§ 1.16 p.m.
§ Mr. Sydney Tierney (Birmingham, Yardley)
I am grateful for the opportunity to raise the question of the registration of acupuncturists and the control of their premises. This is a subject of great public importance in the context of health and safety.
First, I want to refer to the outbreak of viral hepatitis B, relating to the practice of acupuncture in the Birmingham area in the past few months. The area medical officer to the Birmingham Health Authority has reported upon 20 clinical cases of viral hepatitis B, all of them traced to the same acupuncturist. He states that he is not aware how many of them have been primary cases or how many have been secondary cases—silent carriers of the virus—but when I spoke to him on Tuesday he confirmed that there is a total of 35 cases and that he does not know where the chain will end.
Viral hepatitis B is one form of infective hepatitis transmitted by direct injection with infected blood or blood products. It usually has a long incubation period of between six weeks and six months, and carriers of the virus are often unaware that they are carriers. The fatality rate is high, and the infection may also be associated with progression to chronic liver disease, including liver cancer. It is a notifiable disease and must be regarded as a potentially serious one. That is why I am speaking today.
The medical officer claims that acupuncture, tattooing and ear-piercing can, if done by unskilled persons, cause serious outbreaks of the infection. I do not want to dwell too much on tattooing or ear-piercing, but he is concerned at what he considers to be the contribution that they make to the viral hepatitis virus.
The outbreak of viral hepatitis B related to the practice of acupuncture is just one instance where unskilled persons using unsterile instruments, and working in unhygienic surroundings can cause serious lethal hazards within the community. The practice of the acupuncturist to whom these cases are related is conducted in the front living room of his home. A mattress on the floor serves 1175 as a couch. There is no wash basin in the room. The state of cleanliness leaves a great deal to be desired.
On submitting himself to medical examination at the time of the outbreak, he himself was free of the disease, and it seems fairly obvious in the circumstances that he must have contaminated his needles unwittingly on a carrier, and then used them on other patients without adequately sterilising them, thus perpetuating the infection.
One of the difficulties about this practice was that the acupuncturist concerned kept no records at all of his patients, their visits, the dates, and so on. Obviously, this created difficulty in trying to trace patients and thus institute preventive measures. This outbreak of hepatitis associated with acupuncture came as no surprise to the medical profession, according to the medical officer in Birmingham, as the practice of acupuncture has not been regulated or checked in any way in this country. As he has told me, the medical profession can move in only when the damage has been done. That is a rather serious situation. When the authorities moved in, they were frustrated. They could not carry out a follow-up operation because of an absence of records of the acupuncturist's patients.
At present there is nothing that can be done to prevent a similar situation from arising. That is the gravity of the situation. There is no legislation to control the practice and practitioners of acupuncture—or is there? There appears to be some confusion. Government Departments are not clear. Some think "Yes" and some think "No". I refer to my Question in the House on 7th July when I asked the Secretary of State for Health and Social Services if he will introduce legislation to seek to compel the registration of acupuncturists and enfore proper standards of hygiene and safety in their practice." My hon. Friend, the Under-Secretary replied:My right hon. Friend does not consider that new legislation to introduce compulsory registration of acupuncturists would be justified. Application of the Professions Supplementary to Medicine Act 1960 can be extended to provide for the creation of a registration board for acupuncturists should they themselves seek this and should the Council for Professions Supplementary to Medicine and the Privy Council agree following consultation with existing registration boards for other professions registered under the Act.1176 I do not want to pursue that part of the answer in great detail. I want to base my submission today on the premises rather than the theoretical argument about the registration of acupuncturists.
The rest of the answer to my Question—which is the most important part—continues:Registration would not in itself ensure hygiene.I accept that. I think that is readily understandable. The answer continues:A self-employed acupuncturist offering services to the public already has a responsibility under Section 3 of the Health and Safety at Work Act 1974 'to conduct his undertakings in such a way as to ensure, so far as is reasonably practical, that he and other persons (not being his employees) who may be affected thereby are not thereby exposed to risks to their health or safety '. Failure to comply with the provision of the Act can lead to prosecution which is the responsibility of my right hon. Friend the Secretary of State for Employment."—[Official Report, 22nd July 1977; Vol. 935, c. 754–5.]On receipt of that answer I turned my attention to the Health and Safety Executive. First, I contacted the department in the West Midlands. I raised the issue of the acupuncturist and Section 3 of the Health and Safety at Work, etc. Act 1974. The reply that I received from the Health and Safety Executive of the West Midlands stated:The proposition that the Health and Safety at Work Act might be used to control the work of a person offering professional advice or treatment is a difficult one. On the plain words of Section 3(2) of the Act it would appear that a self-employed practitioner has a duty under the Act to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that other persons are not thereby exposed to risks to their health and safety. This duty would appear to extend across the whole field of medical treatment and service as well as consultancies of all sorts. You will appreciate, therefore, that the issue is one of considerable importance.The proposition has not been tested in law so that there is, as yet, no authoritative interpretation of the Section. The Health and Safety Executive is, however, actively considering its implications and I will bring your interest to the notice of the persons concerned at my Headquarters.I have referred the content of my correspondence to the Health and Safety Executive at national level, but as yet I have not received a reply to my representations.
