The views and opinions in this essay are entirely my own, and not reflective of any Professional Association.
Statutory Regulation in the field of
Soft Tissue Therapy/Sports Therapy/Massage Therapy
By Matt Scarsbrook, July 2020
This mini essay is designed to provide practicing therapists a clear understanding of the work that a Professional Association (PA) (also known as a Professional Body) does, and how that compares to a Union. It further explores the landscape of the Soft Tissue Therapy/Massage Therapy/Sports Therapy industry (collectively referred to as MT in this essay), including the PA’s, the General Council of Massage Therapists (GCMT), the Complementary and Natural Healthcare Council (CNHC), and provides a clear overview as to why this industry will not become either regulated or mandatorily registered.
TL:DR The ISRM, STA and key other PA’s are working harder than ever to try and support members, and are not in a position to give a continuous running commentary on discussions and progress because that takes away from the work actually getting done, but they do report progress once it has been consolidated. What might seem like several days of no news is actually hours and hours of conference calls at all levels and an enormous amount of development work, and those involved feel a huge sense of responsibility. Our industry is comprised of at least 12 PA’s (not including regional bodies such as the Scottish Massage Therapists Organisation (SMTO) or overlapping fields such as Bowen and acupuncture) and a voluntary register(the CNHC) that accepts therapists from an incredibly wide range of professions. Trying to achieve a consensus is a challenge, to say the least. The Union proposed by the Association of Physical & Natural Therapies (APNT) is highly unlikely to amount to more than another PA, but this will of course be monitored. Further, we are never going to be a regulated industry with a mandatory register. The Government has made it clear it has no interest in further regulation in the Health & Social Care sector. From my perspective, further regulation is not necessary in MT, but whether you agree with this or not, since it will not happen we are best off putting our efforts into more constructive matters.. Continue reading for the full picture.
The Bigger Picture
To begin, a PA is in effect an organisation set up by an individual or group. As defined by the Science Council in the UK; “A Professional Body is an organisation with individual members practicing a profession or occupation in which the organisation maintains an oversight of the knowledge, skills, conduct and practice of that profession or occupation.” (1) The Quality Assurance Agency for Higher Education (QAA) defines professional bodies as “Independent membership organisations that oversee the activities of a particular profession and represent the interests of its members. They may offer regulation or certification of unregulated occupations on a voluntary basis.” (2)
In short, this means that membership of a PA is entirely voluntary, and your continuing membership is reliant on you complying with the rules and regulations of your chosen PA. The PA will have been originally set up to represent the interests, and oversee the conduct of a specific group, usually defined by their qualification. As there is no single route to MT in the UK, with different schools teaching different approaches, different modalities and qualifying their students to different scopes of practice, there have naturally arisen a wide range of PA’s covering the professional interests of all these practitioners. Clearly, the more broad a single PA’s membership base in terms of qualification, the more difficult it is for that PA to provide comprehensive guidance. The more narrow and specific the PA’s membership, the greater the number of PA’s required to cover the industry. In addition there are naturally going to be disagreements as to which is the “correct” way to govern an area of the industry, so PA’s with overlapping memberships are created. The members themselves can “vote with their feet” by choosing which, if any, PA’s to join.
In this set up there is no “Lead PA”, all are equal regarding their influence on the industry. It is the members of a PA who determine the influence by choosing and following the guidance of the PA that best represents their needs. There have been attempts in the past to bring some collaboration between PA’s in a formal way, which is where the GCMT features. This is not a “governing body of the massage industry” (3) but instead a forum designed to allow direct discussion between PA’s involved with Soft Tissue Therapy, Sports Therapy andMassage Therapy. Whilst a potentially good idea, by its very nature it is voluntary and therefore limited in its scope to shape the industry as a whole unless it can convince all PA’s to provide representation.
The CNHC is a voluntary register (seeing the theme here?) set up to allow practitioners to “demonstrate to the general public and other healthcare providers that they meet UK-wide standards of practice in their work” (4). My personal experience has been that the accredited register is not recognised by regulated healthcare practitioners (which begs the question where is the “marketing” for this that would benefit registrants) and that during the coronavirus pandemic the primary drive of the CNHC has been to try and convince Government that their registrants, who comprise a whole host of modalities, are key workers, just like the NHS. This is something I personally believe to be an absurd sentiment; there are no circumstances under which a reflexologist’s work can be called “urgent” or “frontline”,and we risk losing credibility in our practice by trying to assert such a view.
