OPS – Final Comments

Below are my final comments on the draft Osteopathic Practice Standards Document, which I have submitted to the consultants, Hewell Taylor Freed & Associates. Overall, I feel that this draft is an improvement on the documents it will replace but there is clearly much work still to be done to get it right. I look forward with interest to reading HTF’s report and to the GOsC’s response in the new year.

General comments

The main focus in evaluating this document must be on how it serves as a basis for judging the competence of osteopaths, should their fitness to practice come into question; i.e. does it set reasonable, achievable standards and provide appropriate guidance on how to achieve them in practice? It is important to keep in mind that those pursuing a case against an osteopath are likely to push the interpretation of the language to its limits. There can be no room for ambiguity in what is required as we are held to the letter and not just the spirit of these rules.

Of special concern in this regard is the possibility that the GOsC may at some point be dissolved and osteopaths brought under the HPC. Our regulatory documents need to be clear and straightforward enough that those with no knowledge of the unique approach taken by osteopaths can easily judge our competence based on standards that are directly relevant to the idiosyncrasies of our practice.

Much of the guidance describes specific actions which may not fit with individual practitioners’ diverse styles of practice. It is implied that what is described is best practice and the onus is therefore on practitioners to justify any deviation from the guidance but no prescribed behaviour can account for all of the complexity and uncertainty of clinical practice nor the diversity of osteopathic approaches. Osteopaths are competent, intelligent professionals, trained to exercise their professional judgement as to the most appropriate course of action in diverse and often uncertain clinical situations. The onus should be on each individual practitioner to determine how best to uphold the standards and the guidance should suggest principles for how to approach this, not spell out exactly what to do.

Comments on individual clauses

I have identified the issues that need to be addressed in my comments below and offered suggestions for alternative text or approaches where relevant. I have tried to be as comprehensive as possible but it is likely that there are some issues I have missed.

Introduction

• The final paragraph of the introduction needs to make it clearer that any protocols suggested in the guidance are illustrative examples and not requirements to do exactly what is described. The responsibility for determining how best to uphold the standards must remain with the individual practitioner as only they can take account of the complexity and uncertainty of the unique situations encountered in clinical practice.
• The last sentence should be replaced with something along the lines of: “Osteopaths must uphold all of the standards in their practice. The guidance offers suggestions for how this may be accomplished but the responsibility for determining the most appropriate course of action in any clinical situation rests with the individual practitioner.”

The introduction to Section A

• “Absolute trust” is very rare indeed and can hardly be a requirement. “Absolute” should be dropped.

• Communication involves two parties and often breaks down for all manner of reasons outside of one’s control. Nobody can be required to communicate effectively. This should be changed to “Osteopaths must endeavour to communicate effectively…”

Standard A1

• Requires “the ability to adapt communication strategies to suit the specific needs of the patient.” This statement is unnecessary and could be interpreted as a requirement for osteopaths to speak all languages known to man. Requiring osteopaths to have well developed interpersonal communication skills is sufficient. The ability to adapt within reason to the needs of individual patients should be included in the guidance where it belongs.

A2, point 5

• Some practitioners working alone may need to answer the door or take telephone calls during a session. “Undivided attention” should be changed to “full attention” to allow for this.
• Some patients may demand more time than it is possible to give them and it is not always possible to do everything that one might like in one session. “Allow sufficient time to deal properly with their needs” needs to be re-thought in light of this.

A2, point 6

• It is impossible to be sure that someone has understood you. Change to “When you have explained what you need to do and why, ask the patient if they have understood and if so whether they agree to the procedure…”

A2, point 7

• This guidance is too prescriptive. Some practitioners refer patients to others specifically for this purpose. In such circumstances, requiring the patient to attend two appointments with the practitioner to whom they have been referred will incur an unnecessary and unjustified expense. It would be simpler to require that osteopaths give patients adequate time to consider any treatment we propose and trust that clinicians will use their judgement to assess what this will involve for individuals. The guidance could suggest offering more time to consider but this should not be stated as a requirement.

