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Shared care

Discussion in 'General Issues and Discussion Forum' started by twirly, Apr 16, 2011.

  1. twirly

    twirly Well-Known Member

    Members do not see these Ads. Sign Up.
    I would be interested if any practitioners have experience regarding 'shared care' of patients between the National Health Service & private practitioners in the United Kingdom.

    Any feedback, positive or negative encounters would be greatly appreciated.

    I have a patient (unfortunately I am restricted regarding posting too many details for legal reasons!).

    In short the patient is complex & refuses to attend the NHS podiatry team due to 'issues' & therefore selected to opt for private care for their podiatric needs.

    As this patient is at very high risk of future complications I wrote to their NHS medical nursing team. They responded verbally to the patient that they 'Do not have the time to consult with private practitioners'!

    A little (understatement) concerned regarding the patients best interests & continuity of care I wrote to her general practitioner. Two weeks have passed & still no response. Only second hand information verbally via the patient that 'they' no longer want me to provide treatment! Which is quite odd as the nursing team still provide the patient with ulcer dressings for me to apply post debridement! Is this not implied consent to shared care?

    Rock vs hard place.

    I would be grateful for any opinions.


    Last edited: Apr 16, 2011
  2. W J Liggins

    W J Liggins Well-Known Member

    Hi Twirly

    My area is surgery, so my knowledge tends to be restricted to diabetics who are attending accordingly. However, there are a couple of points which might be useful:

    always write to 'the boss'. In hospital care that means the diabetologist

    you were correct in writing to the G.P.

    Although, of course, young and charming, I know that you are experienced enough not to set too much store by patient opinions and that if they report issues with one clinician, they will probably report issues with you! Remember that with the exception of GP practice nurses, nurses cannot make diagnoses or write to you, or reply to letters; nor does the fact that the nurses hand over dressings to the patient necessarily imply consent to shared care, which only the GP or Diabetologist could consent to anyway.

    I think that looking from another perspective, you have done all you can and as long as you retain copies of your letters and notes you should simply continue to offer the patient the best care and stop worrying about 'the others'.

    All the best

  3. twirly

    twirly Well-Known Member

    Many thanks for your reply Bill.

    I requested in my letter to the GP that the patient would be willing to attend the NHS podiatry department in another area than they have been treated previously.

    I am seeing the patient again this week so hopefully they will be able to let me know if a further referral has been made.

    When I worked for the NHS we were always told that if information is not written then there is no evidence of information being exchanged. I am hoping that means I am still safe to treat this patient until such time as the GP actually writes requesting I no longer provide care?

    I intend contacting Society tomorrow for guidance.

    Thank you again.


  4. Catfoot

    Catfoot Well-Known Member

    I am surprised that there has been no response to your query from our illustrious NHS colleagues, so in the absence of that I shall respond.

    This is an situation which IMO is a ticking time bomb. While you obviously have a duty of care to your patient you need to protect yourself as well. So you need clarification.

    If you haven't already done so, make it clear to your patient that while you respect their right of self-determination, you have concerns about their decision not to attend the NHS for treatment. You must explain to them clearly what the outcome of their decision could be in terms of any deterioration in their foot health status. Be sure they understand this. Either give them this information in writing and keep a copy or mark the notes to that effect.

    As Bill says, you want to also be communicating with the organ-grinder and not the monkey. That means writing to the person who is ultimatley responsible for this patient's NHS care, whether is be the diabetologist or CEO of the Trust. Ask them their policy on "shared care". Stress you are acting in the best interests of the patient and you want to cooperate to achieve a beneficial outcome for the patient. Ask if attendence at another clinic can be arranged. Copy the Head of Podiatry Services in on this to keep them in the "loop".
    Keep copies of everything you write attached to the patients notes.

    (I am writing this with the assumption that you have the patient's permission to write to others concerning their treatment? If not, you must obtain this consent before you do so, otherwise you'll be committing a Data Protection offence.)

