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14 BEDFORD ROW, LONDON, WC1R 4ED www.csp.org.

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THE CHARTERED SOCIETY OF PHYSIOTHERAPY

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FAX 020 7306 6611

Rules of Professional Conduct


2002

Rules of Professional Conduct 2002

The Chartered Society of Physiotherapy

Dear Member, This new set of Rules of Professional Conduct builds on the rules and explanatory notes published to all members in booklet form in February 1996.At that time, it was agreed that the Rules be reviewed on a regular basis to assist members with the ethical, moral and where possible, legal queries they encounter in the practice of the profession. In line with current practice within the CSP, a small review group, led by a member of the Professional Practice Committee, was recruited via Frontline. The response also allowed an external review group to be appointed. Details are set out in Appendix 2 of this document. Wide ranging consultation was undertaken, including placing the penultimate draft on the CSP website .Members will find that the Rules themselves have only marginally changed. This is reassuring as it confirms that the Rules set out in 1996 are still valid. Much work has been done on the explanatory notes and on a wide range of references, including the most up-to-date work on Consent to Treatment produced by the Department of Health (England). We hope that you find the updated Rule comprehensive, helpful and clear. Any comments for expansion or improvements are always welcome and will be considered by the Professional Practice Committee.

Sarah Bazin MCSP Chairman, Professional Practice Committee

Penelope R Robinson MA MCSP Director of Professional Affairs

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Rules of professional conduct


2nd edition

The Chartered Society of Physiotherapy 2002 Produced and published by The Chartered Society of Physiotherapy The Chartered Society of Physiotherapy 14 Bedford Row London WC1R 4ED Telephone 020 7306 6666 Fax 020 7306 6611 Website http://www.csp.org.uk ISBN 0-9528734-3-5 This document is available to members of the public and to CSP members on the Societys website www.csp.org.uk The document is also available in a format for people with visual impairment from The Chartered Society of Physiotherapy.

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Contents

Introduction Background RULE 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 RULE 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 RULE 3 3.1 3.2 3.3 3.4 RULE 4 4.1 4.2 RULE 5 RULE 6 RULE 7 7.1 7.2 7.3 RULE 8 8.1 8.2 8.3 8.4 Scope of practice Scope of the practice of the profession Scope of the practice of the individual Competence/continuing professional development (CPD) Extension of practice/innovation Duty of care/civil liability Professional liability insurance Delegation Relationships with patients Informed consent Touching patients Record keeping Reluctance to treat a particular patient Use of chaperones Patients and their refusal of care Interpreters Inappropriate relationship with patients Legal considerations Confidentiality The multi-professional team Requests for information Extraneous information Security of information Relationships with professional staff and carers Prescriptive referrals Whistle blowing Duty to report Advertising Sale of services and goods Setting up a business supplying equipment Inventing or adapting equipment Endorsing a product Personal and professional standards Conviction by a court Disciplinary procedure by the State Registration Board Disciplinary proceedings by an employer Personal conduct derogatory to the reputation of the profession Conclusion Appendix 1 Disability Discrimination Act (1995) Human Rights Act (1998)
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Sex Discrimination Act 1975 (amended 1986) Race Relations Act (1976) as amended by Race Relations (Amendment) Act 2000 The Children Act (1989) Appendix 2 Members of the Review Group Members of the External Review Group Appendix 3 References and bibliography Chartered Society of Physiotherapy publications Department of Health (DoH) documents on consent Glossary of terms Further reading

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rule 1 Scope of practice Chartered physiotherapists shall only practice to the extent that they have established, maintained and developed their ability to work safely and competently and shall ensure that they have appropriate professional liability cover for that practice. Relationships with patients Chartered physiotherapists shall respect and uphold the rights, dignity and individual sensibilities of every patient. Condentiality Chartered physiotherapists shall ensure the confidentiality and security of information acquired in a professional capacity. Relationships with professional staff and carers Chartered physiotherapists shall communicate and cooperate with professional staff and other carers in the interests, and with the consent, of their patient; and shall avoid inappropriate criticism of any of them. Duty of report Chartered physiotherapists have a duty to report, to an appropriate authority, circumstances which may put patients or others at risk. Advertising Chartered physiotherapists shall ensure that advertising in respect of their professional activities is accurate and professionally restrained. Sales of services and goods Chartered physiotherapists shall not sell, supply, endorse or promote the sale of services or goods in ways which exploit the professional relationship with their patient. Personal and professional standards Chartered physiotherapists shall adhere at all times to personal and professional standards which reflect credit on the profession; behaviour, approach and dress should not cause offence to the patient and carer.

rule 2

rule 3

rule 4

rule 5

rule 6

rule 7

rule 8

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Introduction Rules of professional conduct


Ethical, moral, legal and professional considerations for chartered physiotherapists

