Michael Harty (Clare, Independent)
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In this second session we are meeting representatives of the Chiropractic Association of Ireland, CAI, to discuss the impact on the chiropractors of the transposition of Council Directive 2013/59/EURATOM laying down basic standards for protection against the dangers arising from the exposure of ionised radiation. On behalf of the committee, I welcome Mr. Tony Accardi, Ms Lyndsey O'Leary, Mr. James Cosgrave and Mr. Richard Brown of the Chiropractic Association of Ireland.

I draw attention to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. If they are directed by the committee to cease giving evidence on a particular matter and they continue to so do in respect of a particular matter, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

I also wish to advise that any opening statements made to the committee may be published on the committee's website after this meeting. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable. I invite Mr. Tony Accardi of the Chiropractic Association of Ireland to make his opening statement.

Mr. Tony Accardi:

As president of the Chiropractic Association of Ireland I thank the members of the Oireachtas Joint Committee on Health for agreeing to meet us today. While our requests are technically complex, the principle is simple. These regulations, as currently drafted, will place the delivery of evidence-based, patient-centred chiropractic care in Ireland at a serious disadvantage. They will remove the capacity of duly qualified chiropractors to conduct X-ray examinations of patients or to refer patients for X-ray. This regulatory change will have a profoundly negative impact on the safe and competent delivery of care that chiropractors provide to thousands of Irish patients each year. I hand over to my colleague, Mr. James Cosgrave, to explain briefly who we are and what we do.

Mr. James Cosgrave:

I am a chiropractor practising in Cork for the past 25 years. Chiropractors specialise in the assessment, treatment and management of musculoskeletal disorders, particularly those affecting the spine and related joints. The World Health Organization, WHO, recognises chiropractors as primary healthcare providers, safe to practice competently either independently or as part of healthcare teams at a community level. Chiropractic is statutorily regulated in more than 50 countries around the world. Ireland remains the only English-speaking country in the world that still has no statutory regulation of chiropractors.

The Chiropractic Association of Ireland is the professional association that represents chiropractors and maintains professional standards in the absence of this statutory regulation. The CAI has 110 members working in private clinics nationwide who deliver more than 600,000 treatments per year to patients with musculoskeletal conditions. This a significant treatment volume and it is delivered at no cost to the State. To deliver this level of care effectively, chiropractors require prompt, efficient and well-regulated access to appropriate diagnostic imaging when required. The European Commission has published training requirements for chiropractors to justify, deliver and refer for X-ray procedures. Without exception, our members are meeting these requirements. As part of their five-year, full-time education, chiropractors are trained in the safe and effective use of X-rays and have done so for many years.

In Ireland, chiropractors have been able to refer patients for X-ray for more than 25 years and a number of our members have also had X-ray apparatus in their clinics licensed by the Environmental Protection Authority, EPA, and previously by the Radiological Protection Institute of Ireland, RPII. One member, as far back as 1991, was licensed by the Nuclear Energy Board. We have sought regulation of X-ray by chiropractors for more than 20 years. Members of this committee might be surprised to learn that I made a presentation to an Oireachtas joint committee in 1999 on this very issue of X-ray use by chiropractors. The record shows that the Chairman of the committee at the time, the late Deputy Sean Doherty, advised that the parties should engage further to resolve the situation ahead of the, at that time, upcoming new regulations. There are a lot of similarities to the situation we are in 19 years later.

There was a period of significant activity around the 2002 regulations. The Department of Health did undertake to create a register of chiropractors who could take and refer for X-rays. The CAI fully participated in this process throughout 2003. Progress was going well but it stopped completely in 2004 for an unrelated reason. There was a consultants' dispute at the time.

The Department was in dispute with the Irish Hospital Consultants Association over a medical indemnity issue. As a result, the consultants pulled out of any health committees. One of those was the medical exposures directive advisory group, MEDAG. Therefore, the work of creating the register of chiropractors competent to take X-rays and refer for X-ray was never finished. There was no question at the time that the competencies could not be met. It was simply that the work was never finished. We have a very long paper trail, stretching from 2004 to 2006, from the then principal officer in the Department stating the reason for the delay in creating the register was, in fact, the consultants' dispute and nothing to do with chiropractors' competencies or willingness to engage on this.

The correspondence deserves scrutiny because it gives a very clear indication that the Department gave an undertaking, at the start of the process, of regulating chiropractors under these regulations. Since the time in question, it has been stated that since we are not part of the 2002 regulations, we should not be included in the 2018 regulations but, in fact, the Department has given an undertaking to include us under the 2002 regulations. Nonetheless, during this entire period, chiropractors have had continued access to private X-ray facilities around the country run by Irish Medical Council consultant radiologists. Further, some 11 chiropractors have continued to operate their own X-ray facilities, licensed by the RPII or the EPA, in full compliance with SI 125. These chiropractors participated in a HSE compliance audit in 2012. It is important to point out again that while the 2002 regulations do not specify chiropractors as practitioners, the HSE nonetheless conducted this audit of chiropractors on the basis that they were, in fact, acting in the role of practitioners and had been doing so for many years.

