Diversity of Private Physiotherapy Practice

Introduction 

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Physiotherapy is an internationally recognised profession, where the physiotherapist works with service users to identify and encourage their ability to maximise their movement and function while ensuring treatment is patient-centred, effective and ethical [1]. A physiotherapist has professional autonomy, allowing the physiotherapist to have the ability and freedom to use their professional judgement regarding assessment, diagnosis, treatment and care within their scope and limits of knowledge and competence [2]. The World Confederation for Physiotherapy (WCPT) define physiotherapy as:


“Physical therapy is concerned with identifying and maximising quality of life and movement potential within the spheres of promotion, prevention, treatment/intervention, habilitation and rehabilitation. This encompasses physical, psychological, emotional, and social wellbeing. Physical therapy involves the interaction between the physical therapist, patients/clients, other health professionals, families, care givers and communities in a process where movement potential is assessed and goals are agreed upon, using knowledge and skills unique to physical therapists [3].”
Physiotherapists can work in a variety of environments from hospitals, private practice clinics, community-based rehabilitation centres, outpatient clinics, to schools and workplaces [3]. The scope of physiotherapy is not limited to the role played in a clinic surrounding patient care, but also includes influencing public health strategies, advocating patient health, teaching, research, and helping to develop health policies [3]

The movement from treating acute to chronic conditions due to the ageing population, the cost constraints this shift has on public services, along with the impact of technology are effecting the delivery of healthcare internationally [2], and in turn impacting on the physiotherapy profession. The Canadian Physiotherapy Association state that a change in the scope of practice and development of the physiotherapy profession is associated with this shift of treatment in healthcare; for example practices such as ordering X-rays and screening for orthopaedic surgery which were considered advance practices are now becoming under the scope of practice [4]. The recognition of advanced practitioners in specific areas such as pain and oncology is another development emerging as a result of changes in population and the demands on the healthcare system, therefore broadening the scope of physiotherapy [4].

This plays an important role in the development of private physiotherapy practices, as well as changing physiotherapy roles and broadening the scope of practice. Many people are unaware of the diverse nature of physiotherapy practice as it extends to neurological, oncological, respiratory, and occupational rehabilitation and is not limited to strictly musculoskeletal conditions. Hence, there is a need for increased awareness of these other specialities available to the public and to those who wish to work in these areas.

Neurological Physiotherapy

Neurological Physiotherapy is a specialist area of physiotherapy which can often be seen in private practice. It focuses on the treatment of individuals with neurological conditions and disorders that impact the functioning of the brain, spinal cord, and nerves. Stroke, multiple sclerosis, spinal cord injury and Parkinson’s are common neurological conditions [5]. It also includes conditions of the peripheral nervous system such as Guillain Barre Syndrome. Disturbances in the communication of messages between the brain and the body can result in the loss of movement, sensation, co-ordination, and balance. Other aspects of bodily function, such as perception, speech, memory, cognition, and behaviour may also be affected. Due to the complexity of neurological disorders management often involves working as part of a multidisciplinary team including speech and language therapists, occupational therapist, dieticians, nurses, and doctors.[6] A number of interventions are used, often incorporating a selection of the following as appropriate [6]

  • Stretching
  • Strengthening
  • Balance re-education
  • Gait re-education
  • Joint mobilization
  • Electrical stimulation
  • Postural exercise
  • Spasticity management
  • Advice/Education on lifestyle, fatigue management, and exercise       

Conditions often seen by physiotherapists in private practice include:

See Neurological Physiotherapy in Private Practice for more detailed overview

Benefits of Private Physiotherapy for Neurological Conditions.

A major benefit to private physiotherapy is on achievement of a client’s short term goals, focus shifts immediately to longer term maintenance and progression through a combination of neurophysiotherapy and the use of functional electrical stimulation machines, neuro pilates, personal training, and massage therapy. With the choice of longer and more frequent treatment sessions privately, patients can really experience benefits. Receiving regular physiotherapy can not only impact patients physically, but also psychologically, building patient and family members confidence, positivity, hope, and belief. The video [7] below describes the physical and psychological benefits private physiotherapy brings to the lives of people with a neurological condition and their family members.

