This document is largely made up of things I have stolen from other people – notably Peter Buxton’s excellent article in OT some years ago which predicted precisely the problem the GOsC now faces.  I have stolen ideas and words from many other people and documents as well, and I make no claims for originality in any of the following.

The following is not complete: it is not intended to be a finished article, merely some ideas to form a basis for discussion.  It is intended to give some idea of one way that an alternatice framework could be structured.

1. Principles

Osteopathy is an approach to healthcare that is centred on the patient rather than the disease and that seeks to facilitate a return to health.  To understand osteopathic practice it is necessary to recognise the principles on which it is based:

1.1 The body has intrinsic systems of maintenance and repair

At the core of Osteopathy is the understanding that our bodies have intrinsic systems of maintenance and repair, which normally enable a return to health and full function following an insult.  The body also has some ability to adapt and compensate for dysfunction, but where the systems of maintenance and repair are impeded to a degree that exceeds the body’s capacity to adapt, health will be impaired.

The intention of the osteopath is to enhance the intrinsic health-maintaining and health-restoring capabilities of the individual person. This involves the consideration of a broad range of factors to identify and resolve the causes of impaired health with emphasis on the patient rather than their disease.

1.2 The body is an indivisible unit

Although it is customary to consider the body in terms of “systems” and “regions”, for convenience in teaching and study, no system or region of the body can exist in isolation and the body functions as an indivisible whole.  Impaired function in any part of the body will cause effects elsewhere.

The underlying cause of symptoms may be remote from the site of the symptoms themselves.  Similarly, it is possible for a therapeutic intervention to produce effects remote to the site of its application.

1.3 Rational approach to clinical reasoning based on science

Osteopathy is based on scientific discovery, especially in the fields of Anatomy and Physiology.  Osteopathic assessment is based on rational, critical clinical reasoning to apply knowledge in an integrated and informed manner. 

As scientific knowledge develops, so osteopathic practice is bound to change and develop, even though its principles remain the same.

1.4 The individual is unique

Every patient is a unique individual; the specific path from health to illness is unique to the individual and the instance.  The path of returning to health will also be unique to the individual and will be influenced by a wide range of factors which will combine and interact in a way that is also unique to the individual.

Osteopathic treatment and management of a patient’s health is tailored to the needs and circumstances of that particular individual.

1.5 Relationship between structure and function

Structure and function are inseparably related.

The selection of the specific intervention in osteopathic treatment is informed by an appreciation of the relationship between the functional and structural changes in the patient.

1.6 Importance of Movement

Movement is one of the characteristics of life.  It is essential for the efficient working of the body’s inherent maintenance and repair mechanisms and thus to health.

A principal aim of osteopathic treatment is to improve mobility: both the mobility of individual joints and also the overall mobility of the patient.

1.7 Importance of the neuro-endocrine control systems

The body’s intrinsic mechanisms of maintenance and repair are influenced by the neuro-endocrine control systems.

Interventions that influence the neuro-endocrine control systems may affect the body’s intrinsic systems of maintenance and repair.

1.8 Importance of vascular and lymphatic flow

Tissue health is dependent on adequate vascular and lymphatic flow.

Interventions intended to improve vascular and/or lymphatic flow can form a significant part of the osteopathic treatment approach.

1.9 Importance of the axial skeleton

The axial skeleton links the head and extremities and contains the pathways of neurological control. 

Poor spinal function may cause effects throughout the body, and dysfunction in peripheral areas may cause effects in spinal function.

1.10 Manual mediation of investigation and treatment

Use of the hands in both assessment and treatment is a characteristic of Osteopathy.

While adjunctive methods may be used by some osteopaths, the primary methods of osteopathic treatment are manual and applied mainly through the musculoskeletal system.

1.11 Respect for patients’ rights and values

The patient is an individual person who is entitled to respect and personal dignity.  They are entitled to their own values and opinions; these form an essential part of the individual person and are taken into consideration within the assessment and treatment.  Osteopathy aims to put patients in charge of their own health and enable them to assist their own recovery to and maintenance of health as far as possible.

The osteopath works in partnership with the patient to identify the factors contributing to impaired health and the measures that will enable the patient to take responsibility for their own return to health.

