission of NHAA89) Dates for
article publication
Any article n, (% of total)
Primary research n, (% of total)
RCT n, (% of total)
Systematic review n, (% of total)
Safety/ toxicology
n, (% of total)
Cost effectiveness
n, (% of total)
No date restriction
19766 2462 1262 728 1462 112
2007-2012 9856 (50%)
1118 (45%)
627 (50%)
438 (60%)
783 (54%)
67 (61%)
2001-2006 5975 (30%)
814 (33%)
427 (34%)
247 34%
418 (29%)
32 (28%)
1995-2000 2261 (12%)
357 (15%)
163 (13%)
43 (6%)
165 (11%)
8 (7%)
Pre 1995 1674 (8%)
173 (7%)
45 (3%)
0 (0%)
96 (6%)
5 (4%)
Similarly, an increasing amount of articles have recently been published concerning
the safety and toxicological status of nutritional/dietary supplements also prescribed
by many medical herbalists (Table 2).
Table 2. The increasing publication of nutritional/dietary supplement
research (reprinted by kind permission of NHAA89)
Dates
for
article
publicat
ions
Any
article
n, (% of
total)
Primary
research
n, (% of total)
RCT
n, (% of total)
Systematic
review
n, (% of total)
Safety/
toxicology
n, (% of
total)
Cost
effectiveness
n, (% of total)
No date
restricti
on
27633 8915 5632 1674 413 189
2007-
2012 13886
(50%)
4467
(50%)
3038
(54%)
1067
(64%)
207
(50%)
85
(45%)
2001-
2006 9485
(34%)
3138
(35%)
1949
(35%)
491
(30%)
164
(40%)
79
(42%)
New Zealand Association of Medical Herbalists (1983) Inc.
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1995-
2000 3082
(11%)
996
(11%)
557
(10%)
116
(7%)
32
(8%)
18
(9%)
Pre
1995 1180
(5%)
314
(4%)
88
(1%)
0
(0%)
10
(2%)
7
(4%)
Beyond the direct effects of herbal medicine and nutritional medicine products,
safety issues may also be associated with communication of this use with
conventional care providers”85,88,89
Research has highlighted that there is a public preference to use herbal medicine
compared to over-the-counter (OTC) or prescribed conventional medicine; the public
are more inclined to use a herbal medicine with a conventional medicine than with an
OTC and they believe that because herbal medicine is natural it is safer and can
therefore be used with less caution90.
This belief is clearly erroneous as herbal medicine combined with some medications
has the potential to either increase or decrease availability or utilisation of medicines.
In a 2011 survey of 305 university students, only 25% of herb users disclosed herb
use to a healthcare provider, and 13% had simultaneously used herbs (although
mostly self prescribed) and prescription medication in the last year91. Herb users who
inter-mixed herbs with prescription medications had higher depression and anxiety
scores.
New Zealand data reported by MedSafe for 2011 indicated adverse reports for CAM
were 0.4% of all those reported for that year, and were consistent with reports from
previous years. Of those for CAM 10% were considered to be of a serious nature87.
Based on the above information encouraging open referrals between the medical
profession and medical herbalists would not only increase the transparency of
patients’ use of both conventional and herbal medicine but it would make this
practice much safer.
Correspondence from the New Zealand Health and Disability Commissioner to the
Ministry of Health (2007) supported the regulation of herbal medicine under the
Health Practitioners Competence Assurance Act 2003 (HPCAA) as the HPCAA aims
to protect the health and safety of members of the public by providing mechanisms
to ensure that health practitioners are competent and fit to practice their
professions92 and in so doing encourages an open system of referral between health
providers.
New Zealand Association of Medical Herbalists (1983) Inc.
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Specific Risks
The principal physical risks specifically associated with the use of herbal medicines
include:
risks associated with the potential toxicity of some herbal medicines, including
inappropriate use and overdose;
potential interactions between herbal medicines and pharmaceutical drugs;
potential for hypersensitivity or allergic reactions;
risks associated with use of a herb when contraindicated e.g. during
pregnancy;
risks associated with misidentification or substitution of plant species;
risks associated with use of incorrect plant part;
risks associated with poor product quality, including adulteration;
risks associated with incorrect method of administration and self-prescription.
Adverse reactions due to inappropriate prescribing are rare for qualified practitioners
with good clinical practice. In the interest of public safety and confidence it is
essential that those medicinal herbs considered a risk to the public are prescribed,
administered, and monitored by suitably qualified practitioners of herbal medicine.
Potential Toxicity
Not all plants are safe to use as medicine. Restrictions vary throughout the world.
United Kingdom
Some plants have the potential to poison and are not permitted for use in herbal
therapy (e.g. Aconitum spp, Digitalis spp). Others, whilst potentially toxic, have their
availability restricted to suitably qualified herbal practitioners. This is the case for
herbs like Chelidonium majus (greater celandine), Ephedra sinica (ma huang),
Lobelia inflata (lobelia) and the tropane alkaloid-containing herbs like Datura
stramonium (thornapple)93,94.
Ireland and the European Union
Between 2004 and 2011 herbal medicines were able to be registered for use without
the need for community pharmaceutical marketing authorisation, by a simple
method, if they could demonstrate “well established use”. This meant that they had
detailed references in the scientific literature of efficacious and safe use spanning at
least 30 years and including 15 years of use in the European Union.
In 2007, the Committee for Herbal Medicinal Products (HMPC) was tasked by the
Herbal Directive, with scientifically assessing these traditional herbal substances,
preparations and combinations. They created monographs for registered herbal
New Zealand Association of Medical Herbalists (1983) Inc.
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medicines and their list included all those the EU considered safe with normal use.
The registered list is deemed to be acceptable in all member states95. Those herbal
medicines that were considered to have the potential for public harm are covered by
pharmaceutical legislation. This approach has been taken to allow public access to
herbal medicines without recourse to a qualified medical practitioner96.
In Ireland herbal practitioners are still allowed to prescribe herbal medicines under
Common Law of 1154 in England, Wales, Northern Ireland and Ireland.
Australia
In Australia restricted herbs may be prescribed by registered general practitioners
who not only have no knowledge of, or training in their use, but also have no interest
in using them88. In contrast trained herbal medicine practitioners are properly placed
to assess the potential for adverse reactions from a given herbal medicine based on
knowledge of the individual’s health status. The Expert Committee on
Complementary Medicine has suggested that practitioners with the relevant
education should be given access to some restricted herbs and that this may be
done by using a Schedule under the Standard for the Uniform Scheduling of Drugs
and Poisons and implemented nationally97. The list of scheduled herbs includes
those which are illegal to use such as Aconitum napellus and Schedules 2-4 which
contain restricted herbs for use by registered practitioners only. These herbs are
similar to those that have restricted-use status in the UK, but also include
Symphytum spp (comfrey), Tussilago farfara (coltsfoot) and Acorus calamus (sweet
flag)5, which can be used freely in the UK.
United States of America
Herbal medicine has been classified in the USA according to the Dietary Supplement
Health and Education Act of 1994, as a dietary supplement and as long as no
medicinal claims are made for it, or generic dosing given on the label, they are
accepted as safe until proof exists to the contrary (WHO Regulatory Situation)43,98.
This lack of ability to fully label products leaves the consumer with no guidance and
the American Herbalists Guild believes recognised herbal practitioners are therefore
even more necessary for the safe use of these medicines. Any medicinal claims
made for a herb, unless it is scientifically endorsed as effective and safe in support of
such claims, means it becomes classified as a drug and must fulfil the legal
requirements of premarket review and FDA approval99.
Some herbs e.g. Ephedra sinica cannot be sold in all states.
Canada
Herbal medicines are regulated as drugs in Canada and are subject to the labelling
requirements of the Food and Drugs Act and Regulations. Herbal medicines used
New Zealand Association of Medical Herbalists (1983) Inc.
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for minor self-limiting conditions receive a Drug Identification Number by way of
registration if there is sufficient pharmacologic and bibliographic evidence and
verified traditional use. Standardised drug monographs can also be used to support
the registration of herbal medicines.
At present only registered medical practitioners can prescribe restricted herbal
medicines although the naturopathic professionals are also pushing for prescribing
rights100.
New Zealand
Herbal medicines are currently treated as dietary supplements and subject to the law
under the Dietary Supplements Regulations 1985. This situation is considered
obsolete and “quite restrictive”101. It does not allow claims to be made for natural
health products even where evidence for therapeutic efficacy exists. It is seen as
necessary for public safety and assurance that some form of regulation be instituted.
However under the Medicines Act 1981, medical herbalists can prescribe herbal
medicines to an individual who has requested such a medicine102 and/or following a
consultation with an individual. They are not able to use herbal medicines that may
be classified as restricted e.g. Ephedra sinica (ma huang) or pharmacy-only
medicines e.g. Lobelia inflata (lobelia).
Cases of toxicity from overdose are usually attributable to selected plant products
that are well known in the materia medica for their toxic potential. There are a
number of documented cases of toxic overdose of herbal
products103,104,105,106,107,108,109,110,111,,112,113,114 . These reported incidences of adverse
events show the actual potential of plant substances to inflict harm when used
incorrectly.
A select few herbal medicines have a relatively narrow therapeutic index (i.e. are
potentially toxic at low dosages) and are required to be prescribed with care and
knowledge. These include some of those herbs with recorded toxic overdose such
as Datura stramonium113,114, Ephedra sinica115,116 and Phytolacca americana117. Use
of these herbal medicines requires a thorough understanding of their indications and
safety limits.
Herbal medicines with a narrow therapeutic index should be classed as ‘practitioner-
only’ medicines. With proper training in the use of these particular herbs, and the
physiological activity of their active constituents, their prescription should be limited
to registered medical herbalists. This control is only possible through statutory
regulation. At the present time, there are several medicinal herbs or phytochemicals
from medicinal herbs that are restricted in New Zealand and are available only by
doctor’s prescription or through licensed pharmacies; in both situations the
prescribing practitioner is unlikely to be suitably trained in clinical practice of herbal
medicine unless they have undertaken additional training.
New Zealand Association of Medical Herbalists (1983) Inc.
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The herb Piper methysticum (kava) is an effective treatment for mild anxiety
disorders and insomnia, and its safety profile in this regard is better than that of drug
treatments used for these conditions118. There have been concerns in recent years
about a possible association with the use of kava and liver toxicity, leading to its
restriction in many countries. The incidence of causally related case reports of liver
toxicity is very low, (around 14 cases accepted as “probably” related in 2003119), and
no cases have been reported in New Zealand to date. In Australia, the use of an
aqueous extract form of kava only has been allowed, although the evidence base for
practitioner-prescribed hydroethanolic liquid extracts of this herb posing a risk of liver
toxicity is unsubstantiated120. Indeed many clinical studies using kava have included
liver function tests with no increase in incidence of hepatoxicity121,122. There have
been a number of explanations put forward as to the cause of this cluster of kava-
linked liver problems123,124,125,126,127,128,129 but reviews have concluded that there is
not a single cause for all the events recorded123,128,130. New Zealand medical
herbalists are aware of the literature on possible adverse reactions to kava, and
continue to prescribe hydroethanolic liquid extracts of this valuable herb in a cautious
and safe manner. The United States has never restricted kava use131 and in
Germany, Kava is being prescribed again with limitations on dose and duration of
use118.
Herbal Medicine/Drug Interactions
A high number of patients receiving pharmaceutical medications may also take over-
the-counter (OTC) herbal medicines that are not prescribed by a qualified
practitioner132,133,134,135. As a result, adverse herb/drug interactions are of increasing
concern91,111,136,137,138,139,140.
Interactions can occur through a variety of mechanisms and may involve herbal
agents or foods that may either increase or reduce the effect of concurrent
prescribed drug medication91,119,141,142,143,144,145,146.
Pharmacokinetic mechanisms may affect the absorption, distribution, and/or
metabolism of administered drugs. Many of the studies conducted to date in this
area have centred on the induction or inhibition of cytochrome P450 metabolising
enzymes within hepatocytes by particular plant
products142,143,145,147,148,149,150,151,152,153. A range of other possible mechanisms is also
known to potentially cause drug/herb interactions154 - such as p-
glycoprotein146,155,156,157, a membrane transport protein, and anion-transporting
polypeptide-B158 that can be affected by one agent in uptake of another. Literature
on this subject is somewhat lacking, and while a number of documented interactions
New Zealand Association of Medical Herbalists (1983) Inc.
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are firmly based upon sound clinical evidence, others appear anecdotal or
theoretical.
Presently a number of herbs are under extensive study and there is the possibility
that more may be found to be interactive with pharmaceutical medications as time
progresses. Proper training and ongoing professional education ensures that
registered medical herbalists are kept up-to-date on new scientific findings and as
prescribers of herbal medicine they are likely to experience adverse reactions in
practice and are therefore ideally suited to monitor and avoid possible interactions
between herbs and pharmaceutical drugs.
Hypericum perforatum (St John's wort) is widely taken to assist with mild to
moderate depression. There have been reports of reduction in efficacy of
pharmaceutical medications due to cytochrome P450 and P-glycoprotein induction
as a result of Hypericum perforatum ingestion159,160,161,162,163,164,165,166,167,168,169,170.
Hypericum perforatum is therefore contraindicated where patients may be
concomitantly administered several narrow therapeutic index drugs, including
cyclosporine171,172,173 , tacrolimus165,174, amitriptyline175, digoxin176,177 , indinavir 178,179, warfarin140,166 , simvastatin167, atorvastatin168 and others119,154,180. Interaction
is also suspected but more contentious for oral contraceptives
(ethinylestradiol/desogestrel)181,182,183,184, loperamide185, and selective serotonin-
reuptake inhibitors140,186,187.
Concurrent use of drugs and phytomedicines with very similar pharmacological
actions may produce an additive or synergistic effect145,188,189. The efficacy of herbal
medicines may also be enhanced or inhibited by concurrent drug medication such as
antibiotics120.
Piper methysticum (kava) has achieved popularity through its action as a mild
sedative and its subsequent use as an anxiolytic. In 1993 in Germany, where it is
prescribed by doctors, 547,000 units of kava-containing preparations were sold190.
Four case reports have suggested that the herb could have an anti-dopaminergic
action, an action also suggested by in vitro studies190,191.
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Hypersensitivity reactions
There have been reports of hypersensitivity reactions to several plants; the
frequency of reports is probably increasing due to the increased public consumption
of herbal medicines. Causal factors include alterations in metabolising
enzymes145,192,193,194,195,196,197, allergic reactions198,199,200,201,202,203,204,205,206,207,
adversity to ethanol present in the phytomedicine preparation208,209,210,211; and
idiopathic sensitivities212.
