Introduction

1. Insights from Research on Experiences of Osteopathic Regulation: Towards ‘Relational Regulation’ and ‘Formative Spaces’PSA Conference 23rd March 2016, The Lighthouse, Glasgow Prof Gerry McGivern1, Dr Michael Fischer2, Dr Tomas Palaima3, Dr Zoey Spendlove4, Dr Oliver Thomson5& Prof Justin Waring4 1Lead author, Warwick Business School, University of Warwick gerry.mcgivern@wbs.ac.uk 4 2 3 5

2. Introduction Little evidence of regulation’s effects on professionals in practice (Quick, 2011; McGivern & Fischer, 2012) Mid-Staffs/Francis Inquiry (2013) raised concerns about ‘tick-box’ regulation & compliance; need for professionalism & professional engagement to improve actual compliance The General Osteopathic Council (GOsC) funded usto research: What factors (i) inhibit or (ii) encourage osteopaths from practising in accordance with standards & (iii) what regulatory activities support osteopaths to deliver care & practice in accordance with standards

3. Data collection 55semi-structured interviews with osteopathic stakeholders 37 osteopaths, inc. representatives of osteopathic education institutes, the British Osteopathic Association, ‘Osteopathic Alliance’, regional groups & patients Thematic & template analysis (Richie & Spencer, 1994) On-line survey: 17% response rate (809/4900) from GOsC registered osteopaths T-tests, factor analysis & structural equation modelling

4. Osteopathy Descriptions but no agreed definition of osteopathy: Musculoskeletal manual therapy; ‘hands on’, holistic, patient-centred, relational, empathic, subjective complex practice Seen as unamenable to ‘biomedical’ research & evidence (e.g. RCT) Limited evidence of osteopathy's benefits or risks Only 39%of osteopaths we surveyed agreed ‘practising evidence-based osteopathy improves patient care’ (27% disagreed) Challenges for standards-based regulation 5000 GOsC registered osteopaths; about 25 Fitness to Practise (FtP) hearings per year Low risk justifies ‘light’ ‘right touch’ regulation (PSA, 2012) GOsC’s regulatory focus on ‘peer discussion review’ & ‘CPD providing assurance of continuing fitness to practise’

5. Views of regulation and standards 40% agreed ‘regulation has a positive effect on how I practise as an osteopath’ (29% disagreed) 45% agreed ‘What I do as an osteopath always fully complies with all the OPS’ (19% disagreed; 37% unsure) 28% ‘comply with the OPSbecause they reflect what it means to be a good osteopath’ (35% disagree), Far more (49%) ‘comply with the OPS to avoid getting into trouble with the GOsC’ (20% disagree)

6. Perceptions of the GOsC Historical antagonistic relations between the GOsC and osteopathy professional still affected some osteopaths’ perception of regulators “A lot of the venom that was directed towards them [GOsC] in the early days… there are still people who feel scarred by what the GOsC did.” Recently “much improved” GOsC;listening, communicating and improving relations with the osteopathy profession, also helped by meetingosteopaths in person “[There was] fear of GOsC in the profession… [Now] there is more realisation of the benefits of GOsC… [GOsC staff] come out and speak to us, and we see people… They haven’t got horns on their heads these regulators… They actually care about what they do... [and] understand what we do.”

7. Osteopaths’ experiences of FtP Hearings An osteopath subject to a complaint commented: EXPERIENCE: “The things that the patient complained about weren’t found. In other words, they found in my favour. The only thing they found against me was the [substandard] notes… I wouldn’t be surprised if 75% of people’s [notes were substandard]” EFFECT: “It is a shame… I had something to offer… now really I don’t feel like doing it… my notes are perhaps a little bit more particular but it hasn’t changed the way I practice.” Reflects research in other professions (Papadikis et al 2008; McGivern & Fischer 2012; Bismark et al 2013; GMC 2014; HCPC 2015) questioning the efficacy of FtP hearings in turning around poor practice

8. Stories about FtP hearings affect perceptions of regulation and decisions about compliance Professional narratives FtP hearing produce anxiety and defensive practice (McGivern & Fischer, 2012) “You fear... it [FtP hearing] will be like facing the Spanish Inquisition” “While there are only 10-15 [FtP] cases a year, those 10-15 people talk to other osteopaths, who talk to other osteopaths, & … maltreatment news spreads like wildfire, or the perception of maltreatment.” 23% of osteopaths were ‘confident that the GOsC’s disciplinary procedures produce fair outcomes’ (24% disagreed; 53% neither) Narratives & emotions (fear/anxiety) affecting (out-weighing rational normative) perceptions of regulation & decision regarding compliance? (also in McGivern & Fischer 2012)

