Adjunctive therapies

This guidance helps explain the relationship between the Osteopathic Practice Standards and the breadth of osteopathic practice, adjunctive therapies and other forms of care and treatment provided by osteopaths as well as other non-osteopathic work carried out by osteopaths.

Introduction

The General Osteopathic Council (GOsC) is the statutory regulator for osteopaths in the UK, and in order to practise in the UK, osteopaths must be on the GOsC Register.

The purpose of regulation is public protection and:

1. to protect, promote and maintain the health, safety and wellbeing of the public
2. to promote and maintain public confidence in the profession of osteopathy; and
3. to promote and maintain proper professional standards and conduct for members of that profession.

The Osteopathic Practice Standards (OPS) set out the standards of conduct, ethics and competence required of osteopaths to practise.

The OPS state that: ‘Patients must be able to trust osteopaths with their health. To justify that trust osteopaths must meet the standards expected in the Osteopathic Practice Standards. Osteopaths are personally accountable for their professional practice and must always be prepared to justify their decisions and actions, explaining how they have exercised their professional judgement’.

This guidance supplements the OPS and explores some of the challenges osteopaths face around implementing the standards when offering other forms of care and adjunctive therapies, and regarding the application of the OPS to non-therapeutic activities. Using case scenarios to help highlight some of the issues that may arise, the guidance also considers the key factors that an osteopath might need to pay attention to when deciding how to respond to those issues.

The guidance is intended for osteopaths to use when considering how the OPS applies to all aspects of their work, and to help members of the public and patients by illustrating how osteopaths approach the different forms of care and treatment they provide in relation to the OPS. It will also act as a reference for Fitness to Practise Committees when considering concerns that osteopaths have failed to apply the OPS in their practice.

Osteopaths apply a broad range of treatment approaches and for many this includes incorporating adjunctive therapies into their practice. By ‘adjunctive therapies’ we are referring to therapeutic activities that are in addition to more typical osteopathic approaches. This might include acupuncture, fitness coaching, teaching of yoga or pilates, for example. Sometimes such approaches are integrated within an osteopath’s day to day practice, and sometimes they might be quite distinct in their application. The purpose of the OPS is to protect patients by making sure that osteopaths always practise in a way that is safe and in the patients’ best interests. To protect patients, the OPS applies to all areas of an osteopath’s work. This includes all osteopathic techniques and adjunctive therapies. For example, an osteopath must meet the standards set out in the OPS whether they are treating a patient with spinal manipulation or with acupuncture.

Many osteopaths are also qualified and/or registered with other healthcare bodies to provide different forms of care and treatment. They may change the way they describe themselves to patients and service users depending on the type of service they are providing at the time. The OPS apply to the osteopath’s work in all circumstances. For example, an osteopath treating a patient as a sports massage therapist must apply (in addition to any specific standards relating to their work as a sports massage therapist), the same standards of conduct, ethics and professionalism, as they do when treating patients as an osteopath.

It is important that patients are given the information they want or need to know in order to make informed choices about their care. This includes anticipated benefits and risks of treatment, and the capacity in which an osteopathy is suggesting a potential treatment option – is this an integrated approach as part of their osteopathic practice, for example, or a separate and distinct approach?

Case study example 1:

Kenneth is an osteopath who is also a qualified acupuncturist. He combines osteopathy and acupuncture treatment with half of his patients, but he also treats some just with osteopathic techniques, and works two sessions a week purely as an acupuncturist. The OPS apply to his treatment of all his patients, including those for whom he treats solely as an acupuncturist.

An osteopath will always be bound by standards of professionalism in whichever context they practise and in most circumstances this is relatively straightforward.

However, there are some circumstances which may raise challenges:

Application of different professional standards to an osteopath’s practice. What do the OPS say?

Osteopaths have a duty to protect patients when providing them with any form of care or treatment. The OPS sets out the standards osteopaths are expected to meet when complying with that duty of care. Other statutory healthcare regulators set their own standards for their registrants. An osteopath who is also a registrant of another regulated profession may therefore find themselves with obligations under two sets of professional standards.

