A chiropractic clinic in England that takes X-rays is explicitly excepted from CQC registration for that activity, and can still be inspected by CQC and served an enforcement notice over how it takes them.
That is not a drafting error. It is two statutes doing two different jobs, and the gap between them is where most of the confusion about radiography compliance in chiropractic sits. If you own an X-ray set, being outside the registration system tells you nothing at all about your regulatory exposure.
Are you CQC registrable for taking X-rays?
For the taking of X-rays alone, no.
CQC registration in England runs off the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Schedule 1 lists the regulated activities. Paragraph 7 covers diagnostic and screening procedures, which is where imaging would normally land. But paragraph 7(4) carves out a list of things that do not count, and one item reads, in full:
(e) the taking of X-rays by chiropractors;
The item immediately after it does the same job for a different profession:
(f) the use of ultrasound equipment by physiotherapists;
So the activity is named in the legislation as outside the scope of registration. You cannot register for it, and you are not in breach for failing to.
Two cautions. The exception is activity-specific, not clinic-specific: if your premises does something else that is a regulated activity, registration may be triggered by that rather than by the X-ray set. And this is England only. The same registration logic that keeps most private physiotherapists outside CQC applies here.
So who regulates your X-ray unit?
Two sets of regulations, neither of them the Health and Social Care Act.
IRMER, the Ionising Radiation (Medical Exposure) Regulations 2017, protects the patient: whether an exposure should happen at all, who is entitled to decide, and how the dose is kept down. It applies to every employer carrying out medical exposures. No chiropractic exception, no registration threshold.
The Ionising Radiations Regulations 2017 (IRR17) protect staff and the public from the equipment itself: shielding, controlled areas, local rules, the radiation protection adviser. Those are enforced by the Health and Safety Executive.
IRMER's enforcing authority differs by nation:
| Nation | IRMER enforcing authority |
|---|---|
| England | Care Quality Commission |
| Scotland | Healthcare Improvement Scotland |
| Wales | Healthcare Inspectorate Wales |
| Northern Ireland | Regulation and Quality Improvement Authority |
That is the paradox in one line. In England, CQC arrives as the radiation regulator, not the registration regulator. It does not need you to be registered in order to inspect you, and when it enforces it does not use the Health and Social Care Act at all. It uses section 21 of the Health and Safety at Work etc. Act 1974 to serve an improvement notice.
Who are the four IRMER duty holders?
IRMER allocates responsibility to four named roles. A duty holder is a person or organisation carrying one of them. In a solo or two-chair practice, one individual routinely holds three at once. That is lawful. Each hat still carries its own duties, and each still has to be written down.
| Role | What IRMER says it is | What that means in a small clinic |
|---|---|---|
| Employer | "any person who, in the course of a trade, business or other undertaking, carries out ... or engages others to carry out" medical exposures | The practice itself: the company, partnership or sole trader owning the X-ray set. Carries the heaviest duties, including written procedures, reference levels and the physics expert. |
| Referrer | "a registered health care professional who is entitled in accordance with the employer's procedures to refer individuals for exposure to a practitioner" | The clinician who asks for the image. Entitlement comes from your own written procedures, so a person those procedures do not name is not a referrer. |
| IR(ME)R practitioner | "a registered health care professional who is entitled ... to take responsibility for an individual exposure" | The clinician who justifies the exposure and owns that decision. The word says nothing about chiropractic practice: it is a defined radiation role. |
| Operator | "any person who is entitled ... to carry out practical aspects" | Whoever positions the patient, sets the factors, presses the button, processes the image or evaluates it. Can include support staff handling any practical aspect. |
Entitlement is granted by the employer's procedures, in writing, by name or role, with the scope of what each person may do. And every duty holder needs training evidenced in the relevant areas, kept as a record you can produce on the day.
What must your employer's procedures cover?