1.12 Professional independence and compatibility with congruent practitioners

Osteopathy is an independent system of primary contact healthcare.  Osteopaths practice autonomously, taking full clinical responsibility for the care of their patients, and will co-operate with and refer to other healthcare practitioners where this is appropriate.

Respect for and co-operation with other healthcare professionals, as appropriate for each patient, is an intrinsic part of being an autonomous healthcare professional.

2. Osteopathic Practice

Because Osteopathy centred on the patient, every aspect of assessment and treatment is tailored to the individual, and every consultation will be different.  Osteopaths use a very wide range of treatment approaches, depending on their specific training and experience and it would therefore be misleading to describe a “typical” consultation.  The osteopathic approach used will depend on the individual patient and the osteopath’s clinical judgement.  The individual osteopath must be able to recognise limitations in their competence and practice accordingly.

Despite its wide range, there are certain common factors in all osteopathic practice:

2.1 Comprehensive clinical history

A detailed clinical history and a more detailed osteopathic history, as relevant to the presenting complaint and its impact on the patient’s lifestyle, are taken.

2.2 Physical assessment

The clinical examination process might include (as appropriate):

-          observation of active movements;

-          assessment of passive movements (normally using manual methods);

-          assessment of tissue tone (normally using manual methods);

-          standard clinical examination methods as indicated.

2.3 Development of a logical, clinically reasoned working hypothesis

Based on the findings of the history and examination the osteopath will develop a working hypothesis based on differential diagnosis principles using a logical clinically reasoned approach. 

A principal factor in the history-taking and physical assessment is the need to establish whether it is safe and appropriate for the osteopath to treat the patient.  This may necessitate a very wide-ranging history and examination that includes many aspects that may not appear immediately relevant to the patient.

From the overall assessment of the patient, and on the basis of the osteopath’s working hypothesis, a management strategy is constructed.  This may include a treatment plan or referral, as necessary. An osteopathic treatment plan may include lifestyle advice concerning exercise, diet and nutrition, stress management and coping strategies.

2.4 Manually applied assessment and treatment methods

The use of manual methods of assessment and treatment is a characteristic of Osteopathy, and the critically applied use of the sense of touch (palpation) and proprioception are fundamental to osteopathic methods.  Osteopaths acquire highly developed palpatory and proprioceptive skills that are normally used both in assessing joint movement and tissue tone and also in manually applied treatment methods.

Some osteopaths may also use adjunctive (non-manual) treatment methods such as acupuncture, dry-needling, ultrasound or electrotherapies.

3. Advice for patients

3.1 The osteopathic approach

The osteopathic approach to healthcare is based on the fact that the body has its own ways of fighting disease and repairing injuries.  Normally this works well and we recover from illness or injury, but sometimes it needs help.  So osteopaths set out to find things that may be stopping your body from healing itself.  If we can do something about those things, then your body may be able to return to health as it does normally.

We believe the different parts of the body work together to keep the body healthy.  That means that all the parts of the body affect each other to some degree, so when there is a problem in one part of the body, the underlying cause may be somewhere else.  So osteopaths don’t just look at the area that is causing you problems.  We will look much wider to see if we can spot anything that could be stopping your body from healing itself.

3.2 Your first appointment

Osteopathy is centred on you, the patient.  You are a unique individual and we need to build up a picture of you as a complete person.  Your health also depends upon factors such as diet, exercise and what is happening in your life.   So first we need to listen to what is troubling you, but then we may need to ask lots of questions to find out about:

·         The way it affects you – when it causes you most problems, what makes it worse, and other things like that.

·         Things that have happened to you in the past that may affect the way you are now – and that may be all the way back to when you were a child.

·         The kinds of things you usually do – so we can build up a picture of how you use your body.

Once we have found out about your history, we normally need to examine you to see how your body is working.  We usually look at your posture and how you move your body.  We may also assess what happens when we move it for you and see what hurts, where and when.  Using touch we may also find the points which are sensitive or tight, and this helps us to identify what is going on.

Using the sense of touch is an important part of Osteopathy; the highly developed sense of touch is known medically as palpation.  Osteopaths normally use their hands a lot, both in assessing patients and in treating them, and we gain highly developed palpation skills which help us to get as much information as we can about the way your body is working.

Our clinical examination may also include taking measurements such as your blood pressure, feeling your pulse and checking your reflexes.  If necessary, we may refer you for clinical tests, such as x-rays.