Rules of Professional Conduct have been part of the Society since 1895 and were endorsed at the Societys first Council meeting. Procedures to discipline members contravening these Rules have also been in place since the Societys inception. This document sets out, for qualified members and students of the Chartered Society of Physiotherapy, the relevant ethical, moral, legal and professional considerations that underpin the thinking behind the Rules of Professional Conduct and should be referred to when appropriate. A separate document is available for physiotherapy assistants. This document can also be used by members of the general public for information as to the rules of behaviour and conduct expected of a Chartered physiotherapist and a student physiotherapist. The role of these Rules is to reflect the reasonable behaviour expected of a physiotherapist as a professional. A breach could result in a formal complaint being received by the Society from a member of the public, other professional or Chartered physiotherapist. Following detailed consideration by the Preliminary Committee and a Professional Conduct Committee, the complaint could result in a finding of serious professional misconduct. The Society has the ability to impose a series of penalties following such a finding, the ultimate sanction being to strike the name of a member off the Register of The Chartered Society of Physiotherapy. This means that the physiotherapist concerned cannot call themselves a Chartered physiotherapist; use the designatory letters MCSP or have access to any services of the Society. The Society, however, is not a policing body but acts only on formal complaints received. The activity described above is consistent with the role of an organisation acting as a professional self-regulating body. In considering any complaints that members or students have contravened the Rules, the Preliminary and Professional Conduct Committees may refer to this guidance. Knowledge of and adherence to the Rules of Professional Conduct are part of the contract of membership linked to the Societys self-regulatory function. The ethical background to these Rules is based on the philosophical principles of beneficence, patient autonomy and the professional duty of care. These principles are also reflected as Standards in the Societys Standards of Physiotherapy Practice. These include criteria to provide guidance to members regarding these principles and standards. Chartered physiotherapists also have the responsibility to ensure that: the autonomy of each patient is recognised and accepted consent and involvement in treatment is appropriately sought from the patient or responsible authority and recorded the treatment or advice given is of a competent standard, clearly explained and intended to benefit the patient.

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These principles will be referred to again when considering each Rule in detail. Throughout this document, the term patient is used to describe the recipient, whether of treatment or advice, of the services of a Chartered physiotherapist or a student physiotherapist in the context of preventative, primary, secondary or tertiary health care provision. This will also include family or carers who are the recipients of advice and instruction. These services can take place in any environment in the public or private sector, industry or education, and may be given voluntarily or for payment. The term physiotherapist/therapist used throughout this document includes student members, who are also subject to the Rules of Professional Conduct. These Rules are not a legal document as such but may be used in a court of law as evidence of the standards of behaviour and conduct expected of a Chartered physiotherapist and student physiotherapist. The complete Rules are set out at the beginning of this document. Each Rule is then considered in detail with an explanatory note giving examples of its implications. The explanatory notes are not exhaustive. These Rules need to be read in conjunction with the Standards of Physiotherapy Practice.

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Background
A profession has three specific characteristics: a unique body of knowledge; a set of Rules/Codes of conduct based on acknowledged ethical principles; and the ability to discipline members who contravene those Rules in ways amounting to serious professional misconduct. Koehn (1994) States that the use of the title professional would normally apply to those whose work is: licensed by the State controlled by an organisation which sets standards and ideas such that its members have knowledge and skills not normally possessed or understood by the general public such that they have autonomy over their work of a nature that requires them to have responsibilities and duties to those who need assistance, responsibilities which are not incumbent on others.

In the case of physiotherapy, the Chartered Society of Physiotherapy publishes and regularly updates the curriculum of study which indicates the unique body of knowledge attributed to Chartered physiotherapists. Over the last three decades, the role and status of physiotherapists has changed significantly. Full responsibility for clinical practice has been achieved, with the practitioner undertaking a diagnostic assessment, identification of problems, the development of therapeutic programmes, their evaluation and audit as the norm. The privilege of this autonomy carries corresponding responsibilities for physiotherapists in respect of their own scope of practice and the requirement to undertake continuing professional development. Service Standard 7 of the Standards of Physiotherapy Practice highlights the pivotal role and responsibility which all physiotherapists have in the preparation of the next generation of physiotherapists. An individual can demonstrate active and beneficial participation in continuing professional development (CPD) by providing high quality clinical education for student physiotherapists. Employed physiotherapists should be supported by their employers in identifying learning needs, planning, engaging in and evaluating acquired skills, and should have a Personal Development Plan (PDP).