The audit findings were very good. They stated very clearly that it is encouraging to note that chiropractors have taken steps to implement quality assurance and safety mechanisms, and that virtually all practices have written protocols with regard to safety, justification and optimisation. The CAI has endeavoured to self-regulate any gaps left by the absence of the register that was promised in 2002. We still continue to seek full participation in the relevant statutory structures rather than engaging in self-regulation. The new regulations, to be signed by the Minister, Deputy Harris, in the coming weeks neglect to include chiropractors under their remit altogether, even though the European guidelines on the training of medical practitioners to carry out these roles make it very clear that chiropractors meet the standards required - in the EURATOM directive and the transposition regulations. We met Department officials in February and had an exchange of views but we are unaware of any progress made on this to date. As a result, chiropractors now face being unable to refer for X-ray or take an X-ray for the first time in over 25 years. The Department is fully aware that the equivalent new regulations in the United Kingdom do specify chiropractors are fully competent to take and refer for X-rays, so it is widely understood that the competencies required for chiropractors in Ireland to carry out the same roles are not the issue.

At this time, we are not seeking any additional rights over and above what was agreed by the Department in 2002. We are asking for our use of X-ray to be regulated, as we have always done. We fully endorse the Department's desire to have proper regulation in the area. We still stand ready to engage on any practical solutions the Department might suggest to resolve matters. We fully support the statutory imposition of minimum training standards and of required clinical governance and auditing.

I shall now hand over to my colleague Mr. Richard Brown, from the World Federation of Chiropractors. He will explain the international context.

Mr. Richard Brown:

I thank the Chairman and members of the committee for permitting me to address them briefly today on the international perspective as it relates to this issue. The World Federation of Chiropractic, WFC, is the global voice of the chiropractic profession. We represent the national associations of chiropractors in over 90 countries, spread across seven world regions. Our role is to advance the chiropractic profession and to promote high standards of education, conduct and practice.

Members will have heard that there are some 110 chiropractors in the CAI. Members may regard the profession as small but, in a global context, they will note there are upwards of 110,000 chiropractors in the world today. Most of these are clinicians caring for patients and their communities. Others are researchers, academics, health policy experts or public health advocates. Chiropractic, therefore, is an established, respected and valued global health care profession.

Since 1997, the WFC has been an NGO in official relations with the World Health Organization, WHO. As members already heard, the WHO recognises chiropractic as a primary contact healthcare profession. Back in 2005, the WHO published guidelines on basic training and safety in chiropractic. These guidelines clearly set out the requirements of chiropractic educational programs, which include training on radiation protection, radiography and radiology. They set out practical training in the taking of X-rays and interpretation of X-rays. It should, therefore, come as no surprise that the safe and effective use of ionising radiation in the form of X-rays is a core component of every single chiropractic training programme around the world.

Quite rightly, members will all wish to be satisfied as to the quality of education of chiropractors. As they have already heard, chiropractors undergo minimum of four years' full-time education at masters level. Thousands of hours of basic science and clinical sciences training form the curriculum, and competency is tested at every stage. Upon graduation, chiropractors engage in continuous professional development, quality improvement measures and auditing of their work.

Chiropractic is offered at over 40 educational institutions worldwide. Three of these programmes are in the United Kingdom, namely, at AECC University College, the University of South Wales and BPP University. A fourth, at London South Bank University, will open its doors later this year. These programmes are both nationally and internationally accredited, ensuring quality assurance at a number of levels.

Let us return to the issue of X-rays, a critical component of effective and accurate diagnosis. In the world today, over 85% of practising chiropractors exercise their competency in taking X-rays, interpreting X-ray films and referring for diagnostic imaging, including X-rays. Chiropractors in every one of the 50 states in the United States, every province in Canada, every territory in Australia, and in England, Scotland, Wales and Northern Ireland are entitled to take, read and order X-rays. They take the role of employer, practitioner, operator and referer.

In the United Kingdom specifically, a 2006 multi-stakeholder document, Clinical Imaging Requests from Non-Medically Qualified Professionals, contained the policy statement from the Society and College of Radiographers. It stated it is perfectly in order for radiographers to accept requests from non-medically qualified referers provided the referer is adequately trained and remains competent to refer, and provided that there are written local agreements and protocols. In the same document, the General Chiropractic Council, which is the regulator, stated chiropractors are autonomous primary healthcare practitioners competent to provide diagnostic triage. The majority are fully trained to take as well as interpret images and interpret reports from radiologists. It is stated that when requesting imaging protocols they will provide a clear diagnostic rationale based on a well-founded clinical impression.

