The new Osteopathic Practice Standards have just been issued. They have a 1 year introductory phase before they become the legal standards in September 2019. Mint has studied the standards in detail looking at what’s changed, what’s gone, and what’s new. This article will provide an overview of the changes.
The new standards look quite different. There are fewer standards 37 down to 29. They have been moved around and the whole document has been made a lot more logical. Historically there were two documents published separately – the code of practice and the standards of proficiency. For some time these documents have been combined into one but remained separately identifiable within the document. This meant there was some duplication of themes and if you were looking at the standards relating to one theme for example consent, you would find information in A,C and D. The standards are now more logical in their flow.
The guidance has also been made more readable with topical headings where there is a lot of guidance for a standard.
So, there has been a big shuffle of where the standards are. There has been an expansion of the guidance from of the standards and a few key additions of extra guidance to the standards that you should be aware of.
Theme A Communication and Patient Partnership
Some of these standards have been combined, most have modified wording. It also now incorporates the old standards C4, C5, C6 and D4.
The main additions to the standards are to work with patients to find out ‘what is important to them’ rather than ‘the best treatment for them’ (A2) a reflection of the goal focussed treatment. Standard A3 reflects the changes to consent law so that patients must be given information they want to know as well as need to know. Standard A4 is more explicit in consent requirements that consent is required for ‘all aspects of’ examination and treatment and also includes the necessity to record consent. Standard A5 includes the need to support patients in maintaining their wellbeing as well as health now – a reflection of current health terminology.
The changes to guidance in this section include a few clarifying points to express good communication and patient care:
A1.1 Effective communication is described more explicitly as listening ‘with care’.
A1.2. Being alert to patient’s unspoken signals includes recognising if they are anxious or vulnerable
A1.4. There is a clarification to being aware of the particular needs and values of patients in relation to physical and mental health and disability.
A2.1 and A2.2 are new guidance emphasising the importance of trust in effective communication and the need to care for patients in understanding their symptoms and supporting their health.
A3.2 Adds ‘You should discuss care options, encourage patients to ask questions and deal with these clearly, fully and honestly.’ It also adds informing patients about anticipated benefits as well as risks and confirm their understanding of these with regard to both treatment proposed and if no treatment is proposed.
Under A3 there is no longer guidance that using diagrams and models may help to explain treatments.
A3.3 Adds ‘If you are unable to communicate sufficiently with the patient, you should not treat them.’
Section A4 is one of the best improvements in the standards in my opinion. Consent guidance is logically arranged with headings and clarification of some previously vague areas.
A4.2 New guidance – ‘Gaining consent is an ongoing process. You must ensure that patients are able to make decisions at all stages of their treatment and care, and continue to give consent.’
A4.Voluntarily – these are new guidance
4. To be voluntary, the patient must not be under any form of pressure or undue influence to consent to osteopathic care. You must ensure that patients are given the information they need to reach their own decision and give consent.
5. Situations where you might question whether consent is voluntary might include patients being put under pressure by employers or relatives to accept osteopathic care, or where a patient might otherwise be vulnerable.
A4.6 Additions – The patient needs to understand the nature, purpose, benefits and material or significant risks to them of the examination or treatment proposed
A4.9 Addition about intimate examination or treatment – Some patients may not have come prepared for such a procedure and you should offer to conduct this at a subsequent appointment, and offer a chaperone.
A4.10 and A4.11 New guidance explaining about capacity to consent.
Ways of giving consent are no longer expanded in the guidance by removal of A4.6.
A5.1. Provides additional clarification of what supporting patients in caring for themselves may include – providing information on life choices and lifestyle effects on wellbeing, supporting lifestyle changes, encouraging patients to seek help and respecting patients decisions.
Interestingly under A7 (previous D4) the section stating that practitioners can explain to patients that carrying out a procedure or giving advice conflicts with personal, religious or moral beliefs has been removed.
A6.2.3. offers further clarification that you should only observe a patient undressing if necessary for purposes of diagnosis and treatment and this must be explained to the patient and consented.
A6.2.4. Advocates minimal exposure with only removing minimal clothing necessary and allowing patient to dress again as appropriate. Consent needs to be gained if the patient needs to undress to underwear for examination or treatment.
Theme B Knowledge, Skills and Performance
This is the shortest theme in the standards. B1 has the additional guidance that you need to be able to apply your knowledge and skills. B4 incorporates the necessity of reflecting on information about your practice to enhance patient care.
There are many small changes reflecting changes in evidence and CPD requirements since the last standards. I will just highlight the most notable.
B1.5. Is an new guidance that there is a need for ‘an awareness of the principles and applications of scientific enquiry and the ability to critically evaluate scientific information and data to inform osteopathic care.’
There are quite a few minor changes to the wording of the guidance under standard B1 to reflect the changing nature of diagnosis and interpretation of findings in light of recent evidence on palpatory skills and diagnostic reasoning.
