Concurrent and subsequent treatment - Advice to physiotherapists working in the NHS and private sectors

Patients who choose to be treated privately are entitled to NHS services on exactly the same basis of clinical need as any other patient and should not have NHS treatment withdrawn or refused because they also have private care. Patients have a right to choose where they seek treatment, and in some cases this can result in patients seeking and receiving concurrent treatment in both the NHS and private sectors.

In principle the choice that a patient makes in having additional private provision should not cause a problem, but from time to time it does, and for a number of different reasons.

This information paper includes:

  • Information to support physiotherapists to manage their responsibilities in the event of a patient seeking concurrent treatment
  • Advice to managers and employers as to how they can manage their staff, in the event of patients seeking concurrent treatment
  • Examples of good practice to assist in the management of commonly expressed concerns, related to either concurrent or subsequent treatment.

Can patients be refused NHS treatment if they are already receiving private treatment?

No. Patients who choose to be treated in the independent sector are entitled to NHS services on exactly the same basis of clinical need as any other patient and should not have NHS treatment withdrawn or refused because they are also receiving treatment elsewhere.

Patients have a right to choose where they seek treatment, and in some cases this can result in patients seeking and receiving concurrent treatment in different sectors simultaneously.

Concurrent treatment can only be refused on grounds of the best available clinical evidence, e.g. when it is clear that the effects of two simultaneous treatments will be detrimental to that patient.

As with any other patient who moves between sectors, patients who pay for physiotherapy care should not be put at any advantage or disadvantage in relation to the NHS care they receive. They are entitled to NHS services on exactly the same basis of clinical need as any other patient.

Can a physiotherapist work in both the private sector and the NHS simultaneously?

Yes. There is no reason why a physiotherapist cannot work in different sectors simultaneously. The NHS manager and physiotherapist should review the NHS contract and check for any clauses relating to how potential conflicts of interest should be managed. If the manager confirms that working in a different sector would not breach the individual’s contract of employment, it is important to discuss and agree how this will be taken forward in the most appropriate way.

What happens if conflict arises between the two treating therapists?

In rare circumstances a conflict in approach may be difficult to resolve, e.g. one therapist not communicating with the other. The physiotherapist should first try all means of resolving this through good communication. If, after explanation of the situation, the patient wishes to continue with both therapists, all three parties will need to decide how best to work together, which may require one therapist to take the lead.

If this cannot be resolved, the patient should be invited by one of the physiotherapists to choose which treatment to continue with.

I am an NHS physiotherapist and also work privately. What if my NHS patient asks about private provision?

In the course of their NHS duties and responsibilities NHS physiotherapists should not initiate discussions about providing private services for NHS patients.

Where a physiotherapist is, in the course of their NHS duties, approached by a patient and asked about the provision of additional paid for services, the physiotherapist should provide only standard advice that has been agreed  with their NHS employer. For example, you may consider having a list of local independent providers in the department of which you are one of several suggestions.

What would good communication look like in these situations?

If patients are being treated by more than one therapist concurrently there should be open, honest and regular communication in the interests of, and with the consent of, the patient; criticism of other service providers should be avoided.

Physiotherapists are expected to work closely with other physiotherapy colleagues, regardless of the sector of employment. It is the responsibility of each individual physiotherapist to communicate fully with other professionals involved in the care of a particular patient. For example, if a patient has been receiving treatment from a chiropractor but reaches the top of the NHS waiting list and attends for physiotherapy treatment, it may be appropriate for the physiotherapist to speak with the chiropractor to ascertain the treatment and outcome of treatment to date.

  • Each therapist must obtain consent from the patient to liaise with the other therapist(s).
  • Each therapist should be sure that there is a clear clinical need for intervention in that setting and from that individual team/provider.
  • Any potential risks in concurrent physiotherapy intervention should be explored collaboratively with the therapists and patient.
  • A clear agreement should be reached between the providers that it is beneficial for the patient to receive both elements of intervention and concurrent treatment.
  • Treatment plans and goals of intervention should be discussed and agreed by all parties involved in the intervention, including the patient.
  • A clear communication strategy needs to be identified and agreed, ensuring that the patient does not suffer as a result of lack of communication between treating individuals or organisations. This may require additional actions over and above the usual communication with the referrer.
  • Consider agreeing to identify one therapist as the lead, and the indications for a multidisciplinary team (MDT) meeting if intervention is anticipated to continue from two providers over a long period of time; or alternative monitoring processes such as scheduled telephone calls to the patient or their parent/guardian.

What if the patient does not agree to the therapists sharing information?

On occasion a patient may choose not to declare to the treating therapist that another physiotherapist is treating them. There is nothing that can be done if the patient chooses this route.

However, if the physiotherapist suspects that there is another practitioner involved in the patient’s care, then they should explore this with the patient.

This concern and the patient’s response should be documented. This is so that the best clinical management for the patient can planned.

Do these principles also apply to inpatient care?

Yes. For example, an inpatient in the NHS may feel they are not receiving as much rehabilitation as they would like, and may seek to supplement their treatment by asking a private physiotherapist to visit them during their stay.

In this case the NHS Trust becomes responsible for any activity being carried out on its premises, as the Trust holds a duty of care towards its patients.

It is good practice on the part of the Trust to have a clear and well-communicated policy as to how these matters should be dealt with at local level. This may include issuing an honorary contract or asking the visiting practitioner to sign an honorary agreement, so that matters regarding health and safety and clinical risk management are dealt with clearly by the organisation.

The NHS provider would need to ensure the physiotherapist is HCPC registered, had adequate PLI cover in place and that there is a clear understanding between all parties regarding the use of equipment, access to records and the sharing of patient notes.

What would happen if a claim were made against a private practitioner carrying out concurrent treatment in an NHS establishment?

In these circumstances, the CSP PLI scheme would support the member as long as they were working within the terms and conditions of the policy.

If the claim were made against the hospital, then the hospital and its insurers would have to respond. If they felt that the visiting physiotherapist was liable, they would have to redirect the claim and, in those circumstances, the CSP policy would respond.