Standard A3

• This standard is unclear as there is no definition of “the information they need” and no reference to what they require information for. It would be more appropriate to require osteopaths to “give patients sufficient information to make informed decisions about their treatment”.
• Some patients will struggle to follow even the simplest and most straightforward explanations so it cannot be a requirement to provide information “in a way that they can understand.” This should be addressed in the guidance, not the standard.

A3, point 8

• It is impossible to “ensure” that anyone understands anything. All one can do is take due care to explain clearly and give the patient the opportunity to ask for clarifications if necessary.

A3, point 8.3

• There are often no known risks associated with osteopathic treatment. This should be changed to “any significant risks that may be involved…”

A3, point 10

• This could be interpreted as a requirement for osteopaths to hire professional interpreters for patients whose English is poor, which is of course completely impracticable and not financially viable in most cases.

Standard A4

• The whole issue of consent needs to be thought through more carefully in light of the fluid nature of osteopathic practice. Most osteopathic treatment does not follow the model under which techniques are initially taught (as isolated procedures) but unfolds as an exploration of the patient’s body in which evaluation and treatment merge together and so-called techniques flow one into the next, with the continuity of this flow and the resultant sedative effect on the nervous system being a significant factor in the effectiveness of the treatment. Hence obtaining specific consent for each distinct procedure, at least in the temporal sense, would compromise the treatment and is therefore inappropriate. For these reasons, points 12 and 14 are unworkable.
• The approach described in point 15, where the likely range of approaches is described and consent obtained before commencing treatment is altogether a more sensible starting point for discussing consent as it most closely reflects how the majority of osteopaths approach obtaining consent in practice.
• In addition, many patients prefer not to be involved in detailed decisions about their treatment as they generally lack the knowledge to judge the most appropriate approach and have faith in their practitioner to make responsible professional judgements. If patients state that they prefer not to be informed of risks associated with treatment, it should not be a requirement of osteopaths to do so against their wishes.

A4, point 12 & 14

• This guidance is unworkable in practice. Most patients recognise that being asked for consent for every procedure inhibits their ability to relax and compromises the effectiveness of their treatment. Many specifically ask not to be told when an HVT is coming for exactly this reason. Consent obtained at the start of a course of treatment should be considered sufficient unless a patient subsequently informs the practitioner that they have changed their mind.
• The references to ‘specific’ and ‘informed’ in point 12 should be scrapped to leave “To be valid, consent must be given by the patient or, in the case of children, [..] by a legal parent or guardian.”

A4, point 15

• A patient may become concerned without expressing this in any way. Practitioners cannon be expected to be telepathic. The final sentence needs to be worded more precisely to account for this. I.e. “If the patient expresses concern or you suspect that they may be concerned…”

A4, point 16

• Once again, it is impossible to ensure that a patient understands anything.
• Intimate areas need to be more clearly delimited.

A4, point 19

• The significance of the last sentence to obtaining valid consent is unclear.

Standard A5

• “The best treatment” is often a matter of opinion and “find” implies that this will necessarily be something other than osteopathy. This should be changed to “Work in partnership with patients to determine the most appropriate treatment for them.”

A5, point 25

• Patients may not wish to ask questions and many prefer to defer to their practitioner’s judgement when it comes to decisions about their care. “Encourage” should be changed to “give patients the opportunity to”.

A5, point 26

• “The best treatment” implies a gold standard that does not exist in most areas of clinical practice and should be changed to “Providing appropriate care…” to put the emphasis on the need for individual practitioners to make these judgements based on the circumstances of specific cases.

A6, point 27

• Too prescriptive. In relation to 27.1, this needs to be changed to “…may include:”

A6, point 27.1

• This should not be stated as a requirement as it is often counter-productive. Sadly, many GPs still have very negative opinions of osteopaths and discourage patients from having osteopathic treatment. For this reason, many patients prefer not to discuss their treatment with their GP. Their choice needs to be respected and the guidance should be changed to reflect the fact that an osteopath’s role is only to advise them in this regard. For example: “It may be appropriate to advise patients to inform their GP that they are receiving osteopathic treatment and/or ask them whether you may communicate with their GP.”
• It is also irrelevant to the standard in question and should be moved to A5 where it belongs.

