HC Deb 25 October 2000 vol 355 cc69-90WH

11 am

Ms Hazel Blears (Salford)

I am delighted to have obtained this debate and I feel particularly fortunate in securing parliamentary time to discuss what are extremely important matters. I am well aware that many hon. Members have tried for some time to secure such a debate. Clearly, hon. Members of all parties are concerned about the issues that will be raised today.

I should say at the outset that I totally support the registration process for complementary therapies. I doubt whether any hon. Member would object to that process, provided that it is fair, transparent, rigorous, and designed to ensure consistent standards, excellence and quality in all such therapies. We support registration for a number of reasons. For example, it provides consistency and quality for members of the public, who are entitled to know that the people to whom they seek recourse are qualified, safe, competent and excellent practitioners.

I am sure that we all support the registration process in principle and I am particularly pleased that it is taking place in a number of therapeutic areas. Registration, if it does not give a seal of approval, recognises the value of complementary therapies that the health service has undervalued for far too long, although it is true that recognition has increased in the past few years—not simply because of a failure of conventional medicine, but because complementary therapies can often work hand in hand with it to treat the whole person, treating symptoms that are not always susceptible to a conventional approach.

We support registration, whether it be for psychotherapists, physiotherapists, chiropractors or anyone involved in therapeutic practice. Proper regulation is vital to maintaining standards and public confidence and safety. I have no doubt that the overwhelming majority of practitioners support registration as well. They want the public to know that they can rely on the service offered by registered practitioners. Registration helps them to promote their practice and is in everyone's best interest.

That is registration in principle and, where it is rigorous, transparent and fair, all parties would of course sign up to it. However, Mr. Chairman, it is becoming increasingly clear—

Mr. Deputy Speaker (Mr. Frank Cook)

Order. It might be helpful if I remind all hon. Members that proceedings in Westminster Hall are overseen by a Deputy Speaker unless a name is displayed on the Table here in front of me, which may happen today from 12 noon onwards. In such a case, proceedings are overseen by a Chairman. Those are the requirements of the House and I am obliged to bring them to hon. Members' attention.

Ms Blears

My apologies, Mr. Deputy Speaker; I sought clarification, although clearly in the wrong direction. I shall bear your comments in mind and I hope that we will abide by the noon hour and change our procedure as the clock strikes 12.

Unfortunately, it has become increasingly clear to me and many other hon. Members that the registration process has not proceeded smoothly. Trust and confidence between many practitioners and those responsible for the registration process is on the verge of breaking down. The process was brought about by the Osteopaths Act 1993, which seems a long time ago. I should have hoped for the smoothing out of initial difficulties in the subsequent seven years, but that seems not to have happened. In 1993, around 4,300 osteopaths were practising with no regulation. There were nine voluntary registers and 11 colleges offered courses in osteopathy. All branches of the profession decided that it would be right to bring osteopaths together under one umbrella organisation with a proper education committee, proper standards and proper qualifications. The profession was approaching recognition and its members entered the process with enthusiasm, putting behind them their difficulties, professional cliques and factions. They found harmony and consensus in the bright new world of 1993 and osteopaths were united.

Unfortunately, since the legislation was enacted, just over 2,000 osteopaths have registered and many hundreds are boycotting the registration process because they have lost faith and confidence in it. Approximately 100 of those who have continued to apply have been refused registration, although many of them have practised for many years with a clear record and no complaints. Seven years after the passing of the Act and after the expiry of the two-year transitional period in May, they have still not achieved registration. My concern is that, since May, they have faced the possibility of criminal prosecution and a fine of up to £5,000 for continuing to advertise themselves as osteopaths if they are not registered, although they may have been in practice for 25 years and have great professional respect. It is sad that the profession should find itself in that position.

Information that I have received from practitioners has caused me deep concern about the process. The Department of Health should treat the matter seriously because the allegations that have been made to me, if they prove to be based on fact, go to the heart of the registration process and its integrity. It is worrying that long-term practitioners are boycotting the process or submitting applications and then withdrawing them because of their experience of it.

A couple of cases have been brought to my attention by my constituents. The first concerns Dr. Kalman, who is a holistic practitioner of many years' standing. He has been an osteopath since 1981 and has a background in European and Chinese therapies. He is a renowned practitioner not only in Salford but far beyond. He has a regular radio programme, writes a newspaper column and his advice is widely acknowledged. He makes no bones about being a holistic practitioner, although that may be the wrong choice of words. When people come to him with a pain in the back, headache, nausea, migraine and other problems, he looks not only at the symptoms but at the causes of the condition. He tries to explore their lifestyle, the pressures that they suffer and their posture and to discover whether the problem arises from a physical, emotional or mental health problem. He does not profess to be a doctor in all those areas, but he is a therapist and explores the underlying, deep structural causes of people's ill health, instead of treating them mechanically and manipulatively. He is committed to that approach. He has held a recognised qualification since 1981, has been in practice, has never had a complaint made against him and is, in the terms of the Act, a man of "good health" and "good character", which is a requirement for registration.

The registration process also requires a professional profile and portfolio, which includes an extensive self-evaluation of the applicant's practice. Situations are suggested, people's problems are described and the applicant must decide how to respond as a practitioner: what to recommend, what approach to take, what questions to ask and what information to seek. The applicant must show the General Osteopathic Council how patients would be treated and decisions would be made and what criteria would be considered when someone came with a problem.

The professional profile and portfolio contains a host of such questions. It is a complex process, which—practitioners have told me—takes several weeks to complete and must give an in-depth analysis of the approach that is to be taken. Dr. Kalman, full of enthusiasm for the registration process, filled in his PPP and was called for a clinical interview by the General Osteopathic Council. During that interview, there was no examination of his practice, competence or safety, which are the requirements of the Act. What took place was an esoteric, philosophical discussion about his holistic approach and whether it accorded with the standards and criteria—or, perhaps, views—of the members of the council.

The crux of the matter is this. Does the process judge whether someone is safe, competent and lawful in carrying out the practice of an osteopath, or does it impose a subjective set of views—those of a particular section of the profession—of what it is to be an osteopath? Practitioners who adopt a holistic approach to their patients are finding that they do not meet the narrow paradigm that is set by the General Osteopathic Council for qualification to become registered. That is a serious matter. Registration processes are designed to ensure quality and excellence, but should not be a straitjacket that leads to conformity and reduces the diversity of excellent practice that can be performed. In any profession there are different ways of doing things—one approach is not necessarily better than the others, provided that they are all safe, lawful and competently applied.

