British Chiropractic Association (BCA)
I’m insulted. I’m miffed. My good name…
How could anyone possibly think that I would complain to the Advertising Standards Authority about misleading claims for AltMed?
Someone objected to claims being made by the Craniosacral Therapy Association (CSTA) in one of their leaflets.
It wasn’t me!
- Advertisers’ own marketing communications on their own websites and;
- Marketing communications in other non-paid-for space under their control, such as social networking sites like Facebook and Twitter.
Starting on 1 March 2011, this landmark agreement means that claims made on a seller’s website will be subject to the ASA’s Committee of Advertising Practice Code (the CAP Code), just like adverts in newspapers, magazines, and paid-for online advertising.
When the British Chiropractic Association published its ‘plethora‘ of 29 references they thought supported chiropractic for childhood conditions, it took just 24 hours for it to be utterly demolished by scientists and skeptics. Only 18 of these were relevant to chiropractic and childhood conditions.
Shortly after that, Fiona Godlee, Editor on the BMJ, commenting on an article by Prof Edzard Ernst, said:
But in response to our recent editorial by Evan Harris (doi:10.1136/bmj.b2254), the vice president of the BCA, Richard Brown, has now presented the evidence (doi:10.1136/bmj.b2782). He writes, “There is in fact substantial evidence for the BCA to have made claims that chiropractic can help various childhood conditions” and lists 18 references. Readers can decide for themselves whether or not they are convinced. Edzard Ernst is not (doi:10.1136/bmj.b2766). His demolition of the 18 references is, to my mind, complete.
This, presumably, was the best evidence the BCA could muster and it was left in tatters by those more knowledgeable about science and robust trials.
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.
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.
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.
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.
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.
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.
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?
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.
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.
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?
Following on from Skeptic Barista‘s tenacious questioning of the GCC over the lack of evidence for the chiropractic subluxation, and my obituary of it, the GCC have announced that it is no more than ‘an historical concept’ to be consigned to the rubbish bin of a bygone, pre-scientific, evidence-free history.
GUIDANCE ON CLAIMS MADE FOR THE CHIROPRACTIC VERTEBRAL SUBLUXATION COMPLEX
The chiropractic vertebral subluxation complex is an historical concept but it remains a theoretical model. It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.
Chiropractors are reminded that
- they must make sure their own beliefs and values do not prejudice the patients’ care (GCC Code of Practice section A3)
- they must provide evidence based care, which is 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 (GCC Standard of Proficiency section A2.3 and the glossary)
- any advertised claims for chiropractic care must be based only on best research of the highest standard (GCC Guidance on Advertising issued March 2010)
This is interesting because of their statement about beliefs. They clearly see a chiropractor’s belief in subluxations as unfounded and irrelevant and indeed possibly prejudicial to the best interests of their customers.
However, it’s not so much a ‘theoretical model’ of anything: it’s never been any more than an hypotheses and one that has never had any evidence base. It was a notion that the quack D D Palmer invented to ‘explain’ to the unsuspecting why he was charging them money to crack their backs. As I’ve said before, there has never been any good evidence for either the subluxation nor its supposed effects on nerves.
The way they’ve phrased their second sentence is also interesting:
It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.
It seems to me that this was carefully written so that it included all conditions — anything at all that might be considered a ‘health concern’ is covered whether that is some actual condition such as back pain, or some more esoteric chiropractic condition like ‘feeding problems’. This should prevent them claiming that anything at all is caused by the mythical subluxation and stop them blinding their customers with sciency-sounding words.
All change again
This is a good time to be a web designer. Just think of all those websites that will need to be changed — again — to remove yet more misleading claims.
Of course, it might not be that simple. As Blue Wode has pointed out, there are a plethora of terms used by chiropractors instead of the bogus S word. The GCC’s guidance doesn’t say anything about any of these, and I suspect that some website changes may amount to no more than substituting a few new words. The GCC will need to keep on its toes if they really want to protect the public from misleading claims.
Applying appropriate care
The second bullet point in the guidance cites part of clause A2.3 of the GCC’s Standard of Proficiency. Although in the same document as the Code of Practice, it’s not really been relevant to my complaints, so I’ve not mentioned it before.
However, in full, the clause is:
A2.3 Applying appropriate care
Chiropractors must be knowledgeable about the underlying theories of the care they provide and be competent to apply that form of care in practice. Chiropractors’ provision of care must be evidence-based and appropriate to the patient’s health and health needs. The patient must have consented to the form of care. Chiropractors must care for patients in a way that minimises risk to that patient.
With the ‘theory’ of subluxations finally declared a mere historical artefact, what ‘underlying theories’ of chiropractic are left?
How are they going to explain to a customer why they think a good back crack will make any difference to their cervicogenic dizziness, their migraines or their chronic back pain?
How are they going to explain to a customer that they need to keep coming back for ‘wellness’ or ‘maintenance’ care to stop those nasty subluxations from causing you future health problems?
So whilst this new guidance by the GCC is a welcome step in the direction of evidence-based chiropractic (whatever that is), they may find some abiding by the letter of the guidance but not the spirit. Not dissimilar to the lip-service many have paid to the ASA guidance they are mandated to abide by.