text:
Humpty Dumpty regulation
The phrase Humpty Dumpty chiropractic cropped up in a Google Alert a few days ago. It was the fitting title of an editorial (cached) in the December 2010 issue of Clinical Chiropractic, which discussed the slippery and nebulous meaning of vertebral subluxation complex (VSC).
For those who don't remember their childhood, in Lewis Carroll's Through the Looking Glass, Humpty Dumpty is discussing the meaning of words with Alice. HD remonstrates:
'When I use a word,' Humpty Dumpty said in rather a scornful tone, 'it means just what I choose it to mean — neither more nor less.'
Such equivocation is typical of on-line conversations with chiropractic supporters discussing the VSC, but it applies elsewhere as well.
First decisions
It has been a long and winding road, but we're finally getting to the end of my complaints after 18 months. Although the General Chiropractic Council (GCC) recently published some of their Professional Conduct Committee (PCC) decisions ('Notice of Finding') about complaints I had made about chiropractors misusing the title 'Dr' on their websites (I'll have more to say about them another time), they have just published the first decisions on actual claims.
The two PCC decision notices published last Tuesday are 11 pages long but make fascinating reading. I thoroughly recommend you wade through one to get the full flavour of them.
I'm going to take a look at one: the Notice of Finding for Michelle Carrington (cached). It's a pretty long, yet interesting, process, and one that needs to be documented. However, the next section cuts to the chase and is a summary of what I believe went wrong and what the GCC needs to correct before any further cases are considered by the PCC. Read that if you read nothing else.
Unacceptable Professional Misconduct?
The process the GCC follow is, in summary: the GCC receive a complaint; the Investigating Committee (IC) investigate it; if the IC considers there is a case to answer, they draw up the allegations; the GCC prosecute the allegations on my behalf before the PCC; the PCC, on the basis of what's presented in the allegations, consider the allegations and decide whether or not they are proved; if proved, the PCC decide the punishment. (Please note that it is sometimes easy to confuse GCC and PCC!)
It should be noted that the PCC are selected from a pool of 11 non-chiropractic members and 8 chiropractors. However, I do not know which ones heard my complaints. I also note that at the start of December, Sheila Hollingworth, who had been the Chair of the Investigating Committee became a member of this pool of PCC members. I do not know whether she was on the PCC that considered my complaints, but I note the Chiropractors Act 1994 says at Schedule 1:
24.—(1) A person may be a member of more than one statutory committee.
(2) No member of the Professional Conduct Committee or the Health Committee shall take part in dealing with an allegation referred to either committee by another committee if he is also a member of the committee which referred the allegation.
However, for my complaint against this chiropractor, the PCC found that (in summary), although claims were being made that were not supported by high or moderate positive evidence from randomised controlled trials (RCTs), the chiropractor was not misleading the public and therefore not guilty of unacceptable professional misconduct. She was let off with no sanction.
How did this happen? Read below.
As I see it, there are numerous things wrong with the way the case was presented to the PCC and the way the PCC came to their decision.
1. The PCC totally ignored the requirement of the Code of Practice (CoP) C1.6 that:
…information used must be factual and verifiable. The information must not be misleading or inaccurate in any way.
They appear to have decided that, because it's on paper somewhere, it must be factual and verifiable, but they have completely ignored the 'misleading and inaccurate' requirement. Carrington's observations on my complaint were similar to most of the others I received and it referred to a plethora of guidelines, leaflets, articles, opinion pieces, papers and books (I was not allowed to comment on any of it). In view of the fact there is very significant high quality contradictory evidence, I cannot see how this amounts to a balanced view of all available evidence and is thus a serious breach of the CoP.
2. The GCC did not justify their setting of the threshold for evidence as RCTs, allowing any evidence to be admitted as substantiation.
The GCC interpreted the 'relevant law' as being the Consumer Protection from Unfair Trading Practices Regulations 2008 (CPUTR) and opined that 'advertised claims for chiropractic care must be based on best research of the highest standard' and that this 'will almost certainly mean randomised controlled trials that produce high or moderate positive evidence'. However, they failed to anticipate that the PCC could consider that the use of other, far less robust evidence might not constitute 'a failure to attain the standard of the reasonable chiropractor'.
3. The GCC failed to get a definitive view from Trading Standards or their lawyers as to what standard of evidence was required by the CPUTR.
This is a serious failing. The GCC had had some discussions with Trading Standards (the guardians of the CPUTR) about evidence, but had not justified their 'interpretation' of the required standard of evidence. The PCC 'noted' the GCC's interpretation, but didn't bother to query further. The IC should have foreseen that all the complaints hinged on standards of evidence and should have put a robust case for the prosecution — one that fully protects the public from being misled, not one that could be knocked down with a feather.
4. The PCC failed to form a view of what standard of evidence was required by the CPUTR. Instead, they simply and erroneously decided that, since the GCC had assumed that claims that 'do not rely on RCT evidence are relying on inconclusive evidence', there was no threshold at all.
There is probably a whole other blog post that could be written about the CPUTR and what it has to say about misleading actions and misleading omissions. In allowing the Respondent to rely on all sorts of evidence to substantiate the claims, they have ignored the requirements of the CPUTR.
5. In setting the evidence bar so low, the PCC has failed to protect vulnerable members of the public.
Also, the CoP also says:
[advertising] must not, in any way, abuse the trust of members of the public nor exploit their lack of experience or knowledge about either health or chiropractic matters.
By allowing chiropractors to cite any evidence, they have ensured that members of the public will not be given a balanced view of the available evidence. This restricts choice and could lead the vulnerable to believe that chiropractic is effective for many conditions and may delay or prevent them from seeking proper medical advice from a registered medical practitioner. Caveat emptor should not apply to health claims.
6. The GCC submitted that it was reasonable for chiropractors to rely on information published by the GCC in their Patient Information Leaflets.
The GCC's Code of Practice (CoP) is not binding on the GCC, but it is binding on all chiropractors. The CoP is absolutely clear that it is the chiropractor's own responsibility to ensure all advertising is compliant with the clause C1.6. It might have been hugely embarrassing and costly for the GCC to admit the information they published in their leaflets was wrong, but that is not the concern of the case against a chiropractor making misleading claims.
7. The GCC only provided evidence for manual therapies and the GCC did not anticipate the question of what else a chiropractor might do.
This is something that should have been anticipated by the GCC because it was mentioned forcefully in many of the observations chiropractors made about my complaints. This has opened a huge loophole, allowing all sorts of misleading claims to slip through. The GCC must now grasp this nettle. If they don't, they are still left in the position of not having a clue about what their charges do and what the evidence for them is.
8. The PCC declared that 'general words' on websites were not claims and therefore could not be verified by RCT evidence.
If they are serious about protecting the public, they need to look at it from the point of view of the public. The GCC need to decide that, in line with the guidance issued by the Advertising Standards Authority (ASA), indirect claims are claims nonetheless. It is not credible that a member of the public, viewing a web page that lauds the experience and training in treating children would not believe that the chiropractor was claiming to treat children.
9. The PCC did not take into account the requirement of complying with all ASA guidance as required by the CoP.
The ASA guidance that chiropractors are required to follow has been consistently ignored by the GCC. It should be remembered that 'the guidance issued by the Advertising Standards Authority' consists of the CAP Code and other guidance, including adjudications. This will be the subject of a future blog post.
10. The PCC — somewhat oddly — did refer to the ASA, saying that ASA guidance required robust evidence, but that there was 'no explicit reference to high or moderate positive evidence from RCTs'.
Whilst the ASA's guidance may not repeat the phrase the GCC used in the allegation, it is very clear that the ASA have a requirement for a very high standard of evidence. This is formed in their Codes, other guidance and their adjudications and many ASA adjudications have reinforced this. However, it is curious that the PCC used the ASA as a measure of what standard of evidence was acceptable, but ignored the requirement for chiropractors to comply with the guidance the ASA have issued (see point 9).
With each of these issues — and taking them as a whole — it's an interesting exercise to consider whether Hanlon's razor can be applied to this contorted mess, but several of these issues amount to errors in law and grounds for appealing the decisions.
The GCC need to show some backbone and provide a decent prosecution case to the PCC for all future cases. It is not too late. The Notices of Allegation have already (conveniently, some might say) been issued to other chiropractors. However, the GCC still have the option to submit applications to amend the particulars to take into account these first decisions and ensure all future cases are prosecuted robustly.
If the GCC does not do this, all credibility as a competent regulator, with a statutory duty to protect the public, is utterly lost.
Abuse of process
Now, let's get back to the Decision Notice itself and see what went wrong.
There is obviously a need for some legal technicalities. However, after some preliminaries, there is a section titled Abuse of process submission. This concerns submissions by some chiropractors that the whole process should be stayed (ie halted) because of an 'abuse of process'. This concerns the (flawed) Bronfort Report that the GCC commissioned a year ago to look at what evidence existed for the list of conditions I complained about. The crux of the abuse of process submission is that the Registrar (Margaret Coats) had 'tainted the process' with her involvement in obtaining the report.
Until its publication, the GCC seemed to have had little idea about the evidence for any particular condition that their charges were making claims about. This is a disgraceful state of affairs for a statutory regulator, charged with regulating such a narrow field. How could they discharge their duty to protect the public if they had little or no idea of the evidence for chiropractic? How have they managed to regulate chiropractors for the last ten years? Perhaps they relied on what the chiropractic members of their Council and Committees told them? How would they class that level of evidence? If there was ever a case for having a truly independent regulator, this is it.
Having been forced to consider the evidence because of my complaints, they commissioned the Bronfort Report from five chiropractic experts.
However, in this case, the chiropractor concerned didn't make that abuse submission specifically, but submitted a document headed 'Further Submissions'. I was told about 'addendum submissions' by some chiropractors on 03 November 2010 and I assume these are the 'Further Submissions' now referred to. I thought it perfectly reasonable that I be informed what these further submissions were, but was eventually told:
Having taken advice, we will not be supplying you with any detail in respect of the addendum submissions received by the Professional Conduct Committee. Following referral of an allegation to the Professional Conduct Committee, the original complainant is no longer a party to the proceedings and therefore information provided to the Committee, such as submissions, is not disclosed to the complainant.
The PCC considered the submission to stay the process at a meeting on 17 November and had decided not to. It saw no reason to change that decision, but it wasn't clear to them whether this chiropractor wanted to renew an application to stay the proceedings. In fact, it made little difference:
Rather than adjourn the meeting in this case, the Committee decided to look first at the strength of the evidence in this case. In view of the outcome of this process, any application for a stay is now likely to be academic. Accordingly, the Committee has determined the case, as set out below.
This does not bode well.
The decision notice moves on to the substantive issue: what my complaint was all about. The chiropractor has a right to attend the hearing but she waived that right and it was held 'on papers', ie with just the PCC members meeting and without either parties being present (I get no choice in this and I am not asked). Note that, as the quote above says, they are no longer my complaints: the GCC takes them over at this stage and becomes the prosecutor on my behalf, with the chiropractor being the Respondent.
We are reminded that the standard of proof for any allegation to be found proved is the civil standard, which is the balance of probabilities.
The 'Particulars' of the allegations are the 'charges' that the IC think are appropriate. The PCC have to decide whether each of them is proved or not proved. In summary:
Particular 1: Establishing who the chiropractor is.
Particular 2: That he/she was responsible for the statements on the website I had complained about.
Particular 3: That the highlighted statements were not 'supported by high or moderate positive evidence from randomised controlled trials'.
Particular 4: That these statements were 'potentially misleading'.
Particular 5: That these had the potential to 'put pressure on members of the public…and had the potential to exploit the lack of experience or knowledge of members of the public'.
Once these have been decided, the PCC considers whether this amounts to 'unacceptable professional conduct' and what punishment, if any, should be meted out.
In this case, the Respondent admitted the first two particulars and they were therefore found proved. Before looking at the other particulars, we need to look at the statements I complained about and the Bronfort Report.
The PCC accepted the Bronfort Report as part of the GCC's submission, but declared that it was just 'an academic report and not an expert report'.
They said:
This Committee regarded the Report as a comprehensive statement of those conditions for which randomised controlled trial (RCT) evidence exists for the efficacy of manual therapy. The Report provides a summary of the scientific evidence regarding the effectiveness of 'manual treatment' in relation to a number of conditions.
At least they noted it was about 'manual treatment' and not just chiropractic — see Where the evidence leads.
Getting back to the point of my complaints:
The Committee considered each of the Particulars of the Allegation and in doing so it was mindful of the provisions of Cl .6 of the Code of Practice (effective from 8 December 2005).
The PCC created three categories for the statements made on her website:
(1) Statements which were incapable of being verified by RCT evidence, such as statements about the usual practice of the registrant or general words and headings.
(2) Statements which were capable of being verified by RCT evidence but which, in the opinion of the committee, fell within the categories where the GCC had decided to offer no evidence.
(3) Other statements which were capable of being verified by RCT evidence, typically claims that chiropractic could provide effective treatment for a particular condition.
These three categories are interesting. I'll pick through some of the choicest claims and see how they have been dealt with by the GCC.
Category 1 claims
The claims on this chiropractor's website at Haselmere Chiropractic Clinic (current website) that I highlighted in my complaint were:
Back & leg pain, sciatica, "Trapped nerves", Tension & migraine headaches, Neck, shoulder and arm pain, Hip, knee and foot pain, Tennis & golfers elbow, Jaw pain, Sports injuries, Birth trauma, Colic, vomiting & wind, Feeding problems, Persistent crying, Positional discomfort, Irritability, Crawling and gait problems, Ear infections, Constipation, Sleep disturbance, Asthma, Bedwetting, Dyspraxia, ADHD, Learning difficulties, Cerebral palsy, Cranial support for orthodontic work.
Compare this with the list in the decision notice and see how the PCC categorised the claims.
The claims made on the 'Welcome' page were:
Our team of highly trained and experienced chiropractors offers post-graduate expertise in rehabilitation, antenatal care, paediatrics and cranial work.
This 'Welcome' page will usually be the first page a visitor will see: the words 'rehabilitation, antenatal care, paediatrics' are in bold and link to the relevant pages. The PCC have decided that this belongs in Category (1) and they are therefore 'incapable of being verified by RCT evidence'. Are these claims to treat? If not, why are they there?
But the GCC's Investigating Committee have already stated to me and many of their chiropractors:
The Investigating Committee did note the reference to 'Paediatric care'. The Investigating Committee considered that this could give a member of the public reading the webpage the impression that you provide treatment to babies.
It was mindful that there is no high or moderate positive evidence from randomised controlled trials that would support a claim to treat children using manual therapy.
So which is it? Is chiropractic for children incapable of being verified by RCT evidence or is there no RCT evidence that supports chiropractic for children?
However, last time around, the IC concluded:
In the absence of such evidence, it concluded that it could be inappropriate to make such an advertised claim.
Regardless, whether there is no evidence for the treatment of children and babies with chiropractic or whether the GCC think that such things are incapable of being verified, it remains that they are still stating that such claims should not be being made by chiropractors.
Childhood ailments
Before Carrington's case was considered by the IC, she made some observations on my complaint, and admitted:
This complaint has caused me to reflect on the content of my website and modify it accordingly.
She also received advice from her 'professional association' and removed references to the following conditions:
Until such time that more robust research evidence becomes available…
- sciatica
- trapped nerves
- jaw pain
- colic, vomiting and wind
- persistent crying
- irritability
- feeding problems
- positional discomfort, crawling and gait problems
- ear infections
- asthma
- bed wetting (nocturnal enuresis)
- constipation
- sleep disturbance
- dyspraxia
- learning difficulties
- cerebral palsy
- cranial support for orthodontic work
- abdominal discomfort
- foetal positioning
- indigestion
- preparation for labour
- aching between the shoulder blades
- 'back and leg pain' replaced by 'low back and leg pain'
This is an excellent result and many other chiropractors have done the same, leaving fewer opportunities for the public to be misled by claims for which there is no good evidence. It's just a pity it needed my complaint to make this happen.
So, in the light of what her 'professional association' told her and what the IC concluded, what is she currently saying on her website (cached)?
Chiropractic treatment is suitable for children of all ages, including new born babies.
Michelle Carrington is our chiropractor who has a special interest in treating babies, and cranial work.
You are welcome to bring your child along to discuss any specific problems that they are experiencing, and whether chiropractic treatment might be able to help – Ring Reception on 01428 642778 and book a 20 minute "Free Screening" with Michelle.
At Haslemere Chiropractic Clinic we are pleased to offer you chiropractic care from an experienced practitioner with training in techniques specially developed for younger patients. These skills combine to provide a gentle and safe treatment for babies and children.
It looks like there is still more to be done.
Category 2 claims
These were claims for which the PCC said were capable of being verified by RCT, but fell within the categories where the GCC had decided to offer no evidence.
Curious. Why decide not to offer any evidence?
Remember the saga of the Patient Information Leaflets? Some chiropractors I complained about asserted that they were only repeating claims made by the GCC in their Patient Information Leaflet and the BCA in their Happy Families leaflet (cached) leaflet.
I've already mentioned the untenable position the GCC would get themselves into if they tried to pursue such complaints. But that legal quagmire is of no concern here. The issue at hand is very simple: whether claims were being made by chiropractors in violation of their Code of Practice. The CoP says that claims must be 'consistent with the law and the guidance issued by the Advertising Standards Authority' and that 'the information used must be factual and verifiable'. There is no additional 'but it's OK to repeat claims that the GCC or BCA make whether or not there is any good evidence for them'. That would allow all sorts of claims and is no way to protect the public from misleading information.
Category 3 claims
Having neatly disposed of a whole load of claims, there is one more sleight of hand to be performed.
The Committee went on to consider Particular 3 [that claims were not supported by robust RCT evidence] only in relation to the statements highlighted in Schedule I that fell into Category 3. The Committee noted that the [Bronfort] Report did not identify any high or moderate positive evidence from RCTs in respect of manual therapy to support a publicised claim in respect of these conditions. Therefore, the Committee has found Particular 3 proved in respect of the statements highlighted in Schedule I that fall into Category 3 (as set out in Appendix I).
This is about the claims they decided could be verified by RCT. These claims included golfer's elbow, jaw pain, abdominal discomfort, poor foetal positioning, sleep disturbance, birth trauma, feeding problems, positional discomfort, irritability and persistent crying and ear infections.
Most of these did not appear in the Bronfort Report, so they were unable to find any relevant RCT for them, as confirmed by the GCC to Skeptic Barista:
Where any condition does not appear in the [Bronfort] report, this is because no relevant randomised controlled trials were identified.
So, the PCC decided that my complaint against these claims was found proved because they were not supported by moderate or high positive evidence from RCTs (Particular 3).
However — and there has to be a 'However' — they added:
However, the Committee is mindful that this conclusion only relates to manual therapies. The Committee has not been provided with any comprehensive evidence about RCTs relating to other forms of treatment practised by chiropractors.
But then they stop and move on to whether making any of these claims, including the ones for which there was no RCT evidence, were misleading. But don't worry, the question of what constitutes evidence has not been forgotten and I'm sure many of you will see what's coming…
Were any of the three categories of claims misleading?
After sensibly disposing of the issue of whether someone actually had to have been misled by a claim for the claim to have been misleading, they dealt with the Category 1 and 2 claims.
The Committee found Particular 4 [that the statements were misleading] not proved in respect of the general statements in Category 1. The Committee was not satisfied, on the balance of probabilities, that such statements were inaccurate.
The Committee found Particular 4 not proved in respect of the conditions falling into Category 2 as no evidence was offered by the GCC.
So, the PCC's decision is that claims such as:
Our team of highly trained and experienced chiropractors offers post-graduate expertise in rehabilitation, antenatal care, paediatrics and cranial work.
Chiropractic treatment is suitable for children of all ages, including new born babies.
Michelle Carrington is our chiropractor who has a special interest in treating babies, and cranial work.
Back & leg pain, Sciatica, "Trapped nerves", Tension & migraine headaches, Neck, shoulder and arm pain, Hip, knee and foot pain, Tennis & golfers elbow, Jaw pain, Sports injuries, Many other joint and muscle disorders.
…were not misleading, despite the GCC and Bronfort saying that there was no good evidence to substantiate such claims.
What does it take for a chiropractor to have been considered to have mislead the public? Suggestions on a postcard, please.
But Category 3 is where it gets even more interesting.
The Committee concluded that the statements highlighted in Schedule 1 which fell into Category 3 were not misleading. These were statements to the effect that chiropractors provide treatment for the conditions in question. The Committee considered the submissions made by the Respondent in relation to these conditions. In each case the respondent provided evidence that there was support from a variety of sources for the chiropractic treatment of these conditions. These included undergraduate and postgraduate training and/or materials by the Anglo European College of Chiropractic ("AECC"); research, peer reviewed journals and publications from a variety of bodies including the GCC and the British Chiropractic Association ("BCA").
On this basis, the Committee has concluded that it was not misleading or potentially misleading for the Respondent to make the statements highlighted in Schedule 1, which fell into Category 3 and, therefore, this Particular is not found proved.
So, even though the PCC decided it was proven that there was no good evidence for the treatment of these conditions with chiropractic, they decided that making these claims was not misleading. And they decided this because the Respondent had provided evidence that there was support for chiropractic for these conditions. And this 'evidence' included AECC training materials, 'research', peer reviewed journals and leaflets from the GCC and the BCA.
Evidence? What evidence?
So what the decisions boil down to is what counts as evidence. Is it the robust scientific evidence that the ASA require for advertising claims; the 'randomised controlled trials that produce moderate or high positive evidence' of the GCC's IC; or is it the leaflets, case studies and teaching materials the PCC would have us believe is all that is required? The PCC have set out an unbelievably low threshold — in fact, it's difficult to see how they could have set a lower one.
The ASA have far higher standards; why should a statutory body, charged with protecting the public set such low standards?
Does this mean that chiropractors now have carte blanche to advertise whatsoever they want? It would seem so. But this cannot be good for the public: if such a low threshold continues, then the public is not being protected. Chiropractors can claim to treat anything. Presumably they could claim to treat ADHD? After all, there is evidence in a peer-reviewed journal to support it, so (presumably) the PCC would be quite happy with such a claim.
Chiropractors may rejoice at this decision, but I don't think they should be popping champagne corks — or backs — just yet.
Unacceptable Professional Conduct
The PCC then move on to deliberating whether the particulars they have found proven (that the claims highlighted were not supported by high or moderate positive evidence from RCTs) amounted to unacceptable professional conduct.
They did not.
The problem was that, although the GCC argued that there was no robust evidence (ie from high or moderate positive evidence from RCTs, as the GCC had stated in the particulars), there was still other evidence. And because there was other evidence, and because the CoP didn't specifically demand robust evidence, the charge of not having robust evidence could not amount to unacceptable professional misconduct.
That was a whirlwind tour of one decision but the GCC, as prosecutors of all the cases, now have a dilemma. They could just sit back and let the remaining cases go ahead on the same basis and, no doubt, the PCC would decide them all the same way and all the remaining 500-odd chiropractors would be found not proven.
Humpty Dumpty had a great fall
I would urge them to examine the failings of the cases so far and decide whose interests they are there to protect. And, to protect the public, the question the statutory regulator of chiropractors has to ask itself — and then comprehensively answer — is: what exactly are the meanings of the words chiropractic, evidence, regulation and protecting the public?
'You seem very clever at explaining words, Sir,' said Alice. 'Would you kindly tell me the meaning of the poem called "Jabberwocky"?'
'Let's hear it,' said Humpty Dumpty. 'I can explain all the poems that were ever invented — and a good many that haven't been invented just yet.'
This sounded very hopeful, so Alice repeated the first verse:
'Twas brillig, and the slithy toves
Did gyre and gimble in the wabe;
All mimsy were the borogoves,
And the mome raths outgrabe.
'That's enough to begin with,' Humpty Dumpty interrupted: 'there are plenty of hard words there. "Brillig" means four o'clock in the afternoon — the time when you begin broiling things for dinner.'
'That'll do very well,' said Alice: and "slithy"?'
'Well, "slithy" means "lithe and slimy." "Lithe" is the same as "active." You see it's like a portmanteau — there are two meanings packed up into one word.'
46 Responses to Humpty Dumpty regulation
Sour grapes anyone?
You think she'll have sour grapes because she's had to remove references to that huge list of ailments she was implying she could treat? Let's have a look it again:
trapped nerves
jaw pain
colic, vomiting and wind
persistent crying
feeding problems
positional discomfort, crawling and gait problems
ear infections
bed wetting (nocturnal enuresis)
sleep disturbance
learning difficulties
cerebral palsy
cranial support for orthodontic work
abdominal discomfort
foetal positioning
preparation for labour
aching between the shoulder blades
Hmmm….yes. You're probably right. Mortified too at the sight of your…ahem…'regulatory body' being exposed as a Mickey Mouse organisation, I should think.
That is scandalous. So, basically it all boils down to this…
With regard to chiropractors:
• The Code of Practice is absolutely clear that it is the chiropractor's own responsibility to ensure all advertising is compliant with the clause C1.6. – there being no additional "but it's OK to repeat claims that the GCC or BCA make whether or not there is any good evidence for them".
With regard to the GCC:
• Although it has been discharging its duty to protect the public by regulating chiropractors for nearly 10 years, until the Bronfort Report was published it seems it had little idea about the evidence for any particular condition that its charges were making claims about, and a huge loophole remains due to it only providing (flawed) evidence for manual therapies and not for what else a chiropractor might do.
• The threshold of evidence required by the ASA, TS and CPUTR appears to never have been ascertained by the GCC, and, as a result, the PCC has decided that there's no threshold.
With regard to the PCC:
• It appears to have totally ignored the requirement of the Code of Practice that information supplied by chiropractors must not be 'misleading or inaccurate', and has used the ASA as a measure of what standard of evidence was acceptable. However, it appears to have ignored the requirement for chiropractors to comply with the guidance the ASA have issued.
• In measuring the acceptable standard of evidence required by the ASA, the PCC claimed that ASA guidance requires *robust* evidence, but that there is no 'explicit' reference to high or moderate positive evidence from RCT' (despite it being very clear that the ASA have a requirement for a very high standard of evidence which is formed in their Codes, other guidance and their adjudications and many ASA adjudications have reinforced this).
• Regarding chiropractic for children, it is unknown which of the following two claims is the correct one: The PCC claims chiropractic for children is incapable of being verified by RCT evidence; but the IC says there is no RCT evidence that supports chiropractic for children.
• What the PCC had to determine was whether the claims (direct or indirect) being made by chiropractors were in violation of their Code of Practice which says that claims must be "consistent with the law and the guidance issued by the Advertising Standards Authority" and that "the information used must be factual and verifiable".
• Although the GCC provided evidence that there was no robust evidence (ie from high or moderate positive evidence from RCTs, as it had stated in the particulars), there was still *other evidence*. Because there was *other evidence*, and because the Code of Practicedidn't specifically demand robust evidence, the charge of not having robust evidence could not (in the PCC's eyes) amount to unacceptable professional misconduct.
If that's correct, then Zeno seems to be spot on with his observation that the exact meanings of the words 'chiropractic', 'evidence', 'regulation' and 'protecting the public' must be clearly defined by the GCC – as a matter of urgency.
BTW, fantastic work, Zeno!
I believe the ASA will cover websites from early next year? Will this offer an opportunity to submit a new raft of complaints to an authority that might take real action over the new, more-weasely-worded, claims?
Excellent post Alan. I find it extremely difficult to understand how they could possibly get around their requirements for chiropractors to follow ASA guidelines. Come March, when the ASA regulates claims made on web sites, a large number of ASA complaints which will no doubt produce adjudications can then be followed up with GCC complaints.
The GCC's actions are really quite extraordinary. It really did not seem possible that they could not find that the rules had been transgressed by the various claims cited in your complaints. As far as I could see, the wriggle room would be in how they dealt with those transgressions. Given what it takes to be struck off as a doctor or vet it seemed likely that the Respondents would be given formal advice on conduct or some sort of mild ticking off, but in terms of the wider campaign against unsubstantiated chiro claims we would have obtained a significant victory. Instead, it looks like the GCC has distorted its own rules and create a series of internal contradictions in the stance they have chosen to adopt in order to avoid saying that the Respondents were at fault and having the spotlight thrown straight back onto things like their own leaflets, which surely the Respondents would have cited in pleas of mitigation when arguing that the penalty imposed should be minimal, "It's not just me, Guv, I never realised. Even the GCC was at it."
Can the complainant, i.e. Zeno, appeal?
Great work. I am not a bit surprised at the lack of clarity on CPUTR standards of evidence. The regulations themselves, and the attached guidance, are reasonably clear, but Trading Standards officers can be staggeringly obtuse and ignorant. Some of them still cling to the old Trade Descriptions Act definitions even though they have been repealed.
I am not surprised either at the GCC's abuse of basic logic and due process, as the GMC can be pretty poor also. I have direct personal experience of a complaint for which the GMC's Fitness to Practice panel completely ignored its own written procedures and exonerated a respondent, despite extensive documentary evidence from another public body. The GMC never responded to our protestations about that. It's clear that the entire field of health care professional regulation is hopelessly inadequate at protecting the public.
Been following your blog for a while and this article is astonishing.
it does seem that the GCC are more concerned with the fate of the chiros than with protecting the public, which is the opposite of what they should be doing.
is the GCC actually fit for the purpose of prosecuting these claims or is it too entangled (partially responsible) due to its own incorrect information sheets? Is it this conflict of interest that had turned this into a farce? and if they are too conflicted who regulates the regulators behavior?
keep up the good work Zeno.
Nice work Zeno
this has exposed most if not all the weaknesses of the chiropractic profession in the UK. Thank you.
BSM wrote:
Can the complainant, i.e. Zeno, appeal?
Interestingly, the comments made to me by those that have followed this business are more along the lines of "Can't the chiropractors sue this bloke for causing trouble once it's clear that they're not guilty and have been exonerated?"
She also received advice from her 'professional association' and removed references to the following conditions until such time that more robust research evidence becomes available…
This is an excellent result and many other chiropractors have done the same, leaving fewer opportunities for the public to be mislead (sic)by claims for which there is no good evidence. It's just a pity it needed my complaint to make this happen.
I find your response to this quite interesting. I can see why you would be happy that this and other chiropractors have removed certain claims from their websites, after all, wasn't that the point of the exercise? But it seems that you are unhappy this chiropractor hasn't been punished.
That suggests a degree of malevolence that contradicts the notion of humanism.
I personally read no malevolence in the work above but accept that the course of action taken by Zeno may appear that way to you. I personally think that the exercise is primarily an intellectual one and does actually not do anything that most chiropractors were not already aware of but were too busy/distracted/lazy/apathic to do anything about. Some people would argue that the structure of power in the GCC is intimidating and does not allow for the little individual clinician to take action but eventually the false structure will collapse (as it always does-which I think is very much a humanist and babylonic notion). I think chiropractors can look at this situation and get bogged down with what people in the blog-o-sphere think they know and assume that this is the held view. I would urge every chiropractor to focus on what they are here to do as clinicians and that is to make individual patients better, regardless of what Blue Wode, the GCC, Brontfort et al or the BCA think, whilst not going into denial about the acute lacking in evidence. It is quite simple indeed: claims have to be backed by evidence, the evidence for certain number of things just isn't there, therefore certain claims cannot be made. This in itself does not mean that there wouldn't possibly be any evidence for these things were the studies conducted at all or conducted correctly, just that there isn't any right now. Bottom line is that if we get the patient better, the patient will be happy and will refer others to us. If they in turn get better they will do the same. All this means is that the development of a chiropractic clinic on the basis of certain advertised claims is dead and this only serves to reinforce what all good chiropractors I know have done: build practices on word of mouth. The growing of a chiropractic clinic on certain advertised claims should simply never have been born. Until evidence comes to light as to why and in which cases they are getting these results, it is in my opinion the only thing that can be done truthfully.
Some will argue that the lack of evidence is meaningful. It isn't, it is just symptomatic of where we're at as a profession. Some will argue that in the face of lack of evidence risk becomes a serious issue. It doesn't, it just puts the onus on the clinician to be open and honest about the state of evidence and allow the patient to make informed choices and take informed risks. All in all it just means that we have to work better and harder for our reputations and that cannot be a bad thing.
Stefaan Vossen
I agree with you.
You're quite right, chiropractors have got into the habit of namimg conditions they treat because people quite often don't realise the range of problems that chiropractic can help with. However, the basic principle remains that chiropractors simply improve and maintain function, irrespective of the symptoms that are expressed by the dysfunction.
It does seem though, that whatever problems might exist with making specific claims, there is a desire among "sceptics" for retribution rather than a simple clarification of the evidence for making certain claims.
The trouble is the evidence that chiropractic is effective is so far outweighed by the evidence it is not effective (both in quantity and quality) that "clarification of the evidence for making certain claims" would result in their being no good evidence for efficacy whatsoever!
If a practitioner of a different branch of medicine (or "medicine") was claiming to treat conditions with no proof of efficacy then we would want them to be punished to. It is effectively a form of fraud!
Funny how these things go full circle isn't it? For the chiropractors: you may recognise in this the old proverbs of the "dinosaurs of chiropractic" like "find it fix it and leave it alone" or another gem "look after the patient and the patient will look after you" and finally "adjust the subluxation and the rest will take car of itself".
Good old dinos! The problem really is that those people who don't understand what these things really meant didn't do very well in practice and ended up employing practice management consultants and non-sense technology creating a completely fallacious understanding of their practice. All this stuff rolled in together over two or three decades created the perfect circumstances for Zeno, Simon Perry and Andy to discover a scenery that was not only filled with error but also deluded. For me, personally, whatever their intentions, I am grateful to them, as the result of tehir efforts could be that chiropractic now stands a chance to actually get back to doing what it is supposed to do.
Kind regards,
what is the evidence that "it is not effective"?
Just a question as you state it so confidently…
And what is "it"?
If you'd actually bothered to read the article, you would have found links to Cochrane reviews for:
"Spinal manipulative therapy for low back pain",
"Combined chiropractic interventions for low-back pain",
"Manipulation or mobilisation for neck pain",
"Manual therapy for asthma",
"Spinal manipulation for primary and secondary dysmenorrhoea" and "Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome".
Concluding, respectively, that "The review shows that while combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute and subacute low-back pain, there is currently no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in people with low-back pain. Any demonstrated differences were small and were only seen in studies with a high risk of bias. Future research is very likely to change the results and our confidence in them. Well conducted randomised trials are required that compare combined chiropractic interventions to other established therapies for low-back pain."
And no evidence for any efficacy for the other treatments.
"It" is advertising treatments claiming them to be effective for certain conditions, with no evidence to suggest that they are effective.
ah you see the thing is that what those studies researched is not actually chiropractic practice, but that's ok, we now know that generically manipulating backs to alleviate conditions which may have nothing to do with spinal dysfunction don't elicit significant stats. But that just isn't chiropractic practice.
I fully agree that "it" is effectively a form of fraud, let's punish those fraudsters!
Good work Alan.
#Although the General Chiropractic Council (GCC) recently published some of their Professional Conduct Committee (PCC) decisions ('Notice of Finding') about complaints I had made about chiropractors misusing the title 'Dr' on their websites (I'll have more to say about them another time),#
I have complained three times to the ASA about "Dr" Joanne Middleton (Chiropractor) who not only calls herself "Dr" on her website but also in the phone book and the local newspaper.
All I've had back from them are acknowledgements of my complaints and she continues to be allowed to deceive people.
Oh and in case anybody checks the GMC website, there is a Joanne Middleton registered but I can assure you it's not our Joanne Middleton.
Dr Joanne Middleton (chiropractor) surely is clearly a chiropractic doctor is she not?
Stefaan Vossen wrote:
I would urge every chiropractor to focus on what they are here to do as clinicians and that is to make individual patients better, regardless of what Blue Wode, the GCC, Brontfort et al or the BCA think, whilst not going into denial about the acute lacking in evidence.
It's interesting that Stefaan acknowledges the "acute lacking in evidence". It makes one wonder precisely what chiropractors are being taught during their 4-5 years of training. A (real) doctor of neuroscience recently wrote to the Welsh Institute of Chiropractic (WIoC) at the University of Glamorgan to express his concerns about the claims and information available (or not, in some cases) on its official website. He requested clarification as to the website's accuracy/intent. You can read his letter here:
Apparently the WIoC's reply, which hasn't been published, was wholly evasive in that it sent a run down of the modules taught, but not what was actually in them.
Stefaan Vossen wrote:
Bottom line is that if we get the patient better, the patient will be happy and will refer others to us.
But the patient getting better may have had nothing to do with chiropractic. For example, the following factors could very easily be at play:
The condition may have run its natural course
Many conditions are cyclical
Spontaneous remission
Some allegedly cured symptoms were probably psychosomatic to begin with
Also, you seem to be forgetting that most people lack the basic knowledge and critical thinking skills to make an informed choice when deciding whether a highly touted healthcare product is a sensible buy or not.
Stefaan Vossen wrote:
If they [patients referred by other patients] in turn get better they will do the same. All this means is that the development of a chiropractic clinic on the basis of certain advertised claims is dead and this only serves to reinforce what all good chiropractors I know have done: build practices on word of mouth. … Some will argue that the lack of evidence is meaningful. It isn't, it is just symptomatic of where we're at as a profession.