The Apiaceae (formerly Umbelliferae) and spice plants, including Cinnamomum spp
(cinnamon)213,214, have been the most often implicated with sensitivity reactions. So
too have herbs Matricaria recutita (chamomile)215,216 and Tanacetum parthenium
(feverfew)217,218 from Asteraceae (formerly Compositae) botanical family. It is likely
that reaction is due to idiosyncratic causes, rather than overt toxicity. Plants from the
Apiaceae family can, after ingestion with simultaneous exposure to sunlight,
potentially cause a phototoxic reaction due to their furanocoumarin content219,220.
This highlights the need for careful history taking in relation to allergies prior to
prescribing certain herbal medicines.
There have been reported cases of allergic type reactions to Echinacea purpurea/
angustifolia (echinacea)203,221. This is a classic example of an adverse reaction due
to an individualised sensitivity to the Asteraceae family. Such a reaction is rare and
appears to occur more often in atopic individuals. A careful clinical history performed
by a qualified herbalist can evaluate the possibility of such an adverse event
occurring.
Contraindications
A number of herbs can cause undesirable side effects in some instances. In general,
numerous clinical trials have shown these side effects to be either minor or
uncommon at correct therapeutic doses. Examples of these include:
i. Tannin-containing herbs which may inhibit absorption of some vitamins and/or
minerals222,223,224,225 e.g. Mentha piperita (peppermint) can inhibit iron
absorption 226.
ii. Saponins contained in some herbs can be gastric irritants227,228, e.g. Aesculus
hippocastanum (horsechestnut) and Gymnema sylvestre (gymnema).
iii. Glycyrrhiza glabra (licorice) can cause sodium and fluid retention and
potassium loss and is therefore contraindicated in people with high blood
pressure229,230.
New Zealand Association of Medical Herbalists (1983) Inc.
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iv. Panax ginseng (ginseng) can cause overstimulation - irritability, hypertension,
nervousness, diarrhoea, skin eruptions and insomnia if over-used231. This is
known as the “Ginseng Abuse Syndrome”.
v. Bitter herbs in high doses may cause some people to vomit232, e.g. Gentiana
lutea (gentian).
vi. Thujone containing herbs, e.g. Salvia officinalis (sage), Tanacetum vulgare
(tansy), Artemisia absinthium (wormwood), and Thuja occidentalis (arbour-
vitae), can cause central nervous system symptoms, in overdose, and should
be used with care in people with epilepsy. They can also cause
headaches233,234,235.
vii. Melissa officinalis (lemon balm) has the potential to inhibit thyroid function
and should be used with caution in persons with low thyroid function236,237.
viii. Echinacea spp and Zanthoxylum americanum (prickly ash) in some liquid
forms can cause tingling in the mouth and promote salivation which in high
doses can produce pharyngeal irritation and a choking sensation238,239.
ix. Fucus vesiculosis (kelp) is contraindicated in cases of hyperthyroidism due to
its enhancing effects on thyroid hormone production240,241.
x. Laxative herbs can cause griping and their abuse can lead to electrolyte loss
e.g. Cassia acutifolia (senna)228,242 and Rhamnus purshiana (cascara)228.
Chronic use of these anthraquinone containing stimulant laxatives such as
Cassia acutifolia can cause damage to the myenteric plexus resulting in
cathartic colon243.
Use of such herbs therefore needs to be monitored by a professional medical
herbalist.
Foetal and Infant Development
Plant products have been used to assist pregnancy and childbirth for centuries and
modern herbal medicine is sometimes used during the third trimester of pregnancy.
There are clear guidelines available in herbal materia medica for the use or
avoidance of herbal medicines during pregnancy and lactation. Articles cautioning
on the use of herbal medicines during pregnancy and breastfeeding have also been
published in a range of journals244,245,246,247,248,249,250,251,252,253,254,255.
In general, herbal medicines of concern in pregnancy have the potential to be either
abortifacient or teratogenic. There are a significant number of herbs that fall into one
or other of these categories including Mentha pulgeum (pennyroyal)228,256, Cytisus
scoparius (broom) due to its sparteine content228,257, Thuja occidentalis (thuja)235
and Anemone pulsatilla (pasque flower )258.
New Zealand Association of Medical Herbalists (1983) Inc.
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Risks due to specific physiology
Due to difference in body weights and compromised liver function, paediatric and
geriatric patients are more susceptible to adverse events (generally overdose) if
prescribed full adult dosages259,260. Dosage therefore needs to be determined and
monitored by a qualified medical herbalist.
Misidentification and substitution of species
There are multiple instances in the literature of herbal substitution such as Tussilago
farfara (coltsfoot)261,262,263 and Scutellaria lateriflora (skullcap)264,265 where adverse
events had been attributed to these particular herbs within a herbal product.
However when chemically analysed it was found that the herbs stated on the label
were not in fact present. Substitutions by entirely different plants, whether intentional
or not, were responsible for the observed effects. Reliable sourcing of herbal
extracts by a qualified medical herbalist for therapeutic use is fundamental to good
professional practice.
Incorrect plant part
Inadequate knowledge of the correct plant part/s to be used therapeutically can
result in ingestion of a plant part that is toxic, or a different physiological response to
that expected by use of the correct plant part. These types of adverse reactions are
rare, although some cases have been reported266,267,268,269,270. With adequate
training in herbal medicine and botanical examination and verification by supplier
companies, correct plant parts are able to be clearly identified, differentiated and
appropriately prescribed.
Incorrect administration and self-prescription
Some herbs have been deemed safe for external use, but not internal use (e.g.
Arnica montana (arnica), Aconitum napellus (aconite).
Symphytum officinalis (comfrey) is used externally to treat soft-tissue and bone
injuries and internally was traditionally indicated to treat stomach ulcers, hiatus
hernia, irritable bowel syndrome, ulcerative colitis, and a range of respiratory
conditions, including bronchitis and pleurisy17,271. Internal usage has been restricted
in some countries following several case reports of hepatic veno-occlusive
disease272, which has been linked, correctly or otherwise273, to the presence of
pyrrolizidine alkaloids (PAs). Some types of PAs are known to be hepatotoxic
although if they are present at all in Symphytum their levels have been found to be
low273,274. The rootstock has much higher levels of PAs than the leaf275, and until
clarity has been achieved most professional herbalists have opted not to use root
preparations internally.
New Zealand Association of Medical Herbalists (1983) Inc.
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Self-prescription of herbal medicines is common and the public has access to a wide
range of OTC products containing herbal medicines. Although the majority of herbs
are safe when used correctly they can be misused and result in harmful
consequences. There are examples of health problems resulting from overuse of
OTC products276. There were four cases reported in 1989 of women who were using
commercial herbal preparations, who went on to develop liver disease264. Two of the
cases were co-medicating with pharmaceuticals. Apart from the issues with suspect
OTC products a registered medical herbalist would have recognised early signs of
liver dysfunction and taken steps to investigate the cause(s).
Physical dependence on herbal medicines is not common but can potentially occur.
Medical herbalists are vigilant concerning potential physical dependence on some
herbal medicines, particularly those with psychoactive properties, e.g. Piper
methysticum (kava), Valeriana officinalis (valerian) and Panax ginseng (ginseng).
Use of psychoactive herbs without the supervision of a suitably qualified practitioner
is undesirable, not least because overdosing for some of them has been
reported231,277,278.
Risks associated with poor product quality
Factors that can contribute to poor quality herbal products include:
contamination – potentially toxic microorganisms such as E coli, Staph aureus
and Pseudomonas aeroginosa, and fungal metabolites such as aflatoxins and
ochratoxins in medicinal herbs279
potentially toxic and allergenic ginkgolic acids have been found in commercial
Ginkgo products 280,281 at levels higher than the maximum specified by
German Commission E282,283.
adulteration – at the height of popularity of kava for treating anxiety it appears
that kava root, which has a long growing time, was adulterated with plant
parts such as stem peelings, to meet demand. This may have led to the injury
associated with some of the kava products reported284. Many other instances
of adulteration of herbs with drugs or cheaper plant species have been
reported in the literature.
substitution - Teucrium spp. have been found in several commercial products
purporting to contain Scutellaria lateriflora (skullcap) the latter being
undetectable in the preparation264, 285. Teucrium spp. are associated with
hepatoxicity286.
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sub-standard raw materials - an analysis of the quality of Matricaria recutita
(chamomile), a commonly used herbal tea, and widely sold commercially,
revealed variable quality of flowers. In one study half of the samples lacked
enough of the active essential oil to be effective287. To preserve the volatile oil
flowers need to be processed properly soon after harvesting. Growing
conditions and geographical location can also influence oil quality288,289.
poor manufacturing practice – failure of some manufacturers to follow Good
Manufacturing Practice principles can have serious patient safety
consequences. Extracts and therapeutic efficacy can vary with the solvent
system used290. Bio-availability of actives can also vary enormously
depending on manufacturing methods. Garlic preparations varied 3 - 94% in
the available active constituent, allicin, across 24 different brands291, 292.
mislabeling - Chinese herbal medicines sold in New Zealand were found to
contain pharmaceutical agents, sildenafil or tadalafil that were not disclosed
on the label293. Failure to state the correct botanical species or plant part
used is also relatively common.
Table 3: Potential factors affecting quality of CAM products (Reprinted by kind
permission of Wardle, 2008)Error! Bookmark not defined.
Factor affecting quality Example
Substitution
It is estimated that deliberate substitution of Namibian Devil’s Claw (Harpogophytum procumbens) with cheaper Angolan Harpogophytum zeyheri – a safe yet therapeutically far less effective substitute – may account for 50% of total imports of this herb
294,295.
Not all substitution may be intentional. In Canada Siberian Ginseng (Eleutherococcus senticosus) was initially classed as toxic after being accidently substituted in some products due to a combination of misinterpretation of its traditional name Wu-Jia-Pi and poor quality control by product manufacturers
296.
Ecology (Growing Area)
The essential oil of Basil (Ocimum basilicum) may exhibit different chemotypes depending on area grown. Basil essential oil grown in Madagascar, Comoros, Seychelles and areas of Thailand exhibits higher levels of methyl chavicol – a known skin irritant and carcinogenic agent
297.
Thyme (Thymus vulgaris) may exhibit any one of six major chemotypes with differing chemical constituents – all with very different therapeutic applications – depending on area
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grown and growth stage at which it is harvested
298,299.
Tribulus terrestris, a herb often used in treatment of male infertility and menopause, demonstrates significantly different chemical profiles depending on geographic location the material is sourced from. Research suggests that many markers of quality – including levels of the active steroidal saponin protodioscin – occur in herbal product sourced from Eastern Europe and Western Asia, but not that sourced from India, China or Australia
300.
Part Used Evidence suggests that root parts are more effective and less allergenic than aerial (leaf) parts of Echinacea spp
301 yet most commercial
preparations sold in Australia continue to use the cheaper aerial parts or a combination of parts which leads to wide variations in markers of active compounds
302.
Only standardised Ginkgo leaf tip extract from a limited amount of suppliers is used clinically in Europe as imported crude leaf has been found to contain high quantities of therapeutically inactive leaf and stem material
303.
Variant used Glucosamine is sold in Australia in one of three major forms: glucosamine sulphate, glucosamine sulphate potassium and glucosamine hydrochloride
304. Only
glucosamine sulphate at doses of at least 1500mg daily has demonstrated efficacy in trials
305. More than half the supplements
available in Australia are of the cheaper, ineffective glucosamine hydrochloride variety
304.
Manufacturing process Inactive ingredients used in manufacturing process may render active constituents unabsorbable and therefore ineffective. An investigation of commercially available Coenzyme Q10 supplements in New Zealand found marked differences in bioavailability despite similar labelled doses due to variation in excipients used
306.
The proportion and type of solvents used in the extraction of herbs will determine amount of therapeutic agent extracted
307.
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Contamination Some imported Ayurvedic and Chinese Medicines in Australia have been shown to have dangerous levels of heavy metal concentrations
308. It is currently left to the
discretion of the manufacturer to test for these according to GMP. CAM products may be contaminated with pharmaceutical drugs. An Australian herbal libido tonic was the subject of an urgent withdrawal in 2007 after it was found to contain sildenafil
309.
(Reprinted by kind permission of Wardle,
2008)Error! Bookmark not defined.
Poor quality herbal products have a high risk potential. Whilst we understand herbal
products will in the future be regulated under the Natural Health and Supplementary
Products Bill, numerous potential difficulties with the implementation of this bill could
be avoided through regulation of the practice of Western herbal medicine under the
HPCAA.
Consumer and patient safety would be more adequately protected through regulation
of Western herbal medicine by allowing the development of a clear definition of
‘practitioner only’ herbs, enabling more appropriate regulatory scheduling of these in
the future by providing an avenue for the establishment of a ‘practitioner only’
category of product. Such regulation would also help ameliorate potential regulatory
inconsistencies of the bill and improve consumer and professional acceptability of
the new legislation.
It is of concern, however, that just as with the current 1981 Medicines Act, no clear
definition of what constitutes a natural health practitioner, is contained in the current
wording of the draft Natural Health and Supplementary Products Bill. Without such a
definition or register of natural health practitioners being held by the Ministry of
Health, the current loophole contained in the 1981 Act that enables anyone even
without proper training to prescribe and dispense herbal medicines in the context of
a ‘one-to- one consultation’, is likely to continue.
Regulation would need to include the expertise of qualified medical herbalists as
they are familiar with the issues and are able to assess where products are
undesirable for OTC use. They will also be able to readily establish protocols for
assessing the quality of these OTC products.
Risks associated with practitioner performance
At the present time anyone in New Zealand, regardless of education or training, can
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provide herbal medicine services to the public. Given all of the previously mentioned
factors, it is clear that there are substantial risks to public safety associated with this
situation.
Lack of/or inadequate education and training, and consequent deficiencies in herbal
medicine clinical practices may result in the following:
misdiagnosis and poor patient management;
unnecessary or ineffective treatment;
treatment causing adverse reactions;
failure to identify adverse reactions and to take appropriate remedial action;
aggravation or progression of a condition;
failure to identify conditions requiring referral;
adverse reactions from herb/drug interactions;
adverse reactions due to ignorance of contraindications
failure to ensure quality of herbal products prescribed
There are examples of poor practice on the part of complementary therapists
overseas. For instance, in Australia a Newcastle naturopath who attempted to treat a
child with a congenital heart abnormality, advising against medical surgery was
charged with manslaughter when the child died88.
