What's the alternative?

There are an estimated 500 types of alternative therapies currently available in the UK, with the market for this type of private healthcare rapidly expanding. Just 10 years ago, only a small number of therapies, such as osteopathy and homeopathy, were readily available either through an alternative medicine clinic or mobile therapist. Today, osteopathy is accepted as a mainstream means of treating a range of skeletal problems and has its own self-regulatory body.

What about the more obscure therapies such as crystal healing, gravitonics, aura-soma therapy, and rolfing? As strange as the names may seem, all are therapies being practiced across the UK. However, while some of these practitioners have their own regulatory body, as yet none of them is required to have compulsory public liability or professional indemnity insurance.

Most therapists take out policies either independently or via a group scheme with a recognised trade association.

An alternative therapist who is a member of an association is far more likely to receive a favourable quote for insurance than someone working independently. This is largely because most organisations have strict guidelines as to the qualifications required to be a practising therapist.

If a professional association is self-regulating and maintains high standards, underwriters are more confident members pose a lower risk than someone who works on their own.

A group package can often be substantially cheaper and is an attractive addition to membership of any organisation. The Federation of Holistic Therapists, for example, has more than 20,000 members, the majority of which are part of its group insurance scheme. Scheme participation costs £51 for £3m worth of product, third-party and public liability cover in addition to the £39 FHT membership fee and was negotiated through independent UK insurance broker Stuart Alexander. The policy provides cover for more than 80 different therapies with a choice of indemnity limit.

"Members affecting the insurance are covered for treatment liability, along with public liability and product liability if held legally liable or there is a negligent act, error or omission," explains Mark Forbes, executive director of client services at Stuart Alexander. "It is becoming difficult for a therapist to secure insurance outside of a professional association and they should be prepared for the cost to be significantly higher than the amount they would pay if they were, for example, an FHT member."

Several other key players in this sector, including Royal and Sun Alliance, Towergate SMG and Balens, provide group insurance packages for both large and small associations. These organisations tend to approach an insurance broker with a list of requirements and an outline of the level of professional practice required for membership. Some professional bodies are more choosy about qualifications and experience than others.

For example, the Association of Reflexologists and the International Federation of Reflexologists only allow therapists to become members if they have trained with a school that is accredited by them. In addition, the IFR insists that its members also hold a valid first-aid certificate.

"Associations decide what therapies they want to take on and what level of professionalism they are seeking," says Mr Forbes. "The more professional the criteria for a qualification, the better chance that association has for cover because it will be reflected in its claims record."

This theory is supported by Balens. "We get asked to consider a very wide range of therapies," explains David Balen, managing director. "We always look for a rigour in the structure and length of the course, an external examination process wherever possible, and we also want to see that students have an understanding of anatomy and physiology."

Most organisations will have their own code of ethics or practice and these provide a useful guide for insurers when trying to determine the risks associated with an alternative therapy; because a therapist should abide by an association's code, their actions can be brought in to question should a claim arise.

Risk management

It is vital that detailed notes are taken at every therapy session as actions for damages are now reportedly commonplace and a claimant has a three-year period in which they can bring a case against a practitioner.

The washing of hands both before and after a treatment using a bactericidal washing cream is important, particularly with the recent rise in cases of MRSA. All equipment must be sterilised and where any disposable needles, paper and gloves come in to contact with bodily fluids, they must be disposed of correctly via a local public health department. Such basic procedures can help to ensure therapists are at a lower risk of malpractice claims.

At present, only a small number of organisations are regulated by law, meaning individual insurers and specialist brokers need to keep a close eye on training practices and the efficacy of self-regulation. This is set to change; the Department of Health announced plans in March to set up a Complementary and Alternative Medicine Council, which will set minimum standards of training for therapists. Acupuncture is one such therapy, which will become regulated by 2006 under the Health Act 1999.

Mike O'Farrell, chief executive of the British Acupuncture Council, explains the current situation: "Out of our 2500 members, we currently insure 2164 through the group scheme with RSA. The others are general medical practitioners working within the NHS and are already insured. All of our members have come through an accredited college or university course totalling 3600 hours. As a regulatory body, we ensure standards are maintained and this, in turn, means our members receive a good deal on insurance."