Introduction

This document relates to the GOsC draft proposal for an Osteopathic Practice Framework (OPF).  The approach taken in the draft OPF document has caused great concern to a number of osteopaths.  In its consultation, the GOsC has asked for any suggestions for alternative approaches.  This document is an attempt to sketch out such an alternative.

I have borrowed (stolen!) extensively from other people and very little of this document is original, however, the views expressed in it are also my own (and do not represent a BOA policy).

1. Purpose

1.1   The primary function of the GOsC OPF document is to provide the regulator with a reference against which to regulate osteopathic practice, but it should also provide two other benefits:

a.       to the profession: increase the transparency of regulation by informing osteopaths about the framework of regulation.

b.      to the general public: reduce anxiety and inform expectations by educating patients about the way osteopaths work, and therefore what they might expect during a consultation.

1.2   In order to produce a useful document, all three functions must be fulfilled.

2. Theoretical Basis of the document

2.1   The draft document is based on the division of osteopathic practice into “typical”, “less typical” and “least typical” areas.  These are defined according to the types of technique used, the type of presenting problem and the type of patient.

2.2   It is a basic principle of Osteopathy that our bodies have intrinsic systems of repair and maintenance and normally return to health.  Osteopaths therefore look for factors that may be preventing normal resolution and aim to address these factors to allow the body’s intrinsic mechanisms to work more effectively, rather than setting out to treat the presenting condition itself.  Treatment is therefore specific to the patient rather than the presenting condition.

2.3   Every patient is a unique individual and Osteopathy focuses on the unique individual patient: it is patient-centred.  Thus the history-taking, the examination and the treatment approach will all be unique for every patient.  In addition, every osteopath is also a unique individual with a unique combination of knowledge, experience and skills, and this adds another layer of variability to the individual patient’s experience.

2.4   As a consequence of 2.2 and 2.3 above, it is an inherent characteristic of Osteopathy that there is no “typical” experience for the patient – there cannot be, and it would be misleading to imply such a thing could exist.

2.5   It is, however, true that, even though they will be tailored to the individual patient and circumstances, there are certain features that are common to all osteopathic practice:

1. History-taking.
2. Physical examination.
3. Development of a logical, clinically reasoned working hypothesis.
4. The use of manually applied methods of both examination and treatment.

2.6   In order for osteopathic practice to be reflected throughout the document and for all three functions to be adequately fulfilled, the OPF should have at its heart a statement of osteopathic principles.  This does not need to be a fully elaborated theory of Osteopathy that links the various principles together, but rather just a statement of the very basic components that inform all osteopathic practice.  Despite much scepticism in the profession, the BOA’s Common Language Project (CLP) has demonstrated that there is a remarkable degree of agreement across the profession concerning its basic principles.  Such a statement of principles would demonstrate that osteopathic practice is regulated from understanding rather than the unthinking application of standardised formulations.

2.7   The statement of principles would ensure that the guiding principles of Osteopathy were enshrined within the regulatory framework, and this would be hugely reassuring to many osteopaths.

2.8   The use of manually applied methods of assessment and treatment are a characteristic of Osteopathy.  A significant part of the osteopathic training is the learning of these methods, the development of palpatory skills and the discrimination to recognise the limits of one’s abilities in using them.  The GOsC could therefore be justified in considering the further acquisition and refinement of manual skills, and recognising the limits of one’s competence in using them, to be part of the basic competence of an osteopath.

2.9   The use of adjunctive (i.e. non-manual) techniques could be considered to fall outside the scope of strictly osteopathic training and it could therefore be considered reasonable for the onus to be placed on osteopaths using such techniques to be able to provide evidence of adequate training in their use.  This would provide a practical limit to the range of techniques that the GOsC would have to regulate directly.  The GOsC would only have to consider whether the adjunctive techniques were being used in a way that is compatible with the principles stated in the OPF.

2.10 The areas of obstetric and vetinary care are covered by legislation and the OPF and other regulatory documents need only require osteopaths to practice in conformity with the applicable legislation.

2.11 The area of paediatric care is potentially contentious and practitioners prominent in that area should be consulted for advice in how the issues may best be handled.  [My personal view is that my own undergraduate training in no way equipped me with sufficient paediatric knowledge to be safe treating babies and infants and that I would need additional training to work in that field.  This is a rapidly expanding field and many osteopaths work in it entirely competently with no additional formal training (having gained the requisite expertise informally and through self-directed study), so it may be difficult to insist that evidence of such additional training should be compulsory.  However, it is a concern that inadequately knowledgeable osteopaths could start treating babies with potentially disastrous consequences.]