In New Zealand the case of Ruth Nelson, who is not a qualified medical herbalist,
although she used herbs as part of her treatment, “misdiagnosed” a squamous cell
carcinoma leading to a long delay in appropriate treatment for the patient and
prolonging the course of the disease and its treatment and ultimate death of the
patient310. The doctors who reported this case have argued that self regulation of
CAM practitioners is “inadequate” and that statutory regulation should be considered.
3.3.2 Nature and severity of risk to the wider public
The most significant risks from Western herbal medicine to the wider public are:
self-prescription of over-the-counter products that are inappropriate for the
condition being treated
self-prescription of over-the-counter products combined with medications for a
chronic or acute condition
self-prescription of products obtained via the internet that may contain
pharmaceuticals or toxic substances
availability of herbal products of poor quality due to substandard
manufacturing practices and inadequate regulation
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prescription of herbal medicines by health practitioners of other modalities
untrained in herbal medicine practice
A risk of harm to the wider public also exists when inadequately trained practitioners:
treat patients with serious infectious disease inappropriately, with the potential
outcome of disease transmission to family, friends, colleagues or the wider
community
fail to treat adequately, or refer, patients with serious illness, leading to
progression of illness and consequent negative impact on family and others,
and increased costs to public health
failure to match the patient’s clinical symptoms and diagnosis to appropriate
herbal prescriptions, thus compromising their effectiveness and/or safety.
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4. Criterion C
Is it otherwise in the public interest that the health services be regulated
as a health profession under the Act?
4.1 Is it in the public interest?
It is in the public interest that herbal medicine be regulated as a profession under the
Act for the reasons stated above.
4.1.1 Consumer Protection
As with all health care professions, there is a strong presumption of public interest in
ensuring that those who present themselves as medical herbalists have appropriate
training and that consumers are able to identify the level of competency of a
practitioner. A large and increasing number of people utlilise the services of medical
herbalists, naturopaths and other health practitioners who prescribe herbal
medicine23 and it is therefore appropriate that they are registered and subject to the
competency assurance provisions provided under the HPCA Act. The public has a
clear right to know that their health care provider fulfils the expectations of
competency in their professional scope of practice and that of prescription of herbal
medicine. Regulation of medical herbalists can be seen as a reflection of a modern
healthcare system responding to public interest and public health requirements.
The majority of medical herbalists practise autonomously in individual sole-
practitioner situations. There is little scope for supervision or support for those that
choose not to be part of a professional body such as NZAMH.
Practitoners who choose to belong to NZAMH are bound by rules and ethical
guidelines. However, there are a significant number of practitioners (naturopaths,
other health professionals) who prescribe herbal medicine products, some with
inadequate training that are not members of NZAMH or other professional bodies.
These prescribers of herbal medicine may practise in health stores, chemists, sole
practice, under different titles and practice outside of the established NZAMH rules.
Without guidance of a strong professional code of conduct these practitioners are at
liberty to exploit vulnerable or isolated members of the public, financially or otherwise
and due to the autonomous nature of practice have the potential to cause harm as
described above.
Members of other health professions such as midwifery and chiropractic are also
known to utilise herbal medicine in their practices. These practitioners have very little
formal training in herbal medicine, if any, and as such are practicing outside their
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scope of practice and putting consumer safety at risk. The public have a right to
know their primary health care practitioner is appropriately qualified to use their tools
of trade, which can only be guaranteed through statutory regulation and registration
of practitioners.
Herbal medicine and appropriately qualified and regulated herbal medicine
practitioners are of undoubted benefit in contributing to the treatment of illness and
the maintenance of health and vitality in the general community, but without
regulation there is very limited consumer protection.
4.1.2 Regulation of Herbal Medicines
At present, some useful herbal ingredients are scheduled as prescription medicines
because they are not considered safe when self-prescribed by consumers. Products
containing these ingredients need to be used under the supervision of an
appropriately trained health professional. At the present time the nonsensical
situation exists where these prescription rights apply only to general practitioners
and/or pharmacists, neither of whom receives any significant education in the
prescription of herbal medicine during their training.
In addition to the above scheduled herbal ingredients, there are several medicinal
herbs available for practitioner use in other countries (e.g. Britain) that are currently
unavailable to herbal medicine practitioners in New Zealand. A working group was
established with Medsafe in 2009 to identify herbal medicines that could usefully be
scheduled and thus available for prescription only by appropriately qualified medical
herbalists; however this process stalled when our profession was required to re-
apply for regulation.
The advent of the Natural Health and Supplementary Products Bill provides the
opportunity to establish a functional ‘practitioner-only’ category of herbal products,
but this will be practicable only if herbal medicine is a regulated profession. It is not
currently possible to allow medical herbalists to prescribe these substances because
they do not belong to a regulated profession to which 'prescribing rights' can be
granted. Regulation under the Act would allow for medical herbalists to prescribe
these products where there is a clear indication that their use would benefit patient
health.
Regulation of herbal medicines and medical herbalists would also allow the provision
of enforceable guidelines relating to conservation and biodiversity issues. There is
growing concern that the expanding herbal medicine market and its commercial
potential poses an environmental threat due to over-harvesting of raw materials311.
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There are also issues around herbal medicine practitioners using endangered
medicinal herbs. Whilst this is discouraged by NZAMH and the educational
institutions through education regarding those plants under threat, without regulation
there exists no mechanism to encourage or enforce this across the board.
Panax ginseng (Korean ginseng) for example, is a herb in high demand that is used
traditionally to improve a wide range of health problems. (The name Panax derived
from the Greek word “panacea” reflects its traditional status as a cure-all.) It is the
root that is harvested for medicinal use and therefore the whole plant is destroyed
when it is taken from the wild. In addition, as increased demand raises the premium
paid for ginseng products the incentive to substitute it with other similar species
increases as does the associated risk of health problems311,312,313.
4.1.3 Integrated Health Care
Regulation of herbal medicine would substantially improve the methods of how
integration of herbal medicine is currently occurring in the New Zealand health care
system, improving safety and increasing consumer choice, outcomes, and consumer
satisfaction, and has the potential to reduce health costs and over-use of
medications.
A New Zealand survey of herbal and naturopathic practitioners86 reported that
medical herbalists and naturopaths receive referrals from a range of mainstream
health providers on a regular basis. These referrals primarily occur informally via the
patient and without formalised procedures. This word-of-mouth patient mediated
method of referral poses a potential risk for misinformation to be communicated by
the patient to either practitioner and compromises safety (particularly in drug-herb or
drug-nutrient interactions) and effectiveness due to lack of access to diagnosis and
treatment information between practitioners86.
In a regulated, integrated environment whole practice research could be undertaken
to effectively investigate outcomes of clinical practice as opposed to the efficacy of a
single herbal medicine under narrow parameters that does not reflect use of herbal
medicine in practice314.
Whole practice research (whole systems research) is the study of complex CAM
therapies at the systems level, as opposed to single-agent medicines; it moves
beyond randomised controlled trials (RCTs) to more adequately evaluate the whole
practice of a particular modality, and is more relevant to herbal and naturopathic
clinical practice315.
The National Herbalists Association of Australia (2013) submission to the Review of
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the Australian Government rebate on private health insurance for Natural Therapies
cited 12 studies (pp.20-21) that examined health outcomes associated with
naturopathic care (which includes herbal medicine) using whole practice research316.
The predominant benefit of integration in terms of public health care and health
policy is perhaps best outlined in a 2001 article that featured in New Zealand
General Practitioner journal317.
In this article it was reported that Dr. Gerard Bodeker, senior clinical lecturer in public
health at Oxford University and Chair of the Commonwealth Working Group on
Traditional and Complementary Medicine, stated that the utilisation of
complementary health systems leads to cost savings via lowering the use of health
services alongside a decreased demand for insurance company payouts. He went
on to say that governments are looking to form relationships with Complementary
Medicine as part of health sector improvement and reform, but in a situation of
scarce resources political will is needed to integrate the Complementary Health
sector317.
The World Health Organisation has expressed the desire to integrate CAM
modalities into existing national health care systems and requested that increased
provision of CAM services be made available to the public318.The Health and
Independence Report (2008)319 and the 2011/12 Health Targets320 outline several
areas having priority for health improvement in New Zealand in which herbal
medicine can play a significant therapeutic role:
• reducing the harm caused by smoking
• improving nutrition, increasing physical activity and reducing obesity
• improving oral health
• improving mental health services
• reducing hospital admissions
• improving diabetes services
• improving cardiovascular services
More recently, the WHO Traditional Medicine Strategy 2014-2023321 for the next 10
years has been developed in order to foster appropriate integration, regulation and
supervision to promote the safe and effective use of traditional and complementary
medicine (T&CM) practices in expansion of health care.
In order to achieve this goal three strategic objectives are required:
1) building the knowledge base and formulating national policies;
2) strengthening safety, quality and effectiveness through regulation;
3) promoting universal health coverage by integrating T&CM services and self-health
New Zealand Association of Medical Herbalists (1983) Inc.
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care into national health systems.
4.1.4 Cost Effectiveness in Healthcare
Herbal medicine and other CAM modalities have the potential to save the health care
system a significant amount of money through reductions in direct health care costs.
Most current studies indicate that CAM patients have significantly lower costs and
are much less likely to require hospitalisation in their lifetimes88Error! Bookmark not
defined..
A 2005 Smallwood Report focused on the economic benefits of CAM322. It looked at
the benefits in three centres in the UK where GPs work with CAM practitioners under
the National Health Service (NHS). One of these centres, the Glastonbury Health
Centre, included herbal medicine as one of five therapies used. Other therapies
included: osteopathy, acupuncture, massage and homoeopathy.
Glastonbury Health Centre had offered free access to CAM therapies for patients in
a three-partner GP practice since 1992. Research undertaken since 1990 provided
good evidence that CAM contributed to health improvements including reduced
waiting lists and also significant cost savings. Sixty percent of those patients referred
for CAM therapy had musculoskeletal complaints; a third were referred because their
health problem wasn’t responding to conventional care and two-thirds had a severe
health problem.
Eighty-five percent of patients reported improvement in their condition and
practitioners reported that 50% showed marked improvements. In patients suffering
from short term, more severe musculoskeletal and psychosocial conditions, results
were particularly good; also CAM therapies were found to improve the health and
well being of patients with milder conditions and to encourage positive changes in
lifestyle.
Cost savings included a drop in visits to GPs by about a third and the largest
reduction was amongst those patients who were the most frequent users of GPs
prior to referral. Prescription use fell by about 50% and those who were the heaviest
users had the greatest reduction. There was also a reduction in secondary referrals
such as physiotherapy and X-rays. Estimates made by the Glastonbury Centre were
that CAM service could be expected to generate a sufficient reduction in
conventional care expenditure to cover its costs.
In summary, the Smallwood Report stated that CAM therapies were beneficial
because:
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1) CAM therapies could be used to treat conditions, both physical and psychological,
that would otherwise not be satisfactorily treated within the standard NHS setting -
i.e. they fill the “effectiveness-gap”. These conditions related to pain both acute and
chronic and included:
joints (osteo- and rheumatoid arthritis)
headaches/migraines
anxiety stress and depression;
”ill-defined” chronic conditions
skin conditions, notably eczema.
2) They provided cost savings through less expensive treatment, saving 50% on
prescriptions and a third on the cost of GP visits. Visits to secondary care services
were markedly reduced. A costing was presented for St John’s wort comparing it to
the current conventional equivalent. Antidepressants in 2004 cost the UK £400
million annually, with each prescription costing £13.82. St John’s wort costed out at
82p a week at that time. These cost savings were refuted by Ernst (2006)323 however
the report on cost effectiveness of complementary medicines carried out by the
University of Western Sydney Australia, and published in 2010 compared favourably
with that of the Smallwood report in the UK. The Australian study found herbal
prescription in that country to be less expensive than the pharmaceutical equivalent.
The average cost per day of St John’s wort (at a dose of 900mg per day) in 2009
was 17 cents compared with estimated cost of 57 cents per day to the Australian
government for antidepressants dispensed in the same year. This cost did not
include prescription charges of $31.30 or $5.00 for those with a concession324.
Effective CAM treatments are likely to cost less than conventional ones, especially in
the case of herbal medicine. Where conventional and CAM therapies may be used
together the initial costs may be greater, but this would likely be offset by a reduction
in treatment time required and costs related to people having less time off work. This
cheaper form of healthcare that is out-of-pocket expenditure empowers individuals to
undertake self-care and healthy lifestyle choices and is likely to reduce
pharmaceutical expenditure and curtail rising health costs.
3) CAM therapies can make a significant contribution when used in low socio-
economic areas because these are the populations particularly affected by
psychosocial and chronic health problems and who also have less ability to access
these therapies.
The Smallwood Report318 also recommended increased funding into the research of
efficacy of CAM therapies, restricting the use of CAM therapies to those properly
trained and the early establishment of statutory regulation for several CAM therapies
including herbal medicine.
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Secondary criteria 5. Criterion 1
Do existing regulatory or other mechanisms fail to address health and
safety issues arising from the practice of the profession?
5.1 Existing Regulatory mechanisms
5.1.1 The Health and Disability Commissioner Act 1994 and the Code of Health
and Disability Services Consumers’ Rights
The Health and Disability Commissioner Act (HDCA) 1994, and Code of
Health and Disability Services Consumers’ Rights (Code of Rights)
establishes the rights of consumers, and the obligations and duties of
providers of health and disability services.
The Code of Rights extends to any person or organisation providing, or
holding themselves out as providing, a health service to the public or to a
section of the public - whether that service is paid for or not.
The Code of Rights therefore covers both statutory registered and
unregistered health professionals and brings a level of accountability to all
those who may be considered outside the mainstream of medical practice,
e.g. medical herbalists, naturopaths, homoeopaths, or acupuncturists. The
difference between statutory registered and unregistered health practitioners
arises when the Health and Disability Commissioner upholds a complaint
against them.
A complaint against a registered health professional under the Health
Practitioner’s Competence Assurance Act can be referred to the appropriate
registration authority for review, or to the New Zealand Health Practitioners
Disciplinary Tribunal for disciplinary proceedings, however where the
complaint concerns a non-registered practitioner the principal avenue for
further action is through the Human Rights Tribunal.
