This article was published in the APCP Newsletter on 1 February 2021
This was written following the first lockdown in 2020.
BACKGROUND:
A significant number of paediatric physiotherapists work external to the NHS. This is in a variety of fields including private clinics, community, charities, case management, private hospitals, education, industry, overseas and sports settings. Due to the COVID-19 pandemic, this group of physiotherapists has had to adapt to the impact on their work personally, as physiotherapists and also on their business model.
AIMS:
- To provide an overview of the impact on clinical practice for physiotherapists working external to the NHS, using the Paediatric Physiotherapists in the Independent and Private Sector (PPIPS) committee members experiences during the pandemic to illustrate this.
- To demonstrate the financial impact depending on the nature of ‘employment’ i.e. sole trader, limited company, case manager, overseas, associate, schools.
- To share negative and positive experiences to support clinical reflection and improve future practice
Members of the PPIPS committee work in all of the above areas and come from a variety of backgrounds with all having NHS experience, some for many years, before entering into private practice.
In private practice children are largely seen in the community; in their homes, nurseries, schools, clinics or residential care. In the lead up to lockdown, practitioners in all areas were experiencing similarities. Families were increasingly making the decision to stop their children attending sessions at clinics, group sessions, home visits, withdrawing their children from school or taking them home from residential settings for individual and varied reasons; for example, fear of the impact of COVID-19 on their child, other family members and general uncertainty. Whilst the majority of families from overseas chose to stay in the UK, some families from overseas chose to return to their home countries, driven by their perception of the quality of health provision in each country.
Once lockdown occured, physiotherapists in all areas of private practice ceased face to face contact with clients. Some discussed this verbally with each client and others sent out formal emails notifying why treatment had to cease at present and how contact could be maintained via teletherapy.
Other stressors to consider were that some physiotherapists had to self isolate due to their own health or member/s of their household’s health, now had to care for parents or dependents, had no child care provision and were now homeschooling multiple children or were unable to access support from extended family.
Most practitioners, unless still employed by schools, had a drastic income drop and suddenly had to navigate what financial options were possibly open to them, for example business grants, rate relief, bounce back loans, mortgage breaks, deferring loans, rent holidays on equipment, vehicles and so on.
There was also a significant emotional impact: concern for our acute NHS colleagues. Guilt that when we were worrying about finances whilst they were still working, maybe deployed to unfamiliar areas of work and at risk of much worse! Many of us rang our local NHS departments to see if we could support them in any way. We were also concerned for our clients who were stressed and whose care was being affected.
WIZ CHILTON: IMPACT ON SOLE TRADER
Wiz treats children in the community, homes, education and a clinic in London. She had a planned clinic move in Easter 2020 and still had to manage this move despite being in lockdown and the impact of COVID-19 meant that the premises the clinic had planned to move to were no longer available.
Overall clinical work dropped considerably, and income greatly reduced. All face-to-face therapy ceased and contact was maintained with clients via Zoom to support them regularly or check in on programme sessions and adapt as necessary. Face-to-face clinic and school based work had enabled connection with colleagues, joint working with shared children and running multi-professional groups. This is greatly missed.
Financially, Wiz was entitled to the government self-employed grant but one of the qualifying criteria was that you had to have been self-employed for more than a year, which has excluded many who are new to independent practice. These individuals starting a new business were suddenly without income and likely to have been at a time when they had made initial investments in equipment, rental agreements, and other costs incurred when setting up.
A sole trader is responsible for all decisions made; whether it is justifiable to see a child or not, despite having read and reread the criteria/risk assessments/consent forms/adapting to teletherapy/whether and how charges need to be adapted for teletherapy/where and what PPE to source/how to enable the business to survive and then move forward/what will happen regarding income. They have to be clear and make fully informed decisions despite the nagging concern: what if I get it wrong?
Wiz has a key role as our chair in liaising with the APCP, CSP and PPIPS committee members throughout the pandemic to get paediatric specific information for members, coordinating action, setting up webinars, database, posts for the facebook page and more.
HEATHER ANGILLEY: IMPACT OVERSEAS
Heather volunteers for the charity, PhysioNet, which recycles rehab and therapy equipment. Her trips overseas include equipment training, therapist support and parent training.
All planned trips to Kenya, Ghana, and Mexico were postponed. Although equipment had already been shipped pre-lockdown, there was no possibility of face-to-face training regarding its use. ADAPT, another professional network of the CSP, provided funding that has enabled the training to be filmed and combined with powerpoint presentations in a downloadable format using Google classroom.
DEBBIE TRIGG: IMPACT ON LIMITED COMPANIES
Limited companies can be of varying sizes and employ, or have associate, practitioners.Debbie has a small limited company covering Hertfordshire, Essex & North East London. She is the company director treating clients at her home, domiciliary, in education settings and in her family’s physiotherapy multi-disciplinary musculoskeletal clinic.
Within her practice are three associate physiotherapists and two physiotherapy assistants; all self employed, with one currently on maternity leave. They had to stop work and had to apply for self-employed grants. One therapy assistant decided to increase her care work. Thankfully all staff were happy to have extended leave as all have young children and were now homeschooling. A podiatrist, respiratory physiotherapist, nutritionist, aesthetician and orthotist are also all associates at the clinic.
Due to the impact of COVID-19, all face-to-face treatment ceased and the clinics closed. Debbie was not eligible for rate relief as she works mainly domiciliary or in her own house. If she had rented a property Debbie could have applied for a £10,000 grant for rate relief; her sister was able to apply for this for the MSK clinic.