A huge debate is taking place in the medical profession in general about the holistic model and the purely medical model. The jury is still out, and I am sure that it will be out for a long time—difficult matters of balance are involved. However, it is wrong to interview someone with a tremendously respected practice in such a way that he loses faith in the process because he feels that he is being questioned on his philosophical approach, not his competence. Dr. Kalman has now withdrawn his application and wants nothing more to do with the process. That is a great loss to the profession.

Even more worrying is the fact that therapists such as Dr. Kalman are talking about setting up an alternative register. That would take us back to the situation of 10, 20 or 30 years ago, when there were first-class osteopaths, second-class osteopaths and a variety of different organisations. An umbrella organisation should bring people together, leading to consensus, harmony and unity within the profession, and thereby to public trust. If we end up with different registers because of an internal dispute, the public will be the losers.

Another important issue is the way in which the process has been carried out. Dr. Kalman has brought several worrying cases to my attention. For example, seven osteopathic practitioners in Lancashire got together—almost like students cheating at an exam—to look at a PPP application. Having considered the questions on their clinical practices, they completed and submitted identical papers giving the same answers. Of that group of seven, one received full registration, two received conditional registration and four were failed completely. That gives rise to great concern about the consistency and fairness of the way in which the process is implemented. The Department of Health should investigate on that basis alone.

I was also told about a group of about 35 practitioners who followed the answers to a PPP application that had been worked out by a certain doctor and submitted all 35 applications together. Instead of being refused registration because they had colluded, they were all granted conditional registration for a year on the basis that, provided that they behaved themselves during that year, they would go on to receive full registration. When people who have been excluded from registration see that sort of operation, they understandably form the opinion that one is more likely to receive registration if one's views fit the picture than if one takes a different, perhaps controversial, approach. The purpose of registration is to be fair and transparent—if it is not, an investigation is merited.

Support for young people and students is another concern. Many young people have embarked on expensive, long-term courses in osteopathy. A young man in my constituency has undertaken a three-year course with the Faculty of Osteopaths, but has now discovered that that is no longer one of the recognised organisations. This is not someone who has done a few weekend courses. He has done a three-year course, and was about to embark on his MSc when he found out that his course would not be recognised. He was forced to abandon his practice, his livelihood has suffered, as has his personal health, and he is in dire personal circumstances. He submitted his application for registration and it was refused in September last year. The board promised that it would provide pathways of support and advice about further courses that he could take to ensure that he fulfilled the conditions. It promised to provide him with a mentor to guide him towards being able to practise fully.

I should like to tell hon. Members a little about this young man's experiences with the General Osteopathic Council. His application was rejected in September last year. He was told that until the deadline for registration—May this year—no college could be recommended to him because colleges had not been accredited. He therefore had nowhere to go to obtain his top-up course, to fulfil the conditions for registration. His own clinic was closed in December last year and he subsequently contacted the General Osteopathic Council to ask for support, guidance and mentors on 22 May, 14 June, 22 June, 27 June—twice—4 August, 11 September, 16 September and 21 September. He made telephone contact, left messages, and asked the director of education to get in touch with him. This young man is desperate to fulfil the conditions: he wants to be an osteopath. However, he is receiving no support, and no guidance as to how to deal with the situation. One can imagine the effect that that is having on him.

Such a lack of efficiency in implementation must lead practitioners to the view that they are being discriminated against in the registration process. This all serves to destroy confidence in the system, and to fragment the profession yet again. These extremely serious matters merit an investigation. I have written to Department of Health Ministers on two occasions. On the first, I received a letter saying that the process was new, that there would be teething problems and that matters would settle down. Having received further information, I wrote again in March this year asking for an investigation. Unfortunately, that request has not been taken up and the Minister's reply again suggests that it is inevitable that some people will be refused and that the process is in its early days. The Minister finishes her letter, if I may remind her, by saying that registration is important—with which I agree—and that a profession to be proud of does not take short cuts to high standards and osteopathy is no exception. I agree entirely. A profession to be proud of should provide a fair, rigorous, transparent registration process, in which practitioners and the public can have faith and confidence. At present, I do not believe that practitioners or the public can have faith in the procedures adopted by the General Osteopathic Council. I should like the Minister to agree to an independent inquiry into the criteria adopted by the council—to ascertain whether there is a dispute between the holistic and the medical models—and into their implementation, because a bureaucratic nightmare exists and people are not receiving the support that they need to become proud members of the profession.

11.18 am
Mr. Roger Gale (North Thanet)

I congratulate the hon. Member for Salford (Ms Blears) on securing a debate on a subject of considerable interest to many hon. Members' constituents. As you will appreciate, Mr. Deputy Speaker, it is a sad fact that, due to the parliamentary recess and the nature of the ballot for these debates, hon. Members were given very little notice that this debate had been allocated to the hon. Lady. Many hon. Members, who have written both to her and to me, would have liked to be here today but are unable to attend. The hon. Lady and I will endeavour to represent their interests as well as those of our own constituents—in my case, my constituent, Mr. Tony Matthews—as best we can.

I share with the Minister and the hon. Lady the thesis that the thrust of the Osteopaths Act 1993 was to provide a framework for registration and for what the hon. Lady described as consistency and quality within the profession. I do not know of any Member of Parliament who has written to me on behalf of a constituent who takes anything other than that view. Our difficulty is not the Act itself, but that its interpretation and implementation have not led to consistency and quality. In fact, they have led to the reverse.

On the balance of views held within the osteopathic professions, there is grave concern about the manner in which the General Osteopathic Council, as it chooses to call itself, has been constructed. Specific worry has been expressed about its chairmanship and whether that is lawful. Detailed concerns exist about the professional personal profile that the council has chosen to impose on many of its longstanding and professional members and the manner in which the approved colleges that teach osteopathy have been accredited.

First, I thank and pay tribute to Mr. Amadée Turner who was a distinguished Member of the European Parliament for 15 years prior to 1994. He telephoned me on behalf of Mr. John Wernham, who runs the John Wernham college and who has been practising classical osteopathy since the early 1900s. He is now 94 years old and his college has not been accredited. Mr Turner rightly pointed out to me that there is a difference of views between those who support modern osteopathy and those who prefer classical osteopathy, as the hon. Member for Salford said. The modernists control the General Osteopathic Council and they have chosen, almost arbitrarily, to reject traditional classical views. As a result, those schools teaching the classical method, such as the John Wernham school, have been left outside the net together with their students, and there are four such schools.