Any person in New Zealand can call themselves a CAM practitioner or
medical herbalist irrespective of adequate education. In a case of
misdiagnosed squamous cell carcinoma treated for 16 months by an
unregistered CAM practitioner it has been argued that self-regulation of so-
called CAM practitioners is inadequate and that they require closer scrutiny
and that statutory regulation is an avenue for achieving this. The authors
argued that the HDCA is limited in its ability to prevent such cases occurring
and that there is no HPCAA-equivalent statute regulating CAM practitioners’
competency and fitness to practice and that this is a risk to the public310.
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5.1.2 The Human Rights Review Tribunal
The Human Rights Review Tribunal is a statutory body that deals with cases
brought under the Human Rights Act 1993, the Privacy Act 1993, and the
Health and Disability Commissioner Act 1994.
The Human Rights Review Tribunal can award damages, and has the power
to make various other orders such as requiring a health care provider to
undergo remedial training. However, neither the Health and Disability
Commissioner, nor the Human Rights Review Tribunal, currently have the
power to prohibit a practitioner from practicing, even if found to be in serious
breach of the Health and Disability Commissioner Act.
This situation was highlighted in the Human Rights Review Tribunal of New
Zealand case NZHRRT 9, concerning a ‘natural therapies practitioner’ who
was found in three separate Health and Disability Commissioner cases
(06HDC09325, 06HDC07873 and 06HDC09882) to have breached several
standards of the Code of Rights and who was labelled a ‘sexual predator’. In
their decision, the Human Rights Tribunal stated:
“…since [the defendant] does not belong to any professional body or
association that might have an interest in his conduct, much less any
ability to oversee his activities, there is nothing that can be done by
way of a disciplinary process or otherwise to stop him from purporting
to provide health care services to the public in future”325
This is despite the opinion of the Deputy Health and Disabilities
Commissioner that the defendant:
“…should not now, or in the future, practise as a counsellor or a natural
therapies practitioner”326
This situation is patently unsatisfactory. A health professional providing
services to the public who practises in a way that harms a patient should be
subject to appropriate disciplinary action, including where warranted,
prohibition from future practice. The fact that a health profession such as
Western herbal medicine does pose a risk of harm to the health and safety of
the public, as illustrated earlier in this document, requires that there is
recourse by the public to appropriate means of complaint and protection.
5.1.3 New Zealand Medicines and Medical Devices Safety Authority (MedSafe)
and the Medicines Act 1981
MedSafe regulates herbal medicinal products (herbal remedies) under
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Section 2(1) of the Medicines Act 327:
Herbal remedy means a medicine (not being or containing a prescription
medicine, or a restricted medicine, or a pharmacy-only medicine)
consisting of:
a) any substance produced by subjecting a plant to drying, crushing,
or any other similar process; or
b) a mixture comprising 2 or more such substances only; or
c) a mixture comprising 1 or more such substances with water or ethyl
alcohol or any inert substance
The Medicines Act Section 28 outlines special exemptions for natural health
practitioners from some of the requirements of the Act. These exemptions
relate to the provision of natural medicines classified as general sales
medicines to consumers.
These regulations within the Medicines Act are sufficient to cover false
advertising of efficacy of a herbal remedy and to some degree mitigate the
possibility of practitioners taking advantage of vulnerable consumers, however
there are significant regulatory limitations of the Act, as discussed earlier in
section 4.1.2.
5.1.4 Consumer Guarantees Act 1993 and Fair Trading Act 1986
The difference between the Fair Trading Act (FTA) and the Consumer
Guarantees Act (CGA) is, in general, the FTA covers claims about products
and services prior to sale and the CGA covers the quality of those products
and services after they have been bought.
The Consumer Guarantees Act protects consumers by specifying a series of
guarantees with respect to supply of goods and services for personal use.
Consumers have some recourse if goods and/or services are supplied that do
not meet reasonable expectations of quality. This act provides very limited
protection for consumers of herbal medicine products and services.
The Fair Trading Act prohibits what is called "misleading or deceptive
conduct, false representations and unfair practices". It also sets out when
information about certain products must be disclosed to consumers, and helps
ensure products are safe. This act provides some protection for consumers
with regards to false or misleading advertising, but is not concerned with
safety risk.
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5.1.5 New Zealand Qualifications Authority
New Zealand Qualifications Authority (NZQA) ensures that New Zealand
qualifications are valued as credible and robust both nationally and
internationally.
NZQA awards the following qualifications which are currently considered to
provide sufficient training and education in the practice of herbal medicine to
qualify for professional membership of the New Zealand Association of
Medical Herbalists (NZAMH):
Diploma Herbal Medicine (level 6)
Diploma in Naturopathy and Herbal Medicine (level 7)
Bachelor of Naturopathy (level 7)
Bachelor of Naturopathic and Herbal Medicine (level 7)
Bachelor of Natural Medicine (level 7)
From 2020 only graduates and new members that hold a bachelor degree will
be accepted as professional members.
A NZ survey of medical herbalists in 2011 found that 57% of NZAMH
members at that time held a bachelor degree or higher qualification. In 2014,
68% of surveyed NZAMH members held a bachelor degree or higher with
some (24%) having undertaken a conversion programme from diploma to
bachelor degree offered through an Australian university. From 2013 onwards
the majority of graduates have held a NZ bachelor degree328.
One or more of the above qualifications are provided by three different
educational institutions. There has been one additional programme delivered
by a herbal college in New Zealand that has not wished to be accredited by
NZQA, yet graduates have been previously accepted as professional
members by NZAMH. This qualification no longer meets NZAMH education
standards and is currently in the process of being taught out. NZAMH will
continue to accept graduates of this Diploma in Herbal Medicine as
professional members until December 2015 when the last of the students are
expected to have completed.
Statutory regulation may necessitate practitioners having an NZQA
recognised qualification to qualify for registration. It is also the Association’s
wish to have some form of external assessment established that allows
practitioners from overseas and those without a NZQA qualification to prove
their competence and thus qualify for registration.
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NZAMH considers that it is essential to maintain education standards and to
provide breadth and depth of herbal medicine education to ensure the health
and growth of the modality.
5.1.6 Criminal and Common Law
Criminal law is complaint-based and retrospective in effect. It usually offers
redress only in the most serious complaints, such as grievous bodily harm
and assault, and it is often difficult to gain a conviction. Criminal law and
litigation proceedings frequently pose further trauma to complainants and the
costs for private litigation are often prohibitive, making most complainants
unwilling to proceed.
This fails to address preventative health and safety issues. Indeed, even a
conviction does not restrict or prohibit a practitioner from continued practice.
5.1.7 ACC legislation
Current ACC legislation may restrict complainant’s rights to redress under
common law for medical misadventure. However without regulation medical
misadventure on the part of a medical herbalist falls outside the scope of
ACCs medical misadventure provisions’ leaving the injured party restricted in
their avenues for redress329.
5.1.8 Convention on the International Trade in Endangered Species of Wild
Fauna and Flora
New Zealand is a signatory to the Convention on the International Trade in
Endangered Species of Wild Fauna and Flora (CITES).
It is acknowledged by NZAMH that some plant species traditionally used in
herbal medicine practice are no longer acceptable for use in contemporary
healthcare due to the species being endangered or threatened in the wild.
International trade in species on CITES Appendix I is banned. There are no
plants on this list used in the practice of Western herbal medicine in New
Zealand.
International trade in species on CITES Appendix II is allowed, subject to the
relevant export and import permits and other authorisations being obtained.
CITES Appendix II species used in Western herbal medicine include, among
others, Hydrastis canadensis (golden seal), Panax quinqefolius (American
ginseng), Panax ginseng (Korean ginseng), Picrorrhiza kurroa (Picrorrhiza)
and Prunus africanum (pygeum)330.
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There are however many plant species considered ‘at risk’ that are not subject
to any trade restrictions. These include the widely used medicinal herbs
Echinacea spp.(echinacea), Ulmus rubra (slippery elm) and Euphrasia spp.
(eyebright)331.
Using product derived from endangered and at risk species in healthcare
practice is against the broader public interest. Unscrupulous manufacturers
and practitioners are able to use at risk species without legal impediment and
as an unregulated profession, there is little scope for redress. Regulation
would provide the possibility of censure should there be a breach of the code
of ethics regarding endangered and at risk species.
Many of those plants under threat are now grown commercially for medicinal
purposes e.g. Hydrastis canadensis and Echinacea spp. Ethical
manufacturers and suppliers will do their utmost to ensure they are using
plants that do not put the endemic varieties at risk.
5.2 Product Regulation
As previously discussed in section 4.1.2, herbal medicine product regulation is
presently unsatisfactory and public safety is ineffectively safeguarded. New
Zealand is the only country in the developed world not requiring certification
under the code of Good Manufacturing Practice, for manufacturers of herbal
medicines. The Natural Health and Supplementary Products Bill has the
opportunity to rectify this situation, and to allow for different classes of product
including ‘practitioner only’. Whilst practitioner only products are currently
available in the marketplace, unlike Australia, this designation has no legal
standing. Just as many drugs are inappropriate for consumer or patient self-
selection, so are a small number of herbal medicines. Once Western herbal
medicine becomes a regulated profession, this situation will be easier to
address in an appropriate regulatory framework.
5.3 Supervision by Registered Practitioners
There are no statutorily regulated professions that have appropriate
knowledge of, or training in, the profession of Western herbal medicine. Thus
supervision by registered practitioners of another profession would be
inappropriate and maintain the potential to put consumers at risk.
5.4 Self-regulation
Self-regulation refers to the controlling of a process or activity by the people or
organisations that are involved in it rather than by an outside organisation
such as the government.
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Currently the profession of Western herbal medicine is self-regulated.
NZAMH is the only professional association specifically for Western herbal
medicine practitioners, although many are naturopaths trained in herbal
medicine. The impact of self-regulation has been limited as there is no
statutory requirement for practitioners to join this or any other regulating body
hence many practice herbal medicine outside any professional framework.
Therefore due to the voluntary nature of practice and professional
membership, under the current self-regulation provisions the unregulated
practice of herbal medicine appears fairly widespread resulting in increased
consumer risk and potential for harm.
6. Criterion 2
Is regulation possible to implement for the profession in question?
Western herbal medicine is a well-defined profession, with a clear professional
identity. NZAMH have developed well defined standards, competencies and a robust
code of ethics. These can be carried over for use under the Act.
6.1 Definition of the profession
Western herbal medicine is a traditional system of medicine which uses plants
for healing and is based on observation and experience passed down over
thousands of years. It also utilises modern scientific information and research
in phytomedicine and phytopharmacology, combined with the medical
sciences of anatomy, physiology, biochemistry, pathophysiology,
pharmacology and clinical assessment as well as the sciences of botany and
nutrition.
Medical herbalists practice within a traditional holistic framework of restoring
and supporting the inherent self-healing processes within each individual
patient and by treating the whole person rather than just a disease or isolated
part of the body.
Western herbal medicine practice blends scientific and traditional values,
thereby placing it in a unique and discrete position within the healthcare
sector.
Naturopathic practitioners unlike Medical Herbalists may or may not include
use of herbal medicines as a therapeutic agent. Many naturopaths are also
medical herbalists but not all, just as some medical herbalists are not
naturopaths depending on training. However despite lack of training there is
nothing to stop a naturopath or any other health professional from prescribing
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herbal medicine currently.
NZAMH envisages that application for registration of Medical herbalists under
the HPCA Act would mean all practitioners who formulate, prescribe,
manufacture and/or dispense herbal medicines for the therapeutic treatment
of an individual would be included under the HPCA Act. The act of
formulating, prescribing, manufacturing and/or dispensing a herbal medicine
for therapeutic purposes to another person makes that prescriber a Medical
Herbalist.
6.2 Teachable and testable body of knowledge underpinning practice
The fundamental theories of Western herbal medicine upon which health
assessment and treatment are based, are coherent, teachable and testable.
NZAMH has in place minimum educational requirements for practising
medical herbalists and have proposed education standards for courses in
herbal medicine [Appendix 2].
Whilst incorporating mainstream health sciences including research methods,
there is a strong endeavour to retain the traditional philosophy that underpins
practice, i.e. the individual, patient-centred, holistic approach of medical
herbalists.
6.2.1 Qualifications
The NZAMH currently recognises Herbal Medicine courses provided by the
following NZQA approved educational institutions:
Lotus Holistic Centre
South Pacific College of Natural Medicine
Wellpark College of Natural Therapies
Graduates of the above colleges that include herbal medicine courses in their
qualifications, qualify for professional membership of NZAMH without any
requirement to sit subsequent assessments outside of these colleges.
These institutions each offer one or more of the following qualifications:
Diploma in Herbal Medicine (level 6) [being phased out by 2020]
Diploma in Naturopathy and Herbal Medicine (level 7)
Bachelor of Naturopathy (level 7)
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Bachelor of Naturopathic and Herbal Medicine (level 7)
Bachelor of Natural Medicine (level 7)
NZAMH has a policy in place that by 2020 all new graduates accepted into
NZAMH from accredited colleges will have a minimum level 7 bachelor
degree qualification. Those colleges that currently offer a bachelor degree
provide bridging programmes for past diploma-level graduates to up-skill to
bachelor degree level.
The NZAMH, as part of an ongoing commitment to supporting quality and
effective herbal medicine education monitors the teaching institutions it
accredits by requiring an annual list of tutors and their qualifications. All tutors
of herbal medicine at accredited colleges are required to be members of the
NZAMH.
It should be noted that, due to the currently unregulated nature of the
profession, there are a number of unrecognised providers delivering lower
level courses outside of the NZQA level structure which purport to provide
‘professional’ level training in herbal medicine.
As a result ‘practitioners’ who lack sufficient qualifications and training are
currently able to practice in New Zealand and in doing so pose a potential risk
to the public and the reputation of bona fide practitioners. Practitioners who do
not belong to the bona fide professional body NZAMH have no requirements
for continuing professional development.
NZAMH recognises the qualifications of those who have been accepted as
members of The National Institute of Herbal Medicine in UK (NIMH) and the
National Herbalists' Association of Australia (NHAA).
Applicants who have not graduated from an accredited NZAMH course or
recognised professional association have their qualifications considered on a
case-by-case basis using a formal assessment process involving matching of
learning outcomes for qualification content, submission of case studies and
practice observation.
