At the recent European Chiropractic Union conference in London BCA president Richard Brown outlined why the UK regulatory model is a “cracking success”, I wonder if the pun got a laugh or were there chiropractors present who knew the reality of regulation for the chiropractic profession. Many will see the medicaliseation of chiropractic as a good thing narrowing scope of practice to diagnosable conditions which respond to various treatments and NHS contracts. Forgetting the words of Ivan Illich that by “focusing on illness” we are marginalising ourselves from the majority of healthy people who chiropractors have most to offer. There is no cure for osteoarthritis by the time signs and symptoms have developed from prolonged spinal joint dysfunction / Subluxation, the degenerative process has begun. Immobilise a joint guess what happens GCC chiropractic skeptics? Keep the joints moving what happens then??
As usual BCA med heads like to complicate a very simple process. Brown told chiropractors that The emphasis placed upon patient protection was the over-riding factor that influenced the medical profession to support legislation for chiropractors and was probably the factor that ensured it was smoothly and successfully steered through Parliament. (Presumably to achieve this the BCA had to convince the medical profession that chiropractic is dangerous and the public needed protecting from dangerous unscrupulous chiropractors.) The groundwork undertaken by the BCA in establishing support consistently stressed that for the public to be adequately protected, the chiropractic profession needed to be subjected to a robust system of regulation.
Brown then goes on to explain the benefits of mandatory continuing professional development. Effective from 1 September 2004, all registered chiropractors were mandated to provide evidence of their postgraduate and learning activities by filing a return to the GCC each year. The impact of this on chiropractors was a formalised system of post-graduate learning; while many chiropractors had always engaged in a process of lifelong learning, this was not the case for all. Nevertheless, as a maturing profession, taking responsibility for continuous improvement could not fail to be in the public interest and from a safety perspective, patients stood better protected from those taking a cavalier attitude to practice. However it might be reasonable at this point to ask if the BCA were being cavalier in accepting physiotherapists and medical doctors setting these GCC “standards” of education for the chiropractic profession. Because the GCCs education committee had no answers when challenged by “Skeptic Barista” who merely questioned the fundamental principle underpinning chiropractic; that there is a relationship between the structure of the spine and the function of the nervous system and wellbeing (subluxation theory).
If this relationship does not exist as stated by the GCC, then how can the GCC claims that chiropractic is anything more than a very expensive massage. The GCC will claim the evidence states “Manipulation” is an effective treatment for back pain, but what is causing the pain- NERVES? You would struggle to get ten chiropractors to agree on a medical diagnosis of back pain because of the complexity of the structure of the spine. However most chiropractors could agree on a “vertebral subluxation dysfunction” as a cause of pain and now the GCC is telling registered chiropractors that because they have not been able to answer the questions of a skeptic wind up merchants chiropractic must change. I have engaged with the skeptics and never given an inch, I can agree to disagree. Skeptics are perfectly entitled to their opinions and reading their blogs they are not going to change their minds, even with the better lawyers or plethora’s of evidence. Its difficult to understand why it is more important for the BCA/GCC alliance to win a few skeptics over and ignore the vast majority of chiropractors and their patients. What amuses me is the sketics are still scathing of the GCC, apparently unable to appreciate the only reason anyone is paying any attention to Zeno et al is because the GCC is only regulator who would investigate these complaints. Which takes us to Browns analysis of the Fitness to Practise.
Fitness to practise
Perhaps the most significant consequence of the Chiropractors Act 1994 was the inception of fitness to practise hearings. Chiropractors whose fitness was impaired, either for health reasons or for reasons of conduct or competency, could now be subjected to investigation into their actions with the potential consequence of their having their ability to practise being suspended or withdrawn. For the first time, chiropractors were subjected to legally enforceable rules and their practice could be publicly scrutinised. This scrutiny intensified in the wake of the Bristol14 and Shipman15 inquiries and a number of recommendations were made that impacted on the accountability of health professionals. The failings highlighted in both inquiries prompted a review of standards, criteria and thresholds to guide future fitness to practise panels and to ensure that by their actions the public was protected from similar tragedies in the future.
Chiropractic regulation brought with it a heightened awareness of a profession that hitherto was little known. The publicity that accompanied the passing of the Act and a greater knowledge and utilisation of chiropractic treatment brought with it expectations in line with medical care, that of results-based intervention and high standards of conduct, practice and education. For some chiropractors this was as unexpected as it was unwelcome. The euphoria of anticipated benefits of regulation was quickly replaced with a realisation that accountability was very real and that a failure to reach expected standards may be met with patient complaints and, worse still, referral to fitness to practice tribunals.
The Chiropractors Act required that all allegations against chiropractors be formally investigated by the Investigating Committee.16 There is no room for latitude in the legislation; no matter how trivial the complaint seems, the matter has to be considered by the Investigating Committee. For the chiropractic profession this had and continues to have a number of implications.
