The Nightingale Collaboration challenges questionable claims made by healthcare practitioners on their websites, in adverts and in their promotional and sales materials by bringing these to the attention of the appropriate regulatory bodies.
We also strive to ensure that organisations representing healthcare practitioners have robust codes of conduct for their members that protect the public and that these are enforced.
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Our critics commonly allege that either we are the puppets of the ASA or we have the ASA in our pockets. The latest adjudication on one of our complaints gives the lie to that.
There seems to be widespread use of the term ‘primary healthcare/contact practitioner/profession/provider’ by chiropractors. Some of the many variations include:
Chiropractic is a primary health-care profession that specialises in the diagnosis, treatment and overall management of conditions that are due to problems with the joints, ligaments, tendons and nerves, especially related to the spine. (Source)
The perception of Chiropractic is often limited to the treatment of back, or neck pain, but as Primary Healthcare Providers Chiropractors are consulted about a whole range of conditions. (Source)
Chiropractic is a primary health care profession which emphasises the inherent recuperative power of the human body to heal itself without the use of drugs or surgery. (Source)
As primary healthcare practitioners we are perfectly situated to help you within our areas of expertise and point you towards other specialists as appropriate. (Source)
Chiropractic is the third largest primary health care profession in the world after medicine and dentistry. (Source)
Chiropractors are primary contact, primary healthcare practitioners – as such, no form of referral is required as a prerequisite to visit a chiropractor. (Source)
A Chiropractor is trained to diagnose and treat your condition and will refer you to another healthcare professional if necessary. (Source)
Chiropractors are neuro-musculoskeletal specialists, trained as primary healthcare practitioners – meaning that no matter what the ailment, each patient will receive the appropriate care or referral as necessary. (Source)
There are some common themes in these, but we were concerned that members of the public might see chiropractors as a first port of call for a variety of medical conditions, rather than their GP.
Why would we think this might be a problem? We already know the evidence for chiropractic spinal manipulations is scant, even for their 'trade mark' condition of non-specific lower back pain (LBP). And it's not without specific and non-specific harms either, of course.
But maybe it wouldn't be a great problem if their advertising was restricted to a few musculoskeletal conditions such as LBP and were fully informed?
There are problems, however.
For example, one website claims:
Chiropractic care can also help children with:
- prolonged crying
- sleeping and feeding problems
- breathing difficulties
- frequent infections especially in the ears
These are some of the more common musculo-skeletal conditions which nearly everyone suffers from at some time in their life. Many conditions start as minor ailments which can progress to more severe and longer lasting episodes of pain if left untreated or ignored. Our goal is to get you out of pain as soon as possible, whilst improving joint movement. Failure to restore normal function usually means that any pain relief is temporary.
After the British Chiropractic Association (BCA) dropped their libel case against Simon Singh for an article he wrote in 2008 for the Guardian in which he highlighted chiropractors making claims for many of these same childhood conditions, it's surprising to see them still being made.
Many websites were changed as a result of this and my 524 complaints submitted to the statutory regulator, the General Chiropractic Council; this resulted in the ASA revising their guidance on claims made by chiropractors — and that guidance certainly doesn't include asthma, colic, bed-wetting etc!
So why are such claims still being made? And, more importantly, what is a member of the public supposed to think when they see claims like these?
But for some chiropractors (certainly not all), claims like these are perfectly acceptable and, indeed, an integral and utterly necessary and inescapable part of chiropractic 'philosophy' as invented by DD Palmer. Some are taught that 'dysfunction' of vertebrae in the spine can cause 'nerve interference' that in turn can cause all sorts of medical problems and that what's needed is a chiropractic adjustment to correct the displacement and so allow proper nerve flow, permitting the body's vital force to heal itself. There is, of course, no good evidence that this dysfunction — or vertebral subluxation complex (VSC) in their parlance — even exists or that it results in any pressure on the nerves never mind that any adjustment of the spine can somehow alleviate anything.
So, even claims such as those above are seen as musculoskeletal issues that chiropractic can treat — as that chiropractor states.
We also are aware of concerns about the attitude of some chiropractors to the medical profession in general and things like vaccinations in particular. Prof Ernst warns of such non-evidence based attitudes in the US, but it doesn't take much effort to find similar attitudes in the UK.
We saw the use of the terms incorporating 'primary' as potentially misleading to the general public, particularly those not familiar with chiropractic or health and medicine in general, so we submitted a complaint to the ASA.
We argued that the various phrases used by chiropractors that referred to 'primary healthcare'. We included a definition by the World Health Organisation. In its Declaration of Alma-Ata, the World Health Organisation defined primary care as:
…essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community…It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.
The Health and Social Care Information Centre (HSCIC) introduce Primary Care:
As many people's first point of contact with the NHS, around 90 per cent of patient interaction is with primary care services. In addition to GP practices, primary care covers dental practices, community pharmacies and high street optometrists.
The Department of Health defines the essential attributes of Primary Care as:
- co-ordinates the care of the many people with multiple, complex health needs
- delivers care closer to people, increasing convenience, especially in areas remote from hospitals.