Back pain is the single biggest cause of disability on the planet. Chiropractors manage musculoskeletal disorders, including back and neck pain, at all stages of the life course. Their judicious use of X-rays plays an important role in directing safe, effective care.

My colleagues around the world, not least those in the United Kingdom, United States, Canada and Australia, many of whom trained alongside CAI chiropractors, are shaking their heads in dismay over the prospect of Ireland seeking to prohibit chiropractors, as highly trained skilled health professionals, from exercising their scope of practice and competency. The WFC respectfully submits that to do so cannot be in the best interest of either patients or the public.

Mr. Tony Accardi:

I thank the committee once again for affording us the opportunity to present our case today. My colleagues, whom members have met, in addition to Ms Lyndsey O'Leary and Ms Olivia O'Leary Veal, who are X-ray licence holders, are willing to take questions at this time.

Michael Harty (Clare, Independent)
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I thank the delegates for the opening statements. We will now hear observations from members. The first to contribute are Senator Colm Burke and Deputy Louise O'Reilly.

Colm Burke (Fine Gael)
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I thank the delegates for their very comprehensive presentation on the work they are doing.

With regard to the services currently being provided, the delegates said some chiropractors use their own X-ray equipment and others make referrals.

Could I get clarification on medical indemnity insurance? Does each practising chiropractor have professional indemnity insurance? In particular, do those who are doing extras and giving reports have professional indemnity insurance? Will the witnesses outline the number of people in total who are practising chiropractors in this country? What is the number in real terms? Will the witnesses explain the number who have and use X-ray equipment? The issue arises that if people do not have X-ray equipment, to whom would they normally refer people? Would they refer people to hospitals or private providers of X-rays? I ask about professional indemnity insurance because I came across a person providing an X-ray service but when an issue arose, it turned out the person did not have that professional indemnity insurance. I am not talking about a chiropractor in this case, just in case anybody is worried about it. An error was made in the case I mention and it is a major issue. I have been very involved in legislation relating to this in the past four or five years to ensure all healthcare professionals have insurance. It should be clarified.

I presume the amendment of the proposed regulations would be quite minor in order to include chiropractors. It is not a case of drafting new regulations but rather including rather than excluding chiropractors. I thank the witnesses for the presentation.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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I thank the witnesses for their evidence. I have two questions, with one relating to a submission we have not yet heard. It relates to the training. We will hear from radiologists that "when compared with the trained and regulated health care professionals previously described, we have found no substantive evidence of appropriate training, referral criteria, audit or accountability". Will the witnesses outline for us their training levels and how they compare with training levels in the North or England, where this practice is allowed? Do they do something different 50 or 60 miles up the road that people are not doing here? It would be helpful to explain that for us so we can understand the process.

If the Department continues on the path it has indicated and chiropractors are not brought into the process, what practical effect will it have on work and the ability of witnesses to carry out their work? The comments on going back to 1999 are interesting. Is it correct to say that between 1999 and today, the practice has continued without any adverse occurrences? Is there a reason we should be concerned? It strikes me that in 1999 the association was willing to engage with regard to regulations and satisfying the criteria that might be put in place. I assume the state of play is still the same and the association is still happy to engage on this. In the discussions with the Department, has there been an indication of any minimum standards that should be fulfilled that the association is not currently fulfilling? Has the association been advised of anything not being done that the Department would like it to do?

Michael Harty (Clare, Independent)
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If the witnesses bank those questions, I will bring in Deputies Durkan and O'Connell in order to complete contributions from members.

Bernard Durkan (Kildare North, Fine Gael)
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I have stated my interest in this area from the outset. I am totally supportive of the need to retain X-ray facilities for chiropractors. I say this because there is an obvious need to keep the highest possible standards and to have qualifications of international repute. The degree of training must be observed and updated in line with international standards. Safety regulations must apply with X-rays at all times. I strongly urge that in all cases, high standards must apply and there must be a level playing pitch.

As the Chairman knows, I have on many times in the past criticised the existence of waiting lists for virtually everything in the country but particularly in the health service. One does not have to wait very long for an X-ray by a chiropractor, which is very beneficial for the patient. Nobody else seems to worry about such things but the patient is most concerned about that. A patient can go to a chiropractor and have an X-ray and result within ten minutes. That does not happen in most other places. It could and probably should happen but it does not. I, therefore, strongly support an effort to ensure the full degree of services already available through chiropractors continue to be made available, including X-rays. This can happen if the adequate qualifications apply to ensure patient and practitioner safety with regard to ionising radiation.

Kate O'Connell (Dublin Bay South, Fine Gael)
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I thank the witnesses for coming in today and I apologise for them being delayed for so long this morning. The quote mentioned by Deputy O'Reilly was something I pulled from the statement last night as well when I read it. It is "we have found no substantive evidence of appropriate training, referral criteria, audit or accountability in published literature from the Irish chiropractic community." Reading around this, it almost suggests that there is no evidence. Perhaps the evidence is there but it just was not collated or given in the appropriate fashion.