9. Whistleblowing 28% ‘have had concerns about another osteopath’s ability to do their job’ 20% with concerns made a formal complaint (10% to the GOsC), so regulators are unaware of many concerns 60% took informal action (11% spoke to the osteopath; 23% gave advice to a patient affected; 26% discussed the osteopath with other professionals); 19% took no action (for 9% the concern was not serious or credible) Why didn’t osteopaths report concerns? 53% said their concerns would have been impossible to prove (e.g. their concern was based on hearsay rather than solid evidence) 37% said the issues was resolved 36% did not want to cause trouble (for colleagues in difficulty) 30% feared retribution

10. Dealing with concerns 82% ‘would always report another osteopath to the GOsC for serious malpractice’ (e.g. where patients were at serious risk) (2% disagree) 63% agree ‘Unless it is serious, it is better to deal with concerns about another osteopath informally, rather than go through a regulatory process’ (8% disagree) Osteopaths tend (prefer) to deal with concerns about colleagues informally “We had a professional conversation about [poor practice]”

11. Reflective conversations among osteopaths support high quality practice & professionalism Osteopaths described communication, reflection & engagement with other osteopaths as key to maintaining quality practice/ professionalism “I don’t… get the opportunity to discuss difficult cases with … osteopaths… I could learn a heap from others… I just would love… that sort of thing.” “[In]a safe environment… a critical friend is very important… As autonomous practitioners, it is very easy to get isolated in your thinking” “You could tick all the boxes and fill all the forms… without actually transferring that into practice… a peer mentoring thing… would mean that you would have to translate things into practice”

12. Survey data: Osteopaths’ views of peer review 34% agree (37% disagree): ‘Peer review would have a positive effect on how I practise as an osteopath, as part of the GOsC process to provide assurance of CFtP’ 18% agree if the peer reviewer is appointed by GOsC; 43% disagree 52% agree (24% disagree): ‘Peer review, involving informal discussion of my practice with another osteopath, would have a positive effect on how I practise as an osteopath’ Less GOsC involvement has more a positive effect on practice?

13. ‘Formative spaces’ ‘Red flags’(serious concerns ) need to be reported to the regulator whereas ‘yellow cards’(moderate concerns) may be better addressed among professionals Previous research highlighting the importance of ‘formative spaces’ (McGivern & Fischer 2012) for challengingintra-professionalconversations about difficult aspects of professional work without fearing exposing oneself to a Fitness to Practise hearing. E.g. Professional peer discussion practice groups ‘Preventing small problems from becoming big problems’ by promoting professional engagement with regulation (HCPC 2015) FindingsupportGOsC proposal to introduce ‘peer discussion review’ and health professionals demonstrating ‘continuing fitness to practise’ (rather than regulators assessing their fitness to practise after a complain is made)

14. Analysis of survey data: Factor analysis, structural equation modelling & associations between factors Pro- regulator Pro-evidence based practice +0.35 +0.31 Feeling compliant -0.14 -0.29 Fear-based compliance

15. Relational regulation ‘Spontaneous’ & ‘enforced’compliance(Dutch Ministry of Justice model, cited by Baldwin et al. 2012) ‘The clear message… is that regulation… is far more likely to be complied with when accepted as legitimate by practitioners’ (Quick, 2011: 3) Narrativesframe professionals interpretation of & ‘reactivity’ to regulation (McGivern & Fischer, 2012) “create a culture of fear, people start hiding things… the problem is the attitude towards the practitioners… I’ve been very encouraged by GOsC lately” Relational regulation and ‘macro-management’ (Huising and Silbey, 2011) Attention to simultaneous heterogeneous ‘relational signals’ & ‘gain, hedonic & normative goals’ (Etienne, 2011; 2013) ‘Really responsive’ to how regulatory signals are interpretively framed by (interrelationships between) multiple widersocial, professional, cultural, institutional & political norms & values (Black & Baldwin, 2010)

16. ‘Rethinking Regulation’ (PSA, 2015) ‘Regulators should reopen a dialogue with their registrants and the public aboutthe nature of risk in practice… rebuilding trust between [them]… do less regulating… [encourageprofessionals]to identify and address regulatory risks… where a culture has been created in which colleagues feel comfortable to question & challenge each other…[and] takemore responsibility forthe quality oftheir own work.’ (PSA 2015) Our research supports a move towards ‘relational regulation’ and development of ‘formative spaces’ within regulatory systems GOsC:legitimatingcompliance with standards as good professionalism; leaving spaces [peer discussion review] within regulatory processes for professionals to ensure compliance Promoting an osteopathic evidence-base & evidence-based practice to indirectly increase professional compliance?

17. Reference & further reading McGivern, G. & Fischer, M. (2012) ‘Reactivity & reactions to regulatory transparency in medicine, psychotherapy & counselling’. Social Science & Medicine, 74, 286-296. McGivern, G., Fischer, M., Palaima, T., Spendlove, Z., Thomson, O. & Waring, J. (2015) ‘Exploring & Explaining the Dynamics of Osteopathic Regulation, Professionalism & Compliance with Standards in Practice: Report for the General Osteopathic Council’ http://www.osteopathy.org.uk/news-and-resources/research-surveys/gosc-research/research-to-promote-effective-regulation/?&menushow=true