6.2.2 Standards in relation to conduct, performance and ethics
Quality Assurance (QA) activities within the NZAMH focus on structure,
process and outcome. QA activities in relation to regulation of medical
herbalists cover the following:
Structure
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NZAMH sets standards for education of medical herbalists
NZAMH establishes requirements and fitness for registration of
medical herbalists
NZAMH maintains requirements for ongoing continuing education and
professional development
NZAMH keeps a register of registered medical herbalists
NZAMH has appropriate complaints and disciplinary systems
Process
NZAMH sets standards for education of medical herbalists using
experts in the field of education and the guidelines of the New Zealand
Qualifications Authority
NZAMH evaluates programmes for the education of medical herbalists
in New Zealand
Registration for membership requires each applicant to demonstrate
that he or she meets the following criteria that will be added to the
constitution in the near future where currently not included:
o has the prescribed qualification
o is competent to practise
o is able to communicate effectively with clients
o does not have a condition which may mean he or she is not able
to perform the functions required
o has not been convicted of an offence punishable by three months
imprisonment or more that reflects adversely on his or her practise
o is not under investigation or the subject of disciplinary
proceedings in New Zealand or overseas that reflects adversely
on his or her practise
o has not had a disciplinary order made which reflects adversely on
his or her practise.
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NZAMH requires registered medical herbalists to adhere to the
NZAMH Code of Ethics (Appendix 3) and to the Health and Disability
Commissioner Code of Consumer Rights
NZAMH receives and investigates complaints about professional
misconduct and disciplines where necessary
NZAMH receives notifications about medical herbalists who may pose
a risk of harm to the public by practising below the required standard of
competence and acts where appropriate to ensure competence is
improved
NZAMH requires registered medical herbalists to undertake regular
continuing professional education and to keep a record of these
activities
o Annual practising certificates are issued by the NZAMH for eligible
practitioners who have undertaken sufficient continuing
professional education, in areas which must relate to the clinical
practice of and/or professional development of herbal medicine.
o When renewing annual practising certificates, each member must
furnish proof of having completed their continuing education
requirement.
Outcomes
NZAMH accredits teaching institutions and their programmes for the
education of medical herbalists in New Zealand.
NZAMH registers medical herbalists.
NZAMH sets standards in relation to conduct, performance and ethics.
NZAMH issues annual practising certificates to medical herbalists.
The current practising certificate must be displayed in the practitioner’s
clinic.
6.2.3 Enforcement of standards
Discipline
The NZAMH constitution outlines disciplinary procedures should a complaint
be made regarding a professional member.
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Continuing professional development
NZAMH requires registered medical herbalists to undertake regular continuing
professional education (CPE) and to keep a record of these activities.
A points system is used to record CPE, to allow weighting with regard to the
type of activity/education undertaken. Annual practising certificates are issued
by NZAMH for eligible practitioners who have achieved a minimum of 30
points from activities that must relate to the clinical practice, research and/or
professional development of herbal medicine.
Code of Ethics
Members are required to declare their commitment to the code of ethics each
year on re-registration.
6.2.4 Professional titles used
Herbalist
Medical Herbalist
Phytotherapist
Clinical Herbalist
Western Herbal Medicine Practitioner
7. Criterion 3
Is regulation practical to implement for the profession?
Current NZAMH membership levels (235 professional members) are marginal for
supporting professional regulation owing to the current unregulated status. This
membership, however, is greater than that in 2007 when our previous application for
statutory regulation under the HPCA was accepted by the then Minister of Health,
when NZAMH had 182 professional members. Furthermore, considerable numbers
of practitioners who prescribe Western herbal medicine remain outside of existing
voluntary regulation and supervision structures. There are also two naturopathic
professional bodies some of whose members prescribe Western herbal medicine.
Under statutory regulation naturopaths and other practitioners who formulate,
prescribe, manufacture and/or dispense herbal medicine would be required to
undertake registration increasing the number of registered practitioners and in so
doing increase the modalities capacity to support regulatory costs.
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Western Herbal Medicine could combine with other complementary integrative
medicine [CIM] professions under one CIM regulating authority. A CIM authority
could be responsible for a number of professions as suggested by the Acting Health
and Disability Commissioner in 2007332.
A CIM authority could include a number of professions such as Western herbal
medicine, aromatic medicine, Ayurveda, yoga therapy, naturopathy, Traditional
Chinese Medicine, acupuncture, massage therapy and homoeopathy. Another
possibility could be for all CIM modalities to share the same regulatory authority as
osteopathy and chiropractics (Allied Health) which would be more cost effective
while supporting consumer safety.
As regards the implementation and mechanics of the regulatory environment,
NZAMH has over the past several years been implementing policies and procedures
in line with several currently regulated professions.
Therefore, as with other health modalities it is thought that Western medical
herbalism has the capacity, policies and procedural capacity to transition
successfully to statutory regulation.
7.1 Alternatives to statutory regulation
7.1.1 Self-regulation
Western herbal medicine in New Zealand is at present self-regulated.
This allows any person, qualified or not, to advertise and practise as a medical
herbalist. In light of the safety concerns outlined in section 3, this is considered an
untenable situation.
The major limitation of self-regulation is that it is voluntary and has minimal or no
influence on those practitioners who choose not to participate. As discussed
previously, whilst self-regulation has been successful to some extent in relation to
the conduct of those herbal medicine practitioners who have chosen to be members
of NZAMH, there are many Western herbal medicine practitioners who choose not to
belong and are thus free to conduct themselves how they wish, and in doing so pose
a greater potential risk to the public. Some excerpts from a 2011 Australian Health
Ministers Council paper on Regulatory Options for a Natural Medicines Register,
highlight such challenges:
“The voluntary nature of professional association membership is also the major
disadvantage of self-regulation.
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… it can lead to duplication of co-regulatory arrangements.
Exacerbating this, within any modality… there may be many different professional
associations a practitioner can choose from, limiting the financial and other
resources available to each one and confusing the public334.
It is clear that existing regulatory measures for Western herbal medicine practice are
insufficient to ensure standards of education and practice are maintained across the
profession.
Self-regulation is thus inadequate to protect the safety of the public or provide
assurance of professional standards of care for referrals from other health
practitioners88Error! Bookmark not defined.. Self-regulation therefore is an inappropriate
means of regulation.
7.1.2 Negative licensing
To improve the accountability of unregistered practitioners, the New South Wales
government developed a statutory Code of Conduct for unregistered practitioners.
The purpose was to remove individual health practitioners found guilty of gross
negligence or unscrupulous behaviour from practising and causing serious risk to
public health and safety333.
As applied in New South Wales Australia334, negative licensing may be a possibility
in the regulation of Western medical herbalists.
Negative licensing particularly targets334:
Practitioners who present a serious risk of harm to consumers because of
incompetence or impairment and
People who are unfit to practice because they repeatedly engage in unethical
or illegal practices.
“Disadvantages of the model are that while the existence of the code should of
itself have an educative and preventive impact, it also means individuals can set
up as practitioners with no necessary probity checks or qualifications. Action is
generally taken after harm has already occurred and generally relies on
complaints being made. This means there is strong reliance on public awareness
of the scheme and individual preparedness to make a complaint. The model also
relies on government for the adequacy of the resources it has to take action”334
Negative licensing is a reactive model that can only prosecute once harm has
occurred rather than a proactive model which may protect the public from sustaining
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harm through development and enforcement of high practice training and
standards333.
Further the implementation of negative licensing would require the establishment of
a statutorily enforceable ‘code of conduct’ and in so doing, negative licensing simply
forms a variation in statutory regulation.
Currently negative licensing does not form part of the regulatory landscape for health
practitioners within New Zealand and would therefore require considerable legislative
and structural development in order to implement. Therefore development,
implementation and operation costs would significantly exceed possible benefits,
whilst outcomes would be less effective than existing statutory regulation structures
within the HPCAA.
7.1.3 Statutory regulation
Statutory regulation under the HPCAA is the established model for the regulation of
healthcare professions within New Zealand. As well as being applied to ‘main
stream’ health professions it has also been applied to a number of other
complementary and allied health professions for example chiropractics and
osteopathy.
Given that the practice of Western herbal medicine poses a similar risk to the public
as other regulated health professions statutory regulation is the appropriate tool for
the regulation of the profession.
Further, as with other health professions and in the interests of public safety, there is
a need to acknowledge the requirement for specialist skill sets and appropriate levels
of training in order to practice Western herbal medicine safely and effectively.
As a well-established model, statutory regulation has frameworks and operational
models/structures that can be, as with other professions, applied to Western herbal
medicine.
Statutory regulation could therefore represent the lowest implementation cost both in
terms of legislation and practical terms. Whilst it falls short of extending regulation
from the (current) regulation of title, to (the preferred) regulation of both title and core
practices, it provides the best model for increasing public safety given the limited
efficacy evident in the current self-regulatory model. The regulation of core practices,
that is formulation, prescription, manufacturing and/or dispensing of herbal medicine
based on Western herbal medicine philosophy could, and in fact should, be
legislated through the Medicines Act or future Natural Health and Supplementary
Products Act, which in its current wording, provides no clear definition of a Natural
Health Practitioner, a major inadequacy of the current Medicines Act.
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In 2007, during the consultation process on the regulation of the profession of Herbal
Medicine under the Health Practitioners Competence Assurance Act 2003
(‘HPCAA’), the then Acting Health and Disability Commissioner agreed that it would
be in the public interest for Herbal Medicine to be regulated as a health profession
under the HPCAA, as it would provide tools to ensure the competence of
practitioners and the safety of consumers, although they questioned how Medical
herbalists could be distinguished from other health providers such as naturopaths
and traditional Chinese Medical Herbalists332.
Naturopaths who formulate, prescribe, manufacture and/or dispense herbal
medicines to all intents and purposes are Medical Herbalists as in NZ not all
naturopathic institutions have included herbal medicine as a dominant focus in
education.
Traditional Chinese Medicine (TCM) is a practice that often includes acupuncture as
well as indigenous Chinese herbs, animal parts and other substances. TCM is
furthermore based on a completely different conception and philosophy of biological
processes, diagnoses and treatment approaches to that of western herbal medicine
practice. Traditional Chinese medicines are mostly used in different dosage forms
from that of western herbal medicine. The two disciplines are therefore very different
from each other and would require separate regulation.
Within the current non-statutorily regulated environment there are no legally
enforceable means of ensuring public safety or the proper training and practice of
herbal medicine. This has resulted in inappropriately qualified and/or inappropriately
supervised practitioners of the modality with direct and potentially serious
implications for public risk and loss of confidence by both public and other health
professionals.
New Zealand Association of Medical Herbalists considers the current self-regulatory
framework to be insufficient to ensure public safety and that statutory regulation is
necessary.
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Appendix 1
THE NZAMH CONSTITUTION [2010]
1. NAME
The name shall be the New Zealand Association of Medical Herbalists (1983)
Incorporated.
2. INTERPRETATION
In this Constitution except where a contrary indication appears:
‘Practise’ shall mean the provision of advice regarding treatment with Western herbal
medicine.
‘A.G.M’ shall mean ‘Annual General Meeting’ of the Association.
‘Association’ shall mean ‘New Zealand Association of Medical Herbalists (1983)
Incorporated’.
‘Committee’ shall mean ‘governing body of the Association’ as defined in Rule 12.
‘N.Z.A.M.H.’ shall mean New Zealand Association of Medical Herbalists (1983)
Incorporated.
‘President’, ‘Secretary’, etc. shall mean ‘President of the Association’, ‘Secretary of
the Association’, etc.
‘Year’ shall mean ‘financial year of the Association, as defined in Rule 23.
3. OBJECTS AND PURPOSE
(a) To maintain a Register of Medical Herbalists.
(b) To ensure that every person registered and given professional membership meets the following standards:
(i) They practise according to the Ethical Standards of the Association;
(ii) They have a proper understanding and knowledge of Herbal Materia Medica;
(iii) They have been adequately trained in the essential medical sciences and have had suitable clinical training and experience.
(c) To monitor the standard and quality of the teaching of Herbal Medicine (see
Schedule 4).
(d) To promote Herbal Medicine to the public and other health professionals.
New Zealand Association of Medical Herbalists (1983) Inc.
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(e) To represent members of the Association (and the cause of Herbal Medicine) in
respect of any legislation concerning Herbal Medicine, and make submissions to
the appropriate authorities on their behalf.
(f) To encourage/ provide ongoing professional education for members of the
Association.
(g) To publish and circulate a newsletter and any other material of interest to
members.
4. TRAINING STANDARDS
(a) The Committee shall monitor the standard and quality of the teaching of Herbal
Medicine theory and practice as carried out by the Educational Institutions that
teach Herbal Medicine, and are accredited by the Association.
(b) The Committee shall at its own discretion formally recognise the qualification
conferred by those Educational Institutions, which teach the theory and practice
of Herbal Medicine to a level which meets the Association’s standards.
(c) If the standard and quality of the teaching carried out by any Educational
Institution does not meet the Association’s standards then the Association shall
at its own discretion not recognise the qualifications conferred by any such
Educational Institution.
5. AFFILIATIONS
(a) In keeping with the objects and purpose of the Association, N.Z.A.M.H. may
affiliate with any other body or bodies that the membership sees fit.
(b) Branches of the N.Z.A.M.H. may be formed. The N.Z.A.M.H will represent these
branches.
6. MEMBERSHIP
Members of the Association shall be divided into 4 classes:
(a) Professional members - members practicing herbal medicine, including:
(i) Full or part time practitioners giving advice to clients, whether the client is
paying or not
(ii) Those involved in the formulation or manufacture of medicinal herbal
products for public consumption.
(iii) Those involved in the training or supervision of students in the practice of
herbal medicine.
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(b) Associate Members – members who do not practise but have an interest in
herbal medicine, including:
(i) Educational Institutions.
(ii) Owners and/or employees of business retailing or wholesaling herbal
medicine, who do not provide herbal advice or recommend medicinal
herbal product to customers.
(iii) Other Individuals
(c) Student members – members who are studying toward a herbal medicine
qualification at an NZAMH recognized college.
(d) Fellow members – members of long-term standing who have distinguished
themselves in any branch of the profession OR rendered any conspicuous
service to the Association OR retired from professional practice after long
service to the profession
A Professional Member shall:
(a) Do nothing to bring Herbal medicine, or the Association, into disrepute.
(b) Shall have complied with a curriculum of training and passed examinations that
the Committee accept or prescribes;
OR
Fulfilled the education standards as set by the Committee
(c ) When renewing accreditation / practice certificates each year, each member
must:
(i) furnish proof of having completed professional education relating to the
clinical practice and professional development of herbal medicine, as
specified by the current Continuing Professional Education standards;
(ii) have paid the current annual subscription;
(iii) provide evidence of a current first aid certificate (in case of disability,
provide evidence of current training to instruct others in first aid) from an
NZQA provider.