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Rules 1
rule

Scope of practice
Chartered physiotherapists shall only practice to the extent that they have established, maintained and developed their ability to work safely and competently and shall ensure that they have appropriate professional liability cover for that practice. Scope of the practice of the profession Physiotherapy is an applied science, which possesses its own knowledge base, its own educational methods and practical application based on that knowledge. This is supported by the best available evidence of effectiveness. Physiotherapy research links theory and developing practice. This practice has, at the same time, retained its links to three core skills: manual therapy (including massage, mobilisation and manipulation) electrotherapy (electrophysical agencies) exercise and movement

1.1

A professions scope of practice encompasses those areas that its members are educated for, competent in, and insured to provide. The overall scope of practice of the physiotherapy profession encompasses all individual physiotherapists scopes and sets the outer limits of practice for all physiotherapy practitioners. For those physiotherapists practising as Extended Scope Practitioners, the elements which extend their scope fall outside the general overall scope of the profession. Details are set out in the PA information paper PA29 Chartered Physiotherapists working as Extended Scope Practitioners. A Chartered physiotherapist can ensure they are working within the scope of the profession of physiotherapy if they can either: review how their practice is related to one of the core skills of physiotherapy and/or identify a responsible body of opinion within the profession practising in this way. This could be expressed either through the views of a recognised Clinical Interest Group, other groups with substantial membership amongst physiotherapists, or a selection of members with a recognised expertise in the field. It is, however, expected that the practice has been evaluated, or that there is research to show benefit to patients.

1.2

Scope of the practice of the individual Within the overall scope of practice of physiotherapy, individual physiotherapists practice within their own individual scope. This may be described, in general terms by some or all of the following: occupational role (eg researcher, clinician) sector (eg NHS, private practice, industry, higher education) environment (eg acute, primary care)

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client group (eg children, older people, people with learning difficulties) speciality (eg womens health, neurology, musculoskeletal disorders) treatment approaches and techniques (eg hydrotherapy, acupuncture, Bobath) types of cases that the individual refers elsewhere (eg to other physiotherapists)

More specifically, members need to consider their individual scope of practice in relation to individual patients or circumstances. When presented with a patient, the physiotherapist should ask the following key questions before proceeding: Can I justify the decisions I have made during the assessment? (eg has the research evidence been considered?) Can I identify the most appropriate approach for the patient? Do I have the correct balance of skills, knowledge and experience to be competent in my chosen approach? By answering these questions, the physiotherapist not only identifies and determines the limits of his/her own competence, but demonstrates an understanding of the scope of the profession of physiotherapy. The individual is also illustrating an awareness of other approaches which may be of more benefit to the patient, including referral to another physiotherapist. This approach ensures that every interaction is a learning experience, which will not only inform, but may change and develop that individuals own scope of practice. Inevitably, development in one area of practice will be balanced by the dilution or diminution of skills in another area of professional work, but by following the questions set out above, an individual is able to appreciate the limits of his/her own scope, ensuring safe and effective practice in the best interests of patient care. 1.3 Competence/continuing professional development (CPD) Members of the CSP undertake an initial qualification, validated by both the CSP and the Physiotherapists Board of the Council for the Professions Supplementary to Medicine (CPSM), or The Health Professions Council (HPC), from April 2002. This ensures a level of competency that is expected to ensure safe and beneficial practice by that practitioner. Both the profession and the health and social care arena in which physiotherapy is practised, are subject to constant and rapid change. Every physiotherapist must keep up to date and must engage actively in a constant process of learning and development. The integration of CPD into day-to-day practice benefits the individual by enhancing and developing his/her own performance, which in turn will benefit the patient and the service. CPD activities should be planned in accordance with a thorough and ongoing evaluation of the individuals learning needs, and recorded in his/her portfolio. Fuller information is contained in the Standards of Physiotherapy Practice, Core Standards 19 to 22 and Service Standards 6 and 7. 1.4 Extension of practice/innovation As members of a dynamic and changing profession, physiotherapists have steadily employed and included in the repertoire of physiotherapy a range of treatments, modalities and philosophies which may continue to be modified or developed. But the process must not be developed to such an extent that the member is, in fact, practising another profession under the guise of physiotherapy. This would challenge the professional accountability which is so important to protect patients. However, members clearly need to be able to find out whether a given technique is part of the practice of physiotherapy, or whether its use represents the practice of nonphysiotherapeutic health care. The following is guidance to members wishing to explore new developments in their practice:

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The new modality, technique or philosophy is clearly based upon the core skills of physiotherapy Evaluative research is being, or has been, undertaken into the innovative practice and it has been shown to be beneficial Education relevant to the practice should be undertaken by the physiotherapist(s) using it (in accordance with this Rule) Members exploring new ideas should seek out other members and other professionals who are involved in exploring the same or similar ideas. They should discuss with them the effects of the new approach; the theoretical underpinning; the uses and contraindications; and the education and professional issues relating to the areas being investigated. Published research that has been carried out should also be considered. Members should at all times recognise the responsibilities of their professional practice ie that they should always benefit the patient through the exercise of professional knowledge and skills acquired through education and experience.