The latest announcement in trying to bring some unity to the industry is from APNT and their suggestion of a union (5). Whilst I can’t speak in much detail on this as the details are yet to be released, I can give a general overview of where unions sit in relation to PA’s.
Fundamentally a union represents the voices of the employee’s to the employer. Their origins trace back to the 18th century where the industrial revolution was just getting underway and men, women and children were exposed to horrific working conditions. As individuals they needed to like it or lump it, but en mass as a union they could have some influence on their employers. You may be starting to see a slight issue here. MT’s, by and large, are self employed. For those who are employed there already exist enormous general unions like Unite, who will support their members in any industry. But for the self-employed, the basic concept of a union falls flat. Existing versions in the wider UK are more akin to memberships offering legal advice, training advice and sometimes financial support. Their lobbying efforts are directed to Government but in a world where the loudest voice wins, they need to have a very broad base of members to get the numbers needed. And, once the membership base is broad, the message becomes broad and lacking in focus, and specific industries and groups cannot be represented effectively. The union does not have any power to set professional governance - that is the job of the PA. To take the Chartered Society of Physiotherapists (CSP) for example, they exist as two distinct branches - the PA and the Union. The PA sets the governance and professional conduct for the members. The union side represents members interests in employment such as working conditions and support in disciplinary hearings. So for self-employed MT’s, the PA provides everything that is needed. It will be with great interest that I watch the development of the APNT’s union plan, to see what value it truly provides the MT industry whilst representing a very broad group of practitioners, but but my concern is it will simply become another form of PA.
So what about regulation (which leads to mandatory registration)? This is a common question within the complementary care industry, and particularly during the Covid-19 pandemic when regulated practitioners such as Physio’s and Osteo’s can work but none regulated MT’s cannot. An element that is often referred to is that Physio’s are degree educated where MT’s are not, they are vocationally educated. The obvious exception here are Graduate Sports Therapists (GST). However this is not a discussion on whether there should be a distinction made in the scope of practice between GST and vocational Sports Therapists (ST), because I feel that this particular issue misses the point when it comes to regulation. Because regulation is not simply set on the level of education of the practitioner.
Statutory regulation of certain healthcare professions is a mix of historical context (The Medical Act of 1858 initially established what eventually became the General Medical Council, with acts of parliament for the regulation of midwives and nurses coming in 1902 and 1919 respectively) and the obvious need to protect patients and the public from harm. It ultimately comes down to the risk of harm by any one profession. MT is a very low risk profession when compared to something like medicine.
According to the Department of Health and Social Care, regulatory bodies:
With the removal of the underlined section, I hope you’d agree that this is essentially the role performed by PA’s in MT, although their ultimate action is restricted to removal of membership rather than the legal right to practice
Fundamental changes to the regulation of healthcare professionals began as early as 2008 with The Health and Social Care Act. In February 2011 the then coalition Government published a document called Enabling Excellence; Autonomy and Accountability for Healthcare Workers, Social Workers and Social Care Workers (7). In it they state “Delivering safe and effective care will continue to be the driving principle behind professional regulation. However, the regulatory framework is also complex, expensive and requires continuous Government intervention to keep it up to date. More generally, reducing regulation is a key priority for the Coalition Government.”
The argument for this reduced regulation was to encourage more responsibility by individuals for their actions, and to reduce cost and complexity in the economic climate of the time.
In 2015 the Professional Standards Authority published a paper called Rethinking Regulation. In it they point out that the nine healthcare regulatory bodies in the UK “have a common set of functions yet there are differences in legislation, standards, approach, efficiency, amongst others.” (8) So when MT’s ask for regulation, what precisely do they mean? The executive summary of this paper states; “Health and care regulation is incoherent and expensive and there is little evidence for its effectiveness; if it was going to improve care it would have done so by now. It’s time to rethink regulation.”