Loss of livelihood is a major life event, rivalling divorce, bereavement and bankruptcy. Hearings of the Professional Conduct Committee (PCC) of any of the healthcare regulators strike fear into any respondent facing proceedings, not least because of the available sanction of erasure or suspension from the register. For this reason, it remains one of the most relevant consequences of regulation. For patients, chiropractors and society, the assurance that unacceptable professional conduct can be addressed is one of the strengths of regulation.
There seems no doubt that, had the pan-professional Health Professions Council (HPC) been in existence prior to 1994, the chiropractic profession would have been included under the banner of its numerous professions; indeed, the Foster Review17 makes the point that no new regulatory bodies will be formed, all health professions henceforth being targeted for HPC inclusion.
There are clear risks to the profession in subsuming chiropractic into a body such as the HPC. The separate and distinct nature upon which it has prided itself would be diluted, not least in the eyes of the public who, even now, find it difficult to distinguish between chiropractors and osteopaths. Incorporation into a body in which there are in excess of 20,000 physiotherapists would also be likely to present difficulties; the ethos of a primarily NHS-driven organisation will clearly differ from chiropractic and the historical friction between the professions is likely to make chiropractors deeply suspicious of a disproportionate influence within the HPC.
It is therefore for the chiropractic profession to clearly demonstrate that it has the need to remain autonomous. It needs to do this by acting in a manner that shows its maturity as a profession and its ability to regulate itself effectively to afford maximum patient protection. Although it has been given a stay of execution as a result of the impending UK General Election in 2010; within 5 years, the eyes of the regulatory world will be on the GCC to prove itself worthy of retention as an autonomous body. Success in this area will not guarantee continued sole-profession status but, without a fight, chiropractic as part of a larger regulator seems a distinct possibility.
This ominous prediction of future professional homogenisation tends to suggest that a further programme of streamlining is inevitable. One could argue that with two professions such a chiropractic and osteopathy, governed under near-identical legislation with a similar scope of practice and patient profile, this may be a sensible move. The role of a ‘Manipulative Therapists Council’ may not present significant difficulties of transition or merger, at least as far as the individual professions are concerned. However, it seems more likely that as small regulators they will be subsumed into the much larger HPC.
Statutory regulation of chiropractors has necessarily brought with it exposure to the full impact of regulatory reform. The shift from voluntary regulation to self regulation and the inclusion of the profession under the umbrella of the UK statutory regulated health professions has resulted in it being subjected to legislation which, despite not having arisen from the actions of chiropractors, has nevertheless had a profound effect on the regulatory framework to which they are subjected. Events have changed the way that chiropractors are regarded in law and by their patients and by other healthcare colleagues. The level of accountability for chiropractors has risen in line with the raising of the bar generally amongst healthcare professionals.
Yet, while the focus may be predominantly on conduct, regulatory reform both in the United Kingdom and Europe has impacted in other ways on the lives of chiropractors. Any study of such reform would not be complete without consideration of the Human Rights Act,18 but other legislation has also affected chiropractic practice, such as that relating to the use of ionising radiation and  and accessing patient records.21
One of the most contentious recommendations to come out of the Shipman Inquiry was the revalidation of health professionals. This required that set standards be met for a health professional to remain on their statutory register. It was stressed that such a system of revalidation had to fulfil two criteria: it had to be formative (an aid to development) and summative (there had to be a check that the required standard had been met). For the chiropractic profession in the UK, the format is still subject to consultation, yet it seems inevitable that chiropractors will need to demonstrate core competency on an ongoing basis.
From a relatively comfortable position of self-regulation, healthcare reform has resulted in significant changes for chiropractors and the patients whom they serve. The delivery of health care for all regulated professions has been forced to change through tragic events and the pace of reform has been swift and dramatic. While protection of patients must be the prime objective, this has arguably led to a common practice of defensive medicine, but has also led to a ‘council of perfection’ approach in which healthcare professionals are judged differently and the bar has been elevated to aspirational but unrealistic levels. An emphasis on the civil standard of proof in regulatory hearings has done little to help the fears of practitioners in practice, who perceive that the Sword of Damocles is constantly hanging over them.
For patients, this change hopefully assures them of better standards of care and protection from those who do not meet designated standards. That they can trust their health care provider to deliver safe, effective care is fundamental and regulatory reform has placed these central tenets at the top of the agenda. The process of reform will result in societal changes in attitudes to healthcare with heightened expectations that medical and non-medical professionals may find difficult to satisfy.
Whether this will result in a migration of chiropractors into allied but non-regulated professions remains to be seen. The growth in popularity of the chiropractic profession will dissuade those considering joining lesser known groups, yet a perception of ever-increasing pressures on their practice may drive them to depart. Should this occur, the very objective of regulation will fail; that patient protection is afforded by statutory regulation will have no bearing on these practitioners. However, in reality, it is unlikely that this will occur in great numbers and chiropractors will adjust to the new system of regulation despite protestations of an overbearing system that suffocates their freedom to manage patients and deliver traditional chiropractic care.