In some cases, there will be no question that the new technique falls within the scope of physiotherapy, since it will be a development of well established procedures. In other cases, advice may be sought from the Society. 1.5 Duty of care/civil liability When a patient is received for assessment and treatment by a physiotherapist, the legal and professional duty of care towards the patient is established. Physiotherapists have a responsibility to ensure that the therapeutic intervention is intended to be of benefit to the patient. This responsibility requires physiotherapists to keep up to date with the evidence-based developments in their area of practice and expertise. This evidence may be in the form of clinical guidelines, evidence-based care pathways or research findings which, following rigorous review, are robust enough to inform best practice. Members should be aware that they have a common law duty of care to their patients, and that a breach of this duty may lead to a civil claim for damages by the patient. The duty arises wherever a practitioner holds him/herself out as ready to give professional advice or treatment. A breach of the duty of care to the patient may give rise to a claim for damages for negligence by the patient. A breach of this duty may be tested as follows: The standard of care the practitioner must use is a reasonable degree of skill and knowledge, in other words, neither the highest nor the lowest degree of care and competence. A practitioner will not be guilty of negligence just because someone of greater skill and knowledge would have used a different treatment. The test applied by the courts is whether the practitioner acted in accordance with a practice accepted as proper by a responsible body of medical men (sic). This is known as the Bolam test, as it was established in the case of Bolam v Friern Hospital Management Committee (1957). The test was modified slightly in the more recent case of Bolitho v City and Hackney Health Authority (1993), particularly in relation to its use in establishing the cause of the breach. It is for the patient to prove that the damage was caused by the practitioners negligence. In Bolitho, it was held that, where the Bolam test is applied, the practitioner must demonstrate that the body of professional opinion relied upon to defend the
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claim has a logical basis and that the professionals advocating its use had considered the relative risks and benefits to reach a defensible conclusion. This might sound like a fine distinction, and the reality is that, in the vast majority, negligence cases are successfully defended by showing that distinguished experts in the relevant field consider the treatment in question to be appropriate. 1.6 Professional liability insurance Practising the profession of physiotherapy has its risks, as shown above. It is, therefore, important that any risks are covered by adequate insurance. In the employed situation, physiotherapists are vicariously covered by their employer. Physiotherapists should ascertain from their employer the level and extent of that vicarious responsibility at the start of their employment. It is important that members do not extend their practice in such a way that is unknown or unacceptable to the employer. Doing this could mean that, if an incident occurs in respect of that modality and litigation follows, the employer may not accept liability. Some independent hospitals and other employers do not cover their employees. It is important that the physiotherapist is aware of what cover, if any, is offered by their employer. It is the responsibility of individual Chartered physiotherapists to check on their professional liability cover. For physiotherapists working independently, it is usual for the practitioner who treated to be sued. However, in some circumstances, the business/clinic may be sued either separately or with the practitioner. It is, therefore, advisable for the business to be covered as well as the practitioners. The Chartered Society of Physiotherapy, through its full annual subscription, covers members for professional liability insurance (PLI) practising in the UK or travelling and temporarily working abroad, with the exception of the North American continent. Full details of this cover and exceptions are available in the form of the PA information paper PA32 Physiotherapists and Insurance. 1.7 Delegation Delegation of appropriate tasks to others is an important way of ensuring that effective use of physiotherapy resources occurs. Tasks delegated must be supported by a responsible body of opinion within the profession and by research evidence where this is available. If a physiotherapist decides to delegate physiotherapy care and/or tasks to an assistant, he/she must ensure that the assistant is safe and competent to carry out this care and/or tasks. If not, the tasks should not be delegated. The physiotherapist can refuse to delegate a task or stop an assistant undertaking an activity if, in her/his opinion, the assistant has not been adequately trained, is unsafe or not competent. The assistant also has the right to decline to carry out tasks which he/she is not competent to perform. Advice on delegation of tasks and the responsibility of the physiotherapists delegating such tasks is available from the CSP in the form of the PA information paper PA6 Criteria for the Delegation of Tasks to Assistants.

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2
rule

Relationships with patients


Chartered physiotherapists shall respect and uphold the rights, dignity and individual sensibilities of every patient. The sentiments of this Rule are incorporated into the Societys Core Standards, eg Standard 1 states Respect for the patient as an individual is central to all aspects of the physiotherapeutic relationship and is demonstrated at all times. This Rule covers a wide range of legal rights, including the Human Rights Act (1999) Disability Discrimination Act (1995) Sex Discrimination Act (1998) and the Race Relations Act (1976). It also covers civil rights arising from common and case law. These include the right to have cultural customs respected; right to privacy; the right to complain; and the right to have a complaint dealt with appropriately. Equal opportunities issues and the concept of informed consent are also encompassed within this Rule.

2.1

Informed consent Standard 2 of the Core Standards of Physiotherapy Practice covers informed consent. Information is also provided by the DoH in England. In general, a patient would be considered to have the capacity to give or withhold consent if capable of: a. comprehending and retaining treatment information b. believing such information c. weighing such information in the balance and arriving at a choice.

