Infantile Chiropractic

I am posting this out of sequence, as the last topic made me so angry that I just had to get it up there. I have calmed down a bit now, so can return to another case of a weak regulator. This time, the General Chiropractic Council. It all kicked off in late 2018, when I was tipped off about a piece in a local rag, the Henley Standard. Here is the article in some of its glory.

Note that it isn’t identified as advertising. Full of curiosity, and I confess a degree of mischief, I hopped over to the website of Henley Chiropractic Centre. The Wayback Machine is a wonderful thing, and you can still see the site as it was then, here. I was immediately drawn to the video, which still plays. Happily they embedded it rather than linking to it. It speaks from a solidly vitalistic foundation, talking about the “life force that gives you the ability to self-heal”. Overall it presents chiropractic as a general health practice, rather than focussing on the spine. However two claims are especially unsound, that it can help children to thrive at school, and treat infertility in women.

On 1st January 2019 I submitted a complaint to the GCC, based on the claims in the video, and the newspaper article recommending treatment for newborns. There then ensued a long process of creating witness statements, which were not finalised until mid-June 2019. The two partners in the practice were quite reasonably allowed to respond, and there are some illuminating comments from the senior of them. Jorgen Rasmussen explained that:

We have always tried to follow the standard ASA and GCC guidance for advertising and marketing.

Do they? Here is what the ASA says in its guidance:

…references to treatment for symptoms and conditions that are likely to be understood to be specific to babies, children or pregnant women are unlikely to be acceptable unless the marketer holds a robust body of evidence.

But what is evidence? Rasmussen apparently thinks it’s personal experience, as he says:

Due to very promising results from treating infants in the latter part of 2018 and from a monthly chiropractic newsletter sent to us from Perfect Patients, the American company that also built and upgrades our website, [our practice manager] composed the article in question.

He apologises for failing to check it before publication, and it was withdrawn as soon as my complaint was received. He revealed that the whole website was built by an American company, including the video, which was also removed. Curiously, he says that the video “was more appropriate for the American market rather than the UK market”. So it’s OK to lie to Americans but not the British? At no stage did Rasmussen contest any of my complaints, or defend his actions other than to apologise profusely. The junior partner Adam Manning simply said that he was not involved in marketing the practice, a case of “nuffink to do wiv me mate”. I pointed out that the practice website did not imply any distinction between the partners, who were presented as of equal standing. Therefore any public facing information was the responsibility of both.

The next stage was to commission an independent expert report, which would determine whether there was a case to answer. I asked how independent the expert would be, and was told that they would be an independent chiropractor. This is rather like the peer reviewers for a homeopathy journal – they are usually other homeopaths. I told the GCC that another chiropractor was not independent of the profession, and would be biased in favour of it. My point was noted but not actioned.

Meanwhile I complained to the ASA, who quickly advised the practice that the article and video breached the CAP code.

After protracted delays, the Investigating Committee considered the complaints on 2nd April 2020. You will not be surprised that they found that there was no case to answer. I will try to summarise a long and convoluted outcome letter, as follows.

The decision naturally pivoted on the expert’s report. I wasn’t shown that, but it was quoted extensively. For example:

In relation to the advertising copy, he considers that it is a matter for the Committee to consider whether the words and statements used infer that chiropractors are capable of treating or curing colic, failure to thrive and difficult eating in infants;

I could not help wondering why they had engaged an expert, who then said that whether a claim was evidence-based was not his problem. However his later statements seem to contradict this, eg:

There is inconclusive favourable evidence suggesting that babies may
benefit from treatment for infantile colic, and there is a body of reasonable chiropractors that would consider infantile colic to be an appropriate condition for chiropractic treatment;

What on earth is “inconclusive favourable evidence”? If it’s inconclusive it can’t be favourable. This is a ploy beloved of homeopaths, who like to lump all the inconclusive studies in with the (hardly any) positive ones. He adds more weasel words:

However claims should be made with caution, and in light of the
November 2017 ASA/CAP guidance, claims in that regard made after
November 2017 are likely to breach required standards. However it is
necessary to consider whether this amounts to a falling far short of
standards;

I don’t know what “made with caution” means. Anyway I fired off lots of questions,to which I received a detailed reply. Firstly, the GCC explained that

For the Professional Conduct Committee to decide that unacceptable professional conduct has been committed, the chiropractor’s shortcoming must be serious and there must be an “implication of moral blameworthiness” and a “degree of opprobrium” that is likely to be
conveyed to “the ordinary intelligent citizen”.

