We believe that the Scope of Practice should be determined by the profession and that it should be a simple, clear statement of the fundamental osteopathic concept to which all osteopaths can subscribe. The essential question is can you practise ‘your’ osteopathy freely under this description?

We have been in discussions with the GOsC and have shared the document with the osteopathic undergraduate colleges. We wish now to involve the profession in the debate and are seeking your views. Once we have your views and comments we plan to meet further with all the osteopathic stakeholders to agree appropriate next steps. Your feedback will help to determine how it is best for all of us to move forward.

We urge you to contribute to this process, which will help to shape the future of the osteopathic profession. You can read and comment on the document online at scope.shapingosteopathy.org where you will also find a link to a short online survey which we hope you will complete. The survey is password protected for security. BOA members will find the password in the email accompanying June’s digital edition of Osteopathy Today. Alternatively, you can e-mail us at consultation@apdc.org.uk and we will provide you with the details.

We look forward to hearing what you think.

Nick Handoll

Coordinator for APDC (Association of Professional Development Colleges)

The APDC is constituted of the following organisations:

Osteopathic Centre for Children

Sutherland Cranial College

Osteopathic Pelvic, Respiratory & Abdominal Association

Institute of Classical Osteopathy

Sutherland Society

Society of Osteopaths in Animal Practice

Osteopathic Sports Care Association

Rollin E Becker Institute

British Osteopathic Association

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.

I have done an analysis on Google News Archive for 1999-2009. This searches for all relevant press articles for a given time period (in English). The results are as follows:

osteopathy = 6860 articles, of which:
osteopathy + back pain = 1400 articles (20%)
osteopathy + children = 1010 articles (15%)
osteopathy + athletes = 533 articles (8%)
osteopathy + cranial osteopathy = 185 articles (3%)
osteopathy + joint manipulation = 19 articles (0.3%)

I think this shows that treatment of children is as ‘core’ as treating back pain in the minds of the public. It also indicates that defining ourselves by the techniques we use is not meaningful. One osteopath at the meeting summed up the definition of osteopathy by saying ‘we treat structure to restore function‘. I’m not sure we need to get any more complicated than that.

At present, there is considerable lack of clarity about what constitutes osteopathic practice … we would like to hear whether you feel it necessary to define osteopathy and, if so, how this could best be achieved.

The question is do the GOsC really want to know whether it is necessary to define osteopathy? The same site also contains Frequently Asked Questions (FAQs). One such question, which can be found half way down the page, asks What is osteopathy? :

Osteopathy is a primary care profession, focusing on the diagnosis, treatment, prevention and rehabilitation of musculoskeletal disorders, and the effects of these conditions on patient’s general health.

It would appear that despite the appearance of consultation with the profession and the public about the scope of practice, the GOsC has already decided that osteopathy is ‘focused’ on musculoskeletal disorders. This is re-emphasised in the answer to the next FAQ, “What do osteopaths treat?”, repeating the fact that osteopathy (not osteopaths) focuses on musculoskeletal and related disorders:

Osteopathy focuses on the diagnosis, management, treatment and prevention of musculoskeletal and other related disorders without the use of drugs or surgery.

There is a huge and often subliminal tide towards the focus of treatment on musculoskeletal disorders, as this is what the majority of osteopaths currently treat. Just because there are lots of GPs, this does not mean that medicine does not specialise in anything other than family healthcare in general practice, so why are osteopaths being limited to treatment of musculoskeletal and related disorders?

Another page on the site, about osteopathy, addresses the hot topic of pregnant women, saying that they seek treatment for “changes to posture in pregnancy”. How long before the scope of practice is limited to an even smaller range of disorders than those for which osteopaths are currently allowed to claim benefit?

A page on continuing professional development gives an insight into the way the GOsC think about osteopathy dealing with anything other than straightforward musculoskeletal disorders:

There are now also postgraduate courses for osteopaths in a range of subjects including sports care and osteopathic treatment of children (my emphasis).

The GOsC appear to have made a small concession to the fact that osteopaths can learn more about such new treatment approaches such paediatrics and sports medicine after graduation – what about the long-established Osteopathic Centre for Children; the osteopathic olympic support team; treatment of animals; visceral osteopathy? 

