Safer Care Victoria has concluded its review of Chiropractic Spinal Manipulation on Children Under 12 and passed its final report to the Victorian Minister for Health, Jenny Mikakos MP. The report and recommendations from Safer Care Victoria are expected to form the basis of recommendations that went to State, Territory and Federal Health Ministers ahead of their recent Council of Australian Governments (COAG) Health Council meeting on 1 November.
How did we get here?
In late February this year the chiropractic profession received a high volume of negative news coverage when a video of a registered chiropractor in Victoria treating a young baby was published first in the Herald Sun, and then across the country and internationally. This led to calls for an investigation of the chiropractor in question by the Health Minister of Victoria, Jenny Mikakos MP. The Minister also called for an investigation into chiropractic to “ensure there aren’t other chiropractors around Australia who are similarly undertaking these types of practices.”
The chiropractor in question entered a number of voluntary undertakings with the Chiropractic Board of Australia, including an undertaking not to provide any chiropractic treatment of children from birth to 12 years, pending the results of an investigation by the Board. For the purposes of the undertaking, ‘chiropractic treatment’ of children included assessment, undertaking a diagnosis/clinical impression, formulating and implementing a management plan (including spinal manipulative therapy) monitoring or reviewing care, facilitating coordination or continuity of care.
Victorian Health Minister
Subsequently, the Victorian Health Minister placed the issue on the agenda of the March COAG Health Council meeting, a twice-yearly meeting of Commonwealth, State, Territory and New Zealand Ministers with responsibility for health matters, and the Commonwealth Minister for Veterans’ Affairs.
The COAG Health Council provides a forum for cooperation on health issues by all jurisdictions, especially primary and secondary care and fulfils regulatory/governance obligations that fall within the health portfolio in the areas of national registration and accreditation.
The communique released by the Council immediately following their meeting on 8 March stated:
“Health Ministers noted community concerns about the unsafe spinal manipulation on children performed by chiropractors and agreed that public protection was paramount in resolving this issue.
Ministers welcomed the advice that Victoria will commission an independent review of the practice of spinal manipulation on children under 12 years, and the findings will be reported to the COAG Health Council, including the need for changes to the National Law.
Ministers supported the examination of an increase in penalties for advertising offences, such as false, misleading or deceptive advertising, under the Health Practitioner Regulation National Law, to bring these into line with community expectations and penalties for other offences under the National Law. This decision was informed by recent consultation about potential reforms to the National Law in 2018.
Ministers will consider the outcomes of the independent review and determine any further changes needed to protect the public.“
CBA Interim Policy
Shortly thereafter, on 14 March 2019, the Chiropractic Board of Australia placed a temporary restriction on chiropractors providing spinal manipulation to children under two years of age, pending the outcome of the independent expert review by Safer Care Victoria.
For the purpose of the Boards interim policy, ‘spinal manipulation’ means moving the joints of the spine beyond the child’s usual physiological range of motion using a high velocity, low amplitude thrust.
Safer Care Victoria Review
The Victorian Health Minister tasked Safer Care Victoria to lead the independent review of the practice of spinal manipulation on children under 12 years, and for the findings of that review to be provided to her for reporting back to the COAG Health Council, including any need for changes to the national law.
According to the review terms of reference, it would examine and assess the available evidence, including information from consumers, providers, and other stakeholders, for the use of spinal manipulation by chiropractors on children less than 12 years of age and deliver a final report and recommendations within six months from commencement.
Safer Care Victoria was asked to establish a panel that would be responsible for reviewing the available evidence and public submissions. The review would consist of two principal elements. First, a systematic evidence review undertaken by the Cochrane Australia at the School of Public Health & Preventive Medicine at Monash University. This review would look at evidence for both harm and effectiveness. Second, a call for public written submissions. The panel was tasked with working collaboratively and using the systematic review as well as the evidence gathered from written submissions to inform SCV’s final report and recommendations. Safer Care Victoria would then deliver its final report and recommendations to the Victorian Health Minister.
The role of the panel was to advise on the review, enabling Safer Care Victoria to provide recommendations to the Victorian Health Minister. Specifically, the panel were asked to:
- work collaboratively to develop and endorse the scope of the review,
- set the parameters for the literature searches and systematic review,
- determine the questions to be asked that would frame the call for public written submissions,
- use all evidence gathered to inform SCV’s final recommendations.