Where there is common ground between the two sets of standards, no issue arises. In most cases the standards which relate to the conduct and ethics of the professional will be consistent across all healthcare professions. However, the standards which are specific to the profession may vary. In these circumstances, the osteopath will need to consider carefully what role they are carrying out and what expectations the patient has of them in that role.

Case study example 2:

Roshani is a registered nurse and has recently also qualified as an osteopath. She continues to work three shifts a week as a nurse in a private hospital, as well as starting to build up an osteopathic practice from her home. She asks what the crossover is between the requirements of the Osteopathic Practice Standards (OPS) and the Nursing and Midwifery Council’s Code. Are these clearly demarcated in terms of her professional roles?

When two different sets of professional standards apply, the osteopath must always act in the best interests of their patients. This is the case whether or not the patient is an osteopathic patient. If the osteopath departs from the OPS because another set of professional standards applies, they must be sure this does not go against the patient’s best interests. If the osteopath’s actions are not in the patient’s best interests, this would call into question whether the OPS has been met. The osteopath must always be able to justify how their approach aligns with the patient’s needs, wishes and best interests.

When Roshani is carrying out her duties as a nurse the standards of professionalism apply to her as an osteopath (including D1 and D7), and these will also apply in the context of her work as a nurse. However, the requirement to be able to conduct an osteopathic patient evaluation (Standard C1) may not be relevant. A full osteopathic evaluation of her hospital patients is unlikely to be appropriate and the patients are unlikely to expect or need this from her. Instead, they would expect the care they receive to meet the standards of competence for nurses. A decision not to carry out an osteopathic evaluation in this context is unlikely to represent a failure to meet the OPS.

It is important to note that in those small number of cases where an individual is registered with two regulatory bodies and has been found to fall below one of the standards expected of them in one professional role, it is likely this will also be relevant to their fitness to practise in their other professional role.

Providing professional services other than osteopathy. What do the OPS say?

• D1 states: ‘You must act with honesty and integrity in your professional practice’.
• D7 states: ‘You must uphold the reputation of the profession at all times through your conduct, in and out of the workplace’.
• The associated guidance for standard D7 states: ‘The public’s trust and confidence in the profession (and the reputation of the profession generally) can be undermined by an osteopath’s professional or personal conduct. You should have regard to your professional standing, even when you are not acting as an osteopath’.

The OPS do not prevent osteopaths from providing care and treatment to a patient in a different capacity. However, the osteopath should ensure that the approach they take meets standards D1 and D7. It is important for osteopaths to be aware that although a patient may have chosen to be treated by them in a different capacity they may have done so on the basis that the osteopath is a regulated healthcare professional. This might give the patient a degree of assurance about the standard of patient care they can expect. The osteopath therefore needs to be sure that they understand the patient’s expectations and are clear about the service they are able to provide to the patient in the context.

The osteopath should also be aware that they cannot ‘unknow’ the knowledge, skills and standards of practice they have developed in the course of their training as an osteopath. It would be difficult to make a case for it being in the patient’s best interests to disapply what they know as an osteopath and provide a different standard of care to patients when operating under a different professional title.

Case study example 3:

Lucy has worked as a massage therapist in a gym for ten years. She has now graduated as an osteopath, having studied part-time for the past five years. As well as working as an associate osteopath for two days a week in an established clinic, she intends to continue working as a massage therapist at the gym, as she has built up a busy client list and does not want to give this up. She seeks advice as to the extent to which the Osteopathic Practice Standards (OPS) will apply to her work as a massage therapist. She asks, for example, whether the requirement to be able to undertake an osteopathic patient evaluation (Standard C1) means that she will have to alter the way she works when providing massage so as to undertake an osteopathic assessment even when not providing osteopathic treatment.

Lucy’s registration as an osteopath does not stop her from continuing her work as a massage therapist at the gym. She will have to make sure however that her patients understand the difference between her practice as an osteopath and that of a massage therapist, and the extent to which her osteopathic practice affects her massage therapy work. This might include explaining that a full osteopathic evaluation will not form part of the massage treatment, but her osteopathic knowledge and training may lead her to identify a different treatment approach that would benefit the patient. If a different treatment approach were to be identified, she would need to discuss this with the patient so they would be able to make an informed decision about which treatment approach they preferred.