This is a three stage capacity test from The Meaning of Incapacity (1994). 2 Med. L. Rev 8 Michael Gunn. Patients deserve to know the truth, to participate in decision-making, to refuse to be used for teaching, and to be given full care even when their choice differs from the therapists. All information relating to informed consent emphasises the following: A patients informed consent must be obtained before carrying out any form of examination or treatment Information must be given to the patient as clearly as possible to avoid ambiguity. Treatment options must be discussed with the patient and include information about significant benefits, risks and side effects. Alternative approaches that could be offered by other professionals or by physiotherapists should also be discussed with the patient. This gives the patient, if appropriate, a choice of treatments and a full understanding of what the physiotherapist proposes The therapist must ensure that the patient has the opportunity to ask questions and is encouraged to do so Patients must be informed of their right to decline treatment at any stage without it prejudicing their future care Consent, or the declining of treatment, must be documented in the patients record, with the reasons for declining.

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Patients involved in the decision making process


Patients need to be involved in any decision-making process during treatment planning (Core Standard 8.1) and in any subsequent refining of this. This process is particularly important in physiotherapy, which is a dynamic interactive process involving the patient. With the consent of the patient, named physiotherapy procedures are applied to the patient, (eg electrotherapy or manipulation) or performed voluntarily by the patient under guidance.

How consent can be obtained


Following the above, consent may be implied, for example, by the patient positioning himself/herself for therapy, or it may be expressed either by word of mouth or in writing. With the majority of physiotherapy interventions, consent by implication or word of mouth is quite sufficient. The Society maintains the position it adopted in response to Health Circular HC(90)22, that physiotherapy does not, on the whole, include risk-taking procedures at the level indicated in Para 6-8 of Chapter 2 of the booklet which accompanied the circular and, therefore, it is inappropriate and unnecessary for physiotherapists to use consent forms on a regular basis. However, it is considered good practice to document in the patients notes the fact that consent has been obtained. The use of tick boxes is no longer acceptable and, whereas a signature on a consent form does not itself prove that consent is valid, the point of the form is to record the patients decision, and also increasingly, the discussions that have taken place. There are some specific physiotherapy procedures where it may help to have written consent, for example, movements of force to the cervical spine, vaginal and rectal examinations, nasopharyngeal and tracheal catheter suction with competent patients and exercise tolerance tests for patients with cardiac conditions. When written consent is required and forms are used, some indication of the information given, the options offered and how consent was received should be included to ensure that the form has legal credibility. Clinical and Occupational Groups may provide guidance on this issue, and employers may already have policies which must be followed for particular interventions.

What if a patient refuses treatment?


A competent person over age 16, or one deemed to be Gillick competent, is entitled to refuse treatment, even if this treatment is life-saving and even if the reasons for withholding consent are considered irrational, unknown, or non-existent. It is illegal to force physiotherapy on patients who resist, or who are unable to resist but have made their wishes clear by words or gesture, prior to becoming incompetent. Patients may withdraw consent during treatment. If patients do not know that they have these rights, they should be informed. In the face of refusal, physiotherapists should seek to persuade a change of mind, but must not use duress or deceit.

Summary of consent issues


Mere presence of a patient does not imply consent to treatment only to attending for the appointment. A contractual relationship between a patient and physiotherapist, such as payment for treatment, does not imply consent. Informed consent demands that the patient understands, in lay person terms, all the advantages and disadvantages of the proposed treatment regime. It may be practical to present a written explanation before the first contact, as to what a patient may expect at assessment or treatment and then test understanding

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again or provide further information prior to assessment and treatment. If patients are not offered as much information as they reasonably need to make their decision, and in a form they understand, their consent may not be valid. At all stages of assessment and treatment, it is essential that the physiotherapist is satisfied that valid consent has been obtained, including situations where global consent has been given for other disciplines besides physiotherapy to be included in an integrated care pathway. Consent may be implied, for example, by the patient self-positioning for therapy, by word of mouth or in writing. The physiotherapist should document in the clinical notes when consent is received, either implied or expressed. Some employers such as National Health Service Trusts, may have their own policies on the management of consent for examination and treatment which detail specific types of treatment, including physiotherapy, which require the use of written consent forms. For high risk or invasive procedures, written consent may be obtained. For example, graduated mobilisation and manipulation may lead to a Grade V cervical manipulation being used as a progression of treatment. The physiotherapist is not expected to interrupt the rhythm or flow of a procedure to ask for a signature, but should ensure that the patient is given appropriate information and is in agreement to the progression of treatment, and that due care has been taken when assessing the patient for the suitability of the technique. Other examples include vaginal and rectal examination, catheter suction, and exercise tolerance tests on patients with cardiac conditions. Unlawful touching, even therapeutic touching that is without the consent of the patient, comes within the scope of the criminal offence of assault and battery and the possible civil action of trespass to the person. Emergency treatment may exclude the possibility of formal consent for example, an acutely painful condition or a sports field injury.

The following conditions allow treatment without consent:


Unconscious patients are deemed to have consented to all interventions to maintain life and limb. Any treatment decisions made before the patient became unconscious should however, be taken into account. Common law power to act out of necessity. Patient incompetence. Acute pain and immobility in an emergency situation.