Why is Ireland so different from other jurisdictions? I can only assume it is because there is no undergraduate university course for chiropractic services, so perhaps the profession does not have what pharmacists or physiotherapists have in the form of an academic body in Ireland providing the degree course. Therefore, we depend on people coming in with training from other jurisdictions. I completely understand concerns that people may have with ionising radiation X-ray units in clinics but I wonder is there any evidence that those units are not being monitored and manned properly, or that there is any risk to the neighbourhoods surrounding practices with such facilities? Will the witnesses indicate how many patients the group is seeing on a weekly or annual basis? They might deem this as taking a weight from the health service by dealing with them in their centres. I visited a chiropractic clinic recently and was very impressed by the professionalism of the set-up. It was what I would consider very progressive and like a large GP surgery. It was not just a fly-by-night operation and the person had practised for years.

Following on from the point on indemnity insurance to which my colleague, Senator Burke, referred, and he was referring to the actual machines, when it comes to something being missed, as can happen in any profession, what is the recourse for the patient? If an X-ray is taken of a lower back and if the issue is not mechanical but is, for example, cancer and that is missed, is there any example of what happens next? How is it regulated? Is there any regulation? Does it just go into the ether?

I looked at the regulations for here and the proposed regulations for the UK and I am concerned that we seem to be an outlier. Why can Ireland not match up with what the UK is doing? Do the witnesses have any suggestions as to how they, as a group, could get their house in order? They appear to be well trained and providing a good service, but somehow they operate in a grey area and perhaps will become extinct. Do they have any suggestions as to how, if we as a committee could feed back to the Minister to give the witnesses two or three years to sort out their housekeeping, they could assist us in this regard?

Michael Harty (Clare, Independent)
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Before the witnesses start answering those questions, perhaps they might refer to the definitions of practitioner and referrer because they seem to be central to the issue with regard to being a practitioner who is entitled to refer for X-rays. As has been mentioned, in 2002 the Department undertook to include chiropractors in the regulation, but 16 years later this has not happened. Perhaps the witnesses will explain how that could have happened. Is there statutory regulation for chiropractors in the other countries that have been mentioned? Is Ireland different from other countries in that it does not have a process for statutory regulation? Are chiropractors acting as radiologists and radiographers in the process of taking X-rays, or are they referrer, radiographer and radiologist in the process at present, whereby some chiropractors have access to X-ray facilities?

We have had a lot of questions from five different members but perhaps the witnesses will take them as they wish.

Bernard Durkan (Kildare North, Fine Gael)
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I omitted dentists from people who carry out X-rays. They do it very well and I want to include them.

Mr. Tony Accardi:

Mr. Cosgrave will comment on the practitioner and referrer definitions.

Mr. James Cosgrave:

Must I answer the questions in sequence?

Michael Harty (Clare, Independent)
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No.

Mr. James Cosgrave:

I thank Deputy O'Connell for her questions. We have never asked to be self-regulating. We have asked to be within the regulatory remit of this new statutory instrument and the existing one, SI 478/2002. We have been left outside this. We have consistently asked to be included and to be regulated and held accountable. It is very straightforward. If we are included in the regulations our members will be held accountable. Either they are able to perform the tasks as required by statute or they are not, but it does provide a mechanism for the relevant authority, in this case HIQA, to remove anybody who is not able to operate their duties in a responsible fashion. We feel the lack of statutory regulation of chiropractors' use of X-ray is absolutely undesirable. We have been on the record for more than 20 years as seeking to be involved under the statutory remit of the appropriate regulations.

On the question regarding the use of X-ray apparatus by chiropractors, they are acting as referrer and practitioner, much in the same way as dentists and it is quite routine in dental practice. Chiropractors are trained to interpret the films from a diagnostic perspective, but in most cases radiology reports will also be provided from outside sources.

On the insurance front, it is a compulsory requirement for all members of the Chiropractic Association of Ireland to hold malpractice insurance and insurance that will cover any eventuality. Any of our members using X-ray apparatus is covered under the appropriate insurance. There has never been an issue arising with regard to insurance and X-ray use by any of our members. There are 130 chiropractors in the country, 110 of whom are members of our association, which is approximately 85%, and a total of 11 chiropractors in the State are licensed to have X-ray apparatus. This means 99 chiropractors do not have X-ray apparatus and they have been making referrals to private diagnostic clinics throughout the country. These include the Consultants Private Clinic in Cork and there is also a large private provider of X-ray and MRI services in the State. We have access to refer our patients to these facilities.