Thankfully before lockdown she had ensured all postural management files for clients were up to date and carers had all been competency trained.
Debbie faced a moral and legal dilemma as to whether to furlough or not due to being company director. We are often informal case managers linking professionals or may be the only person a family or individual speaks to or has contact with. If furloughed you are legally not allowed to do any emails or phone calls work related. Therefore morally do you ignore the phone and emails? Or respond politely/briefly answer a query and risk the consequence? You are able to work outside of your own limited company and freelance yourself whilst furloughed.
Employees can get 80% of the PAYE of their salary up to £2500/month if you furlough, but no official scheme exists for limited company directors. There is no cover for lost dividends which is how many people pay themselves. You may be able to apply for a Bounce Back loan for up to £50,000 interest free, payment free first year, with 2.5% annual interest after that. If not eligible for anything you then can claim universal credit.
During the pandemic Debbie worked to develop the facebook page for PPIPS, sharing relevant information and updates from the CSP and Physio First. She developed a good support network amongst paediatric physiotherapists and also a local multidisciplinary network to help with sourcing PPE, sharing information and policies.
JAMES PATERSON: IMPACT ON SCHOOLS
James is employed by a school for children with special educational needs in South London. As most children are being educated at home, face-to-face therapy has ceased.
James uploads weekly exercise videos to Youtube to replace group sessions and uses teletherapy for individual sessions. He has also delivered training over Zoom for school staff. Working entirely from home is challenging when you are used to a busy school environment and delivering video sessions is a new skill. Pre-recorded videos can be time consuming to prepare and do not allow as much feedback or adaptation as a physically present group session.
Physiotherapy input has needed to be flexible as many parents are working from home as well as caring for their children. This has a positive aspect as parents may be present and hands-on with therapy in their child’s day in a way they often cannot be at school. It has also provided more frequent opportunities for communication; though maintaining professional boundaries when everyone is in their home environment is essential.
MICHELLE MOONEY: IMPACT ON INDUSTRY / TRAINING
Michelle works independently for a local wheelchair service. Referral rates are down and some assessments are by video. During this crisis all training has moved online; webinars and online Zoom meetings have greatly increased.
JO FISHER: IMPACT ON CASE MANAGEMENT / MEDICOLEGAL
Jo works with complex clients, managing their needs and coordinating services for them and their families in the South West of England. She has maintained some income as a case manager as her private physio practice has virtually stopped, with no prospect of government support.
Families have needed lots more support with the prospect of no care/respite for weeks, and dealing with support workers/carers being furloughed or not. There has been a reduction in responsibility from local authorities regarding social care and EHCPs along with tribunals cancelled and court dates postponed.
Jo has needed to spend lots of time researching regarding employment guidelines, for example that PPE is not chargeable. Other challenges have included: difficulty sourcing PPE for the care teams, risk assessing every client including risk to them, carers and any essential visiting therapists. Jo has also had to carry out best interest meetings regarding whether a client should go into hospital or not and then if they were eligible to be ventilated or not whilst organising Treatment Escalation Plan (TEP) forms from the GP.
Positively, there are benefits to using Facetime and Zoom for multidisciplinary meetings as these reduce costs for clients, and it is very useful in rural locations.
AS LOCKDOWN EASES:
In the last couple of weeks we have all come under increasing pressure to resume face-to-face contacts as children start to return to school. Sourcing PPE has been hard and prices have greatly increased.
We have all needed time to adapt to the way of working and be clear that the decision to see a child face to face is the right one under current guidance. That guidance has been constantly changing and we all have to keep up with this and constantly write and re-write policies.
CONCLUSIONS:
The government package for businesses has not captured all sectors, and has left some with no support or income. The pandemic has been an anxious time for most private physiotherapists and the struggle to keep their business viable has been very scary when also carrying responsibilities for children, extended family and paying mortgages.
There are positives and negatives to being employed, self-employed, being a sole trader, a limited company or an associate and everybody has been impacted differently depending on their work and home situations, which are diverse.
As physiotherapists we are all used to being hands on and in the children’s space. All of our future practice will have to adapt and going forwards treatment will be different! Experiences of virtual treatment have been variable working well with some families but not with others.
Initially, paediatric specific information from the CSP and APCP was sparse although there was some relief when Physio First and CSP joined forces to deliver some very useful information within webinars that was accessible to all independent practitioners. Within the independent paediatric sector it has been more a case of peer support and trusting our decision making as autonomous practitioners until information has become available to enable us to write our policies and begin to move forward with our virtual and face-to-face practice. It has made us all feel vulnerable, nervous of our decision making yet forced us to find a new confidence so we can move forward.
IMPLICATIONS FOR PRACTICE:
- We will all be more prepared should anything unprecedented like this happen again.
- Business interruption insurance: is this worth it, as many people have not been paid out?
- Zoom and other teletherapy software has increased in use; even after lockdown potentially more aspects of therapy will be managed virtually
- How will ongoing social distancing affect group therapy?
- For physiotherapists working overseas, reduced travel has had a positive impact on global warming and teletherapy offers opportunities for long term relationships with overseas colleagues.
- Self-employed therapists and clinic owners may need a good accountant to guide you through what support that is available.
- There is a need to increase networking to provide support for each other, pool ideas and documentation, enable bulk buying of PPE. Online forums can provide discussion & reassurance. Networks are invaluable and we need to grow these as there is strength in numbers.
- It is essential to form better links with local NHS services, to support each other where possible