I say emphatically that this predicament must be resolved. The public cannot be so blatantly exposed to such health 1177 and safety risks. I know that there is a measure of disagreement about the practice of acupuncture. Members of the public have written to me to say that acupuncture treatment has helped them. A number of people in the Birmingham area have done that. I do not wish to disagree with them. I cannot adjudicate on the subject. Some people have said the opposite, and some are dubious. It is like many other issues that become controversial. I am not a medical man and I do not set myself up as an authority. I am merely concerned with the health and safety of my constituents and the public at large.
In the West Midlands there is one medically trained person, a doctor, who specialises in acupuncture. He is in full-time National Health Service general practice. He informs me in correspondence that he is against any form of registration of non-medically qualified acupuncturists. He seems to think that it will give them a standing of respectability within the profession that they have not earned and do not deserve. He says that the Medical Acupuncture Society, the local medical committee and the local branch of the British Medical Association take the same view. I can understand why my hon. Friend's Department takes that view. It is perhaps to be expected when the profession as a whole seems opposed to the registration of acupuncturists.
It is clear that to deal with the individual acupuncturist is a complicated exercise. Obviously, there is a great deal of resistance to registration within the medical profession. However, in my view, there is no reason why we cannot insist on clean and disease-free premises. The seriousness of the outbreak in the Birmingham area has led the county authority to include a section on the control of acupuncture in the West Midlands County Council Bill.
As I understand it, the Bill has already been deposited in Parliament. I have read the section relating to acupuncture, and the clauses seek to establish that there will be no practice of acupuncture in a district unless the practitioner is registered by the district council. Under the terms of the Bill, the district council may make byelaws for the purpose of securing 1178 the cleanliness of premises that are required to be registered as well as the instruments, materials, towels and other items. It concerns itself with the cleanliness of the persons employed in regard to themselves and their clothing. Appropriate penalties for non-adherence are included in the Bill.
The Bill is to be welcomed. It is positive and clear and meets a genuine need. No doubt the West Midlands County Council has included the acupuncture provisions in the Bill because of the seriousness of the situation in the West Midlands and Birmingham area. Nevertheless, the Bill contains 189 clauses covering a multiplicity of other subjects. It is primarily an exercise of consolidation. The tortuous journey through this place and the waylaying in another place constitute major hazards for any Bill, and certainly one with 189 clauses. The House will recall that the previous West Midlands Bill never got off the ground. It was a consolidation measure and parts of it were found acceptable and other parts were found to be unacceptable. On balance, it appeared that too many parts were unacceptable and the Bill was lost. In fact, it never got on its way.
Except for one local authority, I understand that authorities do not have bye-laws requiring the premises used by acupuncturists to be registered. There seems to be a great need for some urgent and positive Government action to deal with the problem. I raise that especially with my hon. Friend and his Department.
The area medical officer in Birmingham, in correspondence that I have had with him, states:There is no doubt that there is a rising reservoir of viral hepatitis B in this country The current incidence of acupuncture, tattooing and ear piercing only contributes to the bank of carriers. It is now accepted that hepatitis B is probably responsible for a very much larger proportion of chronic liver diseases than is generally regarded.Perhaps the Government should investigate what I call the needle men—the acupuncturists, the tattooists and the ear piercers—and determine standards of hygiene and safety. Certainly—this is the most important matter in my contribution—there should be some control over non-qualified acupuncturists and some check on how many there are in the country at large. The Government 1179 ought to legislate in the interests of the health and safety of the public and not leave it to local authorities to decide whether to do something about the problem.
As I have pointed out, it is not easy for local authorities to acquire the byelaws that they need. Even those which have acknowledged the seriousness of the problem and want to do something about it face difficulties in getting the appropriate byelaws and powers through this House, I revert to the point about the differences between the Departments or the difficulty of one Department enforcing legislation which has been in operation since 1974. The existing legislation—Section 3 of the Health and Safety at Work, etc. Act 1974—must be activated and, where necessary, the premises of acupuncturists must be brought up to standard.
§ Mr. Speaker
Order. I apologise fot interrupting the hon. Gentleman. It is only to let him know, in case he is under a misapprehension, that this debate must finish at quarter to two.