I think they are saying that, although the conduct at issue might not be acceptable (and the chiropractors concerned have accepted this), it just wasn’t bad enough to justify any disciplinary action. But I’ll come back to this. So I will set out the main points of the exchange as follows. My questions are in italics, their answers in quotes (where meaningful).

Your expert reviewer stated that “it is a matter for the Committee to consider whether the words and statements used infer that chiropractors are capable of treating or curing colic, failure to thrive and difficult eating in infants”. Can you explain please what the role of the reviewer is, if they are not going to advise on the evidence for chiropractic in these circumstances?

I won’t bore you with the GCC’s very long reply to this question. Suffice it to say that the entire letter avoids considering the evidence base for the claims at issue.

Whose definition of the word `evidence’ do you accept? The expert reviewer agrees that there is no robust evidence for the treatment by chiropractors of non-musculo-skeletal conditions in infants, but then appears to admit anecdotal evidence as valid.

Again there was no direct answer to this. There was some consideration of scope of practice:

The scope of practice of a chiropractor is not defined by the Chiropractors Act (1994). Chiropractors are qualified and are trained to manage patients across the life course, from newborns and infants to the elderly and there is nothing in the Code which would prevent a chiropractor treating infants to amount to a breach of The Code.

I would not expect an act of parliament to define a profession’s scope of practice, especially when it dates back 25 years. The Medical Act 1983 does not define this for doctors, who are simply required to follow evidence based clinical practice. Not that the GMC enforces this with any rigour, as we have seen.

The expert reviewer agrees that claims to treat infertility would be misleading and fall short of required standards. Is it normal for the expert to abdicate responsibility for deciding how far short?

The infertility claim was completely ignored.

The expert reviewer several times devolves decisions to the committee. Yet the committee says: “This Committee was not in a position to reach any final conclusions about the issues or opinions set out by The Expert”. How does this work? One or other, or both, must be in a position to decide on matters of fact, or the whole process is useless.

The role of the Investigating Committee is limited to determining
whether there is a case for the Registrant to answer at the Professional Conduct Committee hearing rather than making findings of fact. I note the Investigating Committee referred to this in their decision where they have stated, “The Committee noted the content of The Expert’s report. It was mindful that it would be a function of the PCC, if the case was referred to a hearing, to evaluate that evidence in due course.”

I leave you to consider whether this answers the question.

The committee seems to miss a crucial point. Mr Rasmussen says that the article was written by the practice manager “Due to very promising results from treating infants in the latter part of 2018”. This confirms that infants were being treated in the practice, which the committee agrees would be in breach of acceptable standards. Did the committee consider advising Mr Rasmussen about practising within the scope of his expertise, and within the evidence base for the profession? What monitoring was considered to ensure future compliance?

I can’t identify any clear reply to this, other than the previous point about scope of practice and The Chiropractors Act 1994.

The committee says that there is no case to answer. Is this because a breach of standards has been proven but remedied, or because there was no breach?

When deciding whether there is a ‘case to answer’ the Investigating Committee is assisted in its decision making by Investigating Committee Decision-Making Guidance. A link to that guidance is below; The relevant pages are 6 and 7.
https://www.gccuk.org/assets/publications/IC_Decison_Making_Guidance_October_2019.pdf
The guidance sets out, “When exercising its judgement as to whether the facts found proved amount to UPC, the investigating committee should have regard to whether, an ordinary, intelligent member of the public and / or other fellow chiropractors would consider the conduct to be morally blameworthy or deplorable”

So I have told the GCC that I consider the conduct to be deplorable, but they disagree. I don’t think there is much doubt that fellow chiropractors would not find it deplorable, judging by their advertising. So the profession is free to carry on `adjusting’ newborns for utterly no benefit, and with a degree of risk.

The GCC’s reply to my questions runs to over four pages, but fails to answer any of them directly. I hoped somebody would follow my order of questions and give a clear answer to each one, but I was expecting too much. What impresses me is the amount of effort that went into the avoidance of acting as a real regulator.

I can’t help wondering what would have happened if the `independent’ expert had been a senior academic in therapeutics, and not a chiropractor.

Legal Statement

This blog is a public service, so despite whatever constraints anyone might want to place on what they say to me, this post relies on the public interest defence.