Dynamics of osteopathic regulation

188 Pages·2015·1.41 MB·English

Exploring and explaining the dynamics of osteopathic regulation, professionalism
and compliance with standards in practice

Report to the General Osteopathic Council

February 2015

Professor Gerry McGivern1, Dr Michael Fischer2, Dr Tomas Palaima1, Zoey
Spendlove3, Dr Oliver Thomson4 and Professor Justin Waring3

1Warwick Business School, University of Warwick, UK.

2Centre for Workplace Leadership, University of Melbourne, Australia, and Said
Business School, University of Oxford, UK.

3Centre for Health Innovation, Leadership and Learning, Nottingham University
Business School, University of Nottingham, UK

4British School of Osteopathy, UK.

1
Table of Contents

Executive Summary 3
Recommendations 10
1. Introduction and research background 13
2. Research methods 18
3. Osteopathic professional identity, practice and evidence base 37
4. Perceptions and experiences of Osteopathic Practice Standards 51
5. Experiences and perceptions of the General Osteopathic Council and 79
regulation
6. Experiences and perceptions of Fitness to Practise hearings 95
7. Dealing with problems, near misses and complaints in practice 116
8. Strengthening professionalism by creating ‘formative spaces’ in ‘peer 140
discussion review’
9. Summary, discussion and conclusions 157
References 183
Appendix 1: A review of literature on the osteopathic profession, osteopathic
practice and osteopathic regulation in the UK
Appendix 2: A review of literature on professions, health professional
regulation, revalidation and continuing fitness to practise
Appendix 3: Survey questionnaire
Appendix 4: Survey results

2
Executive Summary

Introduction and research aims

 This is a report on research conducted by an independent team of academics
from the University of Warwick, the University of Melbourne/ University of
Oxford, the University of Nottingham and the British School of Osteopathy,
funded by the General Osteopathic Council (GOsC) to answer the research
questions: What regulatory activities best support osteopaths to be able to
deliver care and to practice in accordance with the Osteopathic Practice
Standards (OPS)? What factors inhibit osteopaths from practising in accordance
with OPS? What factors encourage osteopaths to practice in accordance with
OPS?

Research methods

 We conducted literature reviews about osteopathic practice, the osteopathy
profession and osteopathic regulation (see Appendix 1) and professionalism,
health professional regulation, revalidation and continuing Fitness to Practise
(FtP) generally (see Appendix 2) and analysed GOsC documentation to provide us
with a background understanding of osteopathic regulation.

 We then developed interview questions and conducted semi-structured
interviews with 55 people (including 37 osteopaths) involved in and affected by
osteopathic regulation, as well as health professional regulation more generally.
We analysed interviews using qualitative data analysis methods, including coding
and template analysis. We present anonymised narrative extracts from
interviews to illustrate and evidence the points we make in this report.

 We also ran an online survey (see Appendix 3), which 809 osteopaths completed
(17% of the 4900 osteopaths on the GOsC register). We analysed the results of
3
the survey (see Appendix 4) conducting T-tests for statistically significant
variations in responses among demographic groups. We also conducted an
exploratory factor analysis of responses to questions, which indicated 10 factors
(favouring formal peer review; favouring informal peer review; feeling compliant
with standards; pro-evidence-based practice; pro-GOsC; fear-based compliance
with standards; osteopathic distinctiveness; clarity about reporting colleagues’
poor practice; experiential perceptions of GOsC; narrative perceptions of GOsC).

Osteopathic professionalism and practice

 Osteopaths use a range of approaches ranging from quasi-medical structural
musculoskeletal manual therapy to osteopathy akin to esoteric healing. This
diversity may make osteopathic regulation against standards more complex.
Some interviewees said osteopathy and other manual therapies (such as
physiotherapy or chiropractic) overlap, while others said osteopathy was a
unique health care profession. In our survey, 84% of osteopaths agreed that
‘osteopathy is a unique health care profession’. Most osteopaths we interviewed
were proud of their professional identity as an osteopath and believed that
osteopaths improve patients’ health in a distinctive way, so should be regulated
by an osteopathic rather than generic regulator.