Regulation 14.4 caters for people who are not specified as referrers, and at this point in time I am not specified under SI 478 as a prescriber, as it allows for the radiologist in charge to act as the referrer and receive the referral in the event of a referral being made by somebody like me, who is not listed under the current regulations. This situation has worked incredibly well for the past 16 years. I have been referring patients to Irish Medical Council consultant radiologists in the State for 25 years. I have been receiving reports back from those radiologists, and it has been a fantastic service and access has been great. We also have the backup and security of a consultant radiologist's report. This has been working very well, hence the number of X-ray licences issued to chiropractors throughout the country has actually decreased from the 18 licences issued a few years ago to 11 now because there has been good private access and many of our members have utilised this.

Things will change after the introduction of the new regulations, if they remain unamended. I will no longer have the ability to refer to a member of the faculty of radiologists here to have an examination done on a patient. Instead, I will have to refer the patient back to his or her GP and, obviously, provide all of the clinical information as to why I feel the X-ray would be justified, and the GP may or may not make the referral. It means every patient will have to take an extra step. It will delay things and slow them down. Some patients will end up in the public system again and will congest things further. The new president of the National Association of General Practitioners recently said patients could soon wait up to six weeks for a GP appointment, which is curious. It seems very much in contrast to some of the Sláintecare recommendations, on which members of the committee worked tirelessly, to slow down access to diagnostic imaging and delay things. Chiropractors have been working with these arrangements for many years and it has worked very efficiently to the patients' benefit. We are not talking about a huge amount of X-rays per year. We have approximately 600,000 visits per year and we certainly refer a very small percentage of patients for X-ray. It is thought that at present chiropractors take 3,000 to 4,000 X-rays per year, which is hugely at variance with the 1.5 million to 2 million X-rays being taken by other providers in the State. We are not talking about a huge number of X-rays but, nonetheless, when an X-ray is required and used it is a very important diagnostic tool to which we must have access. This change will completely remove access to that diagnostic tool for chiropractors.

Michael Harty (Clare, Independent)
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Will Mr. Cosgrave distinguish between the various types of referrals required? X-ray is one and MRI and CAT scans are others. Is there a difference between them?

Mr. James Cosgrave:

Typically we do not refer for CAT scans. Part of regulation 14.4 states the radiologist receiving the referral must be satisfied the study is required and necessary.

No, the main referrals will be for simple lumbar spine or cervical spine or knee or hip X-ray. We tend to use a lot more MRI nowadays. Therefore, the amount of X-ray referral is actually decreasing, not increasing, and I think this trend will continue. I can see in the foreseeable future that MRI will be much more readily available and utilised much more often. MRI does not involve ionising radiation. Nonetheless, the fact that chiropractors will potentially not be listed as referees under the new regulations could interrupt access for MRI referrals because the assumption is that the private facilities may well be unhappy to take referrals for MRI if chiropractors are locked outside these new regulations completely, even though MRI does not involve ionising radiation.

Mr. Tony Accardi:

Deputy O'Reilly asked us to outline training levels, comparing Ireland to Northern Ireland and England. Perhaps Ms Olivia O'Leary Veal could take that question.

Ms Olivia O'Leary Veal:

I might defer to Mr. Brown on the international level to draw the comparison between the UK-based and the Republic-based systems.

Mr. Richard Brown:

I think one of the original questions was why is Ireland so different from other jurisdictions? It seems as though one of the barriers to regulation of the profession has centred around domestic chiropractic education and the need for a chiropractic educational institution in the country before regulation can be contemplated. I respectfully draw the attention of the committee to three other jurisdictions in Europe which are regulated but have no educational facility in the country. Most notably, Norway is a case in point. Norway has approximately 800 chiropractors. They have a wide scope of practice. They have wide practice rights, including the prescription of sick leave and referral to diagnostic imaging and to physiotherapy autonomously as a profession. They have used this facility very widely, and chiropracting is very well utilised.

Kate O'Connell (Dublin Bay South, Fine Gael)
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Can they take X-rays in Norway?

Mr. Richard Brown:

They have referral rights for X-rays. Most chiropractors in Norway have a very easy facility to be able to refer into local facilities.

Kate O'Connell (Dublin Bay South, Fine Gael)
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However, fundamentally, Mr. Brown has drawn the comparison between Norway and here. Are chiropractors in Norway allowed to have X-ray units in their practices?

Mr. Richard Brown:

No, they are not.

Kate O'Connell (Dublin Bay South, Fine Gael)
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It is not really a good comparison, then, with all due respect. Of the few countries, is there any other jurisdiction that has no school of chiropractors and in which chiropractors are allowed to take X-rays in their practices?

Mr. Richard Brown:

That is unregulated or regulated?

Kate O'Connell (Dublin Bay South, Fine Gael)
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Mr. Brown referred to either three or four a minute ago that had no undergraduate chiropractic degree or whatever. In any of those cases, are they allowed to take X-rays in their private clinics?