Change is inevitable. The opening of the Register back in 1999 started these changes; chiropractors instantly became more accountable for their actions and, for those who chose to register, this accountability meant being answerable to a body which had the power to divest practitioners of their livelihoods. Regulation was soon realised to be a double-edged sword. Fiercely criticised by those expecting a benevolent organisation, the GCC soon became a figure of dislike and distrust amongst those force to comply with standards at odds with their previous practice style. Reform has further fuelled these attitudes and, along with the establishment of a super-regulator, control of the profession has been diminished and a perceived authoritarianism has replaced any initial feelings that statutory regulation might be first and foremost a self-interest group.
Under the umbrella of self-regulation, chiropractors have been subjected to a tide of change that has engulfed all regulated health professionals. Patient protection has been central to this revolution; on the back of historic public inquiries, the chiropractic profession has been forced to adopt changes to its regulatory systems and constitutions that have dismantled a duty to promote the profession and have distanced chiropractors from the regulation of chiropractic.
In the United Kingdom and throughout the rest of the world, there continue to be protagonists, seeking development and furtherance of the profession, and antagonists who strive to plot its downfall. Both groups will shape the future of chiropractic, influencing public opinion, politics and professionalism. The adoption of ideas and the learning of lessons from mistakes made in health care in general and chiropractic in particular will ensure a continued focus on the profession in years to come.
The near-utopian existence that has benefited many chiropractors may be reaching a crossroads. The growth in numbers may limit career opportunities in private practice and, with lessening availability, may come a more concerted effort towards inclusion. The Musculoskeletal Services Framework (MSF)22 and the implementation of the NICE guidelines23 may bring about a change in policy from those who previously had not considered chiropractic to be a viable care option for those suffering from back pain. Future inclusion of chiropractic services in NHS care models may therefore be a realistic prediction over the next decade and several proposals for inclusion have been forwarded,24 although collaborative projects25 will rely upon clear lines of communication between professions and a willingness to embrace new approaches.
Certainly, the prospect of a harmonisation of chiropractic education and standards across Europe seems desirable, yet the regulatory status of nations is irregular and in some cases non-existent. Consequentially, such harmonisation may be some way off, yet a commitment from EU ministers gives encouragement that non-medical practitioners will be included in future health measures.
Future aims for the chiropractic profession must be to secure legal recognition in all nations; to achieve this aim, influence must be brought to bear on governments to secure the political will to drive regulation forward. The model adopted by the UK, i.e. that of focussing on the protection of the public and securing support from the medical profession, has been effective in achieving legislation and integration. Learning from the experience of other nations is vital, and it seems that future countries’ regulation will be under an umbrella act that provides similar frameworks for various professions26 and reflects WHO policy supporting full integration of traditional and complementary/alternative medicine.
The incorporation and implementation of national guidelines will change some historical perceptions of chiropractic; perceptions that, regrettably, have been perpetuated by various quarters of the profession, intent on promoting an evangelistic image of questionable ethical value, and perceptions promoted by those opposing chiropractic for no other reason than malevolence and professional jealousy. The responsibility and duties imposed on the profession by statutory regulation have meant that, over time, the status of chiropractic both in the UK and the world has evolved. That status differs from nation to nation: from South Africa, where chiropractors are regulated with allied health professionals, to Switzerland, where chiropractic education and regulation affords parity with medical doctors. The independent status of the UK, at least for now, ensures recognition as a separate and distinct profession.
The Chiropractors Act was welcomed by those for whom regulation of the profession represented a giant leap forward in terms of acceptance and public protection. The culmination of years of dedicated lobbying, conciliation and unification placed chiropractic on the healthcare map of the United Kingdom, a small profession gaining the recognition of Parliament and joining the elite club of health professions thought by many to be outside the regulation radar. The General Chiropractic Council was established, registration with which was thought to be the path to respectability and status. However, with rights came responsibility and with the advent of fitness to practise hearings, the profession was forced to wake up to the reality that regulation was in fact a double-edged sword.
Despite question marks over autonomy and separate regulation, the future for chiropractic is bright. Changing perceptions and a popularity that belies the diminutive size of the profession, coupled with a growing expectance from colleagues in other regulated health professions would suggest a future in which chiropractic maintains and develops its status as a safe, sound healthcare provider.
Notwithstanding threats to its independence, the status of chiropractic as a regulated healthcare profession will not be taken away and as such, the duties incumbent upon chiropractors will continue to be rigorous. Such rigour will ensure survival as the public continues to demand greater safety and performance from those professionals in whom they put their trust
Having read this, check out Zenos blog and the way his complaints are progressing and tell me Richard Brown or the BCA/GCC alliance is good for the development of the chiropractic profession in the UK.
Remember Chiropractors to not treat or cure conditions they correct subluxations and let homeostasis/ innate do its thing. The chiropractic profession should be thanking Zeno for focusing our minds on this concept. I shall continue to provide traditional chiropractic services as long as members of the public ask for it, the rest of the profession have the same choice I had. Die on your knees or champion the reforms so desperately needed in health care.