 Most osteopaths practice independently or in small practices, often in isolation
from other professional. Osteopaths, particularly those working alone, may have
few opportunities to discuss their practice with colleagues and so become out of
step with best practices. Yet other osteopaths may not know about their poor
practice. Osteopaths also commonly practice as self-employed businesses,
earning higher incomes by attracting more patients. Osteopaths therefore have
an interest in collectively developing the quality and reputation of the
osteopathy profession, while individually competing for patients with other
osteopaths, which may create a disincentive to collaboration and openly
discussing their practice with other osteopaths.

4
 Interviewees described osteopathy as a holistic, patient-centred manual therapy
in which verbal and non-verbal communication and relations with patients, use
of osteopaths’ hands (‘palpation’), subjective interpretations and intuition were
important elements in diagnosing and treating patients. We suggest that the
complexity of osteopathic practice make its regulation against standards more
difficult.

 Many interviewees commented on the limited evidence of the risks and benefits
of osteopathy, which was a source of professional insecurity. Yet osteopaths
were also concerned that evidence should be developed in terms appropriate to
osteopathy, rather than using a biomedical approach. While generally in favour
of evidence-based practice in principle, osteopaths were less positive about its
effects in their practice. The limited osteopathic evidence-base makes
osteopathic regulation against standards more difficult.

Osteopaths’ perceptions and experiences of standards

 Many osteopaths we interviewed believed that OPS provide a useful benchmark
for good osteopathic practice. However others criticised OPS for simultaneously
being too open to interpretation and also legalistic, bureaucratic and rigid.
Osteopaths particularly complained about OPS relating to communicating risks
associated with osteopathic treatments and gaining patient consent, note-
keeping, and patient modesty and dignity.

 Some interviewees said they always thought about OPS, others that they thought
about OPS unconsciously, a few commented that they rarely considered OPS,
relying instead on their professional training. 19% of osteopaths in our survey
disagreed that ‘What I do as an osteopath always fully complies with the OPS’.
Interviews suggest that osteopaths judge compliance with standards using a
“sense” rather than evidence. In our survey, more osteopaths said they complied
with OPS ‘to avoid getting into trouble with the GOsC’ (49%) or ‘being sued by a
5
patient’ (54%) than because OPS ‘reflect what it means to be a good osteopath’
(28% agreed).

 Osteopathic Education Institutions (OEIs) map their curricula against OPS and
seem to place emphasis on getting osteopathic trainees to internalise OPS and
understand how they apply in practice. From our survey, recently qualified
osteopaths were more likely to agree with osteopathic regulation and
demonstrate ‘fear-based compliance with standards’ (from factor analysis).

Osteopaths’ perceptions and experiences of the GOsC and osteopathic regulation

 Interviewees commented that the GOsC had significantly improved in recent
years, largely because it had made effort to reach out and personally engage with
osteopaths. Closer engagement between the GOsC and osteopaths seemed to
have improved osteopaths’ understand of OPS and belief in their legitimacy.
However some osteopaths remained suspicious of the GOsC and questioned the
legitimacy of the OPS due to problems and difficult relations between the GOsC
and the osteopathy profession in the past, when new regulation was introduced.
Our survey data suggests that osteopaths’ perceptions of the GOsC are affected
by the GOsC’s communications, experiences of the GOsC and what osteopaths
hear from their colleagues. Evidence from this study supports the GOsC’s
relational approach to actively engaging with the osteopathy profession, which
we suggest is leading osteopaths to frame osteopathic regulation and complying
with OPS in more constructive professional terms.

 We conducted interviews with two osteopaths subject to FtP hearings and a
patient who made an complaint considered in an osteopathic FtP hearing. These
interviews suggested that FtP hearings were fair and well managed but took too
long. The patient was unhappy because they felt the FtP process had addressed
issues that did not reflect their original complaint. Both the osteopaths described
their FtP investigations and hearings as distressing, believed they should never
have been subject to FtP hearings, and emerged from the process doubting the
6
validity of osteopathic regulation, rather than their own practice, and less
professionally engaged.