Mr. Turner believes that the schools have been wrongly excluded from training. There is no demand for such an exclusion within the Act. The manner in which the council has imposed its standards gives no clue as to proficiency. It simply determines that people can fill in a form or, as I shall demonstrate in a moment, that someone can get someone else to fill in the form for him. There is an in-built bias in the assessment of schools that teach osteopathy. Too much emphasis is placed on modern osteopathy, while not enough is placed on classical. The fault lies within the implementation and interpretation of the Act, not within the Act itself. It is the manner in which the General Osteopathic Council has chosen to implement the Act that caused the first problem.

The construction of the council is a cause for grave concern. I shall quote from a letter that I received from David Dyer, a registered osteopath, on behalf of the British and European Osteopaths Association. He was heavily involved, as were several others, in the original discussions that set up the council and said: as chairperson of one of the voluntary associations (BEOA), I participated in the discussions which preceded the formation of GOsC. The last consensus meetings, held at the Gay Hussar restaurant in London, were attended by the chairpersons of all the existing osteopathic associations— that is, the 11 to which the hon. Member for Salford referred— and therefore represented the entire profession. We unanimously agreed to amalgamate, as the Government had requested, to form one umbrella register. The registration process was to be all-inclusive, in that every osteopath on the database held by the Osteopathic Information Service (OIS) would be registered. In a private conversation, Simon Fielding further assured me that no bona fide osteopath would be excluded from the Register and only envisaged that two or three applicants would fail to achieve registration. When I asked what he meant by this statement, he replied that GOsC might receive applications from bogus practitioners who purported to have an osteopathic qualification. As for conditional registrants, we agreed that if there had been no claims against them after one year of practice they would automatically achieve full registration. We were all led to believe that this would happen. During these meetings there was no mention of the Professional Profile and Portfolio (PPP) or mentoring. Had either of these been proposed, I know for a fact that my association and also the Guild of Osteopaths, under the leadership of Ian Swash, would have withdrawn our support from the negotiations. Since the combined BEOA and Guild became the second largest osteopathic association, we represented approximately 40 per cent. of the profession. The membership of the new Council was shrouded in a veil of secrecy probably because the Council members were, with two exceptions, drawn from a single association (the General Council and Register of Osteopaths). I was only informed of the new Council the night before it was announced at the Department of Health. Ian Swash, the leader of the Guild of Osteopaths, has written to confirm that what David Dyer says is absolutely correct. He writes: I can confirm that Mr. Dyer's account of the consensus meetings held at the Gay Hussar is entirely accurate…in my case the first intimation I had as to the composition of the General Osteopathic Council was at a breakfast meeting (to which I had been invited at very short notice) on the day of the official announcement. Mr. Dyer was also present at that meeting. Prior to announcing his own appointment as the General Osteopathic Council's chairman, Mr. Fielding said in the presence of Mr. Dyer and others: "I'm afraid, Ian, this is going to come as a shock to you". Having just learned that 10 out of the 12 osteopath members of the GOsC had been appointed from the association of which Mr. Fielding himself was the Chairman, this came as no shock to me at all. You may be able to understand from those two letters, Mr. Deputy Speaker, why there is grave concern about the manner in which the members of the council, from which all else has flowed since, were appointed.

There is also concern about the appointment of the chairman. The Osteopaths Act 1993 states clearly that the chairman of the General Osteopathic Council should be a layman. I have before me a list of the members of the working party on osteopathy, which, under the chairmanship of Sir Thomas Bingham, led to the establishment of the Act. The fourth name on that list is Mr. S. Fielding and, under note 4 at the foot of that list, it states that Mr. Fielding is a practising osteopath and Vice-Registrar General Council and Register of Osteopaths. I fail to see how even the meanest intelligence can interpret that appointment as one of a layman. In that respect, the General Osteopathic Council is in clear breach of the Act that it seeks to implement.

I raised all those concerns with members of the General Osteopathic Council, meeting with them here in the House, and we have had a fairly copious correspondence since. A letter to one osteopath from Miss Madeleine Craggs, the chief executive and registrar of the council, states: We have gone to great pains to be fair by maintaining consistency. Let us examine that consistency for a moment. Mr. Anthony Baird, director of the Institute for Complementary Medicine, writes: The actions of the newly formed General Osteopathic Council have alienated osteopaths who support self-regulation and registration and, such are its powers, there is a fear that it will attempt to "take over" the whole of Complementary medicine… The ICM supports regulation but not in this way. My right hon. Friend the Member for Wealden (Sir G. Johnson Smith) passed me a letter this mornig from his constituent Mr. John Scott-Cameron of the Probro Clinic for Natural Therapeutics. Mr. Scott-Cameron writes: I feel that I have been excluded from the profession I love by the intransigent attitude of the GOsC in failing to exercise discretion for practitioners of long and safe service under a "Grandfather Clause". He also states: It is my deeply held conviction that all practising Osteopaths should have been admitted to the Register as in the formation of all other Professions and that steps to improve professional competence be initiated through the most excellent programme of CPD. Andrew Sims, an osteopath, of the Oakspring natural health centre, says that there are many disgruntled osteopaths fearing for their livelihoods as a result of the disgraceful way the register has been formulated. My right hon. Friend the Member for Epsom and Ewell (Sir A. Hamilton) has passed me a letter from Christopher Bell, another osteopath, who says: I graduated from the British School of Osteopathy in 1987 and have been practising as an osteopath until May this year and since as an independent practitioner. I could not bring myself to join the General Osteopathic Council… —for reasons outlined in a letter that he attached— ultimately there is little point in the continuance of the profession with such compromising of academic standards, dubious ethical standards shown by the officers of the GOsC and undemocratic leanings. He comments in some depth—because of lack of time, I will not quote it—about those administering the PPP and the way in which they have shown intolerance to osteopaths who were trained at establishments other than the British School of Osteopathy.

