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.