2.12 With the exceptions of adjunctive (non-manual) therapies, obstetric, vetinary and paediatric care, all other types of treatment/patient/presenting condition should be considered equally usual parts of Osteopathy.

3. Other content

3.1   In addition to a statement of principles, to fulfil its various functions, the document should also include:

a.       A basic description of features common to all osteopathic practice (see 2.5);

b.      Information and advice to inform the expectations of patients.

3.2   It is very important that:

a.       patients are not lead to unrealistic expectations;

b.      any advice to patients is broad enough to cover the full range of osteopathic practice;

c.       patients expect osteopathic assessment and treatment, with all that implies in respect to the need to observe and palpate structures throughout the body and not only local to the site of the presenting symptoms.

4. Integration

4.1   The integration of this document with the other key GOsC documents is highly relevant; it seems inevitable that the Code of Practice (COP) will need to refer to the Standards of Proficiency (SOP) and the OPF, and it is essential that all three be mutually compatible.

4.2   Incorporation of a statement of principles at the core of the OPF and the integrated nature of the three key documents (COP, SOP and OPF) means that these principles will be incorporated into the disciplinary framework.  This would be reassuring for many osteopaths and could increase the perception of transparency in the disciplinary process.

My hope is that the new Code will be as much of an improvement as the new SOP is to S2K. But if we sit back and assume that is going to happen then we lay ourselves open for a rude shock.

The GOsC has just started the consultation process and they expect it to carry on for a considerable time. We all need to think about not only everything that we object to in the old Code, but also what we would positively like to see in the new one.

For example, I would like to see much more emphasis placed on osteopaths exercising their professional/clinical judgement in precisely how they deal with specific situations, with the Code setting out the broad principles of what should be achieved, rather than specifying exactly how it should be done. I would like to see a Code that acknowledges that osteopaths should respond flexibly to individual patients and deal with situations as they consider most appropriate in the specific circumstances. It should also acknowledge that not of us can be expected to perfect all the time – we must be allowed to make mistakes and to handle them appropriately.

Most of all, I want to see a Code of Practice that doesn’t make me fearful and angry when I read it!

In stark contrast, the new OPS, while setting very high standards, sets a level that is reasonable and acknowledges the role of osteopaths’ professional and clinical judgement. If this is the benchmark for all GOsC’s consultations and regulatory approach, then I think we have a chance for the profession to make real progress over the next few years.

Paragraphs 12-19 are also generally OK, despite the fact that I find the whole concept of “Typical experience” objectionable. My problems with this are two-fold:
I do not believe there is a typical experience, even for my own patients. The way I work – from history-taking through examination to treatment is individual to that specific patient and what I do and say can vary enormously. So I think it is misleading to the public to imply that there is some sort of typical or standard experience.
It is a fundamental principle of Osteopathy that we are patient-centred and aim to tailor everything we do to the individual patient; there shouldn’t be such a thing as a typical experience.

Paragraph 20 is where I start to have real problems. An orthodox “diagnosis” may well be a useful shorthand for communicating with other healthcare professions, but osteopaths will always “strive to achieve a more comprehensive understanding and provide a detailed explanation of the factors involved…” – that is one of the distinguishing features of Osteopathy. However, in real life we do not always reach a “diagnosis” on the basis of which a treatment plan will be devised. That is simply far too idealised. In practice it is not uncommon to start treating what you find while you are still examining: the tissue response is part of both assessment and treatment, and the changes created in other structures then give more clues as to the underlying factors. To explain in detail exactly what I am going to do and why at each stage would grind the treatment to a near halt.

Paragraph 23: What it is appropriate to treat osteopathically depends principally on the skills of the individual osteopath. In practice this is certainly true for me, but I can think of people who would disagree with this statement in principle.

Paragraphs 24 and 25 raise the thorny issue of consent. It is, in practice, impossible to prove that a patient has understood. If we have any suspicion that they haven’t, then, of course, we make more effort. But is isn’t those patients that bring osteopaths before PCCs; it is the patient who I am confident has understood, but, in fact, who subsequently decides that they hadn’t. The osteopath has no possible protection against that, and thus the consent law fails to work. I don’t know what the way around this is, since it is a failure of the law. But as things stand there is no point any healthcare practitioner obtaining “consent” because it is meaningless in court.