The Mental Health Act (1983) does not cover physiotherapy treatment. Consent is still required for physiotherapy interventions. Panic, indecisiveness, irrationality and mental illness do not in themselves amount to incompetence. However, if medically diagnosed mental impairment or illness renders the patient incapable of understanding or retaining information so that he/she is unable to make an informed decision and assess risks, this may constitute incapacity to consent. This situation needs to be assessed on a regular basis. Refusal of treatment and subsequent action must be documented, and any decisions discussed with the team. Relatives cannot give valid consent for adult patients unless
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they have specific powers granted by the court. Their opinion should, however be considered and respected. Even where a patient is unable to give or refuse consent any reaction (eg distress) should be considered in the team decision.

Other issues affecting the informed consent process


Much has been written about the informed consent process and members are recommended to read as widely as possible on this subject. The following are additional issues for consideration: Balance of power Patients are often either in an undressed state, in bed or on a couch; the therapist is dressed in a uniform and in a standing position. This means that the therapist is in a position of power, with the patient in the position of submission. Additionally the patient may be in pain, anxious or afraid and in unfamiliar surroundings; the therapist having the power of relieving pain, anxiety and physical impairment. This inequality can inhibit the exchange of information, perhaps depriving the therapist of vital knowledge affecting the care of the patient. Therapists are advised to try to reduce this imbalance of power as far as possible, for example, by taking a history, and other background information with the patient fully clothed and with both sitting facing each other to encourage eye contact. It is vital that respect and dignity be afforded the patient at all times as a precursor of understanding leading to informed consent obtained by a listening therapist. Environment Hospitals and their physiotherapy departments may be intimidating places and patients may need to be reassured and supported while they become accustomed to unfamiliar surroundings. GP surgeries and physiotherapists private practices may be less intimidating. In the domiciliary situation, the patient may be in the dominant position and sensitivity to the situation is needed to ensure that the appropriate flow of information takes place and the therapeutic relationship is established. Consent for research Patients/people who may be potential research subjects must make an informed decision as to whether to enrol or continue to participate in any study. Subjects should be fully informed about the purpose of research, its procedures, potential risks, potential benefits and alternatives, especially if treatments may not be funded or available other than through the trial. They should be given the opportunity to ask questions and also to be informed of their right to decline to participate in the physiotherapy research at any stage without it prejudicing their future care. Further information is available in the NHS Research Governance document Research Governance Framework for Health and Social Care.

2.2

Touching patients The very nature of the practice of what is primarily a handling profession means that physiotherapists handle patients when examining, testing muscle strength, assessing tone, and measuring range of movement; or during treatment, when instructing and positioning, facilitating movement, massage, mobilisation, manipulation and so on. Patients are often in a state of undress and close contact may be made with the patient in the implementation of a particular regime or treatment. This handling and contact must be carefully explained, permission obtained to ensure that the patient is

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adequately prepared. Otherwise, practice is open to misunderstanding and misinterpretation which can lay a member open to allegations of assault or even indecent assault. Therefore, consent must be sought from patients prior to the commencement of any assessment leading to treatment and before any contact is made. Patients may have valid reasons for not wishing to remove clothing or to be touched, which may not constitute an overall refusal of treatment. Physiotherapists need to be sensitive to this possibility. The therapist should offer a full explanation that this action by the patient will not necessarily result in a refusal to treat but may require a modification of treatment. In many cases, it is essential to remove clothes otherwise the therapist may be negligent in failing to observe significant symptoms, such as colour of skin, tumour etc, for which the proposed treatment may be contra indicated. Treatment may be possible with clothes on but assessment is not. By proceeding to treat the patient with clothes on and by not touching, the patients confidence and cooperation may be gained, leading to consent to undress. In best practice, the physiotherapist should explain what is likely to happen during examination and/or without the formality of asking if the patient may be touched by saying, for example, I am just going to hold your leg to see how far the ankle and knee bends. The patient usually gives implied consent to this by offering up the limb which is to be tested or treated ready for the physiotherapist. Obviously, this cannot happen at all times, and the physiotherapist must exercise professional judgement and common sense. The physiotherapist should be alert to unspoken signals from the patient as to whether they are comfortable during handling. At all times, the patient must be suitably clothed or appropriate covering must be supplied by the physiotherapist. 2.3 Record keeping One of the rights every patient expects is that their medical records are full, clear and held securely. The duty of the physiotherapist, as part of the scope of practice and to comply with the patients right, is to ensure that a full physiotherapeutic record is maintained. Core Standards 14 and 15 and Service Standard 19 provide further details. Further information is available in the form of a PA information paper PA47 General Principles of Record Keeping and Access to Health Records. 2.4 Reluctance to treat a particular patient It is important that, if a physiotherapist has either conscientious or moral objections to treating a patient, these are clearly recognised and discussed with an experienced colleague. Discussion should also occur if the physiotherapist objects to treating a patient on the grounds that the patients behaviour towards the therapist is unacceptable (eg salacious behaviour which makes the therapist feel uncomfortable when treating the patient). If, however, the reason for not wishing to treat a patient is because of his/her sex, religion, race, sexual orientation or medical condition, it is unlikely that any change of physiotherapist would be appropriate or should be tolerated. Physiotherapists may, from time to time, be required to care for people whose views or behaviour they might find personally unacceptable. When patients express views or behave in ways which are offensive or harmful to others, physiotherapists are entitled to take reasonable steps to protect both themselves and others. This requires considerable tact and sensitivity. Physiotherapists must not respond in an abusive manner to physical or verbal abuse. Physiotherapists can, however, make patients aware when their behaviour has become unacceptable or potentially harmful to themselves, to other staff, or to other patients. If, in the therapists opinion, a patient may be dangerous or unstable, treatment can be withheld. In the employed setting, referral to, or the seeking of advice from, an experienced colleague is important. In the self-employed sector, where the contract is directly between the therapist and the patient, the therapist may refuse to treat a patient. In these circumstances, it is important that any referring medical practitioner is informed and, if appropriate, an
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explanation should be given to the patient. 2.5 Use of chaperones The Industrial Relations department has produced a guidance document on Chaperoning and Related Issues. The document introduces the subject and covers a number of pertinent issues, including: Identification of groups of members who may be particularly vulnerable to allegations of indecent or inappropriate behaviour Specific measures that can be taken to minimise the risk of such allegations being made Consent and documentation Treatment techniques which may lead to an increased risk of such allegations.