And where chiropractic is at as a profession could very well be where it is going to stay – dependent on the ritual induced placebo of its manipulative techniques, as described not so long ago by a senior lecturer at the Anglo European College of Chiropractic:
Indeed, David Byfield, Susan King, and Peter McCarthy, chiropractic academic staff members at the University of Glamorgan, seem to support that view:
"…it has [also] been shown that patients are very pleased and satisfied with chiropractic care whether they get better or not….Furthermore, it has been said that chiropractic's greatest contribution to health care has been the development of a solid doctor-patient relationship. So, let's not kid ourselves. It may not be what we say…..but simply the way in which we say it that stimulates some measurable change in patient's general health care status. Some studies support this view."
Stefaan Vossen wrote:
Some will argue that in the face of lack of evidence risk becomes a serious issue. It doesn't, it just puts the onus on the clinician to be open and honest about the state of evidence and allow the patient to make informed choices and take informed risks.
Some might ask what's been preventing chiropractors from being open and honest all along. After all, its lack of evidence and its risks have been published in the medical literature for some time now.
you could be very right on all of the comments, but then this is what I, and many colleagues of mine have been telling you for a very long time now, and it's all wearing a bit thin. But it is very good to see that you are finally actually reading what is being written, Well done!
An excellent post, the humpty dumpty quote seems very appropriate!
Problems are always going to exist in chiropractic as long as the question of what constitutes good, robust evidence is left open to interpretation by individuals. Particularly so when those individuals have a vested interest (in this case a commercial one) in accepting any evidence that supports their cause and rejecting non supportive evidence (often of far higher quality).
This becomes even more difficult when there is a huge division between groups of chiropractors in the beliefs of what chiropractic actually is! Many chiropractors have differing (and in some cases opposing) views on a number of topics that are quite fundamental to chiropractic, so the evidence each one needs to justify their position will differ accordingly.
That is why there needs to be unambiguous guidance issed by regulatory bodies and that guidance needs to be effectively enforced. Not everybody will like it, but at least there would be something resembling regulation and everybody would know the boundries. The guidance can always be adjusted as new evidence (of an acceptable quality) comes to light.
The GCC's decisions show that an organisation coming under scrutiny, both from inside and outside the profession, cannot be trusted to act as a reliable prosecutor, judge and jury.
In the interests of the public ( and dare I say it the chiros ) complaints need properly investigating and people need to have confidence in the results.
At some level there are always going to be those who disagree with a decision or the arguments used to reach those decisions, but there should at least be an open, consistent and reliable process in place by which those decisions are made.
@David: (Wednesday 15 December 2010 at 09:15)
You say: "Interestingly, the comments made to me by those that have followed this business are more along the lines of "Can't the chiropractors sue this bloke for causing trouble once it's clear that they're not guilty and have been exonerated?"
So what you are saying is that no one should question chiropractors? The arrogance (and sheer stupidity) is truly shocking!
Stefaan Vossen wrote:
@BW you could be very right on all of the comments…
In which case it is of some concern that the GCC is currently approaching UK University Deans with a view to creating more chiropractic degrees:
Item C-120510-17(a)
Minutes of Education Committee 17 November 2009
Members noted the content of the minutes, and in particular that as a result of the chair's contact with the Council of Deans of Healthcare network ( http://www.councilofdeans.org.uk/ ), several institutions had expressed an interest in exploring the development of a chiropractic degree programme.
Item C-120510-17(b)
Minutes of Education Committee 13 April 2010
Members noted the contents of the minutes, and in particular that representatives of two institutions in north west England had visited the Welsh Institute of Chiropractic. The purpose of the visits was to inform the early stages of their exploration of the feasibility of developing chiropractic degree programmes.
Humpty Dumpty degree courses?
Study concludes that chiropractic can help ADHD. Check it out at: http://nutritiondietnews.com/research-concludes-that-chiropractic-care-may-benefit-adhd/85735/
And after reading it ask yourself about whether the education of chiropractors is anything like that of medical doctors.
Andrew Gilbey wrote:
@David: (Wednesday 15 December 2010 at 09:15)
You say: "Interestingly, the comments made to me by those that have followed this business are more along the lines of "Can't the chiropractors sue this bloke for causing trouble once it's clear that they're not guilty and have been exonerated?"
It's true. That is what people who understand and have benefited from chiropractic have been saying to me. That's not what I said, simply what others have said.
Andrew Gilbey wrote:
So what you are saying is that no one should question chiropractors?
No, that is not what I'm saying. Only an idiot would draw that conclusion from what I wrote.
Andrew Gilbey wrote:
The arrogance (and sheer stupidity) is truly shocking!
I couldn't agree more.
Well actually, you didn't say "people who understand and have benefited from chiropractic have been saying to me", you actually said "those that have followed this business". I think it was reasonable I took that to mean other chiropractors. And surely the bottom line is that most chiropractors have and many still are making or implying claims that are not supported by sound scientific evidence.
Care to comment about the conclusions of the ADHD 'study' I mentioned before your last post?
The issue of advertising and scientific evidence goes much further than chiropractic or even CAM. I suggest you google colic and physiotherapy, you may be surprised. It is also interesting that the level of evidence "high or moderate" set by the GCC is not explicitly that used by the ASA. If we take this further many claims used for physiotherapy would also be inappropriate. Additionally, many private hospitals are offering spinal facet joint injections for low back pain yet this treatment is not supported by robust evidence (see NICE low back pain guidance).
We need a sensible approach to this so that all professions take the same view and we have a level playing field rather than starting a vendetta against a particular profession. If people like Zeno really want to make a difference then they should try an engage with chiropractors and others so that changes are made that are truely in the public interest.
Zeno, can I ask if a Sheila Holingsworth was on the PCC panel for any of the cases processed so far?
And if so, are you aware that until a few weeks ago, she was chair of the Investigating Committee?
I wonder if it is legal for the Chair of the committee that investigated a complaint to be part of the PCC pool that hears the same complaint?
Maybe Jakc of Kent could advise?
I got this from the GCC:
I can confirm that as part of segregation of duties, Sheila Hollingsworth [sic], has not and will not be empanelled to consider any allegation referred to the Professional Conduct Committee by the Investigating Committee, during the period when she was a member of the Investigating Committee. This extends back to August 2009 when she was appointed as the Chair of the Investigating Committee.
that seems right and proper.
andy wrote:
"The issue of advertising and scientific evidence goes much further than chiropractic or even CAM. I suggest you google colic and physiotherapy, you may be surprised."
OK, let's have a look using google.co.uk:
>physiotherapy colic About 51,300 results (0.14 seconds)
Tried it again but this time subtracting a couple of other terms:
>physiotherapy colic -chiropractic -osteopathy About 21,900 results (0.21 seconds)
In the interests of balance, here are some more results:
>chiropractic colic About 251,000 results (0.06 seconds)
>chiropractic colic -physiotherapy -osteopathy About 228,000 results (0.19 seconds)
>osteopathy colic About 195,000 results (0.14 seconds)
>osteopathy colic -physiotherapy -chiropractic About 169,000 results (0.13 seconds)
>chiropractic colic -singh -bca -libel -court -guardian -article -bogus About 160,000 results (0.14 seconds)
>physiotherapy colic -singh -bca -libel -court -guardian -article -bogus About 19,900 results (0.16 seconds)
Nothing very surprising so far. I decided to have a closer look at the first ten practitioners' websites that the first (physiotherapy colic) search brought up. Out of these ten practitioners' websites, the number featuring physiotherapists who claimed to treat colic was five. Of these:
One sole practioner, a physio, claimed to have "sorted out" out a baby's "colic problems" using "connective tissue manipulation".
One sole practitioner had qualified (abroad) as both a physiotherapist and an osteopath. She claimed to treat infantile colic with cranial osteopathy.
One sole practitioner was a physio who claims to treat colic with cranial osteopathy and mentions she has "attended training" in the latter.
One sole practitioner was a physio who used a range of quack therapies (including craniosacral and reiki) and claims to treat all manner of ailments including colic.
One practice comprised just two physios, both of whom claimed to treat colic but don't say how.
The remaining five websites advertise practices that are staffed by a team of two or more practitioners, including a physio and an osteo. All of these claimed or implied that infantile colic could be treated with cranial osteopathy; at one of them the cranial osteopathy is "combined with visceral treatments".
Nothing is particularly surprising about any of the above so I have to wonder what Andy's point is. It will come as no surprise to anybody that some healthcare practitioners who are in private practice make misleading claims on their websites. They do it because they can and that is why an initiative like Nightingale is long overdue.
Andy also wrote:
"We need a sensible approach to this so that all professions take the same view and we have a level playing field rather than starting a vendetta against a particular profession. If people like Zeno really want to make a difference then they should try an engage with chiropractors and others so that changes are made that are truely in the public interest."
I'm sure Zeno is flattered at Andy's high estimation of him but I'm mystified as to why he thinks Zeno or any other member of the public should have any say in any changes made involving chiropractors, beyond having the right to complain when they make misleading claims in their self-promotion.
And, given that Zeno and other complainants are only members of the public, I'm mystified as to why the ambassadors for the chiro profession who comment here and elsewhere think an appropriate and professional response to having their misleading claims complained about is to launch repeated attacks on the character and integrity of Zeno and anyone else who has the temerity to criticise chiropractors for the misleading claims they make.
As for the need for a "sensible approach", given the evident disunity among chiropractors themselves, isn't the suggestion that they will ever manage to take the same view as each other, let alone any other profession, a bit ambitious?
How is the playing field not level? I presume private osteos and physios could stand in shopping malls haranguing hapless shoppers and have national weeks promoting themselves if they wanted to. The point is that chiropractors, more than any other healthcare profession, have drawn attention to the fact that they promote bogus therapies on their websites and elsewhere. (Homeopaths aren't far behind, IMO.) So what appears to be a "vendetta against a particular profession" to them is simply the consequence of their waving their misleading claims in our faces more than anyone else. I don't doubt that "many private hospitals are offering spinal facet joint injections for low back pain yet this treatment is not supported by robust evidence." But I have yet to see a single one accost people outside Sainsbury's to tell them about it.
Interestingly, homeopaths also think they are being singled out. Try googling "first they came for the homeopaths" and you'll realise chiros are not the only ones with a persecution complex. Why is it so difficult for both groups to realise it's all about how visible they are?
There are some physiotherapists that practice magic medicine in the form of cranio-sacral therapy, Reiki and reflexology. Very odd for me to witness this considering physiotherapy is supposed to be a science based profession, but you are right to pojnt out that their "advertising" is modest compared to chiropractors.
However, it might also be worth mentioning the thousands of physiotherapists who practice TCM acupuncture on the NHS. It would be bad enough if they all only believed in the endorphin theory (given that there is no evidence that enough endorphins can be produced by needling), but is is depressing to hear physios talking about Qi and 'weak spleens'!
Remember the tax payer is paying for all this.
Interesting. I didn't know physios practised acupuncture at all, let alone on the NHS though I was aware that the NHS funds acupuncture and a whole range of other unsupported therapies at the RLHIM and have in fact submitted a number of complaints to the ASA about the content of their leaflets advertising these.
Physiotherapy acupuncture is practised widely. The Acupuncture Association of Chartered Physiotherapists (www.aacp.org.uk) has over 6,000 members.
See here the explanation given about acupuncture of the AACP web site:
Good grief.
Steefan, you seem to miss a double standard here with regard to claiming to treat and fraud.
Proper doctors dish out painkillers for arthritis, that's not treating the cause either, there is no proof of efficacy either with regard to painkiller treatment being synonymous with cure of arthritis.
With regard to fraudulent advertising the flu jab has no efficacy evidence either, quite the opposite and we are all paying for a massive toxic placebo here, surely that's more important than privately funded chiropractors.
Skepticat, the vast majority of alternative practitioners don't need to advertise what they do, their reputation is what brings in the work. I don't know anyone who has been affected by this blogslaught, quite the opposite as the public are learning that centralised, organised state regulation is quackery. There is no evidence that governmental control has made much safer, particularly medical science, why should anyone trust a politician, researcher or WHO exec when they are all drinking from the same well.
You won't ever have an impact on good practitioners doing good work however much you don't like it. I am sure you have freaked out a few people but the vast majority watch this kind of Mary Whitehouse stuff with large amusement.
Skepticat we are also paying for the annual flu jab, the EBM for efficacy is non existent, this is far more worrying than a few physios playing pins and needles surely.
Bloody hell, it's as dead as a doornail,
Where have all the septics gone, long time passing.