§ Mr. Tierney
Thank you, Mr. Speaker.
If it is difficult to license practitioners, it seems that in the short term it will be easier, where there is legislation, to license the practice—the premises. I appeal for serious consideration to be given to activating this part of the Health and Safety at Work, etc. Act. I realise that this comes under the jurisdiction of another Department, but my hon. Friend's Department is concerned when people who attend acupuncturists' premises are exposed to risk. I submit that it is vital to tackle the control of the disease by reducing the opportunity for spreading it. The control of premises would be helpful in that connection. It would have a salutary effect on lay practitioners of acupuncture and would encourage a safe practice. Unnecessary exposure to this potentially dangerous disease is unacceptable, and it must be curtailed to protect the public.
I hope that the Department will take the outbreak in Birmingham—not yet concluded, because of the chain of silent carriers of the virus—as a warning and will take steps to introduce appropriate and effective legislation to deal with this serious problem. I ask my hon. Friend not to wait for further outbreaks before something is done. This is an urgent 1180 matter which requires urgent attention. I ask him to heed the warning and to act in the interests of the safety and health of many of our citizens before it is too late.
§ 1.34 p.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Alfred Morris)
I am grateful to my hon. Friend the Member for Birmingham, Yardley (Mr. Tierney) for having raised this subject of considerable public importance. Indeed, he has given me the opportunity to dispel what seems to be a lingering misconception.
I know that my hon. Friend will be the first to accept that registration of a profession or of those who practise it provides no guarantee that it will be practised properly. I know that the analogy is not exact, but even the registration of motor vehicles does not ensure that their owners will keep them clean. The licensing of drivers, after they have been tested, may keep off the roads people who do not know how to drive. However, it does not prevent someone who has passed the test from driving recklessly.
My hon. Friend referered to the serious outbreak of hepatitis in the city of Birmingham. I am deeply concerned, as is my Department, that there should have been such a grievous outbreak of the disease in that city. Between May and October this year 36 cases of hepatitis, which were attributed to the practice of acupuncture, were reported in Birmingham. It is both understandable and proper that my hon. Friend, who represents a constituency from which some at least of these cases were reported, should have expressed his concern in this debate.
My hon. Friend expressed his concern previously and promptly when he put down a Question for written answer in July. There was concern in my Department then, as there has been on other occasions before and since, when techniques involving the piercing of the skin have caused hepatitis. Yet, as was said in reply to my hon. Friend's Question and to one from the hon. Member for New Forest (Mr. McNair-Wilson), I do not believe that the introduction of legislation to seek to compel the registration of acupuncturists will by itself remove the risk. It is not only acupuncture, unhygienically practised, which can cause or spread hepatitis. So, too, can ear 1181 piercing or tattooing. I hope that this will be as widely noted as it deserves to be, not least among young people. After all, hepatitis can be a most grievous condition. Unfortunately, even in the best regulated institutions, there are rare instances of infection notwithstanding the best preventive endeavours of those in charge. That does not mean that we should ignore the threat of hepatitis from unhygienic acupuncture, ear piercing and tattooing. We have to consider how best the threat can be countered and reduced.
I believe that legal powers already exist to provide for the inspection of premises and, where necessary, the prosecution of those who practise their professions in a manner which is a threat to health. Section 3(2) of the Health and Safety at Work, etc. Act 1974 imposes on an employer the obligationto conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that he and other persons (not being his employees) who may be affected thereby are not thereby exposed to risks to their health of safety.The same obligation is imposed by the same section of the Health and Safety at Work, etc. Act on the self-employed. Failure to comply with this legal requirement can lead to prosecution.
I am firmly of the opinion that if local and health authorities, which are themselves equally subject to the Act, Co-operate with the Health and Safety Executive, the Act can be invoked to curb the activities of anyone who by the careless practice of his profession, occupation or craft, threatens the health of people using his services. My advice is that the Health and Safety at Work, etc. Act can be as effectively used to enforce hygiene in ear piercing and tattooing as it can be to ensure the sterilisation of the needles used in acupuncture.
The Government are prepared to consider whether general empowering legislation is desirable to enable local authorities to control the hygiene of acupuncture, ear piercing and tattooing establishments. However—my hon. Friend will no doubt take careful note of this point—we believe that there are remedies in the law as it stands. Nevertheless, everything said by my hon. Friend will be carefully considered by my Department.
1182 The Health and Safety at Work etc, Act is, of course, of wide application and the inspectorate of the Health and Safety Executive is nessarily limited. In consequence, some local authorities may consider that other powers are needed to control the premises of people whose skills, carelessly performed, may lead to outbreaks of hepatitis. If a local authority comes to this view, it can seek powers to enable it to license the premises about which it is concerned. It can then impose conditions upon the licensing of such premises.