Mr. Richard Brown:

Autonomously, in Europe, the other two jurisdictions were Cyprus and Lichtenstein. Chiropractors there do not have the right to own X-ray equipment but they do have referral rights. Outside Europe, I refer to Australia, the US and Canada. Chiropractors there all have the right to own and operate X-ray facilities within their practices. When we consider the numbers of chiropractors globally, which I referred to, they represent approximately 85% of chiropractors in the world today within these jurisdictions.

Michael Harty (Clare, Independent)
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Is it the case that if one has the right of referral, one does not need X-ray facilities in one's practice?

Mr. James Cosgrave:

It seems to be the case that there is much less of a likelihood that one would need one, given that 100 of our members do not hold X-ray apparatus. Some 10% do.

Michael Harty (Clare, Independent)
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Is it that the 10% that do do so because they do not have referral rights?

Mr. James Cosgrave:

In some areas, yes. Some of those licenceholders are in rural areas.

Mr. Tony Accardi:

There was a question about undergraduate programmes in Ireland. We are actively pursuing that. There is an organisation called Promoting Chiropractic Education that has been developed in England. It produced the groundwork for the London Southbank programme that Mr. Cosgrave mentioned. It will help us develop a programme in Ireland, and we are actively pursuing that, as I said. As a matter of fact, a number of years ago, an entire curriculum was developed for our programme, so we hope to have something up and running possibly in three or four years.

Kate O'Connell (Dublin Bay South, Fine Gael)
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If I may, Chairman, someone referred to the fact that 18 X-ray licences were issued to chiropractors a few years ago. There are 130 chiropractors in the country, 110 of whom are affiliated to the CAI. There were 18 who had X-ray machines and now there are 11. Is that due to the cost of maintaining such units or to the fact that the private operators with diagnostic stand-alone setups might be more efficient, or is there any other reason? Within the profession - of the 110 or the 130 or 140 - do chiropractors refer within their own practices? Would it be normal for a chiropractor without an X-ray machine to refer to a chiropractor who has one - in other words, no referral to the radiographer or the radiologist? Do referrals happen within the practice?

Mr. James Cosgrave:

There is some inter-referral, absolutely, but such cases are very much in the minority. In most of the population centres where there is good access to private facilities, patients tend to be referred into those. As to the reason for the decrease in the number of licences, if I may backtrack again to 2002, we are talking about only three X-ray apparatus licensed to chiropractors at that time. It grew to 18 at one point. It has now decreased again to 11. X-ray apparatus is expensive. It is a facility that must be very well maintained, it is absolutely not cheap and, for many people starting practices, if there is a very good private provider run by radiologists in the locale that is willing to accept referrals when justified, that is a very good situation to have. There has been greater reliance on MRI in recent years as well, so many chiropractors now favour MRI. This trend will increase, although I do not see a time when X-ray will ever be obsolete as a diagnostic tool. It has been used by doctors and chiropractors for over 100 years and will continue to be so, although I think the numbers of chiropractors even seeking X-ray licences will come down. Under the new regulations, obviously, we might not even have that capacity.

Mr. Tony Accardi:

Deputy O'Connell asked about any evidence of X-ray units not being monitored properly and whether the community is at risk. Perhaps Ms O'Leary might respond.

Ms Lyndsey O'Leary:

X-ray licences are licensed from the Environmental Protection Agency, which basically regulates us. Every three years there is an inspection. We must have a radiation protection adviser, RPA. We have an Irish-registered radiation protection adviser who is also a hospital-based RPA. The licence is heavily regulated. There are many hoops to jump through. It costs money every year. One must have one's X-ray machine digitally inspected as well, so the regulations are fairly extensive.

Ms Olivia O'Leary Veal:

There are stringent procedures under Statutory Instrument 125/2000. There are many obligations on the licence holder to come to a standard that is accepted across all professions. The Environmental Protection Agency is the regulatory body and considered the competent authority in the area. There must be justification for the application for the licence initially and then one must satisfy the criteria yearly to satisfy an inspection report. Many of the chiropractic facilities within the State have been regularly inspected by the Environmental Protection Agency, and in this sense there is quite inherent regulation within the processes. One will not be passed for re-license throughout the following year if one does not submit one's reports under the radiation protection adviser that is there. There are therefore many checks within the processes in Ireland already. However, the status is not as we would like it to be. We do operate in rather a grey area, but at that we are doing our best to comply with the regulations and what is being demanded of us as a profession under the system under which we exist.

Mr. Tony Accardi:

Deputy O'Connell asked about having our house in order. I reiterate that the Chiropractic Association of Ireland is very much in tune with self-regulation. We try to follow the Health and Social Care Professionals Act 2005.

The Act requires professions to be regulated and among the main criteria are accountability and expertise. The association certainly has a significant proportion - 85% - of the practitioners in the chiropractic field. We have a written constitution and there is open democratic decision-making within the association. We have our codes of ethics and this is our robust fashion of disciplining any chiropractor who has breached those codes of conduct. We are also committed to continued professional development.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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I think Deputy O'Connell was asking how long would it take for the Chiropractic Association of Ireland to be able to satisfy the Health and Social Care Professionals Act or other criteria. Mr. Accardi is essentially saying that there would not be a time lag. He is saying that if we were to speak to the Minister and advise him to give chiropractors a certain amount of time to get themselves up to speed, a huge amount of time would not be required.

