The random thoughts of a sceptical activist

Simon Singh

The beginning of the end? Part three

It’s only taken 433 days to get this far.

On Saturday, I received three batches of letters from the General Chiropractic Council (GCC), sent Recorded Delivery.

These letters are the formal notices that a complaint against a chiropractor has been considered by the Investigating Committee, that they have decided that there is a case to answer and that the complaint will go before their Professional Conduct Committee (PCC).

The letters consist of the formal notice, the Notice of Allegation and some of the website pages that contained the claims I complained of and where they were using the title ‘Dr’. The Notices of Allegation are all very similar to this redacted one; straight and to the point. (There’s lots to be said about the documents and I’ll cover that in a separate blog post.)

I have so far received these formal notices for 93 chiropractors.

There will be far more to follow.

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Murky waters

In The beginning of the end? Part two, I mentioned there was going to be more on sciatica.

I have already described how the GCC have dealt with chiropractors making claims about sciatica, even though the GCC admits that:

…there is no high or moderate positive evidence from randomised controlled trials that would support an advertised claim regarding sciatica using manual therapy. In the light of this, the Investigating Committee concluded that it could be inappropriate for you to make such an advertised claim.

Despite this damning statement, the chiropractors I’ve been told about so far have all been let off for making claims about sciatica.

However, it appears that there is more to this than first meets the eye.

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The beginning of the end? Part two

Last time, I said I’d have more to say on the letters I’ve received so far.

I said that seven of the 36 were dismissed because the chiropractors mentioned on the websites were no longer at that clinic and therefore — by the GCC’s reckoning anyway — were no longer responsible for claims made. My arithmetic was faulty; there were eight, leaving 35 others. I’ve corrected the previous blog post.

This post deals with why the Investigating Committee (IC) decided there was no case to answer in most of these 35.

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The beginning of the end?

The first decisions of the GCC’s Investigating Committee (IC) on my complaints fell with a thud onto my doormat a few days ago.

I received copies of 43 letters sent to 43 of the chiropractors I complained about. All were notifications that the IC (which consists of eight chiropractors and four lay members) had decided — for various reasons — that there was no case to answer and that, therefore, no further action would be taken against them.

Eight of them were thrown out (leaving 35), the IC reasoning:

The extracts from the website, submitted in support of the complaint against you, related to a time you had ceased working at the clinic in question and therefore at a time when you were not responsible for the website content. For this reason the Investigating Committee has concluded that there is no case to answer in respect of the complaint against you.

I’ll leave it to you to tease out the issues I might have with that.

I’ll be saying more about the details of the other letters later, but I thought I’d share some of the gems to be found within them.

The law

After some preamble, they get off to a good start, citing the relevant clause of their Code of Practice that chiropractors are bound to comply with:

C1.6 of the Code of Practice states that chiropractors –

‘may publicise their practices or permit another person to do so consistent with the law…”

All well and good. Except…that’s not all C1.6 says. It continues:

…and the guidance issued by the Advertising Standards Authority.

And indeed, that’s what my complaint was all about: that they were making claims that I believed went against guidance issued by the ASA.

So why cut it short? Why ignore whether or not the claims complied with ASA guidance? Do they think that requirement is somehow null and void; something to be ignored without justification? Publicity has to comply with both requirements not just one.

More questions needing an answer.

However, they go on to say:

In the context of the relevant law (The Consumer Protection from Unfair Trading Regulations 2008) advertised claims for chiropractic care must be based on best research of the highest standard. This will almost certainly mean randomised controlled trials that produce high or moderate positive evidence. (Link added)

Now we know what law they think is relevant. At least they mention ‘the best research of the highest standard’ and that this (almost certainly) means RCTs that give good evidence.

Expertise and preferences

But what about the Code of Practice whose glossary defines evidence-based care, cited by many chiropractors in their observations, as:

clinical practice that incorporates the best available evidence from research, the preferences of the patient and the expertise of practitioners (including the individual chiropractor her/himself).

All the 35 letters stated the following:

The other elements of evidence based care as it relates to clinical practice (the preferences of the patient and the expertise of practitioners (including the individual chiropractor her/himself)) are, of themselves, insufficient to support advertised claims.