GPs are encouraged by the GOsC to refer patients to osteopaths for musculoskeletal disorders (MSDs) :

… treatment is based on mobilising and manipulative procedures tailored to the individual patient, reinforced by guidance on diet, lifestyle and exercise … Conditions appropriate for referral include MSDs such as back, neck and shoulder pain, headaches, and sport- and work-related injuries.  Other commonly treated conditions include migraine, asthma, arthritic pain, digestive disorders and infantile colic.

Only GPs, not the public, are told by the GOsC that osteopaths treat these other conditions. With such an attitude from our ruling body we have a long way to go before the tide turns on osteopathy and we are recognised as being able to (or allowed to) treat the whole person, whoever they are and whatever their health status.

The Practice Framework should protect our freedom to pratcise

A framework that clearly explains the underlying philosophy and principles common to all osteopaths and the reasons why these preclude the possibility of prescribing a limited scope of practice or establishing guidelines that determine which treatment approaches should be used in particular “conditions” would protect our freedom to practice, no matter what our individual approach may be. The current draft has some problems (as others have identified elsewhere) and these clearly need to be worked out, but there is much in there that would seem to meet these criteria. For example, the document states in section 11 that osteopathy is characterised by

“The intention 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”

and that osteopaths achieve these aims using

“Individually tailored intervention and advice encompassing a range of specific technical treatment techniques and approaches.”

This is as inclusive a statement of the common framework that underlies the many diverse approaches to osteopathy as is possible. Surely even those of us whose practice is furthest from the mythical “norm” should be content that this fairly represents us and supports our freedom to work towards the common osteopathic goal of promoting health in whichever ways we personally believe to be most effective.

Section 30 ensures this freedom further by stating that

“The treatment and management of a patient’’s health problem will depend on the needs of that particular individual. There are many treatment approaches in osteopathy and there might be some variation according to the training and experience of the particular osteopath providing treatment. It is not appropriate to prescribe specific treatments for specific conditions as this is contrary to the principle of tailoring osteopathic care to individual need. It is also not helpful to dictate a limited scope of practice for osteopaths as they will practise according to their training and competence using their clinical judgement and skills.”

Statements like these, if included in a document that formally describes osteopathic practice, would protect us from the possibility that the GOsC or other outside forces might try to limit our freedom to judge for ourselves as trained professionals which patients we are competent to treat, what the extent of our ability to contribute to their care might be and which approaches we ought to use to these ends. Can we really afford to miss this opportunity to safeguard our future in this way?

There are many issues with the draft practice framework that still need to be addressed if this document is to fairly represent us all but to throw it out altogether would be to miss the best opportunity we are likely to get to ensure our freedom to continue to practice in the way we each believe to be in our patients’ best interests; whatever that might be.

Ben Katz

• Dividing practice up on the basis of what is commonly and less commonly encountered is arbitrary
• Including electrotherapy as an osteopathic technique (B 40 iv) is wrong
• There is no evidence that pregnant women or children are treated less frequently than any other group of patients
• To suggest that any patient has to be treated under the supervision of a doctor or midwife devalues osteopathy and limits patient choice

It should be stated categorically that osteopathic treatment is manual. Osteopaths who incorporate adjunctive techniques in their practices are not using osteopathy. Osteopathic techniques do not conveniently fall into practice types but they can be thought of as being either direct or indirect; practitioners move from one to the other seamlessly during treatment.

The argument of commonly and less commonly encountered types of practice is flawed. Who knows what individual osteopaths actually do? Moreover, the picture of commonly encountered practice is based on undergraduate training. Experience brings flexibility and individuality into the approach, so that the more expert the practitioner the more he is likely to deviate from the standard model. It is facile to suggest that what is supposedly a less frequently encountered mode of treatment requires more explanation than what is perceived to be common. The issue is one of patient consent: this is obtained (though impossible to prove) or not, regardless of the osteopath’s particular bent.

Osteopaths do not treat pregnant women because they are pregnant, neonates because they are very new, or elite athletes because of their sport. Osteopaths treat people regardless of their age, occupation or type of illness. That some osteopaths have a special interest in particular groups is self-evident. Many choose to undertake post-graduate training 

It is a fact that many osteopaths employ ancillary treatment in their practices and it proper that the public be informed accordingly, but to imply that electro-therapy is osteopathic practice (clause 40 iv) is absurd and misleading.