On 11 September, I wrote to Madeleine Craggs and asked her the questions that have been raised with me: whether the PPP was regarded as a questionnaire, as everybody thought, or an examination. I asked why, as I had been led to believe, special, exceptional provision had been made for GP osteopaths seeking to join the register. I asked what action the council has taken to discipline those who appear to have taken advantage of what I described as assistance with the completion of their applications. On 26 September, Miss Craggs replied: The PPP is described in the Rules as "the questionnaire"… There is no exceptional provision made for GP or doctor osteopaths… Those who are found to have achieved registration fraudulently will be removed from the Register. Let us take a look at the efficiency of the PPP. I will offer only one example. On 3 April, Mr. Derrick Edwards, the council's director of education, wrote to Mr. Andrew Mackay of Worthing: I am writing to you on behalf of the Registrar to invite you to submit some additional information concerning an aspect of your Modified Professional Profile and Portfolio. The information you have supplied so far has been very helpful. We feel however, that your claim for registration should be strengthened by the addition of further evidence. Brilliant—the recipient of that letter requesting further information had not even submitted an application for registration: so much for the council's record-keeping. A rejected applicant, Anne Neal, of Solihull in the west midlands, sought to appeal against rejection because she had treated the PPP as a questionnaire—which is precisely what Miss Craggs described it as in her letter to me—not an examination paper. In desperation, Anne Neal wrote on 3 April to Miss Craggs saying, I now understand that it is not really an Appeal at all but merely a legal exercise to ensure that you have followed correctly the procedures laid down by the General Osteopathic Council— We must bear in mind that those procedures are laid down by the council, not by the 1993 Act. Ms Neal also says: I have an Honours Degree in Chemistry from the University of London, and a Masters Degree in Clinical Biochemistry as well as my Diploma in Osteopathy. It is not that I do not understand contraindications to Manipulative therapy. I studied for five years at the College of Osteopaths and spent one thousand hours gaining clinical experience. I can offer no better summary of the argument than that sent me by the Association of Osteomyologists, commenting on the attitude taken by Mr. Fielding and Miss Craggs. It reads: We all know re: the original members of the founding committees, that the PPP was put forward as a questionnaire for the reference as to each Osteopaths way of working for the GOsC data base. If it had been known that this document was to be used as a basis of safety and competence, the founding committees would never have agreed. Having gone through the process, and filled out the PPP, resulting in my full registration, I can quite honestly state that, with all my reference books etc. and concentrated work, that the PPP as a written document could not possibly be taken as the measure of somebody's safety and competence. We should remember that there is no special provision for general practitioners or doctor osteopaths. The letter continues: In regards to the provisions made for G.P.s or Doctor/ Osteopaths, the GOsC is already allowing them to state on their own exclusive website that Doctor Osteopaths are superior to other Osteopaths, this of course, has no merit whatsoever as an Osteopath is an Osteopath, no matter what other training he/she has had. We ourselves were told by Doctor Members of the LCOM (London College of Osteopathic Medicine) having found one of their members PPP acceptable, the rest simply copied this document and submitted. It was quite a while before the GOsC realised the duplicity, and then stopped them in their tracks. They were also told that their members would be put on a year's provisional registration, which they accepted, but told GOsC that they were not prepared to go for reviews or mentoring. Apparently GOsC assured them that after the one year provisional, they would be allowed on the register as full members. Finally, Mr. Melvin Jessup, a registered osteopath, writes: If GOsC having nothing to fear and can prove that all aspects of the process were fairly and competently implemented in accordance with Act. Then they should welcome an early review instead…of a Court challenge made under Human Rights Act, at a latter date. I hope that, in the brief time that I have had available and with the tolerance of all hon. Members, I have set out the background to the concern felt by so many people. They feel that, as qualified people, they have been and are being excluded by a cabal set up to administer the implementation of an Act. In the light of the overwhelming evidence, I ask the Minister to instigate a full and public inquiry into the implementation and working of the Act.

Catherine Hamilton-Plant, the president of the British Osteopathic Association, wrote to me saying: The Association fully supports the standard of proficiency adopted by the GOsC and believes the GOsC has acted properly and in accordance with the legislation in administering the initial registration process. It will not surprise anyone to know that the BOA is, in effect if not literally, a wholly owned subsidiary of the General Osteopathic Council, so she would say that.

The positions of Simon Fielding, Madeleine Craggs and Catherine Hamilton-Plant are untenable. I urge the Minister to implement an inquiry that many hon. Members—not only those present, but many others on both sides of the House—feel must be held.

11.38 am
Ms Glenda Jackson (Hampstead and Highgate)

I echo the hon. Member for North Thanet (Mr. Gale) in congratulating my hon. Friend the Member for Salford (Ms Blears) on obtaining this Adjournment debate.

The constituents of mine at whose behest I participate in the debate warmly welcomed the Osteopaths Act 1993, which, through its provisions of unification and registration, purported to assure the public that those who put "Osteopath" on their shingle were qualified to treat patients safely. Both the constituents who made representations to me had practised osteopathy for a considerable time, to the great benefit of their patients and to the quality of the profession. However, like my hon. Friend the Member for Salford and the hon. Member for North Thanet, they are concerned about the allegation that the General Osteopathic Council is a cabal that has not abided by the spirit or the facts of the Osteopaths Act 1993.

As we have heard, fewer than 2,000 osteopaths out of a total of 4,500 registered in the transitional period, which ended on 9 May this year. My constituents have made it abundantly clear to me that there is wide agreement within the profession on the requirements for qualifying standards of treatment, probity and best practice in the field. My constituents allege that, far from the general council reflecting the entire profession, it is merely a reworking of the old General Council and Register of Osteopaths. I understand that the general council has 15 members; a constituent tells me that 13 of those members of the council are drawn from that one previously defining body for osteopathy, whereas representation drawn from the eight other previous bodies is limited to one member from just two of those bodies. As the hon. Member for North Thanet said, what we understood to be a requirement in the Act—that the chairman of the council should be a lay member—is far from being met.

A constituent was offered a place on the new register after having completed the professional profile portfolio, which, it is claimed, can identify practitioners who are not safe and competent without taking any account of training or years in practice. He wrote to me alleging that the process is open to collusion and cheating, which are extremely serious allegations. My constituent goes on to say that the conditions attached to the offer of a place on the new register have required him to employ a firm of solicitors with expertise in administrative law to require the general council to explain the reasoning behind its action.

That appears to conflict with the intention behind the 1993 Act. No hon. Member present, none of my constituents and no practising osteopath would deny that the essential foundation of all such legislation must be the protection of the public. However, my constituent is worried that that has become a mantra that the general council is using to deflect and delay questioning and answers.