text:
With a business license you can put a link on your website that lets visitors save your web pages as PDF with a single click. It literally takes only two minutes for you to implement and offers great flexibility and power! All you need to do is put the following link on your web pages.
Save this page as PDF
You can also let your visitors download other pages of your website easily by using the url parameter.
Download the FAQ page as PDF
You can easily control the layout of the PDF by setting defaults in our members area. You can also control the layout of the PDF by adding parameters to the URL from the following table as well as all parameters that are used in our API.
|The page on your website, which you want to convert. If you don't specify this, then we convert the page that the link is on.
Note that you must encode the URL to make sure it's used correctly. This site can help you do so.
|PDF page format such as A3, A4 etc. You can find a full list of allowed values here
|PDF page orientation, either portrait or landscape
|Width of the PDF, in case you don't specify a standard page size
|Height of the PDF, in case you don't specify a standard page size.
If you specify a width, but no height, then we convert your page to one long single page PDF!
|Top margin in unit
|Bottom margin in unit
|Left margin in unit
|Margin margin in unit
|Unit for page sizing and margins, can be mm, in or pt. Default is mm
|Header with markup, page number etc, see the header and footer documentation for more information
|Footer with markup, page number etc, see the header and footer documentation for more information
|Controls which content of the page you want to convert or exclude. See part of page conversion for more info.
|Set to print if you want to use the print friendly version of your web page
|Set the filename for the PDF
|Set the title for the PDF
|Display the PDF inline in the browser instead of as popup to save
If you acquired a business license and you want to use this functionality, then you need to be aware of the following things:
These links show how it works.
Turn this page into a single page PDF!
Show the PDF inline and without margins!
You can get an "in progress message" while the PDF is generated.
This button does this by using our API.