Occupational Rehabilitation

Vocational or Occupational rehabilitation refers to the services that help enable an individual with a health problem to remain at or return to work by addressing barriers in psychological, functional, cognitive or emotional areas. The emphasis in this type of rehabilitation is on restoring functional abilities in order to work or to perform other occupation-related activities rather than treating a specific clinical condition. There is strong evidence that sick absences and disability management services are cost-effective with a reduction in sick absence by 20-60%[8] . Musculoskeletal disorders are a huge contributor to work-related illness and absence from the workplace. Musculoskeletal disorders make up one in eight approved absences from work and the average time on leave being 10 weeks[9]. The estimated number of individuals within the UK who are impacted each year is 2 million with an estimated total of 40 million days of work missed[9]. This equates to roughly 12 billion dollars per year in sickness and absence costs to the UK economy.

The Role of Physiotherapy

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Physiotherapists are particularly useful to employers and companies because of their skills and experience needed to perform workplace

assessments to help identify and treat the potential cause of injury. Not only does this assist with treating an existing patient, but also with identifying the cause can help reduce the likelihood of another staff member in the same role being injured.

Physiotherapists are able to carry out a variety of tasks that can be beneficial for employers and employees, which include:

  • Identifying the probable cause of injury
  • Developing safe and SMART orientated return to work programmes including exercises to help with work conditioning
  • Developing safe and realistic restrictions to prevent further injury when returning to work
  • Reducing the likelihood of further injury by addressing areas such as posture, manual handling techniques, ergonomics and workplace practices [10]

There are also benefits to those who are sick or disabled to stay at work where health status permits which include:

  • Helps promote recovery within the rehabilitation process.
  • Minimizes the side effects of long-term sickness absence, which can include physical, mental and social effects.
  • Reduces long term incapacity.
  • Helps people feel like they contribute to society, maintain their independence, and have autonomy. Improves quality of life [11]

One of the main therapy tools occupational physiotherapists utilize is work hardening exercises that either simulate or mimic tasks that are functional and would normally be performed within an individual’s work setting. Work hardening exercise protocols utilize graded exercise progression to improve physical, psychological and emotional tolerance to exercise that will translate to improve work feasibility. In order to meet a work hardening exercise protocol, its components must address three key elements, which include:

  • Exercises that are chosen to help restore deficits in neurological, musculoskeletal or cardiopulmonary function
  • Clearly stated intent to improve a patient’s work status
  • Clearly stated connection between job demands and the intervention

Work hardening protocols can also include behavioural approaches, pain management, and condition education along with return to work advice.

Within the UK, private physiotherapy companies are providing services to employers to help make the work-place safer and help those who are requiring physiotherapy services return to work faster. Many of these companies including are doing this by preventing employees from missing time at work through job analysis, ergonomic assessments, health screening and functional evaluation of employees. One of the benefits for employees who have access to private occupational health services is the quick appointment service with some patients even being seen within less than two days of booking. Along with quick appointment times, physiotherapists working privately can provide more flexible scheduling to meet individual needs. Among other benefits of choosing private occupational services include:

  • On-site physiotherapy – large-scale companies can benefit from onsite physiotherapy since it allows for direct communication with management staff. Management can be kept up to date with the progress of employees with their consent to assist with scheduling and planning. Along with the direct contact with management, Human resource departments can be kept up to date on current data to better understand the causes of absence. With onsite physiotherapy, a therapist can provide services on specified days per week depending on the number of employees required to see and at the request of the employer.
  • Health promotion – physiotherapists are able to provide workshops for business or companies that are tailored to the department and the demands placed on the employees themselves. These topics include specific manual handling skills to reduce the risk of injuries, promoting good physical health and being fit for the work demands, which refers to the bodies ability to cope with the specific task.
  • Data analysis – private occupational health companies provide data analysis services that allow for better allocation of money and resources for the prevention of further sick absence. The data can be categorized to reflect specific areas including musculoskeletal, medical or psychosocial causes. Having data on sick absence allows for resources to put towards prevention in areas with the most need allowing a shift from rehab to prehab approach to employee health.

Oncology Physiotherapy

Physiotherapists working in oncology help people that have been diagnosed with cancer are undergoing treatment, have survived cancer, and also can be involved in palliative care. The CSP has argued for the need for specialist oncology physiotherapists. Physiotherapists can also advise on physical activity after a cancer diagnosis. Research has suggested that exercise can decrease the risk of cancer arising [12].


The physiotherapist has a role in lymphedema[13], mobilisation, managing cancer-related fatigue, [14] and even managing fitness for work [15]. These roles are similar whether physiotherapists are working in the NHS or in a private setting. Services that physiotherapists will be involved in can include outpatient's cancer rehab and a musculoskeletal cancer service. Patients can also self refer and so would avoid GP visits whether it is private or within the NHS.