B3.1.1 Advises the need to be professionally engaged and comply with requirements for CPD.
B3.1.2. Highlights the need to keep up to date with GOsC guidance, legal requirements and research and other developments in healthcare.
B4.1. You need to be able to collect and analyse information about your practice to support patient care and your own professional development – really just supporting the new CPD scheme requirements.
Theme C Safety and Quality in Practice
C2 now states that patient records must be legible which may necessitate change for some practitioners. Standard C3 says you need to respond appropriately as well as effectively to requests for written material and data.
C6 was one of the controversial standards which previously described your role as promoting public health. The standard settled on states that your role is to contribute to enhancing the health and wellbeing of your patients.
There’s some change of language under C1 reflecting current understanding of diagnostic reasoning and treatment planning, it is less prescriptive in many ways. I haven’t included all the changes but highlighted key changes.
C1.1.3 Practitioners need to formulate an appropriate working diagnosis or rationale for care and explain this clearly to the patient. This replaces the formulating of a diagnostic hypothesis and developing a working diagnosis.
C18.104.22.168. The plan of treatment and care is additionally to be based on patient’s values and preferences. Just being inclusive of the current focus for patient-centred care.
C1.1.8 You should cease care if requested by the patient or care is ineffective or not in the patient’s best interests.
Removed identifying the indications and contraindications of specific osteopathic techniques or modified forms of techniques. Also removed explicit reference to BPS model.
There is additional guidance relating to providing care outside the practice environment – the location must be noted in the notes and the same standards applied as within clinic or justification of why not.
There are a few changes to what should be included in patient records that are of note:
C2.1.4 Adds that concerns and priorities discussed with the patient should be recorded. Recording negative findings has been removed.
C2.1.5. Includes the guidance to record how information and advice is communicated to your patient.
C2.1.15 You need to record the patient’s consent to the presence of an observer. You should include the observers status and identity too.
C4.2. and 4.6 A requirement to keep up to date with safeguarding procedures is now explicitly included in the standards. Also, a need to comply with mandatory reporting for Female Genital Mutilation.
C6.1. is a revised guidance – the need to be aware of public health issues and concerns and discuss these in a balanced way with patients and point to resources or other healthcare professionals.
Theme D Professionalism
D2 Now includes reference to boundaries. You need to establish and maintain clear boundaries, not abusing your professional standing and position of trust.
The duty of candour is now included in standard D3 reflecting the new laws since the last standards. D4 explicitly states that you must have a complaints policy in place.
D5 Adds that you need to effectively maintain and protect patient information.
D6 ‘You must treat patients fairly and recognise diversity and individual values’ further clarifies the equality and antidiscrimination legal requirements.
D7 Has been further clarified that you must uphold the reputation of your profession by your conduct both in and out of the workplace.
D11 Now states that you must not rely on your own assessment of risk to patients with regard to deciding whether your health problems will affect your patients.
D12 Has been expanded to say that you must inform GOsC of any significant information about your conduct and competence ‘as soon as is practicable’ and you must cooperate with request for information or investigation and comply with all regulatory requirements. This has made clear there is no doubt what is required of us.
D1.3. Leaves no doubt about the requirement for Professional Indemnity Insurance.
D2.2 and 2.3 and 2.4. are additions regarding boundaries – including physical, emotional and sexual boundaries. It clarifies the spectrum of boundaries and times where it might be necessary to cross boundaries. Awareness of patient vulnerability and challenges to the therapeutic relationship are highlighted.
D5.1. Now gives examples of behaviour that may be considered sexualised by a patient.
D5.5 and 5.6. give details of how to behave if feelings develop between the patient and practitioner in either direction. 5.7 and 5.8 explain in detail factors that impact on developing personal relationships with patients. These are all new additions making the standards of practice for boundaries and professional/personal relationships much more explicit.
D3.1. and 3.2. are new guidance explaining how to apply the duty of candour – being open and honest with a patient when things go wrong.
D4.3. States that you should provide information to patients about how they can make comments, complaints and compliments about the service they have received. The Mint feedback leaflet includes all these categories of feedback.
D5.1.2 Requires that anyone attending your clinic in a professional capacity must keep information confidential.
There are several new points of guidance under D5 representing the new data protection rules.
D10 Wording has been changed with regard to working with other healthcare providers – encompassing respect, and good procedures.
D12 1.1. and 1.2. now includes that you must inform GOsC of criminal charges received anywhere in the world.
If you want to see a full table of all the changes – I have added it here but be warned it is a long document.
Overall I think this revision of the standards is a vast improvement. They are no much more logical and readable. Some helpful clarification has been added over some previously grey areas. They are a lot more prescriptive in some areas. There will always be areas of debate and areas that could be tweaked. I think osteopaths should find that these standards provide clear expectations that guide them in providing the best standards of practice for their patients.