I am often asked by clients and potential clients what the difference is between NHS and private physiotherapy.  The answer often comes from their own experience, ranging from no difference at all, through to a marked difference in services.

Good NHS Physiotherapy

My first patient this morning would have answered ‘no difference at all’. This lady had suffered a nasty wrist fracture in a road traffic accident and received NHS treatment to surgically fix the break followed by out-patient physiotherapy once she came out of plaster. She couldn’t have been happier- she saw a hand physiotherapist and had manual ‘hands-on’ treatment to help restore her normal range of wrist movement, soft tissue work to improve the flexibility of the scar and surrounding soft tissues, and a comprehensive home exercise programme (HEP) to get her hand back strong and mobile. Her treatment sounded fairly identical to the services of good, private physiotherapy.

Not so good NHS Physiotherapy

My second patient of the day was not quite so complimentary about the NHS. He had been referred by his GP to NHS physiotherapy for neck and shoulder blade pain. His treatment there consisted of an assessment and exercises, nobody had touched him and he felt that his pain had not changed over the duration of 4 appointment sessions. His employer funded some private physiotherapy and, on assessment, we found that his mid-back area adjacent to his shoulder blades was much stiffer than the rest of his spine. Direct spinal mobilisation changed his pain score from 7/10 to 3/10 (where 0 is no pain and 10 is the worst possible pain he could think of) in 3 sessions, and allowed him to then get on with his exercises to further improve his progress.

Hands On Physiotherapy

The ‘hands on’ versus ‘hands off” treatment approach is receiving quite a lot of attention in the physiotherapy literature at the moment. Some NHS trusts cite research as not definitively showing that ‘manual therapy’, which involves the physiotherapist actually touching the patient, as being superior to treatment where the physiotherapist gives exercise and advice alone to the patient. This seems to be an increasing bugbear of many of my ex-NHS clients – ‘they didn’t even touch me!’ being a common complaint.

I can see in certain instances of very recent injury, pain-states or rehabilitation that the ‘hands-off’ approach might work. For the majority of cases that I see however, the patient needs help to get a stiff segment or tissue working after possibly a healed injury or longstanding malfunction and once this help is given, they can then more fully engage in the exercise and advice part of the treatment.

Research in physiotherapy is very difficult due to the many different elements involved and the human factors both therapist and patient. My opinion has always been in the camp that says that ‘lack of evidence is not evidence of lack’. We need more research but we also need to listen to the patient and most patients do not feel that they have had adequate treatment if there has not been some element of touch involved.

Manual therapy is common in most private physiotherapy treatments. There is another issue that concerns me in this debate also – physiotherapists that work in these ‘hand’s off’ environments don’t get to practice and develop their manual skills and it can lead to a skills shortage. The NHS used to be a major source for my recruitment for specialist musculoskeletal physiotherapists- but this is now the exception rather than the rule – 6 out of 8 of my current physiotherapy colleagues are overseas-trained and have not come through the NHS.

Reasons for using Private Physiotherapy

Many patients that we see come to us when they are either waiting for an NHS appointment or when they have not been particularly satisfied with their NHS treatment. As well as the ‘hands-off’ complaint, their main reasons for dissatisfaction are often time-based – lack of time during the appointment – NHS appointments are in the region of 20 minutes compared to on average 30 minutes in many private practices, but also lack of flexibility in timings of appointments around the working day. Frequent changes of therapist causing a lack of continuity are also cited as an issue- NHS therapists often rotate through the different departments as part of their training so a patient can be unlucky and encounter this one or more times. Variation in the standard and expertise of the physiotherapist can also be a reason for dissatisfaction – many NHS hospitals are training hospitals – so a patient can see a student under supervision, or a newly-qualified member of staff, whereas in many top level private clinic,s the treating physiotherapists would have at least 5 years of post-graduate specialisation in that field – often much more. This also means that they can often get to the root of the problem faster and have a variety of tried and tested techniques that they can use to help achieve a good result for the client.

Where the treatment quality is or isn’t an issue, another problem the NHS faces is lack of resources and often large caseloads so there can be long waits to be seen and when you do get in, you may have to wait 2-3 weeks for a follow-up appointment. In contrast, a patient coming for private physiotherapy can be seen as often as required but usually at least once a week to see progress. Quotas are also often seen in the NHS so after a set number of sessions you can be discharged regardless of your symptoms.

To try and even the scales a bit, where the NHS often excels and what is often not available in the private practice setting is group exercise – for chronic back-pain sufferers, post-op rehabilitation and many other later-stage conditions. They are also closely linked to the rest of the medical team in that if there is a problem, the channels should be there for the patient to be reviewed by their medical team.

Costs of Private Physiotherapy

Probably the biggest positive for the NHS and not to be underestimated of course is that it is free to the user. But in my opinion, ‘free’ is not always the best policy for everyone – NHS physiotherapy departments often have to cope with large numbers of missed appointments where patients don’t show and don’t cancel. I’ve personally found that people seem to pay much more attention to advice and information where there is a charge involved, however small – free advice is often taken for granted or ignored – I wonder if it’s the same for the NHS? You do have to pay for private treatment in most instances either personally or in terms of tax deductions if you have a work private healthcare policy. It costs money but then again is very reasonably charged compared to many other private health care services. Interestingly, more and more of our clients are seeing private physiotherapy as a necessity and not a luxury item – pain and dysfunction are distracting and stops them getting on with what they have to do so costing them money in other, maybe not quite so obvious ways.

What to look for in a physiotherapist

In conclusion, the NHS and private physiotherapy are two very different beasts each with their pros and cons. The private system offers choice – the client can, and I recommend they should, ask for details of their physiotherapist’s training and specialisations, the type of treatments that they can offer and what they, as a patient, can expect from treatment. Recommendations from friends, relatives or colleagues are valuable in finding a suitable physiotherapist. NHS physiotherapy can be fantastic but it is worthwhile knowing that the service can be supplemented if and when necessary.

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