    In the meantime I would continue until you are told otherwise. Ignore what the patient says in this instance. If "they" don't want you to treat this patient it is up to "them" to make that clear to you and why. Ultimately it is the patient's choice and I can't see any situation where "they" could stop the patient seeing you if the patient wished to do that.
    Remember - no medical person can over-ride a patient's wishes unless the patient is either unconscious or deemed to be mentally incompetent and unfit to make a decision by virtue of being Sectioned under the Mental Health Act.

    In my experience the NHS do not like "shared care" scenarios. (I don't really want to speculate why that is but maybe our NHS colleagues could enlighten us ?) When I worked for the NHS we were told to discharge any Podiatry patient who had the temerity to seek private treatment in between their NHS appointments. I Have a feeling that this mindset hasn't changed much.

    Hope that helps.

  5. DAVOhorn

    DAVOhorn Well-Known Member

    Dear All,

    My understanding is this:

    If a patient seeks care for the same problem from two independent sources

    NHS Pod Dept and Private Practitioner

    And something goes wrong and they wish to seek damages then they will have to sue both parties at the sametime and prove one or other negligent.

    Both providers will deny any and all liability and suggest the other provider is liable.

    Now the pt will fail to prove either party liable and will thus incur costs from 3 legal teams.:butcher:

    As a practitioner either in NHS or PP i would not knowingly treat a pt who was already or chose to see another practitioner for the same tt.

    It makes the pt make a decision as to which party is best able to meet their clinical needs. Not their financial needs ie 3months NHS 3 months pp equals care every 6 weeks.

    It gets messier if the pt is high risk and gets basic care from PP and wound care from NHS.

    So if it were me i would suggest the pt return to NHS.

    I would wish to know the reason for the pt being unhappy with the NHS. :deadhorse:

    Regards David
  6. Catfoot

    Catfoot Well-Known Member

    You have given a pithy summation, as usual, but IMO it isn't as simple as that.

    One of the challenges we regularly face as Allied Health Professional is "how can i give this patient the best care that I can while respecting their right to self-determination?"
    If the two issues are in conflict then it is up to us as the professional to seek a resolution.

    I am sure we have all had instances of the diabetic who won't stop using corn plasters, the patient with PVD who won't stop smoking etc etc.
    We are not responsible for our patients' final decisions but what we are responsible for is giving them enough information to enable them to make (hopefully good) choices about their treatment.

    If a patient wants to seek treatment from either 1 or 6 Podiatrits to treat them for the same problem then that is their choice, but they must be made aware of the implications. Personally, I would not, knowingly, treat a patient who was under the care of another practitioner. However, I have had quite a few patients who were not entirely open about their treatment arrangements.

    Sadly, if no cooperation can be achieved, either with the patient or other care providers, then sometimes the only choice we have is to discharge the patient. This is easier to do in PP than in the NHS , but again the patient should be told the reasons for this.

    Personally, I like to refer any really "complicated" patients to the NHS specialist teams, where there is the facility for emergency admission if necessary.

  7. twirly

    twirly Well-Known Member

    Many thanks for CF & Dave for your replies.

    I dearly hope the GP refers the patient to the NHS for all the reasons wisely highlighted in your replies.

    I want the best result for the patient. In this instance I don't feel shared care is in their best interests, I have explained this fully to the patient.

    Thank you.


  8. Catfoot

    Catfoot Well-Known Member

    Just another point.

    This type of patient can be very demanding in terms of non-clinical time as they tend to create a great deal of ( very necessary ) documentation. As private practitioners we need to be able to factor this into the fee structure which may create problems financially for the patient. We are not our patients' bankers but, I, personally, think that high-risk patients with lower limb pathologies should be able to have podiatry treatment that is free at the point of delivery.


  9. RobinP

    RobinP Well-Known Member

    Is a phone call to the NHS department manager out of the question? Followed up by some sort of written communication.
  10. Catfoot

    Catfoot Well-Known Member

    I have had abortive attempts to communicate with NHS Podiatry Managers in the past, so personally I wouldn't waste my time.
    The attitude of "we don't have time to talk to consult with private practitioners" is all pervasive and they seem to view Private Pods as the devil's spawn.
    In any event, Podiatry Managers are constrained by the bureaucracy of the system they work in, so they cannot do anything unless the requisite paperwork/referral forms have been completed.
    An official complaint always makes them all sit up and take notice, but hopefully this situation will be resolved without the need for heavy artillary.