Mr. Tony Accardi:

No, we have everything in order.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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Very well.

Mr. James Cosgrave:

There was a question on the training requirements the Department has set out. In this case, the Department has not set out training requirements for us at all. The training requirements are set out in the EURATOM directive to be transposed. The European Commission published guidelines on what exactly chiropractors had to do and what level of training was required in 2014. Curiously, these guidelines were prepared by the European Society of Radiology, of which the Irish Faculty of Radiologists is a member society. The guidelines clearly state requirements for chiropractors referring for, justifying and delivering radiography procedures. At no point have we been looking for a free pass on anything where regulation is concerned. We are asking to be regulated as required. We want our members to be held accountable. If the Department is willing to present us requests to sign up to obligations, we are willing to meet those requests. To date, we have not been given any specific feedback from the Department on what might assist but we remain very willing to engage. We would be exceptionally happy to be held accountable and to employ whatever criteria are required under the new regulations. We absolutely sign up to the idea of audit, minimum standards for training and the most exceptionally high levels of patient safety. We are in full agreement with the thrust of the regulations. What we are not in agreement with is the fact that chiropractors have been left outside the remit. They are not being regulated. Their use of X-rays is being prohibited and we cannot really come to terms with that.

The interpretation of the same directive in the UK recognises me as competent to be a referrer and a prescriber but in Ireland, that will not be the case. This involves the same directive and the same training and involves the same European guidelines. However, there is a very different interpretation in Ireland, one which is based on defined professions as opposed to competencies.

We have submitted a proposal to the Minister for Health, Deputy Harris, which will allow him to regulate us within the regulations. It would provide a very simple measure which would allow this to be resolved promptly. In due course, perhaps regulation under CORU and the Health and Social Care Professionals Act 2005 will provide a more comprehensive resolution for this. We have not had any feedback to date on what information to bring to the table. We have offered information on our undergraduate training and continuous professional development but to date there has been radio silence. We are not getting any feedback from the Department on our request . It has not been a "No" and it has not been a "Yes".

Kate O'Connell (Dublin Bay South, Fine Gael)
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Do the witnesses have any figures on the number of X-rays per head of population seen by chiropractors in Ireland versus the number seen in other countries? If chiropractors have 10,000 patients, are they all getting three X-rays in a lifetime? How does that compare internationally? Is there any indication that there is an overuse of X-ray or any sort of imaging in the Irish context? I am conscious of a recent article in The Lancet, which is considered a very well respected journal. The article referred to over-prescription of X-rays and magnetic resonance imaging, MRI. I am summarising a large document here.It does not just refer to chiropractors but to all referrals. The article claimed there is no improvement in outcomes in the majority of cases and an increase in interventions and surgeries. This is part of a broader discussion around overdiagnosis. Do the witnesses have any evidence that chiropractors in Ireland are X-raying people more than in other jurisdictions?

Mr. James Cosgrave:

I do not have comparative data. I do not have any evidence either way on that. I can tell the Deputy-----

Kate O'Connell (Dublin Bay South, Fine Gael)
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No data at all - so we do not know if it is true or not. Do the witnesses have any data on it?

Mr. James Cosgrave:

I do not have any data on that.

Ms Lyndsey O'Leary:

We know how many exposures take place per year. The HSE did an audit on us in 2011. It found that 3,000 X-rays were taken by chiropractors in Ireland. If that is compared with some information I got this morning to the effect that 2 million X-rays are taken per year in Ireland, we find that 3,000 is 0.0015% of the total. It is not as though we are X-raying every patient who comes through the door. That was a HSE audit in 2011.

Mr. James Cosgrave:

I might add that the dosage per examination from chiropractors falls somewhere between dental and medical examinations. Obviously we are not referring for or carrying out computerised tomography, CAT, scans. We are referring for plain film radiography, so the dosage is thought to be in or around 0.1 mSv.

Mr. Tony Accardi:

X-rays are normally taken on the first visit of a new patient. The 130 chiropractors in the country may have up to 50,000 new patient visits a year between them. With only 3,000 being x-rayed, that is quite a small percentage.

Michael Harty (Clare, Independent)
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In the witnesses' estimation, what is the difference in attitude between Ireland and the UK in relation to X-ray facilities for chiropractors? What is the fundamental difference between the two jurisdictions?

Mr. Richard Brown:

One question is what are the fundamental differences between the situation here in Ireland and the situation 60 miles up the road in Northern Ireland. The fundamental difference is that in the United Kingdom, chiropractors are permitted to take and read X-rays. They are permitted to operate X-ray units in their clinics, as well as to refer patients to other facilities for diagnostic imaging. They are entitled to do both of those things and they do so. Following on from Deputy O'Connell's questions-----

Michael Harty (Clare, Independent)
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To go back to that question, what is the underlying reason for that?

