Waiting to join the Academy of Physical Medicine’s live webinar on advertising, an age- old childhood question about TVs resurfaced:  I can see the screen – but can it see me? This has total legitimacy in the age of webcams and Smart technology, so I decided to hold off on the nightwear and keep my glass of Rioja well out of shot, and after all that, I found I was unable to log in!  So popular was this talk that the server couldn’t cope, and despite a couple of cheery emails from Steven reassuring me that it would work, at 7.30 I had almost given up, when suddenly a new link appeared and I was there, attending the webinar (incognito, to my relief), via my iPad.

Who was there?

In addition to the large but unspecified actual number sitting at home,  like me, there were 5 people on set:  Jane Eldridge from the Advertising Standards Agency, showing a certain amount of courage;  Tim Walker, CEO of the GOsC; Maurice Cheng, CEO of iO; Jonathon Field, a research fellow and trustee of the Royal College of Chiropractors (due to speak at COPA this year),  and the host, Steven Bruce, who was the Academy of Physical Medicine person.

Guess who’s learnt to take screenshots this week?   L-R:  Jonathon Field, Tim Walker, Steven Bruce, Jane Eldridge, Maurice Cheng

You can watch it here, if you register.  It lasts about an hour.  I had to go round the houses a bit to find it, but it’s interesting and worth the effort.

Getting clear what the ASA (Advertising Standards Agency) does and what CAP (Committees of Advertising Practice) does

This is still quite confusing but Jane did a good job trying to explain it.  Basically it seems to boil down to this:

The CAP WRITES the codes – also gives support and training and guidance to industries which sign up to the standards, then…

The ASA ADMINISTERS the codes, making sure that all ads are responsible and people can trust them.  Although “independent”, it seems to derive its authority, in effect, from – *Brexit impact alert* – European law somehow.

Part of our osteopathic standards are that we must meet the requirements of the CAP code, so even though the Council doesn’t police our websites, (it’s not part of their job description), if we refuse to abide by an ASA ruling, this is a breach of our standards and presumably we’d end up in the Fitness to Practise process  i.e. not somewhere you’d willingly choose to be.

The list of conditions approved by CAP

I presume we’ve all seen the list of conditions we can advertise.  (I’ve pasted it at the end of the piece in case you haven’t).  The whole existence of this list spawns a number of interesting questions, not least – what exactly is lumbago and is it still even in the dictionary?  Some of the other curious issues it raises are

1.  Why is it that the exact same osteopaths who get so incredibly fed up with people just not understanding that we treat ‘the person not the disease, for goodness sake!’,  are also the most likely to want to advertise that they can treat dyslexia, morning sickness or Sjogren’s disease?
2. Why is the “chiropractor” list of conditions shorter than the “osteopath” list?  Jonathon Field was quite indignant about this and I can see why.  The answer is that the lists have evolved over time (they were not designed by an omniscient intelligent being in a creationist-style event) and so the disparity has arisen for “historical” reasons.  It is up to the chiros to put their case, and since their last guidelines were agreed in 2010 it is probably timely.  Sports therapists seem to be allowed to say they treat even more than us – whiplash and sciatica, I think, so again it seems it is not a level playing field.
3. How can this list be changed?

Well, it was eventually revealed that the list was in some way ‘agreed’ by an internal committee of the CAP, evoking a process as opaque and mysterious as the inner working of the rugby scrum,  however it seems it is not set in stone.  As the ASA and CAP are largely reactive organisations, their actions are mostly triggered by complaints (97% are from the general public, but also a few from competitors and pressure groups, such as the Good Thinking Society).  This mutability means that they are very open to considering changes in the light of new evidence, so, if you have something to say, and especially if you have evidence to provide, please put your case to them.

The last guidelines for osteopaths issued in November 2016 were the result of a year of discussion and mutual education, and this means that advice from the CAP should be consistent and clear in the future.