Prevalence of Cancer in the UK

More than 2 out of 5 people living in Scotland will develop some form of cancer. Lung cancer is the most common cancer currently in Scotland according to the data published by the NHS National Services Scotland in October 2016[16]. The second highest rate is breast cancer followed by colorectal. In males, prostate cancer remains the highest risk while in females, the highest risk is breast cancer. In the UK alone there are currently 2 million cancer survivors. This statistic is projected to increase by 3% per annum [17]

Cancer Services within Private Practice

Physiotherapists may also work in private hospitals or clinics. The role of a Physiotherapist in a private hospital is similar to those that may work on a ward in the NHS. Physiotherapists can also refer patients into private hospitals for an appointment with a consultant. Waiting times may be shorter to see the consultant than in the NHS and so may attract patients to use their services rather than the NHS. People who have health insurance may be covered and so could utilise the facilities of a private hospital instead of going through the NHS.

Respiratory Physiotherapy

Respiratory physiotherapists treat a wide range of conditions. These range from COPD and cystic fibrosis, to post-surgical patients in intensive care and high dependency units in hospitals. The services of a respiratory physiotherapist can be utilized at any stage of the disease progression, ranging from early diagnosis through to care at the terminal stage. One of the main cornerstones of respiratory physiotherapy has been to aid in the removal of secretions. This area of physiotherapy has now developed to include a wide variety of different techniques to help problems associated with respiratory function, including:

  • Maintaining/increasing exercise tolerance
  • Reducing breathlessness and the work of breathing
  • Educating the patient on their condition and improving their knowledge
  • Improve their capability to engage in daily functional activities.

Prevalence of Lung Disease

Lung disease is believed to affect approximately 12.7 million people in the UK [18] ranging from asthma, COPD and other long-term respiratory illnesses. COPD is the fifth leading cause of death in the UK, beaten only by cardiovascular disease and cancer.[19] Research has suggested that the prevalence of lung disease in the UK is growing. For example, the diagnosis of COPD has increased by approximately 27% in the last 10 years, from under 1600 to 2000 people per 100,000 These figures[18]demonstrate that lung disease is a potentially massive burden on the NHS, with interventions needed to address the treatment plans for these patients.

Pulmonary Rehabilitation

Pulmonary rehabilitation is a non-pharmacological program designed to help patients with chronic respiratory disease. There are numerous different components of this rehabilitation, such as exercise training, disease education and behavioural interventions [20]. It has been shown to significantly improve symptoms associated with chronic respiratory diseases, such as dyspnea, as well as increasing exercise capacity.[21] Pulmonary rehabilitation classes generally last from between 6-8 weeks, with 1-2 sessions a week. People with a variety of respiratory conditions can attend, with the most common condition being COPD. It consists of a group exercise program, followed by an educational talk to increase their knowledge regarding their respiratory disease. Although pulmonary rehabilitation does not reverse the primary pathophysiology of respiratory conditions it has many benefits, such as:

  • Reducing respiratory symptoms, eg. shortness of breath and fatigue
  • Increases exercise performance
  • Increases knowledge about pulmonary conditions and their management
  • Improves health-related quality of life
  • Improving psychosocial symptoms eg. anxiety, depression and independence
  • Reducing hospitalisation
  • Enabling some people to return to work

Potential Barriers to Pulmonary Rehabilitation

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However, although there are obvious benefits associated with pulmonary rehabilitation, it is not without its downside. Due to the need to be referred to these classes, it increases the waiting time for the attendance of classes. Issues with patient compliance have also been documented. Attendance is as low as 50% [22], with 23-31% of patients failing to complete the course. Due to patients not showing up for classes, this prevents other patients from accessing this service, hindering them in their rehabilitation and increasing waiting list times for the classes. Accessibility and times of classes also can have an impact on attendance.[23]. Accessing physiotherapy privately would offer them the opportunity to discuss other options with the physiotherapist, allowing patients more autonomy with the timing and location of their classes. As people may be working full time, this gives them the choice to obtain physiotherapy outside of their working hours, helping progress their rehabilitation.