An Associate Member:
(a) Must do nothing to bring Herbal Medicine, or the Association in disrepute.
(b) Must not practice herbal medicine.
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A Student Member:
(a) Must do nothing to bring Herbal Medicine, or the Association, into disrepute.
(b) Will be in the process of completing a course at an NZAMH recognised
institution.
A Fellow Member:
(a) Must do nothing to bring Herbal Medicine, or the Association, into disrepute.
(b) The Association may elect as Fellow members of the Association anyone who
has distinguished themselves in any branch of the profession OR rendered any
conspicuous service to the Association OR retired from professional practice
after long service to the profession.
(c) If practicing herbal medicine, when renewing accreditation/practice certificates
each year must –
(i) Provide evidence of a current first aid certificate (in case of disability,
provide evidence of current training to instruct others in first aid) from an
NZQA provider.
7. REGISTRATION PROCEDURES FOR MEMBERS
Candidates for Professional Membership must:
(a) enclose the annual membership fee and a one-time only application fee with a
completed application form.
(b) attach photocopies of diplomas/ degrees in Herbal Medicine from their College of
Herbal Training and photocopies of other relevant qualifications. The said
photocopies must be certified as true copies of the original documents by a
Justice of the Peace, Public Notary or Barrister or Solicitor of the High Court of
New Zealand.
(c) If the application is declined the Committee may give an explanation as to why it
has been declined and the Committee will give an explanation as to the reasons
for declining an application if the applicant requests an explanation. The
committee may suggest further training or other appropriate action.
(d) If the Application is successful the applicant’s name is then put on the
Association’s Official Register. A properly signed and sealed certificate is
issued and may be displayed as evidence of Registration with the Association.
(e) The decision of the Committee is final and there is no right of appeal.
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Candidates for Associate and Student Membership must:
(a) enclose both the annual membership fee and a one-time only application fee with a completed application form.
8. ASSOCIATION REGULATIONS
(a) No member other than a Professional Member shall utilise the name, goodwill or
facilities of the Association for monetary gain, to enhance personal reputation, to
solicit patients, or to obtain personal benefits.
(b) Only those on the ‘PROFESSIONAL’ Register may use the title ‘Registered
Medical Herbalist’ and ‘Registered with the New Zealand Association of Medical
Herbalists’. Approved abbreviation is MNZAMH.
(c) Members not on the ‘PROFESSIONAL’ Register may not use their membership
nor the name ‘Member of the New Zealand Association of Medical Herbalists’ or
any other variations of it for any purpose.
9. SUBSCRIPTIONS
(a) The annual subscription for individual members shall be fixed at the AGM.
(b) Any member whose membership subscriptions are in arrears for more then 3
months will have their names removed from the membership roll and may by
required to make a new application for membership should they wish to rejoin.
(c) If a member wishes to suspend membership they may apply for an exemption for
up to 3 years. They will not be issued with a practising certificate during this time.
(d) To enable membership to be maintained (including receiving the NZAMH
journal) the subscription for a Professional Member granted an exemption shall
be the same as that set for an Associate member.
10. COMPLAINTS, DISPUTES, DISCIPLINE
(a) If any member shall willfully refuse or neglect to comply with the provisions of the
Constitution/Code of Ethics or shall be guilty of any conduct which in the opinion
of the committee is unbecoming of a member or prejudicial to the interest of the
Association, the committee shall have the power by resolution to censure,
suspend or expel the member from the Association.
(b) The Association’s Committee will establish a complaints committee and if
necessary a disciplinary committee to carry out these procedures. (See
Appendix - Code of Ethics).
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11. RESIGNATION
Any member may resign from membership by giving to the Secretary of the
Association notice in writing to that effect.
12. OFFICERS/COMMITTEE OF THE ASSOCIATION
(a) The Officers of the Association shall be the President, Vice President,
Membership Secretary, Correspondence/Minutes Secretary, Treasurer, Student
Representative and up to six others.
(b) The Officers of the Association shall be appointed at the AGM of the Association
each year. In the event of resignation of an officers(s), an acting officer(s) to fill
the position(s) until the AGM, shall be appointed by vote at a general meeting of
the Association.
(c) The entire management of the Association and its property shall be deputed to
the Committee. The Committee must inform all members of the Association
regarding proposed changes to its management of the Association and its
property in order that proper discussion and if necessary voting can be held
regarding important decisions.
(d) The Editor of the newsletter may be an ex officio member of the Committee if
she/he so desires.
(e) The Immediate Past-President may be an ex officio member of the Committee.
(f) Members of the Association may be nominated, seconded and elected to the
Committee at a General meeting of the Association, should a quorum of
members be present and voting, if deemed necessary.
(g) The Committee has the right to co-opt additional members of the Association to
attend its meetings or help in its functions, should the need arise. Such
appointments should however be on a temporary basis, and only after a majority
of Committee members deem it necessary to do so.
(h) Members may resign from membership of the Committee by giving to the
Secretary of the Association notice in writing to that effect at least fourteen days
prior to the date the resignation is to become effective.
(i) Members may be expelled from membership of the Committee by resolution
passed at a General Meeting of the Association excepting that this resolution
must have been specified in the meeting agenda and reasonable effort must
have been made at least twenty one days before the meeting to notify the
member or members to be expelled.
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13. ELECTION OF COMMITTEE
(a) Nominations shall be called from all financial members within all branches of the
Association.
(b) Nominations may be only for Professional members excepting for the Student
Representative.
(c) Exceptions can be made when there is no professional member available for the
position and a student/ associate member, who may have special skills and who
is competent enough to undertake a particular duty, is available.
(d) Nomination for Executive positions and Committee members must be received in
writing at least forty eight days before the AGM. Nominations must include the
name of the nominator as well as a seconder and should be accompanied by a
profile of the nominee. Except in case of 12(f).
(e) Ballot papers will be sent no less than 30 days prior to the AGM. These will
include a brief profile of each proposed nominee.
(f) Voting will be finalised at the AGM after a final and definitive count of all votes.
(g) The Student Representative on Committee shall have been elected by the
student members.
(h) Appointment of the Committee shall be made at the AGM. Members may be
elected to vacant positions on the Committee at any General Meeting of the
Association.
(i) If there is no more than one nomination for each position on the Committee there
is no need to hold a postal ballot.
14. COMMITTEE MEETINGS
(a) A Committee Meeting may be called at any time by an Officer of the Association.
(b) Notice of any Committee meeting shall be given to every member of the Committee at least 48 hours before the meeting.
(c) At each meeting five (5) shall constitute a quorum.
15. COMMITTEE VACANCY
The position of a member of the committee shall become vacant if the member:
(a) Becomes of unsound mind or person whose person or estate is liable to be dealt
with in any way under the law relating to mental health.
(b) Resigns the office by notice of writing to the Association.
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(c) For more than six months is absent without permission of the Association from
meetings of the Association held during that period.
(d) Ceases to be a member of the Association.
16. PERSONAL LIABILITY OF OFFICERS OF THE ASSOCIATION AND OF COMMITTEE MEMBERS
(a) No Officer of the Association shall be personally liable for any act or omission
(including negligence). The liability of such Officer of the Association shall be
limited to the assets of the Association.
(b) No member of the Committee shall be personally liable for any act or omission
(including negligence) concerning the management of the association. The
liability of such Officer of the Association shall be limited to the assets of the
Association.
(c) The preceding clauses shall not absolve any officer of the Association or member
of the Committee form taking proper care in paying full attention to their duties in
acting responsibly and with due diligence and where necessary obtaining proper
knowledge in seeking competent advice pursuant to the carrying out of their
respective office.
17. PROFESSIONAL INDEMNITY INSURANCE
The Committee may effect professional indemnity cover in such amount as the
Committee in its discretion deems appropriate for the Association and for all of the
members of the Committee against any liability (including statutory liability) which
may arise out of any act or omission in the course of the Committee’s conduct of the
business of the Association.
18. GENERAL MEETINGS OF THE ASSOCIATION
(a) General Meetings of the Association shall be called by the Committee:
(i) upon its own initiative; or
(ii) within sixty (60) days of receiving a request to do so, in writing
signed by 50% or more of the members of the Association.
(b) Items to be included on the agenda shall be given to the Secretary of the
Association not less than seven (7) days before the meeting.
(c) The Secretary of the Association, not less than seven (7) days before any
General Meeting of the Association, shall notify or make reasonable effort to
notify all members of the time, place, and date of the meeting. An agenda shall
also be available seven (7) days before the meeting.
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(d) The quorum at any General Meeting of the Association shall be seven (7)
members.
(e) The chairperson at any general meeting of the Association shall be the President
or if he/she is not present the Vice President, followed by the Secretary, followed
by a nominated member of the Committee or if none are present some financial
member chosen by the meeting.
(f) Only Professional and Fellow members have the right to vote. If any issue
arises, directly pertaining to students, a motion may be formed at a General
Meeting to enable students to vote on this issue.
(g) Every Professional and Fellow member shall have one vote, and in the case of
equality of votes, the chairperson shall have a second or deciding vote. Voting
will be by ballot. Two or more persons shall be appointed as scrutineers. The
scrutineers shall not have a vote and should preferably be non-members.
19. ANNUAL GENERAL MEETING OF THE ASSOCIATION
(a) The A.G.M shall be held within the first 60 days following the end of the financial year (31st March) on a date determined by the Committee.
(b) A statement of Accounts and Balance Sheet shall be prepared and a copy shall be given to each member of the Association at or prior to the A.G.M.
20. BANK ACCOUNTS
The Funds of the Association shall be lodged with a Trading Bank or Savings Bank.
The bank books, cheque books, together with the Association’s Books of Accounts
shall be produced by the treasurer at each Committee Meeting.
21. INVESTMENTS
If the Committee so determines, any part of the funds of the Association may be
invested in the manner provided by the Trustee Act 1908 or any Act amending or
replacing the same.
22. CONTROL OF FUNDS
(a) The Association’s bank account shall be operated upon the signature of any two
Officers of the Association.
(b) All accounts shall be passed for payment by the Committee, payments under
$1,000 to be approved by two members of the committee, payments over $1,000
to be approved to two members plus the President.
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(c) The Committee shall have power to borrow such amounts and on such terms as
it thinks fit, and to give security therefore and interests thereon such security as
the Committee may determine (in accordance with Rule 12(c).
23. FINANCIAL YEAR
The financial year of the Association shall end on the 31st March each year, to which
date the accounts shall be balanced.
24. ALTERATION OF THE CONSTITUTION
These rules may be rescinded, altered or added to by an ordinary resolution passed
at a General Meeting of the Association, excepting that the proposed repeal,
alteration or addition must have been specified in the agenda and that all financial
voting members have been notified twenty one (21) days prior to the meeting.
25. WINDING UP
(a) The Association shall be wound up in accordance with the Incorporated Societies
Act 1908 or any Act amending or replacing the same.
(b) Upon winding up, any Association assets remaining after payment of all
Association liabilities shall be disposed of in such a manner as passed by
resolution at the General Meeting convened for the purpose of winding up the
Association.
SIGNED BY THREE OFFICERS OF THE NEW ZEALAND ASSOCIATION OF MEDICAL HERBALISTS (1983) INC.
1. PRESIDENT:
Name Date:
Occupation
Address
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2. OFFICE HOLDER Position:
Name Date:
Occupation
Address
3. OFFICE HOLDER Position:
Name Date:
Occupation
Address
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Appendix 2
NZAMH Education Standards Standard One – The educational institute 1.1 The educational institute should preferably be recognised by the NZQA.
1.2 The relevant educational course must be approved by the NZAMH to the
minimum standard of a NZQA level 6 three year diploma, or equivalent, with the
goal of working toward a NZQA level 7 degree. In 2020 all graduate and new
membership requires a minimum of level 7 Bachelor degree.
1.3 The management of the teaching institution supplies such information to the
NZAMH for approval.
Standard Two – Curriculum 2.1 The curriculum is reviewed every 2 years or as advised by the NZAMH.
2.2 The curriculum should be written and reviewed in consultation with lecturers,
practitioners and other stakeholders within the community.
2.3 The NZAMH should be advised of any major curriculum change.
2.4 The curriculum has an identifiable and integrated focus consistent with the
philosophy of Western herbal medicine.
2.5 The curriculum identifies expected outcomes.
2.6 The curriculum allows for appropriate clinical experience that encourages
students to integrate knowledge.
2.7 The curriculum is consistent with the scope of practice of medical herbalists.
Standard Three – Curriculum Content The scope and content of the curriculum includes theory and related clinical
experience to enable students to achieve the expected outcomes of the programme.
3.1 The content includes:
Core knowledge
Anatomy and physiology
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Biochemistry
Nutrition
Pathophysiology
Botany
Plant identification
Herbal horticulture
Sustainability
Herbal materia medica*
Pharmacology (herbal and common medications)
Herbal therapeutics
Introduction to Rongoa Maori
Health promotion
Models of health and wellbeing
History and philosophy of Western Herbal Medicine
Politics of natural health in New Zealand
Cultural awareness
Professionalism and ethics
Safe practices
Relevant New Zealand legislation
First aid clinical practice
Basic research skills
Common biomedical diagnostic procedures and biomedical treatments
Naturopathic diagnostic procedures and treatments
Practice and business management
*The herbal materia medica content should include
- a minimum of 150 herbs including New Zealand natives
- a knowledge of herbs with a narrow therapeutic margin
Students should develop the skills necessary to build upon this knowledge once in
practice.
Professional Practice Skills
The ability to gather, analyse, critically assess and record a client’s holistic
(mental, emotional and physical) health history
The ability to perform basic clinical skills appropriate for the assessment of
client’s health
The ability to interpret and integrate the history and physical examination
findings to arrive at an appropriate treatment
The ability to formulate a safe and comprehensive healthcare management
plan with the client, integrating theoretical and clinical knowledge
The ability to communicate sensitively and effectively to clients, their families
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and other health professionals
The ability to recognise when to refer to other health professionals
The ability to use information technology resources appropriately
Cultural competence
knowledge of the Treaty of Waitangi and its implications
psychological, cultural and spiritual well-being of clients and their families
3.2 The programme provides supervised clinical practice for a minimum of 200
clinical hours for all students, including a minimum of 50 client contact hours.
3.3 The clinical programme experiences have well-formulated learning outcomes
which relate to the competencies for the scope of practice of Western medical
herbalists.