What do the OPS say?

If the osteopath considers that they are providing a service which is completely separate from their work as an osteopath and does not involve treating patients, it would be easy to assume that the standards are not relevant. However, the OPS cannot be disregarded, and the expectations for ethical behaviour, such as those set out in standards D1 and D7 do still apply.
If there is no benefit to the patient in the osteopath arguing a distinction between their different professional roles, then the osteopath may not be able to demonstrate compliance with standards D1 and D7.

Case study example 4:

Aaron has worked as a builder for 15 years. He continued to work in this capacity while training part time as an osteopath, and has now graduated. To maintain his income, he continues to work as a builder. He recently worked on an extension for a client who is now in a dispute with him over the cost of the work. The client has found out that Aaron is GOsC registered and has raised a concern with the GOsC that Aaron has acted dishonestly in his calculation of costs, has lied to him over when the work will be finished, and has shown a general lack of integrity. Aaron considers that this is not an issue for the Osteopathic Practice Standards and is completely separate from his work as an osteopath.

If Aaron’s conduct is found to be dishonest, this could have a damaging effect on public confidence in the profession of osteopathy. This is because registration as an osteopath does not stop and start depending on what work the osteopath is doing. Being registered as an osteopath means being a representative of the profession at all times. As such, in this case for example, Aaron would not be able to decide not to uphold the standards of behaviour expected of him as an osteopath just because he was working as a builder at the relevant time.

Offering novel forms of care and/or treatment. What do the OPS say?

• A3 states: ‘You must give patients the information they want or need to know in a way they can understand’.
• The associated guidance states: ‘You should discuss care options, encourage patients to ask questions and deal with these clearly, fully and honestly. You should inform your patients of anticipated benefits as well as any material or significant risks associated with the treatment you are proposing, and confirm their understanding of these…’

To comply with this, osteopaths must ensure that patients are fully informed of their treatment options so that they can exercise full autonomy in making decisions about their care.

Case Study Example 5:

Michel is an osteopath who has developed an interest in esoteric healing methods, and has formulated his own approach to healing which, he says, combines osteopathy, shamanic practice, crystals and astrological readings to design unique interventions for patients. He claims to offer treatments which address both physical and spiritual dimensions to patients’ health and well-being, ‘which take into account their unique place in the universe’. He suggests that as part of a treatment plan for chronic headaches, a particular patient undergoes a combination of approaches, including attending a shamanic ceremony in a ‘sweat lodge’ in Michel’s garden, an astrological reading to reveal factors affecting the patient’s current symptoms and prognosis, and a spiritual healing session to address past life trauma. The patient consents to this approach at the time, but later has concerns that the treatments are very unusual and raises a concern with the GOsC.

It is important that patients clearly understand what treatment is being offered to them, whether this is osteopathic treatment or another form of treatment. If the osteopath offers treatment which is not osteopathic because they consider that this will be of benefit to the patient, this must be explained to the patient and the patient must be given enough information about the treatment options to be able to give valid consent for whatever treatment option they choose.

Osteopaths should be aware that the consent of a patient does not, on its own, justify a treatment option. In a very small number of circumstances, treatment or care offered by an osteopath may be considered by the osteopathic profession not to have any possible benefit to a vulnerable patient. Osteopaths should always be able to provide a narrative to explain the benefits of the treatment offered to the patient. Such a narrative may, for example, take into account academic research or discussion with peers and will take into account a detailed account of the discussion.

• The Osteopathic Practice Standards apply to osteopaths in their professional work and in other contexts.
• Osteopaths are not limited to providing typically ‘osteopathic’ treatment – many integrate other approaches into their osteopathic practice, or work in a completely different therapeutic capacity in addition to osteopathy.
• Some osteopaths are dual registered as osteopaths and in another profession.
• Something that calls into question an osteopath’s professionalism, integrity or honesty in one context, is likely to impact on their practice in any context.