Osteopathic Practice Standards

This is the document that’s going to define osteopathic practice for the next ten years. With only a few weeks left to have your say, I thought I would share my view with anyone who’s finding the prospect of getting stuck into the document itself a little daunting.

The Osteopathic Practice Standards (OPS) document seems, on the whole, to be an improvement on the old Code of Practice and Standard of Proficiency (S2K) which it replaces. Combining the standards in one document makes things a lot simpler and the restructuring of the standards under four key headings makes everything more concise and accessible. The removal of the notorious clause 20 of the previous code will certainly please a lot of people and seems to be a sign that the GOsC are genuinely listening to concerns raised during the consultation process thus far.

As is to be expected, there are also areas in which the draft OPS still has room for improvement and there are things in here which will be controversial. I will tackle the three issues I feel to be most important first as these have the biggest potential impact on osteopathic practice. I will then go through the rest in the order in which they arise in the document.

1) Clinical Audit

The inclusion of what seems to amount to a requirement for osteopaths to conduct regular audits of their clinical effectiveness is certainly going to ruffle some feathers. Many people were very clear in the consultation meetings that they did not feel they had the time or the skills to meet this demand. It is one thing for a group practice with secretaries or receptionists who can shoulder the administrative burden but sole practitioners, especially those whose IT skills may not be so up to date are sure to find this quite a challenge.

The requirement comes in two parts:

• Section B4 (5.2) demands that osteopaths “keep your professional knowledge and skills up to date by [..] monitoring the quality of osteopathic care you deliver and acting on the findings”
• Section D3 states that osteopaths “will need to [..] collect and analyse both quantitative and qualitative data to monitor the quality of your professional practice.”

Quite apart from the question of whether this is a fair, reasonable and proportionate demand, considering the risks osteopaths pose to our patients and the other mechanisms already in place to ameliorate these, there is also the question of why this requirement has been divided into two parts and why the second part has been included under section D (professionalism) and not under section B (safety and quality) where it would seem to belong. This makes it all rather unclear what exactly is being asked of us.

2) Limiting the Scope of Osteopathic Practice

Section B2 requires osteopaths to have “knowledge of human diseases sufficient to inform clinical judgement and to enable recognition of disorders not suitable for osteopathic treatment” (2.3)

This seems sensible enough on the surface but notion of “disorders not suitable for osteopathic treatment” is misconceived at best. Neither osteopaths nor any other health professional can treat a condition per se. We treat patients who have conditions and our aim as osteopaths is to help their bodies to function as well as they can. The aim is not to treat the condition but to help the person who has the condition by making them more comfortable and supporting their body’s healing process by addressing any mechanical issues that may be compromising it. This is always appropriate, no matter what condition a patient may have and regardless of what other care may be necessary. For example, the BSO has an outreach clinic at the Royal Free Hospital for HIV patients and many osteopaths have worked to ease the suffering of patients with terminal illnesses.

The most emphatic example of this is the work of the Foundation for Paediatric Osteopathy, which been sending osteopaths to work on premature babies at Barnet Hospital for over a decade. Many of these babies are under 28 weeks gestation, on full life support and have some of the most serious life-threatening conditions imaginable. That their doctors have happily invited the Foundation’s osteopaths to work alongside them clearly shows that there are no conditions that preclude osteopathic treatment. That this service has now been extended to Chase Farm and North Middlesex hospitals at the doctors’ request (and with full approval from the clinical governance team at Great Ormond Street in the case of North Middx.) is further confirmation.

If this clause is about ensuring osteopaths have sufficient knowledge of pathology to inform their clinical decisions, the second half is entirely unnecessary. If it is intended to protect patients, it needs to be much more specific and should be included in section C, not B. There are two situations that need to be covered in this regard. Firstly, there are certainly situations in which treatment other than osteopathy is an urgent priority. There is no question that osteopaths must be able to recognise a medical emergency and do everything in their power to ensure that their patients receive any urgent treatment that they need as quickly as possible. Secondly, there are situations in which certain techniques may pose a higher risk than usual to the patient and should be very carefully considered. However, neither of these precludes the possibility that these patients may benefit from osteopathic treatment and both of these are already covered under other sections of the document.