B1, point 1.4

• The wording here is confused. Palpation cannot be described as a “highly skilled sense of touch” because only a person can be skilled and palpation is an ability not a person. Similarly, one cannot have a critical appreciation of a skill, only of its value. This should read: “a critical appreciation of the value and limitations of therapeutic touch and palpation.”

B2, point 2.1

• This wording is also somewhat confusing and rather vague. Try instead:  “knowledge of human structure and function sufficient to recognise and interpret clinical signs of dysfunction and develop appropriate treatment and rehabilitation strategies”

B2, point 2.3

• There are no “disorders not suitable for osteopathic treatment” as osteopathy involves promoting the physiological mechanisms underlying the body’s intrinsic capacity for self-healing and self-regulation and removing any physical obstruction that may impair them. Though there may be circumstances in which certain techniques or approaches may be contraindicated (covered in C2, 2.4) and situations in which treatment other than osteopathy is clearly necessary (covered in C2, 2.8 & C7 14.5), this never precludes the possibility of applying this principle of osteopathy with benefit.
• This is evidenced by the work of the Foundation for Paediatric Osteopathy in the NICUs at Barnet, North Middlesex and Chase Farm hospitals, the BSO’s work with HIV patients and the palliative work that many osteopaths do with terminal cancer patients. It is also demonstrated in research showing reduced post-surgical discharge times for patients given osteopathic treatment in hospital after heart surgery. Everything after “clinical judgement” should be scrapped.

B2, point 2.5

• The old capability (A4) was somewhat clearer but the meaning has been lost in the editing and the resulting language is quite confused. Try: “an understanding of the principles of biomechanics sufficient to apply osteopathic techniques safely and effectively [and judge appropriate levels of force].” The last bit [in brackets] is probably unnecessary.

Standard B3

• This standard needs a complete rethinking. Though the idea of working “within the limits of one’s training and competence” seems sensible on the face of it, this does not allow for learning and development, which always involves working at or beyond those limits in the beginning. Practitioners must be free to take on patients whose problems are beyond their experience otherwise trainees and new graduates would never be able to get started. Similarly, they must be free to try new techniques to allow for continuing professional development and innovation.
• The real issues here are that treatment must be safe (covered elsewhere) and that practitioners must recognise when a patient needs treatment that is beyond their skill and ability to deliver. However, in many cases, the latter is only determined though a trial of treatment conducted with the patient’s informed consent.
• The notions of “limits” and “competence” are too black and white given these considerations. The standard should focus instead on the need for a critical appreciation of one’s skills and abilities in determining the most appropriate course of action. In addition, “training” should be replaced with “knowledge” to reflect the fact that personal study and clinical experience are equally valid forms of learning as formal training. This would give something along the lines of “Clinical decisions should be based on a critical appreciation of your knowledge, skills and abilities.”

B3, point 3

• Following on from the discussion of Standard B3 above, “training” and “competence” should be changed to “knowledge” and “abilities”. In addition, it is often uncertain whether one’s knowledge and skills are adequate to the patient’s care. “If not” should therefore be changed to “if this is in question”. This would give “You should use your professional judgement to assess whether you have the knowledge, skills and abilities to safely and effectively treat your patients. If this is in question, you may consider:”

B4, point 5.2

• This is rather vague and unclear. If it refers to clinical audit, this needs to be made much clearer. However, a great deal more discussion and debate needs to take place before such a requirement becomes mandatory for osteopaths. This is likely to be extremely unwelcome as the administrative and financial burden could be crippling for sole practitioners and those in part time practice. Not to mention the fact that there is no evidence that such a requirement would have any positive impact on the quality of care provided by osteopaths. In fact, there is a significant risk that the onerous bureaucracy involved would detract from patient care. This should not be introduced without a full independently conducted impact assessment and a profession-wide discussion and debate.
• In the meantime, a requirement for reflective practice, which is a well established mechanism for maintaining high standards, would be more than sufficient. For example: “evaluating the quality of the osteopathic care you provide and planning your CPD activities accordingly.”