subset: commoncrawl


text:
Company Overview
Calling the adventurers ready to join a company that's pushing the limits of nanotechnology to keep the digital revolution rolling. At KLA, we're making technology advancements that are bigger—and tinier—than the world has ever seen.
Who are we? We research, develop, and manufacture the world's most advanced inspection and measurement equipment for the semiconductor and nanoelectronics industries. We enable the digital age by pushing the boundaries of technology, creating tools capable of finding defects smaller than a wavelength of visible light. We create smarter processes so that technology leaders can manufacture high-performance chips—the kind in that phone in your pocket, the tablet on your desk and nearly every electronic device you own—faster and better. We're passionate about creating solutions that drive progress and help people do what wouldn't be possible without us. The future is calling. Will you answer?
KLA has manufacturing sites across the globe, including Belgium, China, Germany, Israel, Singapore and Milpitas (CA). The Global Operations (GOPS) team, comprised of Manufacturing, Supply Chain Management, Manufacturing Engineering, Installation, and Quality, is responsible for manufacturing our leading-edge technology. We partner with our world-wide supply base and our design engineering teams to bring new products to market. The GOPS team is continuously working to build our products Better, Faster, Cheaper.


text:
Arnott and Vederoff Ancestors
Created by: Marshall Parker, Record added: Jan 27, 2009, Find A Grave Memorial# 33305281.
William Cato Curry
Cyndi's List
Monroe County, Ohio
The Master Genealogist
Crested Butte Colorado Stories
I would enjoy hearing from "cousins" who find a connection to this family. That is some of what makes this a fun hobby. Contact me by email at the link below.
Lynell Arnott
, 1110 N. Henness Rd Lot 1607, Casa Grande, Arizona 85122
Page created by
John Cardinal's
Second Site
v8.00. | Graphics by
Carla's Graphic Designs


text:
Get ready to buff away all that dry skin and have the smoothest, softest, most GLOWING skin of your life.
Made with skin-loving oils to keep your skin moisturised and hydrated, with the added power of Sugar to help get rid of that dead skin buildup nobody wants.
Simple to use, and will leave you smelling delish.
So, what am I made of?
- Sucrose [A fancy way of saying 'Sugar'. The sugar granules help to buff away any buildup of dry skin. You are left with smooth, glowing skin]
- Cocos Nucifera [A fancy way of saying 'Coconut Oil'. Aside from being the perfect moisturising agent for your skin, Coconut Oil contains anti-inflammatory properties and aids in treating any acne.]
- Jojoba Oil [Contains anti-inflammatory properties and it also helps reduce any redness in the skin]
- Essential fragrance oil [Because of course you need the whole bathroom to smell amazing while you're in there]
- Vitamin E [Keeps your skin hydrated whilst fighting visible signs of ageing and reduce the appearance of any scars.]
But, I have sensitive skin!
Don't worry, Honey. I gotchu.
All of our recipes are formulated with exactly you in mind!
Everything you can find on our store is safe for sensitive skin, with plenty of testimonials to tell you just that.
If you find the scrub to be too abrasive [the skin on your legs is a whole lot tougher than the skin around your neck] add a small amount of water to your hands before applying to the skin to help soften the scrub on delicate areas.
So...not to be awkward, but how do you use a Body Scrub?
Different people have different times they like to use their scrub.
I personally do mine while conditioning my hair. By this point I've been in the shower for a few minutes and my skin is wet and softened.
Using small handfuls, buff the scrub in circular motions over desired areas. If you can leave it sit for a few minutes you'll come out feeling even smoother.
If you are after even more of an exfoliation, you can use it while your skin is dry. While standing in the shower you can buff the scrub everywhere and then shower like normal. The scrub will be coarser if your skin and hands are dry.
Can the Body Scrubs be used everywhere?
They most certainly can!
Different areas of the body will require different levels of exfoliation. For example, the skin on your legs is dryer and tougher than the skin on your neck.
I like to start with my legs as they need the most help, so by the time I've done the rest of my body the scrub has stayed there the longest.
If you are wanting to do it on softer areas such as the neck and the face, add a little bit of water to your hands with the scrub to help soften the sugar a little. It will still work as an exfoliator, it just won't be quite as rough as what you used on your legs.
The Body Scrubs are filled with skin-loving oils, so be mindful that the shower can become slippery when using.
Customer Reviews
I bought this scrub to use hoping the lavender would be calming before bed. It really is. I love the scent and it exfoliates incredibly well. You don't need to use much so it'll last for ages!


text:
A collection of scholarly works about individual liberty and free markets. A project of Liberty Fund, Inc.
1879 - 1940
Historical Period:
The 20th Century and Beyond
Albert Schatz (1879-?) was a Professor of Law at the University of Dijon and an historian of ideas who lived in the early 20th century. He wrote on the history of 19th century individualism, the works of the economist Jean-Baptiste Say and his followers in the early 19th century.


text:
SSchmidt wrote:Not to be picky guys but its two completely different knights
Of course, one is on the horse, but their headpieces are different. Being the case it would make perfect sense for one to have a title while the other doesn't. And by the way, after putting them both together, they are awesome figs
That is true but theres not enough of a difference in the figs to really have it make sense to have him called a white knight. Also the other knight probibly dons't have a horse because LEGO was cutting down on horses because there expensive and it makes you want to get the castle more.
Purple Wolf


text:
Bridgewater, New Hampshire
|This article is a stub. Help us to expand it by contributing your knowledge. For county and town page guidelines, visit U.S. County Page Content Suggestions.
Bridgewater is a town in Grafton county, New Hampshire. It was formed in 1788 and has gone by the following other name/s: New Chester. For more information, contact the county at P.O. Box 419, Bridgewater 03264. On the attached map, Bridgewater is shown as 30 in Grafton.
For information about the state of New Hampshire see New Hampshire Family History Research.


text:
Immigration Lawyers in Washington to serve You!
Washington Immigration Lawyers on stand by!
Do you need immigration advise? Do you wish to get a visa to Canada or the US? Are you under a Deportation Order?
We can help! Why? Because our immigration lawyers supported by our office in Washington, USA, have many years of experience in handling all types of US and Canadian immigration cases.
Niren and Associates:
1776 I Street, NW, Washington DC, USA, 20006
Phone: (202) 249-7611
You can find more information about us by visiting our Washington immigration website at http://www.washingtonimmigrationlawyers.co/
Canadian and US Immigration Services for Washington
We handle ALL types of Canadian and US Immigration and Visa cases. Below is a sample of the services we offer to our clients. The goal always is to get results!
Canadian Visas
- Work and Student and Visitor Visas
- Permanent Residence Applications
- Denied Entry to Canada (TRPs)
- Humanitarian Cases
- Immigration Appeals and Refusals
US Visas
- TN NAFTA Work Permits
- L1 Intercompany transfers
- E2 Visas
- US Green Cards
- Denied Entry to the US (US Waivers)
We are here to help you navigate through your immigration case and are on call. Our experienced immigration team knows how to assess your case and offer effective and affordable solutions so you can meet your goals! Imagine getting that visa for Canada or the US!
"You are closer than you think"
Any information provided here does not constitute legal advice and is intended for general information only. Should you require legal advise, you are encouraged to contact a lawyer directly. All blog postings are public and are not subject to solicitor/client confidentially. Case results depend on a variety of factors unique to each case, and case results do not guarantee or predict a similar result in any further case undertaken by the lawyer.


text:
Capture your Whistler memories with a Snowflake Charm
Sterling silver detailed snowflake charm
Small snowflake has Whistler engraved on the back
Type: Charm
Vendor: Keir Fine Jewellery
Small flat Centennial maple leaf charm in sterling silver
View full product details →
Detailed small maple leaf charm in sterling silver with Whistler engraved on the back
Sterling Silver Pine Cone Charm
Sign up to get the latest on sales, new releases and more …
Copyright © 2020 Keir Fine Jewellery . All Rights Reserved.
Website by Custom Fit Online. Photos by Sea To Sky Photo.