2.6

Patients and their refusal of care Levels of violence and aggressive behaviour by patients against NHS staff have risen steadily in recent years. It is totally unacceptable for any physiotherapist to be abused (physically or verbally), harassed or threatened by any patients, their relatives or other members of the public. Examples of such behaviour may include refusal by the patient to be treated by a physiotherapist from a particular ethnic/racial background, or verbal or physical abuse of a racial nature. Employers have a legal obligation under health and safety laws to ensure the safety and well being of their staff and should have policies in place (which are clearly advertised within departments) to deal with any incidents which arise. Patients have the right to consent to treatment and care and to expect the persons delivering care to be competent to do so. They do not, however, have the right to select or reject the person who intends to deliver the treatment/care on the grounds of prejudice. The concept of patients rights carries with it a responsibility on patients to refrain from aggression and prejudice towards staff. This is set out in Section 2, Your Commitment to the NHS in Your guide to the NHS. Patients may have strong personal or cultural reasons for seeking care from either a male or a female physiotherapist. Although patients do not have a right within Your guide to the NHS to state a preference, their views should be taken into account when planning care. Physiotherapists need to be aware that some patients who exhibit difficult behaviour may be anxious. It is the duty of the physiotherapist to take this into account and to be able to respond in a therapeutic manner. On occasion, however, it may not be possible to establish the therapeutic relationship which is so vital in the physiotherapy process. In these circumstances the physiotherapist and the patient with, if applicable, a senior colleague should discuss the situation and the patient should be referred to another physiotherapist, if possible. Members of staff who experience such behaviour must record the incident in the relevant reporting book and bring it to the attention of their manager. The manager should discuss the various courses of action with the staff member, such as whether they wish to continue treating the patient. Managers must inform any patients or other members of the public that such behaviour is intolerable and explain what action will be taken if the behaviour continues. The manager should also make it clear that if the perpetrator continues to behave inappropriately, treatment may be withdrawn.

2.7

Interpreters It is still the case that some service users whose first language is not English, or who are unable to speak English, are accompanied by a family member who acts as an