Section C2 requires the ability to

• “identify indications and contraindications of using specific osteopathic techniques or a modified form of such techniques” (2.4) and
• “recognise adverse reactions to osteopathic treatment and take appropriate action, including referral to another healthcare practitioner when appropriate.” (2.8)

Section C7 states that

• “providing appropriate care and treatment includes [..] referring patients elsewhere when they need treatment which you cannot provide” (14.5)

Adding a section on recognising medical emergencies would surely be sufficient to ensure patient safety, making the reference to “disorders not suitable for osteopathic treatment” entirely unnecessary.

3) Following contemporary advice

Section B4 demands that osteopaths “keep up to date with contemporary advice related to osteopathic healthcare and integrate this into your clinical practice.” (5.3)

Again, this seems harmless enough on the surface but leaves the door wide open for attempts from outside parties to standardise osteopathic practice under the banner of EBM. The danger is that someone produces a guideline about how to treat patients with a certain condition and then someone outside the profession goes around encouraging patients to make complaints about their practitioners if they do not follow this advice. This would not only limit individual osteopaths’ ability to tailor their treatment to patients individual needs but would also curtail the possibility for innovation in osteopathic practice. I’m sure this was not what was intended here but the wording is too open to interpretation. Adding “where appropriate” would probably be sufficient to shift the emphasis back onto the clinician’s use of clinical judgement, which was of course what was intended by the initial proponents of EBM.

Absolute Trust
The introduction to Section A states that “The therapeutic relationship between osteopath and patient requires absolute trust and confidence.” This is an impossibly high standard. Nobody is absolutely trustworthy. It’s obvious what is meant here but the language is inappropriate for a legal document such as this.

Treatment of Intimate Areas
Section A2 requires that “When proposing to undertake any vaginal or rectal examination or technique, you should schedule the procedure for another appointment. This will allow the patient time to understand what you propose and to ask any questions.” (7) This is rather prescriptive and leaves no room for flexibility. 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. Perhaps it would be simple 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.

Communicating risk
This section is on the whole a great improvement. However, under section A3, osteopaths are required to ensure that patients understand “the risks involved in the treatment you propose to administer” (8.3) Some treatments may have no significant risks associated with them. This should be re-stated as “any significant risks…”

Responding to patients’ concerns
In reference to practitioners who carry out diagnosis and treatment simultaneously, within parameters agreed in advance with the patient, section A4 (clause 15) requires that “If the patient becomes concerned that you are going outside the agreed parameters at any time during the consultation, you must stop the treatment.” The problem here is that a patient may be concerned without expressing this in any way. Practitioners cannon be expected to be telepathic. This needs to be put more precisely to account for this. I.e. “If the patient expresses concern or you suspect that they may be concerned…”

Palpation
Section B1 (1.4) requires “a critical appreciation of the highly skilled sense of touch, known as palpation.” The wording of this definition is somewhat confused. A person may be highly skilled in the use of palpation but palpation may not be described as highly skilled because only a person may have skill; the sense of touch cannot. In any case, it is unnecessary to define palpation here. The old standard, K1 made more sense and what is intended by “a critical appreciation” might also be made clearer by extending this to include the limitations of palpation, giving instead “a critical appreciation of the value and limitations of therapeutic touch and palpation”

Appropriate use of force
B2 (2.5) requires “an understanding of the principles of biomechanics to assess the appropriateness of effective use of force when applying osteopathic techniques.” The idea is fine but this is quite poorly worded and hence unclear. All techniques involve some force and low levels of force are nearly always appropriate, such as the force involved in light effleurage or indirect techniques, for example. The question is how much force is appropriate in this area for this patient at this time.