Regulation 6(1) requires the employer to have written procedures. Schedule 2 sets out what they must address:
- correctly identifying the individual to be exposed
- identifying who is entitled to act as referrer, IR(ME)R practitioner and operator
- enquiring about pregnancy and breastfeeding where relevant
- following quality assurance programmes for procedures, protocols and equipment
- assessing patient dose
- using and reviewing the diagnostic reference levels you have established
- giving information and written instructions where regulation 12(6) applies
- telling the patient about benefits and risks before the exposure
- carrying out and recording an evaluation of every exposure
- reducing the probability and magnitude of accidental or unintended exposures
- reporting significant unintended or accidental exposures
- non-medical imaging exposures, if you carry out any
- dose constraints and guidance for carers and comforters
Two practical points that inspections turn on. The procedures have to be yours, describing what actually happens in your clinic, rather than a downloaded template carrying someone else's workflow. And they need a review date, plus evidence the review happened.
What does it mean to justify an individual exposure?
Under regulation 11, nobody may carry out an exposure unless it has been justified by the IR(ME)R practitioner as showing sufficient net benefit, and then authorised. Justification is per patient and per exposure. A standing policy of imaging everyone with a given presentation is not justification, because the regulation asks about "the specific objectives of the exposure and the characteristics of the individual involved", the total potential benefits, the individual detriment the exposure may cause, and the efficacy, benefits and risks of the available alternatives.
Separately, regulation 6(5)(a) makes the employer establish referral guidelines that include radiation doses and make them available to referrers. Where more than one clinician refers, guidance that contradicts itself across the practice is a finding waiting to happen.
The General Chiropractic Council frames the same test as five questions: does the benefit outweigh the potential harm, is there evidence, does clinical experience support it, will the result significantly affect management, and has the patient given informed consent. Recording your answer in the clinical note is what turns a judgement into evidence a regulator can read.
Why do you need diagnostic reference levels and a Medical Physics Expert?
These two catch small practices most often, because neither is intuitive if your radiography training predates them.
A diagnostic reference level (DRL) is defined in IRMER as a dose level "for typical examinations for groups of standard-sized individuals or standard phantoms for broadly defined types of equipment". In plain terms: for each view you routinely take, a benchmark dose a competent practice would not habitually exceed. Regulation 6(5)(c) makes the employer review them regularly and make them available to the operator, having regard to national and European levels where they exist. A DRL is not a dose limit, and exceeding one on a given patient is not a breach. Having none at all, or never reviewing them, is.
A Medical Physics Expert (MPE) is an individual or group "having the knowledge, training and experience to act or give advice on matters relating to radiation physics applied to exposure", recognised by the Secretary of State. Regulation 14(1) is unqualified: "The employer must ensure that a suitable medical physics expert is appointed and involved ... in relation to every type of exposure to which these Regulations apply." There is no small-practice carve-out. In practice: a named MPE under contract, advising on optimisation and dose assessment, contributing to your reference levels and quality assurance, with that involvement documented.
What did CQC find when it inspected chiropractic practices?
This is not hypothetical. On 6 April 2022 the General Chiropractic Council announced that CQC's IRMER team would run compliance inspections of a sample of chiropractic practices in England using X-ray equipment. Inspections were expected to last around two hours and to cover documentation, quality assurance and training records. The GCC advised practices to review their arrangements with their MPE in advance and identify gaps at that early stage.
CQC's published account of the programme reports no records of practical or equipment training for the chiropractors taking the X-rays, and quality assurance ranging from not happening at all, through a visual inspection only, to physics testing once every three years. In one case there was no evidence of collimation being used to limit the tissue exposed and no dose area product meter fitted, on a set installed in February 2022. CQC recorded that it remained concerned about compliance and understanding of IRMER in the profession, and would share those concerns with the GCC.
