Guy's and St Thomas' NHS Foundation Trust

5. Ms R complains about the care and treatment she received from the Trust between November 2022 and September 2023. Specifically, she complains that: • the Trust only provided her with four appointments in a 10-month period • the Trust refused to refer her for water therapy • the Trust refused to refer her for osteopath services or direct her GP to do so despite her regularly asking them to

6. She says she was in considerable pain during her time with the Trust and she did not receive enough appointments to help. When appointments were cancelled at short notice, she says she was left in pain with nowhere else to seek help. She says this was a frustrating and challenging experience that continues to impact her day-to-day life. She says the Trust’s lack of assistance during this period has contributed to this.

7. She says that the Trust did not consider alternative treatments, like water therapy, even when they had been discussed previously. She says after the Trust discharged her from its care, her GP referred her for osteopath services before the NHS stopped this after only two months as the NHS withdrew all osteopath services to patients. During that time, she says the osteopath treatment she had received had helped and had the Trust referred her or asked her GP to refer her as she had requested, she could have had longer under that treatment.

8. She says that she had to spend a huge deal of time pursuing her complaints and trying to get responses. She says this was incredibly frustrating and distressing as she had to fight for answers.

9. Ms R is seeking financial compensation.

10. Ms R was referred to the Trust for treatment for your pain by her GP in April 2022.

11. She was first seen at the Trust in September before being referred internally for physiotherapy.

12. She attended physio appointments at the Trust beginning in October and had a further three appointments until September 2023. During this time, she also attended nine acupuncture therapy appointments.

13. The Trust discharged Ms R from physiotherapy in September 2023 as, according to the discharge report, she wanted to pursue osteopath treatment and this was not something the Trust could offer.

Number of appointments

17. Ms R complains that the Trust only provided her with four appointments in a 10-month period.

18. Our adviser explained that there are no specific guidelines or standards setting out how many physiotherapy appointments a patient should receive based on their presenting condition. Equally, there are no specific guidelines or standards related to the management of thoracic spine pain due to it being under-researched compared to neck and low back pain.

19. However, we would expect to see physiotherapists comply with the Physio Standards. These set out that professionals should exercise their own professional judgement, make informed decisions based on the evidence available to them, and initiate, continue, modify or cease treatment appropriately. Beyond this, the most applicable relevant guidance would be NG59. These call for an approach consisting of effective self-management, appropriate exercise, and manual therapies.

20. Ms R was referred from the Spinal Clinic to the Musculoskeletal Physiotherapy service in September 2022 to optimise her exercise programme. She was also referred for acupuncture. Within the 12-month period from referral to discharge, Ms R attended four physiotherapy appointments and nine acupuncture appointments.

21. We can see that the physiotherapists involved in Ms R’s care used their own professional judgement as autonomous practitioners in making decisions about the number of appointments to provide. This was done by considering all the information provided by Ms R regarding her presenting condition and using evidence-based practice. The is supported by the Physio Standards.

22. Considering Ms R’s presenting condition, history of previous interventions, outcomes of treatments, current levels of physical activity, and all other factors conveyed within the clinical documentation, our Adviser considered that the number of physiotherapy appointments offered by the Trust were sufficient. There was nothing within the records that suggested further appointments were warranted within the time she was under the care of the Trust. Based on this evidence, it appears the number offered were appropriate and in line with both the Physio Standards and NG59.

Referrals for water therapy and osteopath services

23. Ms R complains that the Trust refused to refer her for water therapy or osteopath services or direct her GP to do so despite her regularly asking them to.

24. Our Adviser explained that, again, the most applicable guidance in this instance is NG59 alongside the Physio Standards. The standards say that, in addition to an approach consisting of effective self-management, appropriate exercise, and manual therapies, psychological therapies can also be considered to aid in treatment and rehabilitation.

25. Under the Trust’s care, Ms R was receiving or engaging in the following treatment: • Exercise specific to her presenting condition as part of a home exercise programme which was reviewed and progressed during each physiotherapy appointment • Manual Therapy – manipulations to her thoracic spine • Acupuncture (classed as an alternative therapy as defined by the NHS) • Query psychological support via Talk Therapy • Appropriate exercise via Yoga and Pilates classes 2 to 3 times a week

26. This is all in line with NG59. Having reviewed Ms R’s records, for reasons we will go on to explain, there was nothing to suggest the Trust should have referred Ms R for treatment services outside of what she was already offered.

27. Regarding a possible water therapy referral, the care and interventions Ms R was receiving were entirely in line with the Physio Standards and NG59. There does not appear to be anything to suggest that the Trust could or, certainly, should have considered referring her for further treatment. Our Adviser explained that, considering Ms R’s presenting condition and factors influencing her condition, the Trust’s management was entirely appropriate and in line with appropriate guidance. Therefore, it did not warrant a wider referral for additional treatments such as water therapy.

28. In terms of osteopath services, we can see from Ms R’s records the physiotherapists had advised her several times during her 12 September 2023 appointment there was no pathway for this treatment. This meant that they were unable to refer her on directly and instead advised that she speak to her GP regarding this. However, the Trust was under no obligation to direct Ms R’s GP to make a referral for osteopathy itself because it was already providing a treatment package for Ms R’s presenting condition in line with relevant guidance.

29. Considering the above, it would appear that the Trust’s decision not to refer her for either water therapy or osteopath services was appropriate. Ultimately, it was managing her condition with a regime that was in line with the Physio Standards and NG59. As such there was no need to refer for additional treatment in water therapy and, as it explained to Ms R, there was no pathway at the Trust for osteopath services either.

30. We recognise that this was really disappointing for Ms R, who, understandably, wanted to do all she could to improve her condition.

1. We have carefully considered Ms R’s complaint. We have, for the reasons we shall go on to detail, decided to take no further action.

2. Having reviewed the relevant evidence, we consider that the Trust offered Ms R an appropriate number of appointments for her presenting condition during her time under its care. This was because the appointments offered were taken in conjunction with the other aspects of care she was receiving such as acupuncture, manual therapies, and her self-management via exercise.

3. In terms of not referring her for water therapy or osteopath services, we consider the Trust acted appropriately here as well. As her package of care was appropriate and in line with the relevant guidance, there was no need for the Trust to look beyond what was offered to an alternative or additional treatment such as water therapy. Regarding osteopath care, the Trust does not have a pathway to refer directly for this type of care and so could not do so.

4. We understand this has been a difficult and frustrating experience for Ms R. We know she has been in considerable pain for some time now and that she feels the Trust’s handling of that pain only exacerbated it. Our decision is in no way meant to detract from how significant these matters are to her.