B4, point 5.3

• “The principle of tailoring osteopathic care to individual need” (GOsC draft Practice Framework, clause 30) precludes the possibility of best practice guidelines in osteopathy on the basis that similar presentations are due to unique combinations of aetiological factors in individual cases and treatment is most effective when these differences are taken into account.
• Similarly, decisions about patient care are always informed by the practitioner’s unique knowledge and skills so that two practitioners are unlikely to make the same treatment choices in the same case.
• In addition, fashions come and go in the healthcare community and the interpretation of research is often biased by ideological or commercial factors, requiring practitioners to be vigilant in their critical evaluation of current opinions and advice.
• This means that the emphasis must be upon the responsibility of the individual practitioner to judge the relevance of theory and research evidence to individual patients. The guidance should be changed to reflect this: “Keeping up to date with contemporary opinions related to osteopathic healthcare and critically evaluating their relevance to your practice.”

Standard C1

• Clinical practice is often marked by uncertainty and in many cases it is not possible to make a definitive diagnosis as further investigations or a trial of treatment are necessary in order to clarify the situation. Hence requiring a diagnosis is an impossible standard for osteopaths to consistently attain. The focus should be placed instead on conducting a sufficient diagnostic evaluation to determine the most appropriate course of action.
• In addition, there is a wide diversity of opinion about what constitutes an osteopathic diagnosis. Whilst a diagnosis is commonly thought of as a category of disease, in the osteopathic model the focus is on an explanation of the unique factors which have led to the patient’s dysfunction, as this is what is necessary in order to tailor a treatment plan to their individual needs. This more commonly takes a narrative form which explains the patient’s symptoms in terms of the multiple mechanical, physiological and psycho-social factors that may be contributing to them and places these in the wider context of their life.
• Any ambiguity about this in the standards could lead to unfairly prejudicial judgements being made about the safety of an osteopath’s practice on the basis of misplaced assumptions about the nature of osteopathic diagnosis, especially if their practice is being evaluated by non-osteopaths as would occur in the event that osteopathic regulation were to come under the HPC.
• For this reason, it is essential that the standards leave no room for misinterpretation here. They must be flexible enough to allow for a diversity of approaches whilst still establishing clearly what is necessary for safe practice.
• This can best be accomplished by shifting the focus from the diagnosis itself to the process of making an evaluation, which is far more important for patient safety. This process involves two parallel activities:

1. The determination of whether the patient needs referral for further investigations or other treatment (covered in C7, 14.5, C2, 2.4 & C2, 2.8)
2. The generation of a hypothesis as to the nature of the patient’s condition and the unique factors that have led to their dysfunction, which must be sufficient to form the basis of a safe and effective treatment and management plan

• The standard should therefore be changed to: “You must be able to conduct a sufficient diagnostic evaluation to inform your clinical decisions” and the guidance should clarify the kinds of judgements that must be made in order to accomplish this without being too prescriptive about how.

C1, point 1.4

• “Appropriate clinical investigations for your patient” implies that there is a correct procedure for every presentation. However, practitioners with more clinical experience and palpatory ability often dispense with certain more formal clinical investigations as they are able to obtain the necessary information without them and, having first excluded the need for urgent referral, many osteopaths use treatment as their primary diagnostic tool. Hence, in order to allow for flexibility in the approach taken, this should be changed to “conduct a sufficient examination to inform your clinical decisions”.

C1, point 1.5

• As discussed above, osteopathic diagnostic evaluation is not so much a question of selecting one diagnosis from a range of hypotheses as coming to understand how the patient’s unique history and circumstances have led to their dysfunction whilst, in parallel, establishing if there is a need for referral for other treatment or further investigation. Point 1.5 is completely inadequate to the purpose of characterizing this process and should be replaced by two separate points describing each of these aspects:
• 1.5   evaluate the need for referral for further investigation or other treatment.
• 1.6   generate a plausible hypothesis as to the nature of the patient’s condition encompassing the unique factors that predisposing, exciting and maintaining their dysfunction

C2, point 2.2.1

• This should be changed to “your diagnostic evaluation” for reasons discussed above under C1. (i.e. it is the process and not the label that is important in diagnostic evaluation)

C2, point 2.2.2

• “Limits of competence” does not allow for learning and development, as discussed above under B3. This should be changed to “a critical appreciation of your personal knowledge, skills and abilities.”