Anxiety has also been expressed about the fees charged for registration. I have been told that the level of fees has an especially heavy impact on osteopaths who engage in their professional activities part time. It is a reflection, not of sexual bias on my part, but of the evidence presented to me by my constituents, to point out that part-time practitioners are mainly women.

According to the evidence that has been presented to me, and according to my constituents who have been practising osteopaths for a considerable period of time, having been trained at relevant colleges before they began practising, an Act that should have heightened the reputation and unified the professional practices of osteopaths is being used to safeguard the interests of a small proportion of that profession. The result might be that a split forms in the profession: as my hon. Friend the Member for Salford said, some practitioners are already arguing that an entirely separate register should be set up.

The overarching and most important facet of our discussion is that, unless they are properly answered and examined, these criticisms can lead the public to believe only that an honourable profession that can bring enormous improvement in people's lives is essentially not to be trusted. I have no doubt that the Minister and the Department of Health will take those considerations into account and examine the issue in detail, to ensure that not only the letter but the spirit of the 1993 Act is implemented throughout the profession.

If an inquiry is needed into the membership of and the creation of the present general council, it should take place at the earliest opportunity. Patients can suffer enormous and long-term damage if osteopathic treatment is not carried out properly, and that is not what my constituents want. The care and treatment of patients is central to their arguments, and I find it distressing that the General Osteopathic Council does not appear to share those concerns.

I urge the Minister and the Department to call in the council at the earliest opportunity. They should put to it the questions that have been raised this morning, which represent a mere fraction of the questions that have been put to me. They warrant answers. A measure that should have been of benefit to the general public, but appears to have become the antithesis of that, can thus be set back on the proper course—a course that the profession as a whole welcomed and the House endorsed in 1993.

11.46 am
Sandra Gidley (Romsey)

I have not been lobbied by any osteopaths and I approach the matter from a slightly different angle. Originally, I had a lot of information from the Association of Osteomyology and I had a number of concerns about some of its statements; I balanced that by approaching the General Osteopathic Council. It is fair to say that, 20 to 25 years ago, osteopathy was regarded as a form of alternative medicine—not by its practitioners or the many who benefited from it, but by the traditional medical profession. That is no longer the case. Osteopathy is now highly regarded and it is therefore right and proper that it should seek to regulate itself.

In many ways, osteopathy can be regarded as the first alternative therapy to have come of age. It faces some adult decisions, but it is probably safe to say that it suffers from the lack of a suitable role model. We have heard about the introduction of the Osteopaths Act 1993, since when the various provisions of which have been commenced in stages. The General Osteopathic Council was set up by approaching the many relevant groups, but someone somewhere made a decision on how to select its membership from those groups, and I should be interested to hear how that decision was reached. It has been put to me that the predominant group was probably dominant in the profession anyway, but an unfair balance appears to have been struck.

The statutory register was then opened and the registration process began, and since 9 May the title osteopath may be used only by those on the register. So far, so good—it is right that the public now have some protection and reassurance. They know that someone calling himself an osteopath will be a safe and competent practitioner, or at least that he is deemed to be so by the profession; that he will be covered by professional indemnity insurance; and that he is bound by a strict and enforceable code of practice. As with the traditional medical professions, a practitioner can be struck off the register for malpractice and then cannot legally continue to practice.

It all sounds very good, but, as is so often the case, the devil is in the detail. How does one regulate more than 4,000 osteopaths with nine different voluntary registers and with different colleges providing different qualifications? With the benefit of hindsight, we can see that whatever was done, someone was bound to be upset. The GOC had to try to devise a fair and equitable way of dealing with the diversity of practitioners, but whether that has been achieved is open to debate.

Practitioners had to be given a chance to show that they could fulfil the criteria of safe and competent practice, and I question why any confident and competent professional would refuse to undergo that process. The hon. Member for Salford (Ms Blears) used a good example. Dr. Kalman is an holistic practitioner—the description given is not that of an osteopathic practitioner per se. I should probably quite happily visit Dr. Kalman, but not necessarily if I specifically wanted an osteopath; I would visit Dr. Kalman if I wanted to visit a holistic practitioner.

In this day and age, it is not right that a certain number of years in practice should result in automatic qualification. Some people who previously called themselves osteopaths have less medical knowledge than others and take a different approach. Although that is not to say that their approach is not right, the fundamental question must be asked whether it is, strictly speaking, osteopathy.

The General Osteopathic Council came up with the idea of using the professional profile and portfolio— PPP, as it is affectionately, or perhaps not affectionately, known. Osteopaths had to provide details of experience, how they kept up to date, the number and type of patients treated, and details of good character. They also had to work through the case studies: those are 47 pages long and it is claimed that they take 40 hours to complete, but I did a straw poll of local osteopaths who all said that they took much longer. If an application was deemed insufficient, further written evidence was requested, or the osteopath was called for a further interview. Twenty per cent. of applicants were interviewed, a result that could be viewed in two ways: it could be thought either that the General Osteopathic Council was taking its job seriously or that it was conducting a witch hunt. I believe that it was trying to do its best in difficult circumstances.

How is the process scrutinised? Some of the examples that I have heard today of people sending in copied applications, each of which was treated differently, give rise to concern. The basic idea behind the process was good, but it has become soured by what appears to an outsider to be infighting. The fact that there used to be nine voluntary registers gives a clue to the diversity of practices that had to be included in a single entity. As usual, minority views lost, and it seems that a subset of "would-be" osteopaths—I use the term "would-be" in inverted commas, since clearly they regard themselves as being osteopaths already—feels that it is being marginalised because the ways of its members are not those of the majority.

In many ways the issue is one of branding. A brand name is used to give an identity so that consumers know what they are getting. In this case, the General Osteopathic Council had, in effect, to decide what the brand "osteopath" should mean and to regulate accordingly. Therein lies the problem. Four to 5 per cent. of applicants were denied registration. That might appear to be a high figure, but I suspect that if any other medical profession were to be regulated from scratch, a similar proportion of practitioners would not be up to date and would not conform to current accepted safe practice. Those denied registration are able to carry on practising, as long as they do not call themselves osteopaths. I understand that some are calling themselves osteomyologists. That is fine, because the public know that in those cases they are getting something different from the brand "osteopath".

One aspect of the regulation concerns me greatly: the way in which the accreditation of the schools of osteopathy and the courses has been organised. The schools of osteopathy knew about the changes dating from 1993, and by September 1997 all schools had become involved in the process of developing a standard of proficiency. However, late in the day, some of the schools have been refused accreditation. My sympathies lie with the students, some of whom have completed two or three years of study, only to find that their hoped-for qualification is useless.