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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That was actually the crux of my question. I know there is a difference in practice. Chiropractors are entitled to make the referrals in Newry but they may not be so entitled in Dundalk, although they may have the same qualifications and practice at the same level. Mr. Cosgrave made the point that if he went to the North he would be completely covered to practise, whereas he may not be in this State. That is what I was trying to get at. There may be no difference in the person but there is a difference in what the law will and will not allow them to do.

Mr. Richard Brown:

The Deputy is absolutely correct. That is the scenario. On the surface it seems rather perverse that one can jump in a car and get an X-ray at a chiropractor in the North without any problems, as one can here at present. Under the proposals, however, the situation would be dramatically different. I was particularly keen to outline the educational institutions in the UK because many of the members of the CAI are graduates of UK institutions.

They have undergone exactly the same level of training as chiropractors who remained in the UK to practise, with the rights that they have to practise in terms of ionising radiation and practice generally. The proposals would create quite a significant differential in the competency and scope of practice in exercising the competency between chiropractors practising in Ireland and chiropractors in the United Kingdom, who, essentially, have undergone exactly the same training from exactly the same institutions.

Michael Harty (Clare, Independent)
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Are chiropractors in the UK or Northern Ireland regulated differently from those in the Republic?

Mr. Richard Brown:

The regulation in the United Kingdom is under the Chiropractors Act 1994 which provided for establishment of the General Chiropractic Council. The General Chiropractic Council is the statutory regulator of the chiropractic profession.

Michael Harty (Clare, Independent)
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Is the fundamental difference that there is a statutory regulatory authority in the United Kingdom but there is not here?

Mr. Richard Brown:

That is a difference, but the enforcement of ionising radiation regulations in the UK, although it is quoted within the Chiropractors Act and the code of practice, falls to the Health and Safety Executive in the UK. In terms of compliance, the Health and Safety Executive is the enforcing agency. My colleagues can speak more on compliance enforcement here in Ireland.

Michael Harty (Clare, Independent)
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On that point, the submission from the faculty of radiologists states, "We regard the provision for enforcement by the independent regulator HIQA as the major difference in the new legislation, which the Faculty of Radiologists wholeheartedly welcomes." Is the fundamental difference that there is not enforcement here but there is elsewhere, and this regulation will bring in enforcement?

Ms Olivia O'Leary Veal:

At present, we are covered under two separate pieces of legislation that govern ionising radiation. SI 125 of 2000 would concern the holding and monitoring, and licensing, of the equipment. However, as a profession, we lack the protection of the statutory regulation here. That precludes us from being included in the regulations as they stand currently. In the UK, the two processes are separate. Originally, when the Chiropractors Act was brought into the UK, it was not mandated that statutory regulation was necessary for chiropractors to be able to X-ray. We believe this is a disadvantage to us as a profession as we stand because there is no statutory protection afforded to us. We are allied to the best practice of voluntary regulation which is based on the UK model of statutory regulation. The Chiropractic Association of Ireland would represent the chiropractors in the implementation of the necessary clinical governance and fitness to practise in the absence of there being a statutory model.

Bernard Durkan (Kildare North, Fine Gael)
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Most practitioners in any field have complaints from time to time. Would they be aware of any complaints about the operation of X-ray equipment, the carrying out of X-rays or the referral for X-rays?

In the context of giving us an idea of what preparation they could have made or have made, have they been aware that this directive has been coming down the tracks for some time?

Mr. James Cosgrave:

If I could speak first as a referrer rather than a X-ray taker, the ability to refer is fundamental. In the event of a significant issue arising on an X-ray, it is important that the pathways are in place to ensure the patient gets to see the correct person, consultant or GP without delay. Great effort is taken to ensure that there is no delay in onward referral when indicated and hence I have never experienced a complaint arising as a result of non-referral. In terms of onward referral, I would have a good relationship with the other consultants my patients might require to see in the area.

Nonetheless, with 600,000 patient visits a year, somebody will be unhappy about something. That could be the patient who has been kept waiting or did not get better or the patient felt he or she got worse. I am not aware of complaints that have arisen specifically out of a delayed referral in anything to do with X-ray. In the event of an X-ray that is deemed to be non-diagnostic, for instance, which is what I think the Deputy is asking, any time there is an issue raised to the association, the association deals with it promptly and urgently, contacts the member involved and discusses the situation to find out what has happened and what is the source of the complaint.

Michael Harty (Clare, Independent)
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On behalf of the committee, I thank the witnesses for coming in to give evidence this morning on behalf of the Chiropractic Association of Ireland.

The committee will suspend for a few moments to allow the next group of witnesses to come in.