Steps towards regulation are being welcomed by the insurance market, which hopes that the process of risk evaluation will become much more straightforward. "It is very difficult for insurers to police the alternative therapy market by saying that people should have this or that qualification," says Jo Mountain, associate director and head of operations at Towergate SMG. "We insure nearly 500 different therapies and for each different therapy you will have several schools offering a course - and we can't say which courses are acceptable. The purpose of regulation is to protect the public from bad practice and to ensure standards are consistent and policed."

Invasive therapy

A therapy is usually considered high risk if it is invasive, such as colonic irrigation and acupuncture, or if manipulation of the joints is necessary, as it is in chiropractice. Therapies tend to be divided into three risk categories: low, medium and high when determining the cost of premiums. Towergate SMG, for example, uses three rate bands, with therapies such as reflexology and counselling falling into the lowest rate band (band one) while homeopathy and allergy testing fall in to band two, and acupuncture and physiotherapy fall into rate band three.

"It is important to recognise that if the therapist is in any doubt about a medical problem that might be the cause of any symptoms presenting, a referral is made to a GP," explains Ms Mountain.

In addition to assessing risk based on how invasive the treatment is, the underwriter will also question the practitioner's ability to speak English if it is not their first language because communication is key.

They will be asked to show evidence that they are competent up to International English Language testing level seven, which is a requirement for anyone working in the NHS.

Liability claims vary depending on the treatment. Severe cases have included water being too hot in a colonic irrigation process; and misleading a patient by promising cures for diseases such as cancer can also lead to claims. "Many of the people who turn to complementary medicine are vulnerable and, under no circumstances, should a practitioner make claims that they can cure cancer," stresses Mr O'Farrell. "Communication is an important part of the process and practitioners must make clients aware of every stage of the treatment process."

Mr Balen agrees that problems often arise when the relationship between the patient and practitioner breaks down. "You have to remember that complementary therapy is largely in the private medicine sector and, therefore, people may have higher expectations. Often it is not so much that the practitioner has been negligent in the treatment but that, after one or two treatments, the relationship breaks down because the treatment process has not been explained or managed adequately and the patient's expectations were not met quickly enough." Sometimes symptoms can worsen, intensify or new ones appear as a part of the healing process, he explains, adding: "We support clients dealing with complaints or fee-refund requests in these situations".

Research by Howden Medical Insurance Services suggests that first-time patients represent an unusually high proportion of claims in this field and that lack of communication is a key factor in the decision to make a claim. In order to reduce this type of risk, the FHT has advised all of its members to give patients an after-care leaflet explaining any side effects that might occur as a result of the treatment.

A lack of accurate note-taking is also causing problems when it comes to defending claims. "Practitioners are getting caught out because they do not follow what is effectively common sense to a mainstream medical practitioner - that is the maintenance of clear and accurate records," says Sian Davies, senior associate at Plexus Law. She recommends that therapists take a detailed medical history, including details of the patient's GP and, where appropriate as well as with the patient's consent, liaise with the patient's GP to ensure there are no contra-indications to the proposed treatment.

"Defending therapists is made far harder with only limited notes. While it might seem inappropriate for practitioners to keep making notes during a therapy session, defending allegations without them can prove to be very difficult - particularly if you are defending a claim made years after the treatment, which itself covered months or, in some cases, years."

While the number of practising alternative therapists continues to rise, the cost of premiums remains low - with some insurance companies suggesting they have been too low for too long. "Some insurers remain rightly concerned about the sustainability of existing premium levels, and new insurers, although interested, will not compete until premiums are at a more realistic level," explains Asgar Hassanali, director of HMIS. "In the early 1980s, premiums were higher than they are today but with growth and increased professionalism, coupled with new entrants into the capacity market, very low rates were the product of the soft market in the 1990s."

There is a danger that increased regulation of alternative therapies will only increase the number of claims being made. As a result, insurers will have to make more payments to claimants, as well as covering the cost of legal fees incurred in defending such claims. Therefore, it may only be a matter of time before premiums increase in this area.

"At present, premiums for alternative medical practitioners are very cheap," says Ms Davies. She gives the example of a recent policy she saw whereby, for a payment of only £75, the practitioner secured an indemnity limit for any one claim of £2m. "As this area of practice expands and the number of claims increases, insurers are going to have to review the premiums being charged," she warns. "I can see there will be a significant increase in the future. On these types of policies there only needs to be a few large payouts by insurers to negate the profitability of the entire scheme for the insurer."