Paragraph 26 uses the term ‘manipulation’. To medics and physios this is normally synonymous with HVT. It should be avoided. The reference to ‘visceral structures’ reflects something that we believe but for which we lack “scientific” evidence. This is a red rag to the “quackwatchers” and should be removed.

Paragraphs 27 – 30 are OK.

I could not disagree more with paragraph 31. To attempt to categorise osteopathic practice in terms of type of treatment technique, type of ‘condition’ treated or the type of patient group, completely misses the point of Osteopathy. The characteristics of Osteopathy are that it is, in principle, independent of treatment modality, that it addresses the patient rather than the condition and that the only patient the osteopath cannot treat is the dead one. Those are principles of Osteopathy.

The patient only knows the osteopath(s) they have encountered. It is not helpful to the patient to know how ‘commonly’ those particular methods may be. The only things that matter to the patient are:
Is it safe?
Does it work?

I agree that the use of manual techniques for assessment and treatment is a characteristic of Osteopathy, but I think it is very misleading to patients to categorise treatment techniques as typical. If I choose not to use a ‘typical’ technique that may be because the patient isn’t ‘typical’.

Paragraph 32 refers to “the types of presenting problems that osteopaths may treat”. We should never use this language – for 2 reasons:
It isn’t true. We don’t treat conditions, we treat patients. That is the point of Osteopathy;
We have no evidence to support this. Professor Ernst would be on our backs in an instant complaining that we are advertising treatments for which there is not a jot of evidence. All we can say is: “Patients with the following problems tell us that osteopathic treatment has helped them.”

Paragraph 33 states: ‘This lies with the clinical judgement of the osteopath.’ This is precisely the point – and obviates the need for much of this document!

I disagree with paragraphs 35 and 36 so complketely and so fundamentally that no more needs saying.

Paragraph 37 hits the nail on the head and states clearly why much of this document is not needed.

Paragraph 38 isn’t needed, but it does allow for Osteopathy to develop, which is good.

For obvious reasons I think paragraphs 39-41 are not helpful or relevant. Para 39 uses ‘manipulation’ again. Paragraph 40 states that osteopaths using cranial techniques ‘will explain them fully to patients so they can understand them”. I would love to see that! No-one has yet been able to explain cranial techniques to me in any way that is physiologically remotely plausible, let alone ‘fully’ – and I use cranial techniques myself. Not because I understand them fully but because I observe changes in my patients when I use them. Mind you, no-one has a proven model for the way HVT works either…

As far as I can see the purpose of all this is that we have to able to demonstrate that we are competent to use the methods we do. If those were taught at undergraduate level, then they were part of a GOsC-approved course and the GOsC can legitimately assume our competence unless there is evidence to the contrary. But all the osteopaths I know continue to learn and develop throughout their career. I graduated a mere 6 years ago, but most of the techniques I use now were not formally taught at the BSO. If we are using methods we have learned post-graduation the GOsC has no way of knowing whether we are competent in them. That puts the onus back onto us to demonstrate that we really have gained the knowledge and skills to work in that way (or with those patients). To mind that is part of being a responsible competent professional, and rightly lies within the scope of our professional judgement.

Paragraph 43 is the consent problem again, only this time with a twist: the more rarefied your practice, the more careful you need to be about getting consent. I disagree, and if you put it the other way round, you can see why: the more mainstream your practice, the less fussy you have to be about getting consent.

The PCC does not see it that way! We are required to be meticulous about gaining consent under absolutely all circumstances regardless. Full stop.

And, actually, if consent were worth gaining, then that is how it ought to be. It is just a shame that the consent isn’t worth anything anyway. This paragraph again requires us to ‘ensure the patient understands’, which is not really possible.

Paragraph 44 states that ‘Although it is essential that osteopathic practice should be grounded in plausible and reasonable evidence, it may sometimes involve the use of techniques that are based on clinical judgement and experience and where evidence for their use is yet to be fully developed.’ To the best of my knowledge, that includes, if not all, then the vast majority of what we do, as far as EBM is concerned.