CQC reported that the first two inspections in the programme both ended in improvement notices, and its published enforcement summary names one of them. Following an inspection on 25 May 2022, Enfield Chiropractic Clinic Ltd was found in breach of IRMER regulations 6(5)(c) and 14(1): no diagnostic reference levels in place, and no contract with a medical physics expert. An improvement notice was served on 27 June 2022 under section 21 of the Health and Safety at Work etc. Act 1974. The employer submitted evidence and was deemed to comply on 27 September 2022.
Read the statutory basis of that notice again. Not the Health and Social Care Act. A clinic that cannot hold CQC registration for taking X-rays was enforced against by CQC under health and safety law.
A practical IRMER compliance checklist
- Name your duty holders in writing. Who is employer, who may refer, who may act as IR(ME)R practitioner, who may operate, and the scope of each entitlement.
- Write employer's procedures against Schedule 2. Your workflow, your equipment, dated, with a scheduled review.
- Establish referral guidelines including doses and give them to every referrer. One version, not several.
- Set and review diagnostic reference levels for each routine view, and make them available to operators.
- Appoint a Medical Physics Expert under contract. Keep the advice, reports and dates of involvement.
- Run a quality assurance programme covering procedures, protocols and equipment, and keep the results.
- Keep training records for everyone, theory and practical or equipment training, refreshed and dated.
- Record justification and evaluation for every exposure, in the patient record, at the time.
- Have an incident procedure for accidental and unintended exposures, and know your notification route before you need it.
- Do not forget IRR17: radiation protection adviser, local rules, controlled area, staff dosimetry.
Points 7 and 8 are records problems more than radiation problems. Whatever system holds your clinical notes should store the evaluation alongside the note, keep the image and report on the patient's record, and show an audit trail of who changed what. Atlacare does those things. Training certificates and MPE reports are practice documents rather than patient records, so keep them in a dated, controlled folder of their own. No software will write your employer's procedures or appoint your physics expert.
Why an osteopath with an X-ray set is in a different position
Paragraph 7(4) names chiropractors. It does not name osteopaths.
On the face of the legislation, an osteopath taking X-rays is not covered by that exception, so the activity appears to fall inside the regulated activity of diagnostic and screening procedures and to require CQC registration, while a chiropractor doing the identical thing on identical equipment does not. IRMER applies to both in exactly the same way.
If you are an osteopath with imaging equipment, do not assume the chiropractic position transfers. Confirm it with CQC directly, in writing, and keep the answer. More on the operational side in our guide to practice management software for osteopaths.
Frequently asked questions
I am the only chiropractor here. Can I be employer, referrer, practitioner and operator at once?
Yes. Holding several roles is normal in a small practice and IRMER does not prohibit it. It does require that your employer's procedures state each entitlement explicitly, and that you can evidence training appropriate to every role you hold.
Do I need an MPE if I only take a handful of films a month?
Regulation 14(1) does not scale with volume. Low throughput changes how much involvement is proportionate. It does not remove the appointment.
Does the GCC regulate my X-ray use?
The GCC regulates you as a registrant and publishes guidance on ionising radiation, but it is not the IRMER enforcing authority. In England that is CQC. Both bodies said in 2022 that they would work together on compliance in the profession.
What about the records side of imaging?
Images and the reports on them are health data, and therefore special category data. Retention, access and consent duties sit under data protection law rather than IRMER. See our guide to UK GDPR for physiotherapists, which applies equally to a chiropractic practice.
This is general information about the regulatory position, not legal advice. IRMER duties depend on your equipment, your workflow and your entitlements. Take advice from your Medical Physics Expert and, where the registration question is live, from CQC directly.
Sources: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Schedule 1, paragraph 7 · The Ionising Radiation (Medical Exposure) Regulations 2017 · GCC, ionising radiation and the use of X-rays · GCC, CQC IR(ME)R inspection programme of chiropractic practices, 6 April 2022 · CQC, IR(ME)R annual report 2021 to 2022, chiropractic inspections
Related: Practice management software for osteopaths · Do I need CQC registration as a private physiotherapist in England? · UK GDPR for physiotherapists