Most recently in July 2019, the Government published the paper; Promoting professionalism, reforming regulation - Government response to the consultation (6). In the executive summary they state; “The UK’s model of professional regulation for healthcare professionals has become increasingly complex, outdated and is seen as adversarial and legalistic. This makes it difficult for regulators to be responsive to the changing needs of the healthcare environment, to support the development of a flexible workforce and to protect the public in the most effective way.” The paper continues by laying out the steps the Government is taking to reform and reduce regulation in healthcare in the UK.
From these documents spanning the past 12 years, it is quite obvious that the Government has no interest in further regulating healthcare by extending it to sectors currently unregulated, and it is in fact taking active steps to deregulate it. It could be argued that they have good reason! So the lack of regulation in our industry is not because the PA’s don’t want it, it’s because the Government doesn’t want it.
Also, I think it’s clear that “regulation” is not necessary for MT. As noted by the Professional Standards Authority; “Calls for statutory regulation are often made by those referred to as ‘aspirant groups’, reflecting an out-of-date view that regulation is a badge of professional status and something to be achieved, rather than a system to be applied where risks justify its intervention. Whether and how a group is regulated should not be based on how successfully or how determinedly that group aspires to it. The decision should be based on what form of assurance is the right one for the nature of the risk of harm that the practice in question presents to the public. Statutory regulation should be preserved for those professions for whose practice it is the most effective risk management approach.” (8)
We pose a relatively minor risk to our clients or the public and our PA’s perform all the duties of the regulatory bodies. In fact, to become regulated would by definition reduce the ability of the PA’s to make meaningful changes in our profession in any sensible and cost effective timeframe. Regulation is also expensive - the average annual membership fee for the General Osteopathic Council is £560 (9), and for the General Chiropractic Council £800 (10)! Whilst it seems attractive during Covid-19, as this seems to be the bar set by the Government regards returning to work, it would be a very expensive, convoluted short term fix that left us with a very expensive, convoluted long term faff. Plus the Government have no interest in it. So I consider it time to drop this line of enquiry once and for all - it’s dead, let's move on and focus our efforts on more realistic and beneficial goals.
For me the first such goal is achieving a level of recognition for our work from the Government and public at large. It is quite right that we are appalled by the reference to us being “massage parlours”. But what, as a profession, can we do to improve that image? For a start we can look at the differences between MT and regulated healthcare. What major difference stands out? To me, the key one is the use of evidence based practice. If we want to be taken seriously we need to stop promoting anything not properly supported with evidence, such as “negative energy”, “releasing fascia”, “breaking down scar tissue” and “accelerating healing”. If we want to be viewed as professionals we need to represent ourselves as professionals, using the correct language, and being accurate and evidence based in our claims. This is something that every single member of the MT profession can do. They can educate themselves, bring themselves up to date with what the evidence says is really going on under our hands, and embrace it. Our training schools can stop teaching outdated concepts and, in some cases, pure fantasy. And then we can stand proud as professional practitioners alongside, and complementary too, mainstream healthcare.
To the world at large, maintaining high quality standards means providing consistent standards of treatment with expectations in results based on clear evidence. Only once this is set as the objective is it worth discussing how this objective is to be achieved, and how as an industry we can govern our practices.
Response from Mel Cash, ISRM, LSSM
I must thank Matt for this excellent essay which I believe very accurately describes the situation regarding regulation and recognition in our profession. But it is hard to come away from this feeling encouraged because it all looks so negative, nothing seems to work for us.
So where do we go from here?
I think it is time for a fresh new approach and we should get away from the terms Recognition and Regulation which have so much baggage attached to them.
All we really want is ACCEPTANCE.
We have already come a long way in establishing Soft Tissue Therapy without the help or favour of others. We have done it on our own through the good work we do and by actually succeeding in the private healthcare marketplace. We only exist because there is a genuine demand from the public for the work we do.
Mainstream medicine should accept us for who we are and what we do. Soft Tissue Therapy is unique; no other modality uses the same range of techniques with such a high level of expertise so we are not competing with others medical professionals working the same way. We offer something different which has great therapeutic potential, which supports and complements the rest of musculoskeletal medicine and it deserves its place in modern healthcare.
We can and should be able to all work together for the greater good. All we want is ACCEPTANCE.