Diagnosis and evaluation
I don’t have a major problem with the standards in the OPS in this regard but I don’t feel that they reflect the nature of osteopathic practice as well as they might and I think there is an opportunity here to make a positive step in making it clearer what osteopaths do in practice. The relevant standards are C1 (1.5), which requires the ability to “formulate appropriate diagnostic hypotheses to explain the patient’s presenting complaint and, through a process of deduction, select the most likely diagnosis” and C7 (14.3) which states that “providing appropriate care and treatment includes [..] formulating a diagnosis and treatment plan.”

The wording in these standards fails to reflect the distinction between a diagnosis, which involves determining what kind of condition the patient has (i.e. ascribing a category), and making an osteopathic evaluation, which involves determining the mechanical, physiological and psychological elements of that condition and where osteopathic treatment may be able to influence these (i.e. coming to a holistic understanding). This is an important distinction in osteopathic practice as the former is the basis of our triage process and hence important in ensuring patient safety, whilst the latter forms the basis of our treatment plan.

I would like to see the diagnosis and osteopathic evaluation more clearly distinguished along these lines and perhaps the osteopathic evaluation could be more fully expanded to include such elements as recognising the predisposing, maintaining and precipitating factors and appreciating the relationship between the mechanics, the physiology and the psychology contributing to the condition.

Dressing and undressing
C6 (8.2) advises “allowing a patient to undress, and get dressed again, without being observed.” This is not clear enough and could be interpreted as implying that we must always let them undress in private rather than giving them the choice, which is clearly what is intended. Adding “if they wish” or something similar would rectify this.

Covering up
Under the same section, clause 8.5 advises “ensuring that patients are only undressed to the level needed for the procedures being used at any given stage of the consultation and not left undressed for longer than necessary.” This is rather prescriptive and could be problematic for those who work with a whole body approach in which the flow of the treatment is seen as just as important a contribution to the therapeutic benefit as the individual techniques. Continually stopping to move covers around may compromise both the flow of the treatment and the osteopath’s ability to judge the effect that treatment is having on the patient’s overall posture and bodily coordination.

Intimate areas & chaperones
Under clauses 9-13 in section C7, guidelines for the treatment of intimate areas are set out, including the requirement to offer a chaperone (11) and the requirement for patients to countersign their refusal of the offer of a chaperone. This makes sense in regards to vaginal and rectal examinations and techniques but the absence of a specific definition of intimate areas here leaves this whole section much to open to interpretation.

Since most osteopaths routinely or frequently treat the pelvis and groin regions, for example, this could be interpreted as meaning that we need to get patients to sign off every time that we do this. Apart from being unnecessary, this would be a source of considerable irritation for many patients who would much prefer that their practitioner just gets on with doing what they feel is necessary, within reasonable limits.

Under C8, section 16.14 requires osteopaths to record “ whether a chaperone was present or not required.” It needs to be clarified that this is not always necessary but only in such instances as it is necessary to offer a chaperone by adding “when relevant”, for example.

Staying within your level of competence
Section C7 (14.4) demands “providing good quality treatments (which must be within your level of competence)” This is another one that seems fine in principle until we think through what this literally means. Whenever we learn a new technique or approach and set out to integrate this into our clinical practice, or when we are developing new techniques and approaches, we are at the edge of our competence, if not beyond it. This standard needs to reflect this ongoing process of development.

Requiring instead the ability to “critically evaluate your ability to provide adequate treatment” would put the emphasis more firmly on the clinician’s responsibility to make appropriate judgements about their ability to meet the patient’s needs.

Inform your professional association
Section D7 (13) requires that “You should inform your professional association and professional indemnity insurers if you receive a complaint.” Whilst I’m sure the BOA would love every osteopath to be a member of their association and as a member I would encourage others to join, the fact is that many osteopaths are not members and requiring them to inform the BOA in such circumstances, where they would be unable to avail themselves of the support the BOA offers to its members in such circumstances, seems rather cruel.