Tuesday, August 2, 2016

Advertising by Chiropractors - AHPRA Forum 28 July 2016

On 28 July 2016 I attended a forum on Advertising that was convened by AHPRA and the Chiropractic Board of Australia in Melbourne. I was there in my capacity as a member of the AHPRA Community Reference Group.

The purpose of this forum was to facilitate open communication of different perspectives on advertising by chiropractors and provide stakeholders with information to increase understanding of issues around advertising by chiropractors. There was discussion of the role of advertising by chiropractors in supporting good healthcare decision-making and the risk of harm by misleading advertising. There was agreement about the importance of the responsible provision of information by registered chiropractors to the public. The participants were also encouraged to identify ways to improve the quality of advertising by chiropractors.

Participants were from a range of stakeholder groups including AHPRA Community Reference Group, CHOICE, Friends of Science in Medicine, Chiropractic Board of Australia, Chiropractic Council of NSW, Australian Securities and Investment Commission, ACQSHC, Chiropractor’s Association of Australia, Consumers Health Forum and Chiropractic Australia.

The Chiropractic Board of Australia and AHPRA have noted that there continues to be a high number of complaints made about chiropractors’ advertising; and the Board is concerned about the ongoing issues and confusion about advertising guidelines.

The Board is working with AHPRA to inform chiropractors of their responsibilities, as outlined in the advertising guidelines, in order to improve compliance with the guidelines and the law. The Board has run seminars around Australia to explain the Guidelines for advertising regulated health services, as well as to provide additional information and answer questions about advertising.

I spoke on a panel in the afternoon. I thought my speaking notes might be of interest.

For consumers, control and choice are important aspects of our health system.

Consumers must be able to make informed choices regarding our health care. Informed choice are dependent on receiving reliable, balanced health information that is free from the influence of commercial imperatives and is communicated in a way that we can easily understand.

We want to make informed choices about therapeutic goods as well as medical and health-related services. So I’m talking about over the counter and complementary medicines, prescription medicines, medical devices as well as medical and surgical procedures.

Advertising can play a role in this. It is not all bad.

There has been considerable attention given to this in the past decade. More recently the focus of advertising has turned to health professionals and services.

As with all things it is a question of balance. While there are risks that advertising can drive unwarranted testing and interventions there is also the argument that it reduces under diagnosis and under treatment of conditions. Advertising can enhance patient perceptions about conditions that could be medically treatable and encourage dialogue with health care providers. Advertising can build on levels of health literacy. But that is dependent on quality.

Advertising can also play a role in changing the way we think about diseases such as depression, incontinence or erectile dysfunction. Good advertising can reduce the stigma associated with these conditions.

Advertising can promote competition and transparency.

What do we value?
Choice and control
Being supported to make an informed decision about our health
Honesty and truthfulness
Patient centred care
Information that I easy to read and understand

What do we assume?
That professionals are well trained and supported to deliver services
That they are working to support us to live as well as we can
That they will put our wellbeing ahead of their business interests
That they will be truthful
That they will first do no harm

We trust our health professionals. We have trust in the health system and have a heavy reliance on this. And we are influenced by the authoritative role our health professionals play in our lives. They are influential. And many of us trust advertising. There is not a high level of critical literacy in our community but programs like the Gruen Transfer and The Chase are helping.

What do consumers want?
Want to make decisions to improve out health
Reliable information based on current evidence
Include registration number and membership of professional bodies
Truthful, no false claims, not manipulate us.

Advertising can play a useful role in building consumer understanding of health care, of procedures and medicines. Advertising can raise awareness of health issues, diseases and chronic conditions. It can also play a role in reducing stigma associated with some conditions that people may be embarrassed by eg. Depression, incontinence, erectile dysfunction.

Advertising can provide lifestyle advice and encourage consumers to take a more active role in managing our own health. Advertising can help consumers to take action, seek attention and reduce under-diagnosis or delays in treatment.

Rather than recommending chiropractors, seek independent advice. Why can’t the Board and AHPRA take more action to provide this? What role can consumer panels play in providing this advice?

Ultimately until we have public reporting of outcomes and adverse events we will continue to be reliant on advertising and word of mouth from consumers.

Risk to Consumers:
We need to build community understanding and awareness of the importance on truth in advertising in health care. There are risks in all health care but we do not talk about this enough. And it is consumers who wear the risk of misleading advertising. It impacts on our health, on our lives. We may make decisions based on misleading information. So this is an important public interest matter.

Misleading advertising can lead consumers to have unnecessary treatment.

National law is very clear, they are not permitted. This is an area of interest for consumers. It is also about consumer feedback. Partly it is because they educate/ inform consumers about the work health professionals do. Many consumers do not know what the scope of practice of individuals is. Instead of testimonials, why not use case studies? Examples of safe practices? We need more information about what we can expect.

Continuing Professional Development (CPD)
All registered chiropractors must comply with the registration standards set by the Chiropractic Board of Australia and make a declaration of their compliance with these standards when they complete their registration renewal application each year.

The CPD standard requires all practising chiropractors to complete at least 25 hours of CPD per year. And at least half of this have to be in formal learning activities. The Boar d provides advice on their website on what constitutes formal and informal learning. All practitioners must hold a current Senior First Aid (Level 2) certificate or equivalent. First aid certificates need to be renewed every three years to remain current.

My talk:

As is the case, most of the speakers who spoke before me covered many of my points so my notes were put back in my bag and I started again.  What follows are the hastily written notes I made for myself:

A few points to start off with.

I find it very difficult to separate advertising from practice. I am not alone.

Public reporting of outcomes would improve this situation as it would mean we are not reliant on advertising and the experiences of family and friends or the rapport we have built with our health professionals. Our health decisions could be based on data.
I strongly support consideration of reviewing the CPD courses to make sure that they include the science of evidence based medicine as well as being educationally sound.

And yes, AHPRHA registration means something. It implies that registered health professionals are competent and will do no harm. AHPRA registration – right or wrong – can be taken as a proxy for competence.But risk is inherent in health care and we need to improve the way risks are talked about in the public arena as well as by health professionals seeking informed consent of their patients and clients.

And who are the registered chiropractors who are not members of professional bodies? Is there a correlation between those who are not affiliated with professional bodies and those who do not comply with the advertising rules?

I am interested to know how the three professional bodies are taking an active role in reviewing websites and advertising? There are risks to consumers and reputational risks to the profession.
Easy to be dispassionate but health care is about emotion. We are invested – we have relationships with the people who treat us. Our health is about our life and about the lives of the people who we love. What about those people at the end of their tether? They have tried other health services and not received relief from symptoms. These people are vulnerable and desperate and may make emotionally based decisions. It is good to see emotion in this room because this matters.

We make emotional decisions about health care. We don’t always look at the evidence and some of us may not have the skills or awareness to do this.

And advertising can tap into that. It is influential and can shape our health decisions.

The system is reliant on professionals doing the right thing but the eyes and ears of the public are focussed on identifying breeches. And we need AHPRA to act. Regulatory responses seem to be too slow. AHPRA is totally overwhelmed by the number of complaints on advertising. Over 600 complaints but only about 20 significant actions, and in what timeframe? Responsiveness and timeliness is an issue. This needs to improve.
Whose voices haven’t we heard?

What about vulnerable people who may not understand their rights, or consumer law?

What about people who are recent arrivals in Australia and do not have knowledge of our health system? Will they have the critical literacy skills to work out if they can trust the advertisements and make informed health decisions?
And what about people with poor English language proficiency or cognitive impairment?

This is why we need to be vocal and call for more action. These people may not make complaints – it is up to us.

Further information

Darlene Cox

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