C2, point 2.4

• There is almost no research on the safety of specific osteopathic techniques or approaches and no general consensus about their indications or contraindications. In addition, the notion of indications and contraindications implies that general rules can be generated as to when to use specific techniques but this is not possible because each treatment is necessarily unique as similar patterns of dysfunction respond clinically to different approaches in different cases and because each practitioner’s skills and abilities are unique and their decisions about treatment will depend on this. The guidance should be changed to “identify appropriate techniques or approaches and deliver them safely and effectively” to place the emphasis on the practitioner’s professional judgement.

Standard C3

• There are many medical conditions that are still poorly understood. Osteopaths cannot therefore be required always to understand our patients’ conditions. This should be changed to ”Care for your patients and do your best to understand their condition and improve their health”

C6, point 8

• This whole section is very prescriptive. The last sentence should be changed to allow more freedom for practitioners to determine for themselves according to each situation how best to uphold the standard. The last sentence should be changed to “Respecting your patients’ dignity and modesty may involve:”

C6, point 8.2

• This is too prescriptive. Much clinically useful information can be gleaned from observing a patient get dressed/undressed and this is partly dependent on their being unaware that one is critically observing them so explaining why one wishes to observe them somewhat defeats the purpose. The important point is to give the patient the option of changing in private. E.g. add “…if they wish”.

C6, point 9

• “You must offer a chaperone” implies that the osteopath has to provide the chaperone which is impracticable for many sole practitioners or for those doing home visits. In many cases the patient will have to arrange for a chaperone themselves if they wish to have one present and the guidance should reflect this. E.g. “You must offer the patient the option to have a chaperone present if:”

C6, point 13

• Asking the patient to countersign one’s notes seems rather like overkill.

C7, point 14.2

• As discussed under C1, 1.4, what constitutes “appropriate clinical investigations” in a given case is a matter of opinion and the inclusion of this term could lead to prejudicial judgements being made about an osteopath’s practice by those whose perspectives on this differ. The emphasis should be on “conducting an examination sufficient to inform your clinical decisions”.

C7, point 14.3

• As discussed under the standard C1 and it’s guidance point 1.5, the notion of “formulating a diagnosis” needs to be replaced with “conducting a diagnostic evaluation…” (…and formulating a treatment plan).

C7, point 14.4

• The notion of “good quality treatments” is somewhat problematic. There is so much disagreement about what this means in osteopathy and so little research to support claims of efficacy that the most sensible approach here would seem to be to focus on the need for treatment to be based on a rationale.
• As discussed under standard B3, the notion that treatment must be within one’s level of competence is problematic because it precludes the possibility of learning or development. It may be helpful here to distinguish between two aspects of competence, namely safety and effectiveness. Whilst there is no question that osteopaths must not attempt treatments that they are not competent to deliver safely, they cannot be required to be competent to deliver them effectively as there is no agreement or evidence regarding what is effective.
• The guidance should be changed to “providing safe and justifiable treatments”.

C8, point 16.8

• This should be changed to “(a summary of) your osteopathic diagnostic evaluation and treatment plan” (see discussion under standard C1)

C8, point 16.8

• Consent forms are not always required. Add “where necessary”.

C8, point 16.10

• Not all communication with, about or from a patient is clinically relevant. “clinically relevant” should be added to the beginning of this guidance.

C8, point 16.14/15

• The wording implies that one always needs to record the presence or otherwise of a chaperone/student/observer but this is not always relevant.

C8, point 18

• The meaning of “complete” is unclear here and it seems unnecessary.