text:
The 67th session of the General Assembly of the United Nations opens in New York on 18 September, with Ministerial week beginning the following Monday, 24 September. Commission President José Manuel Barroso, High Representative of the Union for Foreign Affairs and Security Policy/Vice-President of the Commission Catherine Ashton and Commissioners Kristalina Georgieva (International Cooperation, Humanitarian Aid and Crisis Response), Connie Hedegaard (Climate Action) and Andris Piebalgs (Development), together with European Council President Herman Van Rompuy, will travel to New York to represent the EU in discussions on peace and security, sustainable development, human rights and strengthening the role of the United Nations.
The background:
The EU will be represented in the General Debate on Wednesday, 26 September by President Van Rompuy. The EU's priorities for the 67th UNGA session were adopted by the Council in July.
President Barroso will address the High Level Meeting on the Rule of Law at the UN General Assembly on Monday 24 September, will participate in a number of high-level bilateral meetings and together with President Van Rompuy and High Representative/Vice-President Ashton, will inaugurate the new offices of the EU Delegation in New York on Wednesday 26 September, in the presence of EU Ministers for Foreign Affairs. Furthermore, President Barroso will deliver a public lecture titled "European Union: An Indispensable Partner" at the Woodrow Wilson School, Princeton University, on Thursday 27 September.
High Representative/Vice-President Ashton will be in New York from 23 to 28 September. On her agenda will be priority issues relating to Syria, Iran, the Middle East peace process, Libya, European Neighbourhood Policy, the Belgrade/Pristina dialogue, Somalia and the Sahel. Notably, she will meet with a number of Foreign Affairs Ministers and will discuss the crisis in Syria with United Nations/League of Arab States Special Envoy Brahimi and League of Arab States Secretary-General Nabil El Araby.
Commissioner Georgieva will participate in the event "Ensuring Resilient Livelihoods", organised by USAID, on September 25. Together with other high-level figures from the world of humanitarian and development aid, she will discuss the Sahel and Horn of Africa crises at the "Resilience Champions" meeting on September 26, as well as the humanitarian situation in Syria, Yemen and Sudan/South Sudan.
Commissioner for Climate Action Hedegaard will meet with representatives of the Least Developed Countries (LDCs) and the Alliance of Small Island States (AOSIS) to advance negotiations in the run-up to the next round of international climate negotiations. Besides a series of bilateral meetings, Commissioner Hedegaard hosts an Informal High-level Climate change Roundtable for the Durban Platform on 28 September. She will also take part in the Major Economies Forum on 27 September.
Commissioner for Development Piebalgs will highlight the leading role of the EU in development. He will participate notably in the Sustainable Energy for All high-level meeting and will present his ideas on addressing food security challenges to the G8 Global Alliance for Food Security and Nutrition. He will participate in a meeting on natural resources and transparency, and at the Scaling-Up Nutrition meeting he will reiterate the EU's commitment to reach at least seven million malnourished children with its development programmes by 2025.
The event will be available on EbS. Press and audio-visual material will be available on the Europa and EEAS websites as well as via EbS.
Source: European Union @ United Nations / Top News from the European Commission 22 September – 19 October 2012
The Brussels based United Nations Regional Information Centre for Western Europe - UNRIC provides information on UN activities to the countries of the region. It also provides liaison with institutions of the European Union in the field of information. Its outreach activities extend to all segments of society and joint campaigns, projects and events are organized with partners including the EU, governments, the media, NGOs, schools and local authorities.
United Nations Regional Information Centre for Western Europe (UNRIC Brussels)
Residence Palace, Rue de la Loi/Wetstraat 155, Block C2,7th and 8th floor, Brussels 1040, Belgium
Tel.: +32 2 788 8484 / Fax: 32 2 788 8485


text:
Choosing the best college may seem formidable to any parent. It's an very personal decision. But there are lots of factors that needs to be stored in your mind when you begin searching out to find the best college for the child. What factors in the event you bear in mind? Continue reading.
• College search 's time-consuming
Get ready for that college search process. Searching for the best college 's time-consuming. And so do lots of persistence and. Looking process could be aimless and unpredictable. Some children might have their brains focused on a university, while some might not have any opinion. Being a parent, you need to have the ability to function as a help guide to your kids.
• Select a college that meets your son or daughter
Choosing the best college one of many is difficult. There are lots of schools and colleges. You shouldn't depend around the status of the college or status inside a college guide. You need to select a college that meets your son or daughter. The school atmosphere ought to be one that will challenge your son or daughter and also at same time not overwhelm her or him. Your son or daughter should have the ability to grow in understanding and self-esteem.
• Enable your child possess a say
Parents always want the very best for his or her children. Being a parent, you need to offer your guidance. However in the finish, it is best to depart the choice to your son or daughter because it is your son or daughter who needs to study. Enable your child affect a university where he/she's interested. Many youthful grown ups know their interests and thus ought to be allowed to put into practice their instincts. If your little one has an interest in going after the humanities stream, then allow him toOrher achieve this. Don't push your son or daughter to pick a significant that you are looking at.
• Let there be options
It's good to help keep a variety of college choices. It's okay if your little one lists favorite schools. If your little one doesn't get selection in a single college, then you've others within the list to use to.
• Get just as much information as possible
Be considered a wise parent by obtaining just as much information as you possibly can about schools. Enable your child also perform the same. Go to a campus to discover the college from college guides. You may also feel the college magazines within the college library. It may be beneficial to speak to your buddies or neighbors concerning the college you are looking at.


text:
You Have Refined By:
Refine By:
Photo Cards : Photo Card : Season's Greetings : Flat Double Sided
The American Cancer Society's photo cards offer customizable card options for any occasion. Photo Cards allow you to upload your own photograph; children, families, pets, choose beautifully printed custom cards today! From holiday cards, seasonal cards, birthday cards and announcement cards, you won't be disappointed in our selection. And 100% of the net proceeds benefit the American Cancer Society's fight against cancer. Have fun customizing your card!
Showing 1-1 of 1
100% of the net proceeds from these cards support the American Cancer Society and its mission to save lives and create more birthdays by helping people stay well and get well, by finding cures, and by fighting back. This holiday season, choose a Christmas card, Hanukkah card, corporate or photo card from the American Cancer Society Greetings store. All our cards can be personalized, and each card helps the ACS in its fight against Cancer.


text:
Thing One and Thing Two Costume
Rate this costume:
14 votes
|add a comment
Thing One and Thing Two Costume
Our mom worked really hard sewing these costumes for us by hand! It was her first time making a costume and we are really proud of her, plus we look AWESOME!!
Our favorite part of the costume is getting to have Blue Hair! How many dogs can say that they have had blue hair! Mom got most of her supplies from Jo Ann's fabric and for our hair she used some old dog hats we had. She sewed a blue feather Boa to the top and a jawstring and some elastic; so we could run and play without losing our hair!
It's really fun walking around town and seeing everyone get all excited and honk at us! Please let us know if we win, we will be keeping our paws crossed!!!
Oscar (I'm 9yr.s Old and my breed is Yorkie) and Einstein (1 yr. old and breed is Snorkie)
Oh yeah and our mom is Amanda (we are not allowed to mention her age but her breed is human)
You can also check this list of dog costumes from My Pet Needs That
|Costume type:
|Costumes for Pets
This homemade costume for pets entered our 2009 Halloween Costume Contest.
Similar costumes:


text:
new documents released by the National Archives shed new light on the origins of the term "military-industrial complex," first uttered in then-U.S. President Dwight Eisenhower's farewell address and still in use today.
While durable--aides to the president later said they were surprised it lasted so long--the phrase was in fact toned down a few times and considered "vanilla." Despite that, it was potent enough to define much of the era, giving protestors something to rail against, and setting the stage for a buildup of American military power.
The article notes some interesting speaker details: Eisenhower underscored the phrase, and put into all capital letters some of those words in the version of the speech he read. Was the delivery part of what propelled the phrase forward?
(Photo by jamiedfw on Flickr via a Creative Commons license)
Go here to subscribe to Step Up Your Speaking, my free email newsletter that looks at a different speaking topic in depth each month...then become a fan of The Eloquent Woman on Facebook and join the conversation with thousands of other women (and men) about public speaking skills and confidence.
Inspiration, ideas and information to help women build public speaking content, confidence and credibility. Denise Graveline is a Washington, DC-based speaker coach who has coached nearly 200 TEDMED and TEDx speakers--including one of 2016's most popular TED talks. She also has prepared speakers for presentations, testimony, and keynotes. She offers 1:1 coaching and group workshops in public speaking, presentation and media interview skills to both men and women.