3.4 Where an educational institute uses external student clinical hours and clinical
placements these should be rigorously documented and monitored.
Standard Four – Teaching staff The curriculum is implemented by lecturers who are qualified for their roles, or who
are assisted to obtain these qualifications.
4.1 Lecturers/supervisors involved in the clinical programme should have at least five
years clinical experience and should have a current client base.
4.2 Lecturers involved in the herbal programme should have at least three years
experience in herbal medicine practice.
4.3 Lecturers/supervisors should have current NZAMH practicing certificates.
4.4 Lecturers must maintain and update knowledge and skills relevant to the area in
which they are teaching.
Standard Five – Teaching and Learning The environment supports the teaching-learning process and there is documentation
to demonstrate this.
5.1 Teaching and learning resources are appropriate to achieve programme
outcomes and purposes.
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5.2 Student performance is assessed against learning outcomes relevant to practice.
5.3 There is a process for ensuring relevant and appropriate student assessment.
5.4 Students undertake a variety of assessments to test application of knowledge
and clinical skills.
5.5 There is a process of moderation in place for all courses.
NZAMH Competencies Medical herbalists assess health needs and support and enable individuals, families,
groups and communities to restore, maintain or improve their health. They apply
their knowledge competently and appropriately and always have regard for safe
practice. They practise independently and in collaboration with other health
professionals. Medical herbalists may also use their expertise to educate, research
and promote health and well-being. Medical herbalists have an in-depth knowledge
of herbs as medicines including herbal horticulture, plant identification, manufacture
and prescribing according to individual needs.
There are five domains of competence for medical herbalists.
Core knowledge
Medical herbalists should have a knowledge and understanding of:
Anatomy and physiology, biochemistry, nutrition, pathophysiology, botany and
plant identification, herbal materia medica, pharmacology (herbal and
common medications), herbal therapeutics, history and philosophy of
Western Herbal Medicine, first aid, clinical practice and basic research skills.
The aetiology, pathophysiology, symptoms and signs, progression, and
prognosis of common mental and physical ailments at all life stages.
Common biomedical or naturopathic diagnostic procedures and biomedical
treatments.
The psychological, cultural and spiritual well-being of clients and their families,
and the interactions between people and their social and physical
environment.
Professional Practice Skills
Medical herbalists should demonstrate:
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The ability to gather, analyse, and critically assess record a client’s holistic
(mental, emotional and physical) health history.
The ability to perform basic clinical skills appropriate for the assessment of
client’s health.
The ability to interpret and integrate the history and physical examination
findings to arrive at an appropriate diagnosis or differential diagnosis.
The ability to formulate a safe and comprehensive healthcare management
plan with the client, integrating theoretical and clinical knowledge.
The ability to recognise when to refer to other health professionals.
The ability to use information technology resources appropriately.
Cultural Competence
Cultural Competence refers to the acquisition of skills to better understand members
of other cultures in order to achieve the best health outcome (Mason Durie, 2001).
It is important to recognise that culture includes but is not restricted to age, gender,
sexual orientation, occupation, socio-economic status, ethnic origin or migrant
experience, religious or spiritual belief, disability.
Medical herbalists will
Understand the relevance of the Treaty of Waitangi to the health of Maori in
Aotearoa/New Zealand.
Demonstrate cultural safety and practice in a manner which follows culturally
appropriate assessment.
Show an understanding and respect for clients’ cultural beliefs, values,
practices and individual differences.
Have an understanding of their own cultural beliefs, values and practices.
Communication
Medical herbalists will
Use effective communication at all times including being able to listen and
respond sensitively and effectively, to clients and their families, other health
professionals, and the general public.
Be aware of barriers that impact on communication and act appropriately.
Professional responsibility
Medical herbalists will
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Practise lawfully in regard to all relevant legislation.
Abide by the NZAMH Code of Ethics.
Work within the Scope of Practice.
Visibly display the current annual practising certificate issued by the NZAMH
and the NZAMH Code of Ethics.
Visibly display all relevant information on consumer rights, under the Health
and Disability Commissioner Act and Health and Disability information.
Recognise that their primary professional responsibilities are the health
interests of the client and the community.
Demonstrate a commitment to ongoing learning and professional
development, and an appreciation of the responsibility to maintain standards
of natural health practice at the highest possible level throughout a
professional career.
Demonstrate an appreciation that they must act with integrity when they
supply clients with product.
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List of herbs for Materia Medica
Education establishments are required to teach 150 herbs made up of 75 Mandatory
herbs and a further 75 of their own choosing including medicinal NZ plants.
Mandatory herbs:
Achillea millefolium Yarrow
Aesculus hippocastanum Horse Chestnut
Allium sativum Garlic
Aloe spp. Aloe vera
Althaea officinalis Marshmallow
Andrographis paniculata Andrographis
Arctium lappa Burdock
Arctostaphylos uva-ursi Bearberry
Astragalus membranaceus Astragalus
Avena sativa Oats straw/ seed
Bacopa monnieri Bacopa
Berberis vulgaris Barberry
Boswellia serrata Boswellia
Bupleurum falcatum Bupleurum
Calendula officinalis Pot Marigold, Calendula
Capsicum minimum Capsicum, cayenne
Centella asiatica Gotu kola
Cinnamomum zeylanicum/ C. cassia Cinnamon
Crataegus oxycantha/C. monogyna Hawthorn
Curcuma longa Turmeric
Echinacea angustifolia/E. purpurea/E. pallida Echinacea
Eleutherococcus senticosus Siberian ginseng
Equisetum arvense Horsetail
Euphrasia officinalis Eyebright
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Filipendula ulmaria Meadowsweet
Foeniculum vulgare Fennel
Fucus vesiculosis Bladderwrack
Galium aparine Clivers
Gentiana lutea Gentian
Ginkgo biloba Ginkgo
Glycyrrhiza glabra Licorice
Gymnema sylvestre Gymnema
Hamamelis virginiana Witch hazel
Harpagophytum procumbens Devil’s claw
Humulus lupulus Hops
Hydrastis canadensis Golden Seal
Hypericum perforatum St John’s wort
Inula helenium Elecampane
Lavandula officinalis Lavender
Leonurus cardiaca Motherwort
Matricaria recutita Chamomile
Melissa officinalis Lemon balm
Mentha x piperita Peppermint
Paeonia lactiflora Peony
Panax ginseng Panax, Korean ginseng
Passiflora incarnata Passionflower
Phytolacca decandra/P. americana Poke root
Piper methysticum Kava
Rehmannia glutinosa Rehmannia
Rhodiola rosa Rhodiola
Rosmarinus officinalis Rosemary
Rumex crispus Yellow dock
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Salix alba White willow
Salvia officinalis Sage
Sambucus nigra Elder
Schisandra chinensis Schisandra
Scutellaria baicalensis Baical scullcap
Scutellaria lateriflora Skullcap
Serenoa serrulata/S. repens Saw Palmetto
Silybum marianum St Mary’s Thistle
Taraxacum officinale (folia and radix) Dandelion (leaf and root)
Thuja occidentalis Thuja
Thymus vulgaris Thyme
Trigonella foenum-graecum Fenugreek
Turnera diffusa Damiana
Urtica dioica/U. urens Nettle
Vaccinium myrtillus Bilberry
Valeriana officinalis Valerian
Verbascum thapsus Mullein
Verbena officinalis Vervain
Vitex agnus-castus Chaste tree
Withania somnifera Withania
Zea mays Corn silk
Zingiber officinale Ginger
Zizyphus spinosa/ Z. jujube Zizyphus
New Zealand Native Plants
Coprosma robusta Karamu
Dodonoaea viscosa Akeake
Hebe salicifolia Koromiko
Hoheria populnea Hoheria
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Leptospermum scoparium Manuka
Macropiper excelsum Kawakawa
Myrsine australis Red Matipou/Mapau
Pomaderris kumerahou Kumerahou
Solanum aviculare Poroporo
Phormium tenax Harakeke
Kunzea ericoides Kanuka
Phyllocladus trichomanoides Tanekaha
Podocarpus dacrydiodes Kahikatea
Podocarpus totara Totara
Porphyra columbina Karengo
Gnaphalium luteo-album Pukatea
Pseudowintera axillaris Horopito
Dysoxylum spectabile Kohekohe
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Appendix 3
CODE OF ETHICS
(CODE OF CONDUCT, COMPLAINTS AND DISCIPLINE)
Preamble
Medical Herbalism involves a relationship between practitioners and patients
that is based on principles of integrity, trust and beneficence. Medical
Herbalism supports and enables individuals, families, groups and
communities to restore, maintain or improve their health.
This code of ethics has been developed for Medical Herbalism within the New
Zealand context, and shares many aspects with the ethical practice of Medical
Herbalism in the western world.
This code of ethics is a set of principles that serves to guide good professional
conduct for Medical Herbalism. These principles delineate the nature of a
contractual basis, which is made between a Medical Herbalist and patients,
colleagues, professional acquaintances and the public at large. It does not
serve as a statute but may be used as a benchmark for professional conduct
within the profession of Medical Herbalism.
This code cannot resolve all ethical issues but does provide a framework for
addressing ethical and Medical Herbalism practice-related issues.
This code of ethics expresses the general principles applicable to all Medical
Herbalists and then identifies the specific areas of ethical practice along with
annotations. The general principles are addressed and blended within the
sum of these specific areas.
Due to the changing nature of Medical Herbalism practise; alongside the ever-
changing face of health care, this code of ethics will be reviewed every three
years or, if deemed necessary, at short notice.
General Principles
The general principles of the code of ethics are as follows:
Respect for Autonomy
Non-malfeasance
Beneficence
Justice
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Specific Areas of Ethical Practice
The specific areas of ethical practice of the code of ethics are as follows:
1: Compliance with the Code of Ethics
2: Relations with Patients
3: Relations with Colleagues
4: Relations with the Public
5: Competence
6: Practice Management
7: Infringement of the Code of Ethics
8: Complaints Procedures
9: Disciplinary Procedures
1: Compliance with the Code of Ethics
1.1: Members and practitioners of NZAMH shall at all times comply with the
code of ethics.
1.2: Compliance to the code of ethics will be considered when a complaint
is made against a member or practitioner of NZAMH. Practitioners
failing to meet the requirements of the code of ethics may be subject to
disciplinary measure on the grounds of unacceptable professional
conduct (see section 7).
1.3: Members and practitioners are reminded that this code of ethics is no
substitute for either medical or civil law.
1.4: Members, particularly practitioners, are encouraged to be covered by
professional and public liability insurance.
2: Relations with Patients
2.1: Practitioners shall recognize an obligation towards the patient at all
times, and shall practise their profession to the best of their ability for
the benefit of the patient. The patient’s comfort, welfare and future
health must always have priority.
2.2: No discrimination will be made against patients on any grounds
including age, race, colour, gender, religion, education, sexual
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orientation, social class, political belief, philosophical persuasion or
disability.
2.3: All actions and treatment applied to a patient must be carried out with
the informed consent of that patient or the caregiver of that patient. A
person from whom informed consent for examination or treatment is
sought must possess the necessary intellectual and legal capacity to
give consent. A patient will have the intellectual capacity if able to
understand in simple language what the examination or treatment is, its
purpose and why it is being proposed, to understand its principle
benefits, risk and alternatives, and to retain the information long
enough to make an effective decision with free choice.
2.4: Written or spoken consent must be obtained from the parent or
caregiver of patients under the age of sixteen (16) years who seek
treatment. Physical examination of a child under the age of sixteen (16)
years requires the presence of a third party, usually the parent or
caregiver.
2.5: Examination or treatment of any intimate area of any patient regardless
of age or gender requires the presence of a third party unless explicitly
agreed to by the patient. Consent for examination or treatment without
the presence of a third party should be recorded in writing.
2.6: In an emergency situation where the patient, or the patient’s caregiver,
is unable to give consent, treatment may be given if it is deemed to be
in the patient’s best health interests.
2.7: The confidence of the patient, and diagnostic findings acquired during
consultation, or in the course of treatment, shall not be divulged to
anyone without the patient’s consent except where required to by law
or where failure to take action would constitute a menace or danger to
the patient or another member of the community.
2.8: Practitioners shall not give guarantees regarding the results of any
treatment nor exploit a patient for financial gain through inferences or
misrepresentations of any sort.
2.9: Practitioners must act with consideration with regard to fees and the
justification for any treatment.
2.10: Practitioners shall not use their professional position to instigate nor
pursue an improper relationship with a patient, personal companion or
relative of that patient. This includes personal, professional, political,
financial or sexual gain.
2.11: Where deemed necessary the practitioner should refer patients
promptly to another competent health professional.
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2.12 Practitioners shall provide, to the satisfaction of the patient, details of
the herbal medicines prescribed, if requested by the patient to do so.
3: Relations with Colleagues
3.1: Members and practitioners must at all times conduct themselves in an
honourable manner towards other health care professionals
3.2: Members and practitioners should be respectful towards the treatment
philosophy of other health care providers.
3.3: Members and practitioners must not speak publicly in a derogatory
fashion of other health care providers.
3.4: Practitioners having patients referred to them by another practitioner
shall return such patients to the original practitioner when the specified
treatment is completed.
3.5: Members and practitioners shall not denigrate another practitioner's
treatment plan.
3.6: A practitioner shall not knowingly interfere with any ongoing treatment
instigated by another practitioner whilst the patient is under that other
practitioner's care.
3.7: Practitioners concerned with regard to a patient's treatment in any way
whatsoever must proceed to address these issues in a discreet and
professional manner through the appropriate channels.
3.8: When patients request a health care service outside the scope of
practice of the Medical Herbalist it is the responsibility of the
practitioner to assist with that request.
3.9: Practitioners shall respect the intellectual property of other practitioners and use it only with explicit consent.
4: Relations with the Public
4.1: Members and practitioners must at all times conduct themselves in an
honourable manner towards the public, irrespective of the medium
used (direct communication, newspaper, television, radio, internet, any
media avenue)
4.2: Members and practitioners will never make misleading claims
regarding the ability to treat or cure illness, nor imply abilities beyond
their competence.
4.3: Advertising must be in compliance with legal requirements.
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4.4: Advertising must be compatible and congruent with the standards of
the profession of Medical Herbalism and must not contravene any of
the points of the code of ethics.
4.5: Members and practitioners are permitted to lecture to the public on the
topic of Medical Herbalism where the purpose is to promote and further
the understanding of Medical Herbalism.
4.6: Practitioners shall not use titles or descriptions that give the impression
of medical or other qualifications to which they are not entitled.