It could be argued that the schools should bear some of the responsibility, because they did not warn students of the potential pitfalls, but why should they, when they thought that they were doing a good job? An 18 or 19-year-old student would not be aware of the General Osteopathic Council's internal politics and would not think to ask whether the course would exist in two or three years. My hon. Friend the Member for Carshalton and Wallington (Mr. Brake) says that some osteopathic students at Nescot college have approached him because accreditation of their course has been opposed and badly handled. I suspect that that issue affects more than just the osteopaths who are fighting the system at the moment.

I ask the Minister thoroughly to investigate the matter. I should like to know how the students will be compensated for having been the victims of false pretences. Some have paid many thousands of pounds for their courses and are severely in debt with no qualifications and nowhere to go. I have no doubt that other professional bodies will face the same process. The issues must be considered so that we can learn from any mistakes, whoever made them.

In summary, the General Osteopathic Council has tried to do a good job. I am reassured that the public can consult an osteopath in the knowledge that he or she will be a professional who has passed the scrutiny of the profession and is practising according to the standards laid down by that professional body. There is a clear distinction. I am not saying that those who have not been accepted for accreditation are not excellent practitioners in their own right.

Mr. Gale

Does the hon. Lady accept that many practitioners, including some who have been quoted this morning, are eminent and reputable and have stated clearly that they do not consider that the processes are a sensible measure of efficacy or safety?

Sandra Gidley

No process could cover that fully and there would have been problems whatever process had been implemented. Years of practice do not mean that someone is fit to continue—we often see instances in the medical profession of people who were accredited years ago and are subsequently struck off, so it is only right and proper that everyone is considered afresh. Any professional who wants to continue being a member of a professional body should willingly submit to the required process. None the less, I am willing to acknowledge the concerns about the way in which the matter has been handled, because I believe that the Minister will address the matter.

I end by quoting an immortal line from "Star Trek": Bones said to Jim, "Captain, we mustn't leave him at the mercy of 20th century medicine". With safeguards now in place, 21st century osteopathy is trying to go forward. Whether it has succeeded is for others to decide.

11.58 am
Mrs. Caroline Spelman (Meriden)

Perhaps you would put me right, Mr. Deputy Speaker, on how you should be addressed. Did I understand correctly that we should change to using your name at 12 noon?

Mr. Deputy Speaker

At 12 noon, I shall concede the Chair to Mrs. Ray Michie, who is hovering ready to displace me. She should then be addressed as Madam Chairman or Mrs. Michie.

Mrs. Spelman

Thank you for your clarification, Mr. Deputy Speaker. I sought it because this is a traditional place and one wishes to abide by the procedures.

I congratulate the hon. Member for Salford (Ms Blears) on securing the debate. I know that other hon. Members had tried hard to obtain a debate on osteopathy, so it has come not a moment too soon. In fact, it comes too late for many osteopaths, who are now unable to practise without incurring penalties, as the hon. Lady rightly said.

I also pay tribute to my hon. Friend the Member for North Thanet (Mr. Gale), who revealed a veritable clutch of examples from other hon. Members who had been approached by their constituents, illustrating how widespread the concern is and how much hon. Members have sought to have this debate.

The difficulty was revealed in the line taken by the hon. Member for Romsey (Sandra Gidley), because it depends a little on whom one talks to. The problem for us as Members of Parliament—who are, with the best will in the world, jacks of all trades—is to try to get to the bottom of the matter. However, one does not have to be a rocket scientist to work out that there is a problem if there are about 4,500 osteopaths and only 2,500 of them are registered. The General Osteopathic Council said in a briefing document that there is no smoke without fire, so I think that even it would acknowledge that there is a problem.

The difficulty for us is to ascertain the scale of the problem. The General Osteopathic Council told me that there were only a few disgruntled osteopaths. However, when one speaks to some of those few, one realises that their number may be up in the thousands. We do not know. I urge the Minister to try to establish—as part of the review that is essential to how the profession is regulated—how many people have been rejected from registration and to estimate how many have failed to register, however difficult that might be.

My hon. Friend the Member for North Thanet referred to the high degree of consensus and to consensus meetings taking place when the profession was examining implementation of the Act. Something must now be seriously wrong, however, as that consensus has obviously broken down. Otherwise, why would qualified practitioners fail to apply for registration? Something must be wrong and, when our constituents turn to us for help, it is our responsibility to try to get to the bottom of the process.

I endorse the argument that there is nothing wrong with the Osteopaths Act. Indeed, I pay tribute to the hon. Member for North-East Cambridgeshire (Mr. Moss), who was responsible for its introduction as a private Member's Bill. However, a careful reading of the Act and of the statutory instruments that followed it, leads even a lay person to see a divergence from where the spirit of the Act started to where the statutory instruments have taken it.

The Act shows an inclusive approach consistent with the consensual meetings that took place at the time of its introduction. However, the raft of statutory instruments that have followed it seem to get further and further away from that inclusive approach. Indeed, one of the latest statutory instruments—SI 251, which was introduced on 13 April this year—is severe in its final say over someone's ability to practise. On the transitional arrangements for registration—nothing to do with a person's conduct subsequent to registration—it is very harsh. It states: Where an applicant has exhausted his rights of appeal and accordingly no further appeal against an appeal decision or a decision refusing permission to appeal is possible, this will be the final decision disallowing appeal. No door is open, under the statutory instruments, if an applicant is unsuccessful in the registration procedure.

In the first instance, there is a right of appeal to the General Osteopathic Council, but we have heard enough today to place a question mark over how well that appeals process is working and how much confidence potential applicants have in it. If that appeal is unsuccessful, under the statutory instruments a failed applicant can go to the High Court. However, that is expensive. We have heard about the cost of training as an osteopath and about the situation of someone whose application has been refused, who cannot practise and therefore has no income. Such a person might think twice about a High Court action, but there is nowhere else for them to go. That is not in the inclusive spirit of the 1993 Act, which is why I support calls for a public inquiry into what has gone wrong.