I am informed that some local authorities already have powers to control tattoo parlours. The West Midlands County Council, no doubt because of the very serious—and, I hope, not to be repeated—outbreak of hepatitis in Birmingham to which I have already referred, is seeking powers to require district councils to register acupuncturists and their premises and to make byelaws for the purpose of securing the cleanliness of such premises and of the persons employed in them. The Bill seeking these powers has already been presented to Parliament. My strong advice is, therefore, that high standards of hygiene should be required of and enforced upon anyone who offers services for which he charges and which may threaten the health of his clients or customers.
I am deeply aware that there are many people, including hon. Members of this House, who believe that acupuncture, if properly practised, has much to offer in the treatment of the sick. I shall not, therefore, limit my reply to this debate to my hon. Friend's concern about the uncontrolled practice of acupuncture as a threat to public health.
There are those who wish to see acupuncturists become State registered. Indeed, this is sought by the British Acupuncture Association and possibly also by other organiastions of acupuncturists. They believe that registration would give recognition to acupuncture as a medical therapy in its own right and permit its practice within the National Health Service by other than the comparatively few doctors who are now its practitioners. They believe also that it would enable the public who seek acupuncture treatment to distinguish between those who are qualified to provide it and those who are not. In this respect, 1183 what the proponents of acupuncture want and what my hon. Friend wants tend to coincide.
There are, however, difficulties, in registering the members of any therapeutic profession. These have been explained on a number of occasions in the past. This happened, for example, when my hon. Friend, the Member for Wood Green (Mrs. Butler), introduced a Private Member's Bill for the registration of osteopaths and also when Lord Ferrier, in another place, sought the registration and recognition of chiropractors.
We have a tradition in this country of self-regulating professions. It is initially for the professions to determine what is involved in the exercise of their professions, what training and qualifications their members require and what are the ethics and standards of practice demanded of them.
§ Mr. Tierney
I am not sure whether the right Minister is present. Perhaps we should have both Ministers here, one from the Department of Health and Social Services and another from the Department of Employment. I do not wish to become involved in the long argument about the medical people themselves. I hope that my hon. Friend will make a bit of a noise about the fact that existing law on the registration of premises is not being activated.
§ Mr. Morris
My hon. Friend can be assured that my Department has the closest possible rapport with the Department of Employment. I am in some difficulty about the time.
I was referring to the question of ethics and the standard of practice. Under the National Health Service Acts, the paramedical professions must practise therapies which arebased on a systematic body of knowledge, which may or may not be wholly scientific in character, which is compatible with the body of knowledge for the time being attributed to and acknowledged to be the basis of contemporary medical practice".That is not a quotation from the National Health Service Acts. It is a quotation from guidelines published by the Council for Professions Supplementary 1184 to Medicine in its annual report for 1976–77. The council intends to follow these guidelines in considering applications to extend the provision of the Professions Supplementary to Medicine Act 1960 to new professions. There is nothing to prevent acupuncturists from applying to the council for an extension of the Act's priorities to cover acupuncture. Indeed, I am told that the procedures necessary for making such an application have been explained in writing and at meetings with my Department to the British Acupuncture Association.
The Council for Professions Supplementary to Medicine is a statutory body. It is not controlled in any way by my right hon. Friend, and appeal from its decision is to the Privy Council. I cannot say how acupuncturists would fare if they applied to have the Professions Supplementary to Medicine Act extended to cover their profession. I do not and nor does my Department make value judgments about the comparative efficacies of different methods of treatment. We quite properly leave such judgments to be made by the medical profession as a whole. This is demonstrated in the way that its profession exercises individual clinical judgments. The Royal Colleges and their speciality organisations speak on behalf of the profession. We look to the Council for Professions Supplementary to Medicine on the basis of applications made to the council to determine to what professions to extend the application of the Act. It is for the council to create the machinery for the State registration of the members of professions whose members accept that their work is supplementary to medicine.
The law does not exclude the offering of new therapies which the medical profession has not yet generally adopted or recognised. Nor does the law exclude the introduction to this country of forms of treatment which are exotic but very old, as is the case of acupuncture. The law permits practitioners of such therapies to offer them under the common law. Meanwhile, our traditions permit the spread of new ideas or the removal of old ones. Their acceptance or rejection depends ultimately, of course, on the people at large and by Parliament as their representatives.
I am sorry that I have not been able to give as comprehensive a reply as I 1185 should have liked, but I am mindful of the importance of the claims of hon. Members who have later debates. My Department will remain in contact with my hon. Friend about the other points that he raised in his speech.