If we are to preserve our freedom to work according to our interpretation of what is the best interests of our patients then we must prevent the publication and implementation of  unnecessary prescriptive and proscriptive measures by GOsC. So long as GOsC policy is beneficial to patients, both in the immediate and long-term future, then we should work cooperatively

Over recent years regulation has become the scourge of businesses of every kind, much of it in the name of ‘Health & Safety’ or consumer protection. Remember we are healers: we already have the best interests of our patients at heart without having to produce statistics or jump through hoops as many of us did with the Personal Profile and Portfolio registration process farce. Practice audit is something that could be easily integrated into the routine of most osteopaths, but redefining osteopathy, limiting our scope of practice and having to fit into a box every few years could seriously add to the burden of making an honest living through helping people.

What many forget is that the current Government are not there forever, and with a general election looming, they may now be more open to influence or persuasion than when there was a seemingly unshakeable hold on power. As a group we would have political lobbying strength if we were united in what we want. With our patients behind us, we could achieve even more. The British Osteopathic Association are our voice to lobby for what we want as a profession, and must listen to us as individuals, groups and colleges. All we have to do is say what we really think.

GPs are constantly battling against paperwork, but they have the resources to back them up – practice managers, receptionists, and the NHS. As lone osteopaths, or as part of a small group practice, we should be very wary about accepting more paperwork just for the sake of political correctness and the trend towards acting through fear espoused by ever-increasing Orwellian regulation.

A definition should be attempted only in the wider context of care. It is invidious to try to define osteopathy without a definition of medicine. If medicine is defined then perhaps a definition of osteopathy could be achieved. Osteopathy is not an “alternative” to medicine. It was not Dr Still’s intention to found a new profession. He wished to reform the existing system (Korr 1995). After a slow start in the UK with the challenges of the war and the formation of the NHS free at the point of delivery, osteopathy is now beginning to take its rightful place in the delivery of health care to the nation. In the early days, osteopaths had no choice but to restrict practice to neuromusculoskeletal conditions. There were far too few osteopaths even to attempt treating conditions beyond this narrow range. Not surprisingly, the profession developed a name for this, not because it summarised osteopathic care but because neuromusculoskeletal conditions are so extremely common and are poorly served by allopathic medicine. However, to restrict osteopathy to this narrow practice now, poorly serves public choice.

The osteopathic concept can be described simply. Dr Still recognised in the 19th century that the body is a self-healing, self-regulating, self-adjusting organism. This is conventional wisdom today. In disease, therefore, should the issue be to control the disease or should it be to find out what has impaired or compromised the self-healing, self-regulating and self-adjusting mechanisms (the health) to have allowed the disease to occur in the first place and not to have resolved on its own? There are two clear differences in philosophy here. Allopathic medicine is concerned with the control of disease, while osteopathic medicine is concerned with that which has compromised the health. Dr Still himself said “To find health should be the object of the osteopath. Anyone can find disease”.

This may be achieved many different ways. The osteopath will do what is necessary to assist the health mechanisms to resolve the disease naturally. It is not technique centred, neither is it restricted to a system of the body, a part of the body, a group of conditions, nor an age group.

The model proposed in the Consultative Document is technique centred and divisive. Osteopathy is not technique centred. What sound evidence is there for the claim that there is a typically encountered practice? This is described in Clause 35 as “the features of the typical experience most likely to be had by patients when seeing the majority of osteopaths”.
Which patients see the “the majority of osteopaths”?
How many patients are there who see “the majority of osteopaths”?

The typically encountered osteopathic practice is that which is typically performed in each individual practice. My patients and many other osteopaths’ patients would be highly alarmed if they were given the “typical approach” as described in Clause 39.

This GOsC Consultative Document should be scrapped and consultations begun not just with the BOA and Regional Societies, but with some of the groups who are driving this profession forward, such as the Foundation for Paediatric Osteopathy, the Osteopathic Sports Care Association, the visceral osteopaths, veterinary osteopaths, the Sutherland Society and the Sutherland Cranial College. There is no “lack of clarity around what constitutes osteopathic practice” (GOsC p2). The philosophical basis of osteopathy is clear.

Nicholas Handoll, DO
April 2009

This proposal is endorsed by Stuart Korth D.O., on behalf of the Foundation for Paediatric Osteopathy, Peter Armitage D.O. on behalf of the Sutherland Cranial College, Nicholas Woodhead D.O. on behalf of Post Graduate Cranial Faculty, Stephen Sandler, Ph.D., D.O. on behalf of Post Graduate Obstetric Training, and Christian Sullivan D.O. on behalf of the Sutherland Society.

Please take the time to engage the consultation process as fully as possible.

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.