NB The ASA can regulate what you SAY in your advertising, but not what you DO in your practice.  Your practice is not restricted by this list in any way. They also don’t regulate the content of phone calls.  And you CAN say that you treat children.  Just don’t mention conditions in your advertising – even colic – even though that is more a description of symptoms than a condition – but I digress – so many grey areas we can’t really cover them all…

Thresholds of evidence

The central conversation which is key to this whole controversy, is, just what constitutes adequate evidence?  The standards are high for the healthcare sector and I think that health and beauty are all in the same bag,  so confusingly products like anti-dandruff shampoo are in the same category as complex multi-modal health interventions like osteopathy.

The ASA previously had not been aware of the breadth of what we offer, and indeed think our websites do not convey what we do very well.  Jane’s advice to us was to advertise how we work in our editorial content – if you do a mix of Pilates instruction, acupuncture, massage techniques and manipulation,  and you also have a diploma in paediatric osteopathy, then make all that really clear, along with details of your various bits of training.

The bigger issues are about 1) how osteopathy becomes an “evidence-rich” profession, to quote Maurice Cheng, and 2) what type of evidence is acceptable.  We can begin to meet the first need by using PROMS to collect data, which is slowly and steadily taking root, and as to the question of appropriate evidence, there is a growing body of high level academic thinking in the scientific and philosophical communities about the nature of evidence and the suitability of different research approaches for different things.  (See CauseHealth and the European Society for Person-Centred Medicine on the subject.)  In the foreseeable future this might impact the current scientific consensus on what constitutes acceptable and appropriate evidence to support claims in fields similar to ours.

But even if RCTs are for the moment the only acceptable evidence, we shouldn’t just throw up our hands and plead poverty – i.e. the usual reaction.  Tim pointed out that if one patient a week donated £1 a week from all of our practices, that would fund a large RCT.  Maybe we just need a system to make this easy, or more motivation.  And I personally think that that £1 would be more likely to come from osteopaths not their patients, who are already doling out for their treatment.

Why are osteopaths not sorting their websites out?

I have to trot out all the usual things that are said about our profession  – isolation, apathy, disconnection, head-in-the-sand disinterest and so on.  Many (most?) osteopaths think that this advertising restriction is just another GOsC directive, designed to make our life difficult for no good reason.  This is not true.  This tightening up does not emanate from the GOsC or from the ASA, who, while they see its necessity and value, have no interest in bullying osteopaths.  It was initiated by anti-CAM campaigners who want us to be more scientific and have more of an evidence base for the claims we make to the general public.  That is something that many in the profession also have much sympathy with, even though they would not go about it in the same way, I’m sure.  I am still astonished that many osteopaths have never even heard the name Simon Singh, and don’t realise there is an aggressive and hostile campaign being waged against CAM therapies in general, which the GOsC and indeed the ASA are doing their best to help us deal with.  It’s almost as if there is an idea that he-who-shall-not-be-named will be strengthened and emboldened by direct reference, so many osteopaths are oblivious to what’s been going on behind the scenes..

So, final  message:  head-in-the-sand is not an option.  If you haven’t already, do go and find the guidance and sort your website out, because it’s the right thing to do.  We were sent info in November 2016, so dig it out, or download it here, and also look up the CAP advice.

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Here is the List of Conditions you can claim to treat, in case you’re not aware of it. I got it from here, part of recent official advice from ASA/CAP which interestingly also indicates that osteopaths should not use the title Doctor.  Not something I’ve ever been tempted to do, it always seemed a bit needy to me, but it’s not unheard of, and it’s good to have an official line on it.

• generalised aches and pains
• joint pains including hip and knee pain from osteoarthritis as an adjunct to
core OA treatments and exercise
• arthritic pain
• general, acute & chronic backache, back pain (not arising from injury or
accident)
• uncomplicated mechanical neck pain (as opposed to neck pain following
injury i.e. whiplash)
• headache arising from the neck (cervicogenic) / migraine prevention
• frozen shoulder / shoulder and elbow pain / tennis elbow (lateral epicondylitis)
arising from associated musculoskeletal conditions of the back and neck,
but not isolated occurrences
• circulatory problems
• cramp
• digestion problems
• joint pains, lumbago
• sciatica
• muscle spasms
• neuralgia
• fibromyalgia
• inability to relax
• rheumatic pain
• minor sports injuries and tensions