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