As hon. Members pointed out, osteopathy is the first of a series of professions that are allied to medicine that is taking the path of self-regulation. Therefore, it is important that grandfathering should be seen to work, but the grandfathering process is not working very well in osteopathy. That is likely to become an issue as other professions take a similar approach, wishing to protect their titles and to allow a period of time during which practitioners can gain registration. In some other disciplines of alternative medicine or complementary therapies, there may be two schools of thought between classicists and modernists. This is a test case for getting the process right so that the public can see that it works properly and confidence can be restored to practitioners, who feel aggrieved at present. For that reason alone, this debate has important implications for the way in which the Government's work goes forward.

I urgently appeal to the Government for a review and inquiry. Since May, a large number of people have not been in a position to practise in the profession for which they trained and have therefore been unable to obtain an income stream based on their qualifications and experience. For their sakes, it is important for the Government to act promptly to review what is going on.

12.7 pm

The Minister for Public Health (Yvette Cooper)

I congratulate my hon. Friend the Member for Salford (Ms Blears) on her success in securing a debate on this subject. I listened with great care to the points that were made. It has been an interesting debate, which has highlighted one of the strengths of Westminster Hall— that hon. Members are able to discuss such matters in considerable detail and raise their concerns with the Government. I will reflect on and investigate the matters that were raised; in many cases I would not wish to give a hasty response.

Before I deal with those concerns, I shall set out some of the principles behind the operation of the Osteopaths Act 1993 and why the Government strongly support them. Although all hon. Members who contributed to the debate clearly endorsed the principle of statutory self-regulation, their views about the importance of the underlying issues appear to vary.

We strongly support the principle of statutory self-regulation—not only for osteopaths, but for other health professionals—and wish it to be extended, if possible, to other areas of complementary and alternative medicine, as the hon. Member for Romsey (Sandra Gidley) suggested. The key principle is that of protection for patients—in terms not only of safety and competence, but of patients' understanding of what they are getting, of the standards that the professional who is treating them has achieved and of what the regulatory framework should be.

The purpose of statutory self-regulation is to have nationwide, specially-set independent standards— where the profession itself sets the standards because it is best placed to establish what those standards are—and to ensure both that there is a proper mechanism for enforcing those standards and that people are up to the standards that the profession has set. The public will then know exactly what they are getting when they seek treatment.

We have said that we want to improve statutory self-regulation across the board. That is why, last November, the Government issued a consultation paper, "Supporting Doctors, Protecting Patients", which sets out our desire to help the small minority of doctors whose performance gave cause for concern. However, it also contains proposals to improve the regulation of all health professions and makes clear our belief that regulatory bodies should put patients firmly at the centre of their activities. That includes involving more lay members in their governance and focusing on patient interests above professional interests. It means establishing transparent disciplinary and complaints procedures and clear and effective accountability mechanisms and setting high standards to ensure the ongoing clinical competence of practitioners. It also means being demonstrably objective in administering those standards and responding to change.

The national health service plan reiterates the Government's determination to protect patients by strengthening and modernising professional self-regulation across the entire field. We have set out the need to make such improvements, including the establishment of the UK council of health regulators, which will provide better co-ordination and a framework for improving regulation across the board. Against that backdrop, I will reflect on the points that were made this morning.

Mrs. Spelman

I am interested in what the Minister is saying about the importance of lay membership. According to the consultation document, the envisaged membership split of the new health professions council is 12 practitioners to 11 lay members. How does that compare with the General Osteopathic Council, which will have similar status?

Yvette Cooper

It is exactly those areas that we will need to look at in greater detail. We have talked about the importance of increasing lay membership in respect of regulation and improving the focus on patients. As those fields develop and as discussions on improving regulation take place across the board—rather than for a particular health profession—we must consider such factors.

I doubt whether all those who object to what is happening would necessarily sign up to some of the important principles embodied in statutory self-regulation. We need to recognise that, as the hon. Member for Romsey said, it is not easy for a health profession to move from voluntary to statutory regulation. Inevitably, some will be unhappy with the entire concept of statutory self-regulation. They will see it as a form of interference and scrutiny by a statutory body that they have never experienced in their practising lives. There will be some whose practice does not match the standards that the profession has set and others whose practice may be excellent but does not match standards in osteopathy.

During the transition—before new procedures for establishing the council are in place and when the council members remain those appointed by the previous Government, rather than the profession itself—some will question the council's legitimacy. The important question arises of the matters with which statutory self-regulation should be concerned. The hon. Member for Salford asked whether it should be concerned with safety and competence or the philosophy of osteopathy. Clearly, it must deal with safety and competence, but existing measures contained in consumer protection, trades description and health and safety legislation provide protection for consumers and patients. However, it must also deal with standards in osteopathy.

Under statutory self-regulation, it must also be the case that it is for the profession to determine what those standards should be. This is about protecting the title of osteopath; it is not about preventing people from offering therapy. Clearly, it is far better if the profession can achieve complete consensus about what it means to practise osteopathy and to produce core standards in osteopathy to which everyone should sign up.

Ms Blears

I entirely accept that there will be standards as well as competence and safety. Competence and safety act as a safety net and above that there will be standards to be reached. The Minister also said that the profession should be seen to be demonstrably objective in implementing those standards. From what she has heard in the debate, would she agree that whether there is demonstrable objectivity in implementing those standards causes us great concern?

Yvette Cooper

I certainly want to look into the questions that my hon. Friend raised about people sending in identical forms and getting different responses. However, I disagree with some of the arguments, in particular that of the hon. Member for North Thanet (Mr. Gale). I do not accept that everyone who practises or uses a particular title should be able to continue to do so, even if they have been practising under that title for many years.

Mr. Gale

I did not make that point; it is being made very forcefully indeed by senior members of the osteopathic profession following the meetings at the Gay Hussar. It was upon that agreed basis that the General Osteopathic Council was established. Had it not been on that basis, they would not have agreed to it and they represent 40 per cent. of the profession.

Yvette Cooper

Whoever is making the point, be they members of the profession or Members of Parliament, we do not agree that it is an essential principle behind statutory self-regulation that everyone who has been practising under a title should continue to do so, even if they have been serving for a long time. We are moving towards increased revalidation of all health professionals. That means that health professionals should not simply be judged on the basis of qualifications achieved a long time ago or on the basis of how they define themselves. We judge all our health professionals on the basis of continuing competence to practise. Those are the principles behind the use of a PPP. Those are the principles behind judging people on the basis of competence to practise and not simply on the basis of qualifications achieved a long time ago.