  11. RobinP

    RobinP Well-Known Member

    Not been my experience but I'm sure your sentiments will be echoed by others

    Not sure that people reading this should be discouraged from trying to create a good working relationship with their local department?
  12. Catfoot

    Catfoot Well-Known Member

    I am speaking from my own experience. If anyone else can tell me how they created a good working relationship with their local podiatry department I would be pleased to hear it.

    I am sure that you have read on other threads how some NHS Podiatry Departments are discharging patients into the care of Social Enterprise organisations (who have minimally trained persons providing nail-cutting) thus bypassing the private sector podiatrists. I think this shows just how much regard the NHS has for IPPs.


  13. twirly

    twirly Well-Known Member

    Many thanks for all your replies.

    The patient has just attended an appointment with me. Although no direct communication from the GP to me, the patient has now been referred to her chosen NHS team for assessment & treatment.

    I have explained fully to the patient that care under the NHS 'umbrella' providing coordinated continuity of care will be most appropriate given their high risk status.

    Thank you all.

  14. DTT

    DTT Well-Known Member

    Hi Hun

    Welcome to my world :bang:

    Get a patient that should get urgent NHS care ?? = no one interested prattling on about you go private you stay private.

    bastards!!!! etc etc etc :mad:

    I have just had a pt of mine a DM2 that I have tx for 20 years without a problem, went to Spain damaged his hallux and was in a Spanish hospital for 2 weeks.
    Came back with a mega ulcer on the side of the hallux and "something" going on the apex of the second toe.
    Saw his GP who... Sent him to me , "his podiatrist" for continuing care.

    I sent him straight back for multidisciplinary care and involvement of a vascular team.

    The diabetic nurse sent him back to me with a message " he is getting "multidisciplinary care between you and me " :craig:
    3 times I sent him back ( it was like table tennis) and finally he was sent to the NHS podiatry clinic who told the pt " You Podiatrist was right you should have been sent for vascular involvement straight away

    " BUT " we cant refer direct is has to come via your GP !!!!!!!!!!

    He came here last week minus his big toe and the second "waiting to fall off"

    Me, Pi***ed off big time coz no-one except me gave a Sh**t as to his well being and now a very nice intelligent guy has been earmarked for early brass handles.

    The bureaucracy stopped me referring direct.:bash:

    I've got a 24 year old golf professional I have to tell tomorrow I believe he has Seronegative Arthropathy = his career is finished.

    The GP couldn't give him an appointment for a rheumatoid factor blood test for over a month. The patient told me the results the GP couldnt be bothered to reply to me allbeit I sent a fully informative letter requesting the results of the testing.

    I have just finished a letter to his GP requesting a referral to a professor consultant rheumatologist under his private health scheme for proper continuing care.

    NHS Mand forget it

    Your on your own girl so get used to it.


    Pi**ed of of Beddington

  15. twirly

    twirly Well-Known Member

    Hi Del,

    I agree that in the cases highlighted the GP is letting the patient down & causing unnecessary distress & suffering to patients (not to mention anxiety & sleepless nights for clinicians!).

    As the years roll by experience tells me that we cannot change the opinions of those with no foresight & cloth ears! I have previously written to local GP teams introducing my practice, including details of qualifications & past experience. I have also written on many occasions requesting GP involvement with high risk patients.

    I don't expect them to hang on my every word but a little professional courtesy would go a long way to improving patient outcomes & patient satisfaction (after all the patients pay the bills for both parties).

    Until these individuals stop seeing patients & other health professionals as an interruption to their busy working day I see no improvement.

    I am grateful to all the medical teams who realise the importance of communication. It is a shame part of the GP training did not involve communicating & involving lesser mortals in patient care.

    I will still write letters to GPs. A reply? Like a response from Santa...........................

    All the very best,

  16. Thought for the day...........

    Highlights the importance of a strong professional body to work on you behalf to improve the working relationship between all Pods (NHS and Private) and other medial professionals.
  17. cornmerchant

    cornmerchant Well-Known Member


    Do you have the name of a strong professional body that actually does this?


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