No matter what a chiropractor might think; no matter what a chiropractor might have seen with his or her very own eyes; no matter what he or she believes might work; no matter what a customer might prefer — none of these are sufficient to back up claims in any publicity. All claims must be supported by robust evidence, and that severely limits what many chiropractors can now get away with claiming.

About time too.

There is, of course, a subtle difference between what a chiropractor is allowed to advertise and what he or she actually tells customers and what they do in their clinics. My complaints were about what they were advertising; what they were using to pull in new customers. I have no idea what goes on within the four walls of the clinics, although Skepticat has first hand experience of one.

However, it would be utterly perverse if what they were allowed — tacitly or otherwise — to practice was in any way different to what they were allowed to tell people they were allowed to practice.

What about the kids?

Many of the letters mentioned that the chiropractor had said something on his or her website about children and babies. One example:

The Investigating Committee did note the reference to ‘Paediatric care’. The Investigating Committee considered that this could give a member of the public reading the webpage the impression that you provide treatment to babies.

Other letters mentioned similar claims about children. Despite the fact that Bronfort found that there was no good evidence that chiropractic worked for children or babies for any condition, the GCC have taken the opportunity to remind all the chiropractors:

It was mindful that there is no high or moderate positive evidence from randomised controlled trials that would support a claim to treat children using manual therapy. In the absence of such evidence, it concluded that it could be inappropriate to make such an advertised claim.

An odd choice of phrase, ‘could be inappropriate’, but the meaning is all too clear: there is no evidence for treating children with chiropractic. Not a jot. Not for colic; not for bed wetting; not for hyperactivity; not for feeding problems; not for sleeping problems. Not for any condition.

Chiropractors should therefore not be making any claims for children.

But isn’t it odd that they managed to decide that unsupported claims were being made, but still found no case to answer?

Good advice

In addition to the specific guidance offered to the 35, the GCC chose to deliver the following message to all 43 chiropractors — the ones they’ve decided have no case to answer:

The Investigating Committee recommends that you carefully consider the guidance issued to the chiropractic profession by the General Chiropractic Council in February/March 2010 and that you ensure that any advertisement of your services complies with C1.6 of the Code of Practice. (the GCC’s underlining)

Taken individually and together, these are welcome steps in the right direction.

But there is much more to come.

The Cracklash begins

It’s not just the evidence for chiropractic that’s a bit shaky these days.

For a long time, there has been an uneasy truce between the different chiropractic factions in the UK, all believing different things and each with different rituals.

It seems that they all came together when statutory regulation was first mooted and the carrot of respectability that that offered overcame those fundamental differences — temporarily at least.

Since the GCC was set up, the trade bodies representing the different factions (‘straights’, ‘mixers’, etc) appear to have been reluctant bedfellows, and there seems to have been various fallings out and lots of jostling for position and power.

But they trundled along and put a brave face on things for the sake of the profe$$ion.

After the BCA’s misconceived attack on Simon Singh, sceptical eyes were focused on chiropractic and the claims made by its followers. After being disgusted by the claims we saw being made by a large number of chiropractors on their websites, Simon Perry and I independently poked the GCC with a somewhat sharp stick.

What a hornet’s nest we stirred up, with the GCC eventually acknowledging that chiropractic had to be based on proper evidence and not on wishful thinking.

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The Long and Winding Road

It’s been a while since I blogged about the progress of my complaints to the GCC and it’s time for an update.

In fact, it’s been a full 12 months — to the day — since I submitted my complaints. How time flies.

I’m sure no one is interested in all the minutiae of this, so here’s a brief summary:

  • Hundreds of emails and letters have been received and sent;
  • I’ve had two meetings with GCC’s two firms of lawyers;
  • I’ve received 11 lever arch files of paper copies of chiropractors’ websites;
  • I’ve been sent 290 sets of chiropractors’ observations on my complaints, sometimes at the rate of 40 a day: the postie complained.

Meantime, the GCC:

  • have had to get their rules changed by the Privy Council to allow them to survive financially;
  • have had to employ six new staff (admins and paralegals) to cope with the workload;
  • have commissioned a review into the evidence for chiropractic — the Bronfort report;
  • have held lots of meetings with the Department of Health, a QC and their lawyers.