Options for Working in Private Practice

There are many different options for working in private practice in the UK from treating the occasional client to setting up a new practice. The many choices are listed below:

  • Treating the occasional private patient – any chartered physiotherapist in the UK can accept private business from a self-referring patient, or on referral from any other professional.
  • Working as a support worker in private practice - it is possible for Associate members to work as self-employed private practitioners. To remain within the scope of practice of a CSP Associate member, it is essential that your work is delegated to you by a registered physiotherapist, which requires a formal arrangement between you and a physiotherapist. In private practice this will need to be determined by the written “contract-for-services” that you will create as the legal basis for the operation of your services.
  • Becoming a partner in an existing practice - if you are considering becoming a partner or entering into a directorship, legal and financial advice should always be sought and a formal partnership or directorship agreement will need to be established.
  • Purchasing an existing practice – it is possible to purchase an existing practice that is already up and running with its own equipment and clientele. Businesses are often advertised in CSP’s Frontline publication, Physio First’s in Touch Journal as well as in local papers.
  • Setting up a new practice - a practice can be owned by a sole proprietor, by a partnership of two or more people, or by Directors of a Limited Company. Each of these scenarios will have different tax and legal implications, and these should be considered before choosing which is the most appropriate for your circumstances.

Different Types of Practice in the UK

  • Partnership - For this type of practice, two or more people share the risks, costs and responsibilities of being in business. Partners do not enjoy any protection if the business fails. Each partner is self-employed and takes a share of the profits.
  • Sole Trader - A sole trader runs their business as an individual. You are responsible for all aspects of the business and you pay personal tax on the profits of your business. You will be personally liable for any debts incurred, meaning that this could be a risky option for businesses that need a lot of investment. Advantages: independence, any profits made go to you. Disadvantages: lack of support, unlimited liability, and personal responsibility for any business debts.
  • Limited companies - Limited companies exist in their own right and company finances are distinct from the personal finances of their owners. Shareholders are not responsible for the company’s debts unless they have given guarantees however, they may lose any money they have invested if the company fails.

Private Practice and Referrals

Referrals can come from many different sources and will rely on forming networks and developing a marketing strategy to inform users of physiotherapy services. The most common source of referrals are:

  • GP referrals – there are a number of factors that may impact upon referrals from GP’s such as the GP being responsible for purchasing physiotherapy services for their community. It is important here to highlight that GPs do not directly commission health services in Wales, Scotland or Northern Ireland.  As a physiotherapist, you may need to apply to the GP directly to become capable of providing physiotherapy services to a particular community.
  • Self-referral – this will be the majority of the type of patients you will see in private practice as they are the most important market segment for independent practitioners. Evidence from self-referral pilot studies by the Department of Health has delineated that people who self-refer to physiotherapy take fewer days off work and are 50% less likely to be off work for longer than one month when compared with people referred from other pathways.
  • Health insurance companies – there are two choices for practitioners:
    • Patients pay for services directly to the practice and are advised to follow up with their insurance company. OR 
    • Practitioners complete insurance claim forms to be reimbursed for services by the insurance company. The majority of insurance companies will use a GP or specialist as a pathway to a physiotherapist. Some companies, however, will accept claims for patients who self-refer. It is important to note that some insurance companies may limit the number of sessions reimbursed per course of treatment.
  • Commercial intermediary companies – these companies handle the management of claims for insurers. For instance, for a person who has been in a car accident, their insurance company may pass their details to a commercial intermediary company who may then:
    • Arrange for a referral to a physiotherapist.
    • Pass the details to a legal representative.

Conclusion

The role of a physiotherapist is constantly developing due to the change in healthcare services and provisions. Physiotherapy is not confined to the realms of the NHS and diversities found within the private sector of physiotherapy over services and opportunities within neurological, oncological, respiratory and occupational rehabilitation as well as a wide range of disciplines that have their foundations based in improving human movement and function.