I understand that there is opposition to that principle. I accept that but I back those principles strongly because the principle of revalidation is important. It will affect some people who have perhaps studied for many years or who have practised for many years or who may have been popular with patients or who have never received any complaints against them and have never had any questions raised about their safety. However, it would be inappropriate for Ministers to say whether those individuals met the core standards for osteopathy. That must be a matter for a proper regulatory framework and for the GOsC to consider. Individuals should not simply decide themselves whether they meet those standards; otherwise we might as well not have a statutory self-regulation framework at all. It is clearly appropriate for the Government to take a view on the overall approach to regulation. It is in that context that I want to reflect further on many of the points that have been made.

Considerable consultation took place before the 1993 Act was introduced. The approach was first to establish the new General Osteopathic Council. From next year, members of the GOsC will be elected. The previous Government made the appointments and the transitional arrangements. The hon. Member for Romsey asked about the process for appointing those members. Because it was done under the previous Government I will go back and look at the procedures that were in place. I am assured that they were in line with the Osteopaths Act and with the public appointments procedures of the day, but I will investigate that further.

The hon. Member for North-East Cambridgeshire (Mr. Moss) made it clear during the passage of the Osteopaths Bill that the initial members of the GOsC should be chosen, not to represent particular osteopathic organisations or schools, but on the basis of individual merit and their ability to act as ambassadors for the profession as well. The then Government's criteria for selecting the most suitable candidates did not include the need to represent particular osteopathic bodies.

The statutory rules that the GOsC has drafted at each stage to govern its functions were carefully scrutinised by Government solicitors to ensure that they had legal propriety and were compliant with the Osteopaths Act before the Privy Council approved them. As the House will be aware, all statutory instruments are also scrutinised by the Joint Committee on Statutory Instruments. It has not identified any significant problems with the rules that the GOsC has prepared.

The GOsC is obliged to publish core standards as part of the Osteopaths Act, which again must be the right thing to do. The core standards proposed were the standard of proficiency based on the statement of minimum standards given in the King's Fund report and also on the subsequent 1993 document "Competences Required for Osteopathic Practice", which had been commended by the British Medical Association. I am not clear from the debate whether hon. Members are concerned about the content of that standard of proficiency, the definition of the core standards and the process that the GOsC has gone through to define them, or about the implementation of those standards. Unless any hon. Member corrects me, I shall assume that the concern surrounds the implementation of those standards rather than their definition.

The purpose of setting those core standards is to have a framework to decide who can practise as an osteopath and how to set up a register for osteopathy. The statutory register for osteopaths was formally opened in May 1998, which marked the beginning of a two-year transitional period during which existing osteopaths could apply for registration. Although the Osteopaths Act gave the GOsC the power retrospectively to recognise osteopathic qualifications for the purpose of registration during that period, it chose not to do so. I am informed that that was because it thought it would be difficult, if not impossible, for qualifications that were granted many years before, by institutions that in many cases had ceased to exist, to be properly verified. I understand that it also felt that it would not allow consideration to be given to those who had not undertaken formal qualifications at an early stage, but had gone through apprenticeship or other routes and other forms of personal and professional development. It certainly seems valid to set up a process that allows different routes in.

The GOsC chose to use the professional profile and portfolio as the basis of applications and in some cases that was supplemented by an interview and test of clinical competence. The Government were not involved in that decision and the principle of the PPP is in keeping with the approach to increasing revalidation. I will take up the points that have been made about the interpretation of this and about many people submitting identical forms. I will write to my hon. Friend the Member for Salford and other hon. Members who have raised specific points about this issue.

Clearly, to prove to the public and to patients that people have gone through appropriate statutory regulation, a proper framework must be in place. We should not simply accept the judgment and the self-description that people have used in the past.

Within the statutory scheme, transitional arrangements to register existing practitioners have come to an end. The Osteopaths Act 1993 established a transitional period ending on the second anniversary of the opening of the statutory register. Since 9 May, no one has been able to make a new application for registration using the transitional provisions.

Hon. Members have asked about transparency and an appeals process. There is a right of appeal through the courts after the right of appeal to the General Osteopathic Council has been exercised. Proper procedure involving transparency and accountability is necessary, but a proper regulatory framework requires a final decision to be taken. It is important for the credibility of the profession that the General Osteopathic Council can demonstrate that it is responding and that its processes are transparent and accountable. I am glad that it has been willing to meet hon. Members who have raised concerns. I hope that that will continue. It is important that the council should respond directly to concerns raised by Members of Parliament.

Some hon. Members referred to the number of people who do or do not apply for registration. The latest figures that I have show that of the 4,247 practitioners on the GOsC's database who could have made a claim that they were osteopaths, 2,442 have now been registered and a further 749 are having their applications assessed. That means that 75 per cent. of those claiming to be osteopaths have either registered or applied for registration. In addition, I am informed that 142 are likely to have been denied registration by the end of the process and 591 have chosen not to register. I am informed that many of those are due to retire from practice or are practising overseas and are not required to register. I thought it important to put those numbers on the record.

Mr. Gale

The Minister has pointed out several times that the previous Government approved the body, but she is incorrect. It was approved by the Privy Council, which is non partisan. That is relevant, because she spoke of its being re-elected in a year's time. She is right, it will be. However, it will be re-elected only by registered osteopaths, which means that, according to her figures, 25 per cent. of members of the profession, who by implication will not be registered will not have the right to vote. The GOsC will then become, in its present form, self-perpetuating.

Yvette Cooper

The hon. Gentleman is right to say that the process ultimately goes through the Privy Council, but the appointments procedure took place under the previous Government. He is also right to say that the election will be by registered osteopaths. I take the comments that have been made about the appointments process seriously, which is why I responded to the hon. Member for Romsey by saying that I would look into it.

Hon. Members also mentioned education and qualifications and those people who, having gone through the education process, are not likely—in the short term at least—to receive a qualification because their organisation has not yet been recognised by the GOsC. Colleges have a contractual responsibility to their students and a responsibility not to mislead them. I understand that the GOsC has no statutory responsibility for students in colleges where the qualifications are not recognised, but I am also informed that it is working with those colleges to try to find a way forward with respect to the validating process.

I shall further consider the matters that were raised by my hon. Friend the Member for Salford about obtaining information and support from the GOsC about alternative places at which to gain qualifications, should those initially obtained be turned down. I take the points that have been raised very seriously. I will look into them further, but the fundamental principle that statutory regulation is right, and that it must be achieved by a rigorous process rather than self-definition, is important.