- is a first point of contact for patients to facilitate the early detection of illness, and thereby improves outcomes.
- provides a long-term perspective to support disease prevention and healthy lifestyles.
- provides more cost-effective treatment for minor illnesses and injuries than hospitals
The primary care systems for the 21st century are built on the foundations of:
- multi-disciplinary teams of healthcare professionals trained for family medicine
- suitable facilities and infrastructure, integrating digital healthcare, to provide a range of access options and support dispersed populations
- clinical pathways for consistent and effective care, with referral processes for specialist consultations
- information systems including electronic patient records to optimise clinical activity
We did not see chiropractic as fitting any of these criteria and therefore believed any association with 'primary healthcare' to be misleading.
But it's not what we think that's important. We don't make the rules or enforce them. In this case, because this was all about adverts on the websites of chiropractors, we submitted a complaint to the Advertising Standards Authority (ASA), providing them with quotes from 12 websites and inviting them to choose whichever they felt best covered the issues.
They considered our complaint and, as we had suggested, chose just to investigate the wording on one website, Kingsbridge Chiropractic Clinic. They considered two points and decided that there had been no breach of the advertising code. However, we don't think the two points fully covered the issues we complained about.
The ASA's adjudication is published today.
What the public thinks
The ASA decided:
The ASA understood that the term "primary healthcare practitioners" was not protected and did not have a fixed definition; although we acknowledged that the term "primary healthcare" was generally used in the health sector to refer to the first point of contact for the public to access healthcare in the community, such as GPs, dentists and optometrists. We considered that the average consumer was likely to have an awareness that chiropractic focussed on musculoskeletal conditions and considered that, in the context of the ad, consumers were likely to understand the term "primary healthcare practitioners" to refer to their ability to access chiropractic treatment directly, without referral. We did not consider the term implied that chiropractors held general medical qualifications, that they were able to treat a wide variety of conditions (beyond musculoskeletal conditions) or that they could act as a primary contact for those with general health concerns. We also did not consider the term was likely to discourage essential treatment for conditions for which medical supervision should be sought. We therefore concluded the claim did not breach the Code.
Their assessment rested on the assumption that "average consumer was likely to have an awareness that chiropractic focussed on musculoskeletal conditions". The ASA are generally good at understanding how a member of the general public would regard adverts and what they would take wording to mean. However, we think that the public are not as aware as the ASA assume.
We cited research conducted by the General Chiropractic Council in 2012: Research into Patients Views and Expectations of Chiropractic Care 2012 that concluded:
The majority of patients in the national survey rated their knowledge of chiropractic prior to treatment towards the lower end of the scale i.e. ‘I knew very little’.
We also cited an older study: Consulting the Profession: A Survey of UK Chiropractors, 2004. The GCC has asked chiropractors what they treated: as well as musculoskeletal conditions, other conditions included (number and percentage of chiropractors who believe this can be treated or managed by chiropractors):
- Asthma 491 (57.49%)
- Digestive disorders 461 (53.98%)
- Infant colic 539 (63.11%)
- Menstrual pains 542 (63.46%)
- Sciatica 826 (96.72%)
26.58% believed they could treat the following range of conditions (some are musculoskeletal, but the majority are not):
- Biomechanical disorders
- Growing pains
- Cervicogenic H/A
- Carpal tunnel
- Pregnancy care – pre and post natal problems
- Neurodevelopmental problems in children, ADD, ADDH, COCD, dyslexia, dysproxia, nocturia, podiatric conditions, bed wetting, growth, behaviour, developmental
- ME, FMS, MS
- Allergies/intolerances including hay fever, eczema
- Scoliosis and Kyphosis
- Menstrual irregularities
- Disc, whiplash
- Tinnitus, vertigo, dizziness, balance disorders, visual problems
- Chronic upper respiratory infection
- Palliative relief for incurable conditions such as osteoporosis, cancer, multiple sclerosis
- Post operative
- Hypertension, stress, chronic fatigue syndrome
- Immune system
- Correct nervous system dysfunction to enable the body to heal itself – do not treat specific medical conditions
- Promotion of optional health – wellbeing/preventative care
We believe this amply demonstrates that chiropractors represent themselves are treating a lot more than just "musculoskeletal conditions".
However, the ASA was not convinced by our arguments and did not uphold the complaint.
Setting the precedent
Although we didn't win the adjudication, we now have the ASA's view on what an average member of the public would be likely to understand by the phrase "primary healthcare practitioner":
…consumers were likely to understand the term "primary healthcare practitioners" to refer to their ability to access chiropractic treatment directly, without referral.
This now gives us something concrete to work on and, no doubt, we will refer to this in future complaints.
As a result of this adjudication, we have updated our Results page. The following chart shows our ASA record so far:
"Daniel David Palmer" by Unknown - http://www.palmer.edu/PFCH/hometowngallery/3-family-dd.jpg. Licensed under Public domain via Wikimedia Commons.
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