 While based on a small sample, our interview findings echo previous research on
experiences of osteopathic complaints (Leach et al. 2011; Moulton Hall, 2014).
Our survey data also points to relatively low levels of understanding of and
confidence in FtP hearings among osteopaths more generally. Interviews suggest
that stories about damaging experiences of FtP hearings may produce anxiety
about regulation and consequent defensive practice in the wider osteopathic
population.
 While legislation provides the GOsC little discretion about whether to investigate
osteopathic complaints, and serious complaints do need to be heard in FtP
hearings, our findings suggest that the GOsC should aim to minimise the number
of FtP hearings. Developmental professional processes, like peer discussion
review, may proactively prevent potential osteopathic malpractice, complaints
and consequent FtP hearings.

Osteopaths’ worries and concerns about practice and how to address them

 Concerns about osteopaths’ own practices were common. In our survey, 22% of
osteopaths had worried about their practice not complying with the OPS.
Osteopaths suggested that reflection, communication, sharing, learning and
discussion with osteopathic colleagues were the most effective ways of
addressing malpractice and maintaining high quality practice. However, many
osteopaths lack such opportunities. Our research suggests a need for more
reflective discussions between osteopaths in ‘formative spaces’ (McGivern and
Fischer, 2012), where they feel safe to openly reflect on and discuss their
practice. These would proactively reduce professional malpractice and isolation,
engage osteopaths in professionalism and improve the overall standard of
osteopathy.

7
 Concerns about colleagues’ practices were also common. In our survey, 28% of
osteopaths reported having had concerns about colleagues’ practice or
behaviour. While most osteopaths said they would report ‘serious’ concerns
(involving sexual abuse, harm to patients or criminality) to the GOsC, our
interview and survey data suggest that few concerns are reported, due to lack of
solid evidence and not wanting to cause trouble for colleagues. Osteopaths seem
more likely to discuss concern about an osteopath with other colleagues, to
advise patients to make a complaint, speak to the osteopath they were
concerned about, or, more worryingly, take no action.

Peer discussion review

 The introduction of ‘peer discussion review’ within the GOsC’s process to assure
osteopaths’ continuing FtP provides an opportunity for reflective discussions in
which osteopaths can address worries about their own practice and peer
reviewers can raise concerns about osteopaths they review. In our survey, 52%
of osteopaths agreed ‘peer review, involving informal discussion of my practice
with another osteopath, would have a positive effect’ (only 34% agreed ‘peer
review would have a positive effect on how I practice as an osteopath’ in
general). 69% agreed they ‘would be able to bring up problems and tough issues
during a peer review involving informal discussion of my practice’. Osteopaths
were more likely to agree with both statements if they are able to choose their
peer reviewer.

 Our research supports the introduction of informal peer discussion review as
part of the GOsC process to assure osteopaths continuing FtP. However, peer
discussion reviews should be confidential. Unless serious concerns are raised the
content of peer discussion reviews should not be formally recorded or reported
to the GOsC, to encourage open reflection and discussion of problems.

8
 Some osteopaths used the language of ‘red flags’ (signalling serious concerns
about osteopathic practice or professionalism) and ‘yellow cards’ (signalling less
serious concerns). Other osteopaths complained about abstract, legalistic and
educational language used in the GOsC’s earlier revalidation pilot, which
osteopaths struggled to understand or relate to. Explaining regulation using
terms familiar to osteopaths may better communicate its purpose. ‘Red flags’
have a specific meaning in clinical contexts, which might not reflect the precise
intension of osteopathic regulation, but the GOsC could consider using similar
language when designing regulatory process. ‘Red flags’ need to be reported to
and investigated by the GOsC, to protect patients and the public, but our
interview and survey data suggest that ‘yellow cards’ may be better addressed
between professionals during peer discussion reviews, as we will discuss below.

Promoting compliance with regulation

 Our research adds to evidence (Quick, 2011) suggesting that professionals are
more likely to comply with regulation when they understand why regulation is
necessary, the evidence underpinning the regulatory approach, believe
regulation is legitimate, reflects and promotes good professional practice, and
professionals have been involved in its development.

 Osteopaths need regulation aligned with wider societal norms to demonstrate
their practice is a safe and legitimate and ensure ongoing demand from patients.
Our research suggests that osteopathic regulation based on formative, informal
and confidential ‘peer discussion review’ and CPD providing assurance of
continuing FtP is ‘right touch regulation’ (PSA, 2010), balancing societal
expectations and osteopathic practice. It is an approach likely to support
compliance with the OPS, reduce malpractice and produce improvements in
osteopathic practice overall.
9