Standard C9

• This is another impossibly high standard as nobody can keep anyone else from harm, especially not “whatever the cause”. Taken literally this sensible ideal would have us following our patients around in case we needed to pull them out of oncoming traffic or defend them against random attacks in the street. In addition, acting quickly on concerns one might have is not always the most appropriate course of action. This should be changed to “Do your best to help patients and keep them from harm”

C9, point 21

• This needs to be thought through very carefully. Concerns about colleagues or other healthcare practitioners require evidence before they should be acted upon and this needs to be made clear.
• Discussing one’s concerns with the patient should be included amongst the courses of action to be considered.

Standard D2

• It is unclear what is meant by “requirements for the production of high-quality written material and data” or what it has to do with clinical practice. As it stands, this standard appears to be a requirement for compliance with regulatory bureaucracy for its own sake, which has nothing to do with proficiency in osteopathy. Unless it can be made much clearer what this standard refers to and how it is relevant to clinical practice, it should be scrapped.

D2/3, point 2.4

• This is worded as a requirement to conduct clinical audit, which is not a guideline as to how to meet the relevant standards and would require a separate standard for itself were it to be introduced. However, as discussed above under B4, point 5.2, a full impact assessment followed by a profession-wide discussion and debate is necessary before this can move ahead. It should not be included at this time.

D4/5, point 5

• It should be stated clearly that the list (5.1, 5.2, 5.3) is not exhaustive.

D7, point 13

• Not all osteopaths are members of a professional association.

D14, point 26.5

• There is no valid reason not to accept referral fees if this does not prejudice one’s decision to refer. Since GPs’ decisions to prescribe are financially incentivised by NHS targets, this would constitute a double standard. It also contradicts point 31.

Standard D15

• Osteopaths’ personal lives are not subject to GOsC regulation. The reference to personal financial dealings should be removed from the standard.

D15, point 32

• There is no reason not to allow organisations offering valid and legitimate services to use one’s name to promote them if one endorses them.

D16, point 36.6

• The meaning of “take advantage of your professional standing” is somewhat unclear here as it could be taken to mean that relationships with ex-patients are prohibited. This is clearly untenable as any two individuals have the right to freely choose to pursue a relationship with one another. This should be modified to make it much clearer that the guidance is aimed at preventing the abuse of professional power in pressuring a patient into entering into a sexual or personal relationship.

Standard D17

• It is hard to see the clinical relevance of this standard or what it has to do with patient safety. Notions of what constitutes disreputable behaviour are extremely subjective and this standard opens the door wide open for the persecution of osteopaths whose beliefs or activities are outside of the mainstream by those in positions of power with political or ideological agendas. I am not suggesting that this is the intention here but it is just as important that the code protects osteopaths from the possibility of such abuses of regulatory power as it is necessary that it protects patients from harm.
• This standard is irrelevant to patient safety and its inclusion leaves osteopaths unnecessarily vulnerable to abuses of regulatory power, especially in the event that the GOsC is dissolved and osteopathic regulation comes under the HPC. It should be replaced with something that shifts the emphasis back onto patient safety such as: “Act responsibly in all areas of your professional life” and all references to “upholding the reputation of the profession” in the guidance should be removed.
• In addition, osteopaths’ personal lives are not for the GOsC to regulate. All references to osteopaths’ personal lives should be removed from the guidance.

D17, point 38

• Should be scrapped. See above.

D17, point 39

• “Upholding the reputation of the profession” should be changed to “acting responsibly” and the guidance that follows should be modified to make it clear how it relates to clinical practice.

D17, point 39.2

• What constitutes the abuse of drugs or alcohol is quite subjective. The key issue here is that practitioners should not allow anything to compromise their clinical judgement, including prescription medications taken for genuine health problems. This should therefore be changed to place the emphasis on how it relates to clinical practice, e.g. “not allowing you clinical judgement to be compromised by the influence of drugs or alcohol”

D17, point 39.3 & 39.8

• “Personal” should be removed.

D17, point 40.1

• “Charged” should be change to “convicted”. (See BOA feedback)