text:
goldfish need music too. this one's taste is ultra-refined. only the best for the fattest fish around. read the blog. we'll drag you through concerts, websites, new music reviews and the same stuff you read everywhere else. except here, we're ruled by a creature whose memory is three seconds long. it's a tough swim.
contact the fish
save to del.icio.us
- Feist - The Reminder: Even Cowgirls Get The Blues
- Field Music repost - bonus video
- new Kaiser Chiefs - Yours Truly, Angry Mob
- new Kings Of Leon - mp3 tripleblast
- limited time offer - NIN leak three
- new The Sea And Cake for 2007
- more NIN; not the radio rip
- Low - Drums and Guns
- Feist - the latest.
archives05.2006 / 06.2006 / 07.2006 / 08.2006 / 09.2006 / 10.2006 / 11.2006 / 12.2006 / 01.2007 / 02.2007 / 03.2007 / 07.2007 / 08.2007 /
Tuesday, July 24, 2007
what a long, strange dream i've had.
oh, my.
well. imagine me, little me, tapping on a microphone in a loud room. you are all bustling and hustling and moving very fast, talking louder, yelling over the sounds and beats which clash in a cacophony called Headache. ah the noise, the noise(!), the noise the noise the noise
and suddenly, the Noise is now in capitals, and the crowds start to part, and it is the Noise for toaster (for who?) for Toaster, damn it, and it is me at the microphone tap tap tapping AHEM!
hello. welcome back. this is the blog, it is about my great fish (alive and well!) Sir Toaster, and it is my duty to bring him the music which he cannot find for himself. it's been a stormy few months (you wouldn't believe me if i told you the whole story) but the fact is, we're back, and as much as we're treading the ocean, we're still in it for the fish.
come on back. the water's fine.
you're back, huzzah! 4.5 months, i think i just worked out. But i still checked ever day in the hopes that you'd be back. And finally, you are!
Hey there,Post a Comment
I am building a blog spot to post updates of mixtapes, mixes, shows, dj mixes, live concerts, podcasts ect....
In the future you can post your update`s yourself and i will post them on my blog.
I only post the links to your site, NO deeplinking.
And if you want to support me you can put a back link on your site
Thx and keep up the good work.
<< Home
NOTE: as much as toaster loves free music, he'd like to encourage you to buy the cds of the artists you enjoy. he'd also like to remind you that any music hosted by or linked to from this page is property of its respective owners, so if that's you and you'd like it to not be here, just let us know.
READ ME: if files are not working properly upon opening or saving [ex: unknown file type], make sure that there is a .mp3 at the end of the filename, and all will be well.
also: all files posted will only remain available for two to three weeks. if you find something in an old post that you'd really like to hear, tell us.
be our god damn myspace friend. damn it.
boston loyalty
love for these blogs
magazine style (no fins required to flip pages)
buy stuff, look around, find things...


text:
ST. AUGUSTINE, Fla. – The investigation into a stolen Kia Sorento that was the focus of St. Johns County deputies when a 17-year-old was shot early Thursday morning has yielded two more arrests.
The Sheriff's Office says Brandon Rich was approaching the SUV in the parking lot of the Quality Inn on State Road 16 by Interstate 95 just after 6 a.m. when he refused to comply with deputies ordering him to lie on the ground. He was shot in the leg when he continued into the vehicle and reached into the center console.
Rich (pictured, below) has been released from Flagler Hospital and was booked into a juvenile detention facility on a charge of dealing in stolen property. Detectives say other charges are pending.
A 31-year-old woman who was with Rich complied with deputies, but was arrested on an unrelated, outstanding warrant.
The Sheriff's Office announced Friday it has arrested Lenna Obrien, 26, on two counts of grand theft auto. She is accused of stealing the SUV from her grandmother Wednesday night. In addition, a clerk at another hotel -- Wayne Mort, 53, was charged with obstruction, accused of tipping off Obrien that U.S. marshals were looking for her.
Channel 4 was told that investigators believe Obrien was going to enter an arrangement with Rich to allow him to use the stolen SUV -- perhaps to sell the 75 rocks of crack cocaine that deputies found inside the vehicle.
Obrien was arrested walking away from the Days Inn on State Road 16, where Mort was working.
The second count of grand theft auto against Obrien was connected to another stolen vehicle in December 2012. She remains in the St. Johns County jail on $10,000 bond.
Mort was released Friday morning after posting $500 bond.


text:
Review: Only 40 euro. Where's the catch?
In case you're looking for an affordable yet quality case that packs USB 3.0 connectors, then look no further than Cooltek K3 Evolution USB 3.0. Needless to say, you won't have an easy time finding a USB 3.0 equipped case below €40, which is exactly the price Cooltek set for the K3 Evolution.
Although we're talking about a lower end case, we did not lower our criteria. So, we'll soon see whether the K3 Evolution has the necessary build quality, design and other accessories.
When it comes to design, we think that K3 Evolution will fit just fine into any office or home, but we'll let you be the judge.
The case measures 443x180x485 mm (HxWxL), which means the K3 Evolution is a smaller midi-tower case. It weighs in at 4.92kg, making it one of the lightest midi-tower cases we've tested.


text:
9/28/2020 » 10/2/2020Safety Certification Program - Springfield, IL 656-456
9/28/2020 » 9/29/2020Certified Driver Trainer Program - Private Onsite - Walmart - Sutherland, VA 729
9/29/2020 » 9/30/2020Safety & DOT Compliance Series - Brooklyn Center, MN 771
9/29/2020 » 9/30/2020Fleet Accident Investigation - Columbia, SC 223-VIRTUAL ONLY
9/30/2020 » 10/1/2020Certified Driver Trainer Program - Private Onsite - Walmart - Sutherland, VA 730
Want to become certified?
The course below is applicable toward NATMI's nationally recognized, university accredited certification programs. Taking the course is the first step toward earning a credential that will help you become a more competent professional, earn industry recognition and credibility in court testimony. If you have the job experience, you can pay one lump sum that covers all fees for certification, and complete the process within a 60-day time frame – or less.
NATMI & the ATA Technology and Maintenance Council CSME and CDME Certification
Essentials of Fleet Maintenance Management - February 27-28, 2020
Certification Exam held on February 29, 2020
Atlanta, GA
Held in conjunction with the ATA's Technology & Maintenance Council Annual Meeting & Transportation Technology Exhibition
Want to become certified?
The courses below are applicable toward NATMI's nationally recognized, university accredited certification programs. Taking
the courses is the first step toward earning a credential that will
help you become a more competent professional, earn industry recognition
and credibility in court testimony. If
you have the job experience, you can pay one lump sum that covers all
fees for certification, and complete the process within a 60-day time
frame – or less.
How to Become Certified:
- Certified Director of Maintenance/Equipment (CDM/E): 5 Years in fleet maintenance management
- Certified Supervisor of Maintenance/Equipment (CSM/E): 2 Years in fleet maintenance profession
NATMI Accelerated Certification School Format
Certification Category:
CDM/E and CSM/E
On your own prior to courses:
Course requirement: CSME & CDM/E
Essentials of Fleet Maintenance Management
Exam and Exhibit workshop:
Certification examination following the training courses
On your own following courses:
Submit certification application and exhibit binder within 60 days of classroom training and exam
Fees for Professional Certification Applicants:
All-inclusive tuition for Accelerated Certification School Program
(includes both course fees, NATMI membership fee, certification kit and certification application fee):
$1,295 - CDM/E or CSM/E certification
Essentials of Fleet Maintenance Management Course Only: $880 members / $1080 Non-members
Job Experience Required (job experience only required for certification applicants - no prerequisite for attending the training):
Essentials of Fleet Maintenance Day 1 benefits:
1. Learn why computers save money but don't always reduce labor costs;
2. Learn to schedule work effectively;
3. Discover the common pitfalls of computer software;
4. Develop supervision skills to motivate mechanics;
5. Find out what "ground work" needs to be done before a shop goes "on-line";
6. Learn essential preventive maintenance skills;
7. Learn how to deal with upper management effectively;
8. Find out how to train mechanics on nearly anything without spending a fortune;
9. Learn how to present effective meetings and programs; and
10. Understand the maze of state and federal rules that cover maintenance operations.
Course Description
The program covers topics essential to effective management and administration of motor fleet maintenance operations. Students
learn how to cut costs through efficient use of personnel, equipment,
and technology, while complying with the maze of State and Federal
regulations governing maintenance operations.
· Shop Equipment: equipping for shop safety and compliance and the environment; special tools and equipment.
· Maintenance Shopwork Planning and Scheduling: shop administration; improving maintenance cost control.
· Preventive Maintenance:
administering a preventive maintenance (PM) program; how program is
monitored, enforced, revised; related factors in setting up a PM
· The Functions of Management: the maintenance/equipment manager; the framework of management; running successful shop meetings; quality management systems.
· Maintenance Budgeting: tracking costs; calculating Cost Per Mile and Revenue Per Mile; developing a budget.
· Computers in Maintenance: why, how and what to computerize; steps in choosing the ideal system; organizing your information management system.
· Federal Regulations Applicable to Maintenance Shops: OSHA, EPA, HazMat, Motor Carrier Safety Assistance Program, compliance and training programs.
· Labor and Industrial Relations: overview; collective bargaining sessions; management procedures that can reduce grievance rates; strategic involvement.
1. Discover the tools available to spec' equipment in the computer age;
2. Develop a systematic method to evaluate new products;
3. Find out how to maximize warranty recovery;
4. Learn how to cost out new equipment, and develop ROI numbers;
5. Learn to speak the CFO's language;
6. Learn the technical characteristics of alternative fuels;
7. Discover the common pitfalls in laying out a new shop;
8. Learn how to replace components just before they break;
9. Ascertain what it takes to move from one generation of computerization to the next; and
10. Learn how to audit to find out where you are in relation to your department's goals.
You'll learn how to effectively spec' vehicles, purchase wisely, negotiate warranty and best select suppliers and manufacturers. You'll gain an in-depth knowledge of today's computerized management systems. You'll
learn how to reduce costs through predictive maintenance, and how to
properly analyze failures when they occur - and more.
· Vehicle Specifications: Developing vehicle specifications; evaluating component choices; using mission simulations to predict performance.
· Purchasing: selecting vendors, negotiating terms; evaluating parts quality and warranty.
· Warranty: vehicle warranties, extended coverages; federally required coverage; policy adjustments; negotiation.
· Computerized Management Systems: Identifying needs and wants; evaluating software and hardware choices.
· Advanced Budgeting and Financial Statements: Writing budgets; cost justification; communicating with the finance department.
· Failure Analysis and Predictive Maintenance: Develop your own predictive maintenance program and prevent recurrent repairs through failure analysis.
· Shop Layout and Design: Planning new facilities and expansions; designing your shop for safety and the environment.
· Diesel and Alternative Fuels: A look at the pros and cons of currently developing alternatives to diesel power.
· Shop Audits: Evaluating all aspects of the maintenance program.
Omni Atlanta Hotel at CNN Tower
Embassy Suites by Hilton Centennial Olympic Park
Westin Peachtree Plaza
Hilton Garden Inn Atlanta Downtown
Remember Me
2460 W. 26th Ave., Suite 245-C
Denver, CO 80211
(303) 952-4013
Fax: (775) 370-4055
Registered Office: 555 E. Braddock Road, Suite CS-4 • Alexandria, VA 22314-2182