References

  1. Chartered Society of Physiotherapy. Physiotherapy Framework: putting physiotherapy behaviours, values, knowledge and skills into practice. Chartered Society of Physiotherapy:2013. 40p. Available from: https://v3.pebblepad.co.uk/v3portfolio/csp/Asset/View/6jqbh3GzhGWrrcGqpknwmZzh8Z
  2. 2.0 2.1 Higgs, J.,Refshauge, K., Ellis, E.. Portrait of the Physiotherapy Profession. Journal of Interprofessional Care. 2001; 15(1):79-89.
  3. 3.0 3.1 3.2 World Confederation for Physical Therapy. Policy statement: Description of physical therapy. World Confederation for Physical Therapy: 2001. 12p. Available from: http://www.wcpt.org/policy/ps-descriptionPT
  4. 4.0 4.1 Canadian Physiotherapy Association. Description of Physiotherapy in Canada. Ottawa (CA): Canadian Physiotherapy Association; 2012. 17p. Available from: https://physiotherapy.ca/description-physiotherapy
  5. Neurological Alliance of Scotland. Neurological conditions factsheet. Available from: http://www.scottishneurological.org.uk/content/res/Neurological_Conditions_Factsheet.pdf (Accessed 31st October 2016).
  6. 6.0 6.1 Neurological Physiotherapy Information Guide and Resource Centre. Neurological physiotherapy. Available from:http://neurologicalphysiotherapy.comfckLR(Accessed 31st October 2016).
  7. Challenge Center. Challenge center video 2014. Available from: https://www.youtube.com/watch?v=TDGETLa4Bm8 (Accessed 3rd November 2016).
  8. Waddell, G., Burton, K., Kendall, N. Vocational rehabilitation: what works, for whom and when? 2008; 2-303. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/209474/hwwb-vocational-rehabilitation.pdf
  9. 9.0 9.1 Addley, K., Burke, C., McQuillan, P.. Impact of a direct access occupational physiotherapy treatment service. 2010; 60: 651-653.
  10. Physiomed. 2016. Available from: http://www.physiomed.co.uk/pages/physio-med-provides-quality-and-affordable-occupational-physiotherapy-and-ergonomic-solutions
  11. NHS Scotland. Getting Vocational rehabilitation working for Scotland: education needs of staff supporting vocational rehabilitation. 2008; 1-37. Available from: http://www.gov.scot/resource/doc/924/0077375.pdf
  12. CSP. Physios play key role in cancer care. Available from: http://www.csp.org.uk/frontline/article/physios-play-key-role-cancer-care [Accessed 25th November 2016]
  13. Lacomba MT, Sánchez MJ, Goñi ÁZ, Merino DP, del Moral OM, Téllez EC, Mogollón EM. Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial. Bmj. 2010 Jan 13 Available from: doi 340:b5396, [Accessed 25th November 2016]
  14. Donnelly CM, Lowe-Strong A, Rankin JP, Campbell A, Allen JM, Gracey JH. Physiotherapy management of cancer-related fatigue: a survey of UK current practice. Supportive care in cancer. 2010 Jul 1;18(7):817-825.
  15. Chartered Society of Physiotherapy. Information paper: Fitness for work. March 2016.
  16. Cancer in Scotland (October 2016): Information Services Division, NHS National Services Scotland
  17. Maddams J, Utley M, Møller H. Projections of cancer prevalence in the United Kingdom, 2010–2040. British journal of cancer. 2012 Sep 25;107(7):1195-202.
  18. 18.0 18.1 British Lung Foundation. Lung disease in the UK. Available from: https://statistics.blf.org.uk/. ( Accessed 18th November 2016).
  19. Masoli M, Fabian D, Holt S, Beasley R. The global burden of asthma: executive summary of the GINA Dissemination Committee Report. Allergy. 2004; 59(5): 469-478.
  20. Hayton C, Clark A, Olive S, Browne P, Galey P, Knights E, Staunton L, Jones A, Coombes E, Wilson A. Barriers to pulmonary rehabilitation: Characteristics that predict patient attendance and adherence. Respiratory Medicine. 2013; 107(3): 401-407.
  21. Nici L, Donner C, Wouters E, Zuwallack R, Ambrosino N, Bourbeau J, Carone M, Celli B, Engelen M, Fahy B, Garvey C, Goldstein R, Gosselink R, Lareau S, MacIntyre N, Maltais F, Morgan M, O'Donnell D, Prefault C, Reardon J, Rochester C, Schols A, Singh S, Troosters T. American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation. American Journal of Respiratory and Critical Care Medicine. 2006; 173(12): 1390-1413.
  22. Keating A, Lee A, Holland A. What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? A systematic review. Chron Respir Dis. 2011; 8(2): 89-99.
  23. De Sousa Pinto J, Martin-Nogueras A, Morano M, Macedo T, Arenillas J, Troosters T. Chronic obstructive pulmonary disease patients' experience with pulmonary rehabilitation: A systematic review of qualitative research. Chronic Respiratory Disease. 2013; 10(3): 141-157.