5: Competence
5.1: Individuals are entitled to be members of NZAMH on the completion of
adequate training, as approved by the committee.
5.2: Members are responsible for undertaking continuing professional
development.
5.3: Practitioners must be aware of the current information regarding the
healing techniques they practise.
5.4: Practitioners shall not claim competence that they do not possess.
5.5: Practitioners shall diligently monitor their fitness to practise with respect
to their physical, mental, emotional and spiritual health.
6: Practice Management
6.1: Practitioners shall share the responsibility of upholding the integrity of
the profession of Medical Herbalism.
6.2: Practitioners shall act with honesty and integrity.
6.3: Practitioners are obliged to manage their practices with due diligence.
6.4: All external notices and name plates advertising any professional
practice should conform to legal and professional requirements.
6.5: Any persons employed within a clinical practice are required to be
suitably trained for their position.
6.6: The practitioner is responsible for any actions undertaken by an
employee or assistant working within their practice who is not
registered as a member of NZAMH.
6.7: Practitioners must provide a practice complaints procedure within their practice that is clearly visible to patients in accordance with the NZ Health & Disability Consumer Code of Rights. A standard complaints
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procedure notice for practitioners to display is available from the NZAMH.
6.8: Practitioners shall display current practicing certificates and this code
of ethics in a prominent position in their premises within easy viewing
of the patient.
6.9: Practitioners premises must be maintained in a safe and hygienic
condition.
6.10: Practitioner's are responsible for the safe and effective disposal of
items deemed unsafe.
6.11: Telephone email and internet (including web cam) consultations with unknown persons are to be strongly discouraged. Where in exceptional circumstances a face-to-face consultation is not practical, the practitioner:
a) must ensure that the patient is assessed by an appropriately qualified practitioner before any course of treatment is recommended;
b) has the responsibility to sight any relevant reports generated from a consultation conducted by another appropriately qualified practitioner;
c) should conduct a face-to-face follow-up consultation at least once every twelve (12) months if treatment of the patient is ongoing.
6.12: Patient confidentiality is a legitimate expectation of patients and must
be adhered to at all times. Practice personnel must maintain this same
level of confidentiality
6.13: Patient records are the responsibility of the practitioner.
6.14: Patient records must be kept in a safe and secure place for no less
than seven (7) years from the date of last appointment.
6.15: The transfer of patient records is to be carried out only with the consent
of the patient.
6.16: Patients or registered caregivers are allowed access to patient records
at all times.
6.17: Patient records can be disclosed without patient or caregiver consent in
situations of legal requirement or where failure to disclose would
constitute a menace or danger to the patient or another member of the
community.
6.18: Patient records and the information contained therein may be used in
instances of clinical trial, clinical audit, case-history reporting,
qualitative research or any other method of research only with the
informed consent of the patient or caregiver concerned. This must be
accompanied by an assurance of maintenance of confidentiality
New Zealand Association of Medical Herbalists (1983) Inc.
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6.19: Whenever acting as locum tenens practitioners shall not attempt to
secure the future care of any patients.
6.20: Practitioners in private practice are expected to prescribe herbal
medicines in combinations that are individualised to the needs of the
patient that they are treating at that time.
6.21: Practitioners should not use herbal medicines derived from any wild
species that are known to be threatened or endangered in their natural
habitat. Practitioners have a responsibility to ensure that they are
aware of the population status of herbal medicines. Practitioners
should be aware of and respect any treaties and national laws relating
to medicinal plant conservation, especially the 1993 Convention on
International Trade in Endangered Species of Wild Fauna and Flora
(CITES). Information is available from the NZAMH.
6.22: Practitioners should respect Article 24 of the 2007 United Nations
Declaration on the Rights of Indigenous Peoples, namely that
"Indigenous peoples have the right to their traditional medicines and to
maintain their health practices, including the conservation of their vital
medicinal plants... ".
6.23: NZAMH is opposed to genetic engineering and/or modification of
medicinal plants as being contrary to and not conforming with
traditional usage. Members therefore have a duty not to prescribe or
recommend plant medicines or foods derived from this technology.
6.23: Practitioners shall continue to develop their professional knowledge
and share this knowledge with colleagues, other relevant health
professionals and the public.
7: Infringement of the Code of Ethics
7.1: Infringement of this code of ethics may render members liable to
disciplinary action with subsequent loss of privileges and benefits of
registration with NZAMH.
7.2: Any complaint against any member can only be upheld if there is
shown to be a breach of the code of ethics.
7.3: The interpretation of infringement of the code of ethics cannot be
exhaustive and is intended as guidance only.
New Zealand Association of Medical Herbalists (1983) Inc.
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8: Complaints Procedures
8.1: A Convenor of the Complaints Committee will be appointed at the first
Committee Meeting of the Association in each financial year.
8.2: At least two other members will be recommended as potential
Complaints Committee members at this same committee meeting.
They will then be available if called on.
8.3: A complaint may be presented to the President of the Association if it is
believed that any member has wilfully refused or neglected to comply
with the provisions of the Constitution/Code of Ethics, or is guilty of any
conduct unbecoming to that member, or prejudicial to the interest of the
Association.
8.4: The complaint shall be in writing.
8.5: Any written complaint received by the President of the Association
must be passed to the Convenor of the Complaints Committee
immediately.
8.6: The Convenor of the Complaints Committee must begin action within
fourteen (14) working days of the complaint being received by the
President of the Association.
8.7: Said Convenor will then appoint at least two other members to the
Complaints Committee to deal with this specific complaint, one of
whom may be a non-member of the Association. At least one person
on this committee must have knowledge and experience of the area
under consideration. None of the Complaints Committee members
should be involved already in this particular case. It is recommended
that both genders be represented on this committee. This committee
has the power to co -opt, and, if deemed necessary, to consult a
lawyer.
8.8: Any complaint received will be processed in a fair, open and
transparent manner with prompt information disseminated to the
parties involved. Full details of the complaint will be sent to the
defendant by the Convenor of the Complaints Committee within
fourteen (14) working days of the receipt of the complaint.
8.9: If the Complaints Committee decides that the complaint is not one with which it is empowered to deal with, a report will be made to the Committee of the Association and the complainant will then be informed of this in writing by an officer representing the Association Committee.
8.10: The first objective of the Complaints Committee is a resolution of the dispute.
New Zealand Association of Medical Herbalists (1983) Inc.
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8.11: It is recommended that a meeting with both parties be held as soon as possible. It may be that the Complaints Committee deems it appropriate to meet with each of the parties separately first.
8.12: A mediation process is to be considered a priority.
8.13: If the defendant is shown to be not in breach of the Code of Ethics/Constitution and is deemed not guilty of conduct unbecoming of a member or prejudicial to the interests of the Association, then it is to be recommended to the Committee of the Association that the complaint be dismissed.
8.14: If the defendant is deemed in breach of the above, then a full report is to be made to the Committee of the Association, with recommendations of the disciplinary action to be taken.
8.15: If the involved parties are dissatisfied with any part of the complaints
process the matter can be referred to the Health and Disability
Commissioner.
9: Disciplinary Procedures
9.1: If the Complaints Committee recommends disciplinary action, either the
President of the Association or a member appointed as Convenor of
the Disciplinary Committee shall appoint at least two more members to
the Disciplinary Committee.
9.2: It is recommended that these include one person of each gender. The
two appointed members can, but do not need to be members of the
Association.
9.3: Disciplinary action may take the form of censure, suspension from the
Association, expulsion from the Association, a fine of up to $1,000 or a
recovery of costs to the Association from one or both parties. There
could be a combination of some of these actions.
9.4: It could be recommended that the matter be referred to the Health and
Disability Commissioner.
9.5: The Convenor of the Disciplinary Committee shall inform the
complainant, the defendant and the NZAMH Committee of the
disciplinary action to be taken within fourteen (14) working days of the
decision being made.
9.6: The defendant shall also be given the date of the next scheduled
committee meeting of the Association.
9.7: The defendant may then give notice that she/he will be appealing this
disciplinary action at this committee meeting. The defendant may at this
New Zealand Association of Medical Herbalists (1983) Inc.
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committee meeting give orally or in writing any defence that she/he
sees fit. The full committee will then decide whether to uphold or to
change the disciplinary action.
9.8: No member, except for the purpose of pleading her/his case, shall take
part in the determination of any dispute in which she he is personally
involved.
9.9: If a member is fined, or expected to pay costs, and has not paid, that
member is not entitled to voting rights, receipt of the Association
magazine or meeting attendance. The Association retains the right to
follow standard debt recovery procedures if necessary.
9.10: No member, who has been suspended or expelled or chosen to resign
as a result of a complaints process, is entitled to any refund of
subscription or other sum.
9.11: Readmission to NZAMH once struck off is entirely at the discretion of
the Officers of the Association.
New Zealand Association of Medical Herbalists (1983) Inc.
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Appendix 4
Scope of Practice - Medical Herbalist General Scope of Practice Medical Herbalists provide primary health care based on nutrition, Western Herbal
Medicine, biomedical science and traditional philosophy of practice.
Medical Herbalists principally use herbal medicine a traditional system of medicine
and nutrition to promote well-being and healing. Western Herbal Medicine is based
on observation and experience passed down over thousands of years and includes
modern scientific information and research into phytomedicine, phytopharmacology
and nutritional science. These are combined with the medical sciences of anatomy,
physiology, biochemistry, pathophysiology, pharmacology and clinical diagnosis as
well as the science of botany. Medical Herbalists practice within a traditional holistic
framework of restoring and supporting the inherent self-healing processes within
each individual patient and by treating the whole person rather than just a disease or
isolated part of the body.
Medical Herbalists promote health and well-being and provide primary health care
through assessment, advice, education and treatment to clients. Medical Herbalists
practice independently in a variety of settings including clinical, education, research
and an advisory capacity, commonly in shared care with other primary health
practitioners.
In the clinical setting, a medical herbalist utilises diagnostic and assessment
techniques for the identification of disease, disorder and dysfunction. They perform
comprehensive health assessments through case history and physical examination,
identifying differential diagnoses, and ordering and interpreting diagnostic tests.
Medical Herbalists provide appropriate herbal and nutritional therapy and practical
lifestyle advice for health improvement.
Medical Herbalists working in education, research and advisory roles utilise their
professional education and practice experience to provide education and advice to
individuals, groups and communities on health promotion and prevention of ill health.
Medical Herbalists include but are not limited to the use of nutrition and herbal
preparations as their primary therapeutic tool. Medical herbalists may prescribe and
formulate herbal prescriptions for therapeutic application which can be dispensed or
extemporaneously compounded for that client.
New Zealand Association of Medical Herbalists (1983) Inc.
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Medical Herbalists work in collaboration with other health professionals wherever
possible to ensure clients receive the best possible health care including risk
management and referrals.
Transitional arrangements
Medical Herbalists who are full members of “NZAMH” and who meet Annual
Practising Certificate requirements are granted full registration as Medical Herbalists
within the scope of practice.
Qualifications
New Zealand Graduates
Level 6 Diploma in Herbal Medicine or Naturopathy [that meets NZAMH herbal
education standards] or their equivalent.
From 2020, NZAMH will require a bachelor degree in Herbal Medicine and/or
Naturopathy [that meets NZAMH herbal education standards] or their equivalent.
Medical Herbalists from Overseas
a. Qualification in herbal medicine accepted by:
- National Herbalists’ of Australia Association (NHAA)
- European Herbal and Traditional Medicine Practitioners’ Association
(EHTPA)
- National Institute of Medical Herbalists in the United Kingdom (NIMH)
- Australian Register of Naturopaths and Herbalists (ARONAH)
b. Overseas qualifications and experience are assessed on case by case basis
for eligibility for full practitioner membership. This process requires details of
the course completed including proof of at least 200 hours of clinical practice
(if recently qualified) and details of the applicant’s recent practice/experience.
c. The applicant may be requested to submit case studies for review by the
education sub-committee if their suitability is unclear, at which point limited
registration would be granted.
d. Limited registration may be granted to those deemed to require additional
training or clinical supervision to achieve eligibility for professional registration.
Practising Certificates
Medical Herbalists who are professional members of “NZAMH” are required to apply
for an Annual Practising Certificate. Annual Practising Certificates are only awarded
if Continuing Education requirements are met and verified.
New Zealand Association of Medical Herbalists (1983) Inc.
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Reserved Titles for Registered Medical Herbalists
Medical Herbalist.
Phytotherapist.
Clinical Herbalist.
Practitioner of Western Herbal Medicine.
Herbalist
New Zealand Association of Medical Herbalists (1983) Inc.
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Appendix 5
Practice Profile Practice profile of an independent Medical Herbalist, 1
st April 2004 – 31
st March 2005
Hart Road Herbal Medicine Clinic
Client gender Female Male
74% 26%
Age of clients 1 – 29 30 – 49 50 – 69 70+
10% 34% 38% 18%
Major diagnoses of clients (Most clients had multiple medical conditions)
Skin conditions Anxiety or depression CVD/Hypertension Menstrual/Female GU Digestive problems Endocrine conditions Musculoskeletal Hypercholesterolaemia Respiratory disease Obesity/Weight management Male GU Cancer Migraine Chronic Fatigue Syndrome
35% 28% 23% 22% 20% 16% 14% 11% 10% 10% 6% 6% 4% 4%
Clients referred by Medical Herbalist for laboratory test
32%
Major medications already prescribed by General Practitioner
Cardiac/BP meds Antidepressants Hormonal therapy Lipid lowering drugs Steroids Anti-inflammatories Prescribed analgesics Pr/pump/H2 inhibitors Bronchodilators Sleeping pills Oral contraceptives Antihistamines
33% 21% 18% 18% 15% 12% 15% 12% 9% 8% 6% 6%
Self prescribed supplements client was taking on first consultation
Vitamins Minerals OTC herbs Essential fatty acids OTC analgesics
28% 23% 13% 11% 8%
Clinic treatments purchased by client after consultation, assessment and discussion of treatment options
Diet/lifestyle advice Herbal products (practitioner) Minerals/vitamins/amino acids Essential fatty acids Individualised herbal tinctures Herbal creams Probiotics
100% 87% 77% 50% 47% 13% 6%
Follow up visits Nil One Two Three Four Five of more
12% 28% 15% 7% 10% 28%
Client outcomes No improvement Small improvement Moderate improvement Significant improvement Unknown
5% 32% 33% 21% 9%
New Zealand Association of Medical Herbalists (1983) Inc.
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