The panel was chaired by Safer Care Victoria CEO Professor Euan Wallace AM, and included the Victorian Chief Allied Health Officer and Chief Medical Officer, as well as expert paediatric medical practitioners (with expertise in evidence translation), a paediatric allied health clinician with expertise in musculoskeletal practice and an academic allied health professional (with expertise in evidence translation) as well as two consumer representatives. The panel also included representatives from the Chiropractic Board of Australia (Dr Wayne Minter AM), Australian Chiropractors Association (CEO, Adj Assoc Prof Matthew Fisher) and a registered chiropractor with paediatric experience (Dr Genevieve Keating).
SCV Public Consultation
The Safer Care Victoria public consultation opened in late May and ran for approximately six weeks. The ACA strongly encouraged all chiropractors to make their views known in this consultation and encouraged practitioners to ask their patients to participate also. In all our communications to members we reiterated that stories from patients would be particularly valuable in informing the review panel of the importance of paediatric chiropractic care to families across Australia.
From the very beginning the ACA anticipated that the review would demonstrate limited evidence of harm arising from chiropractic care for children and that this care is highly valued by parents across the country. Nevertheless, in her media release announcing the start of the public consultation, the Victorian Health Minister said:
“Now is the time for parents who have experienced the dangerous practice of child spinal manipulation to have a say and share their story.”
“We won’t rest until babies are protected from practices we know to be harmful, and that we can be sure children under 12 are not being exposed to harm.”
“The risks of spinal manipulations on newborn babies outweigh any benefits, but more needs to be known about children under 12. We need a national approach and that may involve changes to the law if necessary.”
The ACA Represents Chiropractic
The ACA’s submission to the Review Panel noted there is little or no evidence of risk of harm to the paediatric population undergoing care from a chiropractor, specifically under the age of two years and, more broadly, under the age of 12 years, either in Australia or internationally. This is supported by a number of systematic reviews and analysis of available complaint and/or insurance data.
While it is It is appropriate for regulators to act to restrict patient harm when there is credible evidence of risk, when no such harm has been reported or demonstrated, informed patient choice should be a priority.
The ACA has always maintained that the Victorian Health Minister has initiated an unusual step in the process of health care regulation in Australia by targeting a single profession. The ACA has advocated strongly and persistently that chiropractic should not be singled out for age-related regulatory restrictions when medical practitioners, physiotherapists and osteopaths can all provide similar care. There is an existing system of regulation dealing with risk in Australia which is, and continues to be, effective and this should be applied uniformly across all fifteen registered health professions.
Over the course of the past six months, the ACA CEO travelled to Melbourne on eleven separate occasions to attend meetings of the review panel. According to Dr Fisher, “the review panel process I participated in was conducted robustly, and it was extremely pleasing that the public consultation elicited such a huge response from members of the community. I have consistently maintained this information should be made available to help all decision makers across the country understand public opinion and sentiment about this matter.”
As the profession’s peak body in Australia, the ACA has worked tirelessly to educate, inform and influence the views of Commonwealth, State and Territory decision makers including legislators and bureaucrats. In this time ACA staff have travelled around the country to meet with Health Ministers, political advisors, public servants, and other key decision makers to represent our view on the report at the highest levels. In these meetings the ACA has spoken about the important role we play in our patient’s health outcomes, the ACA’s position on the SCV review, and why your ability to treat all Australians who could benefit from your care, regardless of age, should not be restricted.
However, the ACA did not do this alone. There has been a large and persistent effort by chiropractors to advocate and lobby on behalf of the chiropractic profession. Most importantly, this included mobilising our patients to ensure their voices were heard by decision makers as well. Throughout this process, only the ACA has provided members with the resources and campaign materials to assist you to undertake this work.
The ACA has kept you up to date with all the latest information via email, news articles, videos and on social media, including important information for you to share with your patients.
The ACA Board appreciates we have asked much from you over the past six or so months however, with your support and the support of your patients, we hope we have been able to ensure your ability to care for Australians of all ages is not restricted unnecessarily.
(Note: this story was written prior to the 1 November COAG Health Council Meeting).