Paragraph 45 makes a good point. Osteopathy has fuzzy edges, yet I firmly believe there is a recognisably “osteopathic” approach to healthcare. But also bear in mind that you could practice entirely within the ‘Typically encountered osteopathic practice’ defined in this document and be a Physio or Sports Massage Therapist.

Why is it happening?

Revalidation comes out of the Shipman Enquiry and the various initiatives it has spawned, including the Foster Review. The government decided it needed to be seen to be doing something to “prevent another Shipman”. In reality, there is nothing a government can do that will prevent a doctor killing patients. So instead of doing something that will be effective, it can only do something – whatever it can actually do, rather than whatever will actually work. It really doesn’t matter what, as long as it deflects political flak.

The Department of Health (DoH: what a brilliant abbreviation – straight out of The Simpsons!) has decided that it is self evident that whatever is inflicted on doctors must also be A Good Thing for every other healthcare profession. So we have to undergo a process whose ostensible purpose is to stop doctors killing patients!

It is important to realise that the purpose of this process is purely political and that it is in Alice in Wonderland territory as far as logic is concerned. It has been imposed on the GOsC and there is absolutely nothing they can do to prevent it happening.

What will it involve?

The DoH has, naturally, focussed entirely on the NHS and developed a revalidation model based on “360 degree appraisal”. As a profession mainly comprising self-employed practitioners in private practice, many of them single-handed, the DoH’s NHS model is as inappropriate to Osteopathy as it can possibly be.

So the GOsC has decided to develop a model that is appropriate to Osteopathy: one that will not place an unrealistic burden on individual osteopaths, and that will provide a positive benefit to the profession as a whole. To that end the GOsC started consulting with as wide a range of the profession as possible, through the network of GOsC regional reps, the colleges, and the BOA.

It is a principle of Revalidation that it should address risk. Where doctors are concerned the principal risks to the public are of death or serious disability due to either incompetence, neglect or malice. Osteopaths have, in comparison, a remarkably unexciting record when it comes to killing and disabling our patients!

The government’s Better Regulation Executive set out the principles of “Better Regulation”; that it should be:

• Proportionate
• Accountable
• Consistent
• Transparent
• Targeted

The GOsC is committed to ensuring that the Revalidation scheme meets these criteria in terms of the risks posed to the public by osteopaths. Any scheme that is targeted at and proportionate to the risks we, as a profession, pose cannot be too onerous. Any scheme that is consistent, accountable and transparent, is one we need not fear.

I feel the current discussion document is not sufficiently closely targeted and that it is still a bit too big. If it looks too big, people will tend to try to work out what they think the GOsC wants as an answer, rather than thinking properly about the questions in relation to their own practice. Being forced to reflect on your own practice is always a useful process, if not always a comfortable one!

The issues are about identifying the relevant risks and determining in what way the scheme should provide a benefit to the profession.

Some people are alarmed by the remediation component and see it as a sinister way for the GOsC to control the way we practice. In fact, this is a required principle outlined in the government’s Non-medical Revalidation Working Group’s report. Its purpose is to ensure that anyone “caught out” by the Revalidation process should have a chance to remedy the situation as simply and easily as possible; no-one need fear being struck off because they didn’t fill out their revalidation form properly.

What can we get out of it?

I feel that, since Revalidation is being (quite unnecessarily) foisted upon us, we should subvert the process as far as we can, to ensure that we get something out of the effort we will, inevitably, have to make.

The most useful thing the Revalidation process can do for us as a profession is to force us into doing clinical audit. If we have data from 20% of the profession every year that would provide a massive database from which real evidence about real osteopathic practice can be obtained. If we are ever to justify ourselves to the medics and the policy-makers, then that is precisely what we need. But, to be realistic, the only way we will get it is by being forced to do it. Do I perform routine clinical audit on my own practice? No. Why not? Because I am busy and there is always something else that is more urgent than setting up the system to do it. Making it part of Revalidation would certainly get it to the top of my priority list pretty quickly!

The key to audit is building in to what you do every day in practice. That way it isn’t a massive effort. I have been using the BOA’s Data Collection Tool for the past year. It collects data on new patients and I have integrated the questions it asks into my history-taking. I don’t even have to think about it, and recording the data (on the provided spreadsheet) takes less than 20 seconds. Practically effortless, and now I have data on every new patient I have seen for the past year

If a clinical audit tool were standardised in every practice in the UK, we would have a fantastic resource.