But they have barely started to even consider the first of my complaints.

So, what’s taken all this time, what are the 290 envelopes all about and when will it all be over and done with?

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Bronfort on: Ear Infections

Time to take a closer look at some of the conclusions of the Bronfort report.

Otitis Media is, to the average parent, an ear infection — of the middle ear, to be precise. This can affect children and can be very painful and disturbing to both infant and parents. About one in five chiropractors I complained about made claims about ear or similar infections. It was also one of the childhood ailments that Simon Singh mentioned in the Guardian article the BCA had a hissy fit about.

Because of my complaints and because there appeared to be no definitive list (other than the ASA’s list of acceptable claims, of course) of what conditions were backed by robust evidence, the GCC commissioned five US chiropractic researchers to review the good evidence for all the conditions I complained about. I’ve already said something about the kinds of evidence Bronfort et al. decided should be included in the report: they were interested in only relying on quality evidence.

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Chiropractic Awareness Week 2008-2010

The British Chiropractic Association has finally dropped their misconceived libel action against Dr Simon Singh.

Best of all, the BCA have done this in Chiropractic Awareness Week.

The first announcement of it was from the Chambers of one of Simon’s QCs, William McCormick:

British Chiropractic Association v Singh – BCA admits defeat.

The BCA today served a Notice of Discontinuance bringing to an end its ill-fated libel claim against Dr Simon Singh arising out of criticisms he made of its promotion of treatments for childhood ailments.

Dr Singh’s predicament as the sole defendant in an action brought in respect of a comment piece in the Guardian newspaper (to which the BCA never directed any complaint) was seen as a rallying point for those concerned about the abuse of UK libel laws in connection with scientific debate.

Interest intensified when Eady J ruled that his words were not comment and that in order to defend himself he would have to prove the objective truth of what he wrote.

Earlier this month the Court of Appeal overturned that ruling and this has lead the BCA to abandon its claim.

William McCormick QC acted for Dr Singh instructed by Robert Dougans of Bryan Cave LLP.

This is great news, but the question of costs still has to be resolved. However, even if he recovers his costs, Simon has still spent the last two years fighting this misconceived and unnecessary libel case.

It is not known what will happen to the BCA: their finances are in a bit of a sorry state and their members should be asking a lot of searching questions of those individuals responsible. Indeed, those running the BCA need to do a lot of soul searching. But that’s up to them.

And the nominees are…

The inimitable Jack of Kent has been longlisted for the Orwell Prize 2010 and he will find out later today if he has been shortlisted.

Perhaps the BCA should also receive  a prize: Lifetime Achievement Award for their contribution to Chiropractic Awareness Week?

They get my nomination.

Update

The Guardian has now reinstated the original article Simon wrote for Chiropractic Awareness Week 2008, the one that the BCA had such a hissy fit about: Beware the spinal trap

What better way to celebrate Chiropractic Awareness Week 2010 and make everyone aware of chiropractic.

Mass Lobby for Libel Reform

Do you know who your MP is?

If you don’t, you can find him or her on the excellent They Work for You website.

Why is this important? Well, in case you’ve been hibernating all winter (and who could blame you), there’s going to be a General Election fairly soon and there’s no better time to lobby your MP and find out what his/her views are on important issues.

In case you’re struggling to think of something to ask your MP, here’s a suggestion:

Libel law.

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Talking the talk

The first few pages of Bronfort et al. certainly talk the right talk:

EBH [Evidence-Based Healthcare] is about doing the right things for the right people at the right time. It does so by promoting the examination of best available clinical research evidence as the preferred process of decision making where higher quality evidence is available. This reduces the emphasis on unsystematic clinical experience and pathophysiological rationale alone while increasing the likelihood of improving clinical outcomes. The fact that randomized clinical trial (RCT) derived evidence of potentially effective interventions in population studies may not be translated in a straight forward manner to the management of individual cases is widely recognized. However, RCTs comprise the body of information best able to meet existing standards for claims of benefit from care delivery. The evidence provided by RCTs constitutes the first line of recommended action for patients and contributes, along with informed patient preference, in guiding care. (page 4)

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