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interpreter between the patient and clinician. The use of children to carry out this function is likely to be inappropriate. Patients may be embarrassed to discuss intimate details about their health in front of children or indeed other relatives or carers and so important information may be missed. The person interpreting may also have difficulties in understanding the language used by the clinician resulting in inaccurate information being relayed to the patient. Every attempt should be made to select a suitable interpreter through appropriate channels with the skills and experience to provide an effective interpretation service. It is advisable to ensure that the name of the interpreter is recorded in the records or elsewhere. 2.8 Inappropriate relationships with patients The therapeutic relationship between a physiotherapist and their patient must be based on mutual trust and respect. A physiotherapist who exploits this relationship, either within or outside the treatment environment, is acting in contravention of these Rules. Patients may also seek to exploit this relationship. Physiotherapists must be alert to any signs of this happening and take steps to restore the appropriate interaction or to withdraw from the situation. It is forbidden for a physiotherapist to have sexual relations with a patient. Members are reminded that it may be a criminal offence for a clinical practitioner to have sexual relations with a patient. It is an offence if the patient is under 16, is incapable of giving consent, or of full age without consent ie rape. It is also a specific offence under the Mental Health Act (1983). Members have had, and do have, close relationships with former patients. Both the therapist and the patient must, however, be clear that this is well outside the therapeutic contact. If therapy is re-commenced or continued, this must be undertaken by another practitioner. It is usually clear when a therapeutic relationship is becoming improper in respect of emotional or sexual relations. Members are reminded, however, that conversations which include references to politics, religion or sex can also be inappropriate. 2.9 The legal framework within which physiotherapists practice Chartered physiotherapists, as well as working to Rules of Professional Conduct, are also expected to work within the law of the land relating to the practice of their profession within the constraints of the country within which they work. If a member works outside their personal scope of practice, or practises in such a way that causes damage to a patient, a patient may have cause to claim under the civil law of negligence. Negligence is defined as a breach of the duty of care which results in damage. A patient is required to show causation, ie that the damage or injury suffered was due to a negligent act or omission on the part of the practitioner. An error of judgement may not necessarily constitute a negligent act, even if damage is caused. Unfortunately, in any risk-taking profession accidents do occur. If the physiotherapist believes damage has occurred when treating a patient, it is important that a full record of the incident is made. Any accident or incident documentation should be completed as soon as possible after the incident, completely and appropriately signed and stored safely with the patients records. It is rare for a physiotherapist to be sued by a patient. There is evidence, however, of increasing litigation by patients. Members are reminded that by working safely, effectively and by maintaining full records it is unlikely that they will be subject to a claim in negligence. Further information about negligence and about being a witness of fact (ie being a witness in respect of any negligence claim) is set out in the Legal Work Pack, available from the Professional Affairs Department. Again, it is important to emphasise that a full, complete and adequate record of the patient with detailed information regarding any incident should be available to both the therapist and the
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court. Physiotherapy is a profession that has a licence to touch patients. It is, however, incumbent upon the physiotherapist to ensure that patients are aware of when and how touching will take place in the physiotherapeutic process. Physiotherapists use touch for diagnostic purposes, and therefore, when patients are to be examined, they must be informed of how the examination will take place, what clothes need to be removed and why, and what is to be expected. Physiotherapists often get very close to their patients and this also needs to be carefully explained. If a patient refuses treatment, following careful discussion with the patient about the possible effects of such a refusal and a full record made, a physiotherapist must not proceed with that treatment. If touching without consent takes place, an action may be brought in the criminal courts for assault or even indecent assault (if an improper motive can be proved). A civil tort of trespass to the person may also be pursued. Physiotherapists, therefore, need to be very aware of patients susceptibilities to being both unclothed and touched, and explain fully and carefully any processes that will be implemented. They may, on occasions, defer a preferred treatment if a patient is clearly uncomfortable in the unclothed state or when being handled. Information regarding a number of relevant Acts of Parliament are set out in Appendix 1 of these Rules.

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3
rule

Confidentiality
Chartered physiotherapists shall ensure the confidentiality and security of information acquired in a professional capacity. The Data Protection Act (1998) forms the legal framework for this Rule and a number of NHS circulars are also relevant. This Rule outlines the physiotherapists responsibilities in relation to the confidentiality and security of information gained by him/her during the course of practice. All the information, which the patient gives to the physiotherapist, is treated in the strictest confidence. All personnel (eg clerical and reception staff) involved with patients in the delivery of a physiotherapy service should be made aware of and adhere to all aspects of this Rule. Physiotherapy information is only released to sources other than those immediately involved in the patients care where there is a signed patient consent form. This is unless the physiotherapist is required to do so under statutory authority or so directed by a competent legal authority such as a judge, solicitor representing the patient and acting with consent, or where it is necessary to protect the welfare of the patient or to prevent harm, or if it is (rarely) justified in the public interest. If there is any doubt, the Chartered physiotherapist should seek advice either from their line manager or the Chartered Society of Physiotherapy. The Standards of Physiotherapy Practice, particularly Core Standards 3, 12, 13, 14 and 15 and Service Standards 19 and 20, provide explicit statements to assist physiotherapists in the practical application of all aspects of this Rule. The following bullet points give examples and offer guidance as to how to deal with some of the complex situations, which arise in respect of confidentiality: If a telephone call is received in a physiotherapy department, unless the physiotherapist is confident that they recognise the voice of an anxious relative, the caller must be informed that no information about the patient can be divulged Messages from the physiotherapist should not be left on a patients un-screened answer phone without permission Information relating to confirmation of an appointment and/or notification of attendance for physiotherapy must be treated as confidential If a patient is proposing to undertake an activity, which because of their clinical and/or other condition could be harmful to themselves and/or others (eg driving or operating potentially dangerous machinery) the physiotherapist must try to persuade the patient not to undertake this activity, usually by informing the patient of the possible consequences of doing so. However, if the physiotherapist is unsuccessful, he/she should inform the patients doctor or other relevant authority, having first informed the patient of the action proposed.

Use of identifiable clinical information


The written informed consent of patients must be obtained before using identifiable clinical information, such as photographs and videos. Wherever possible, such material should be anonymised (merely blanking out the eyes of a facial photograph is not acceptable).

Use of information for the purposes of audit and research


All the information which the patient gives to the physiotherapist in the course of the research or audit must be treated in the strictest confidence. The patient must sign an
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informed consent form for any information obtained during the audit or research project, which may identify that individual patient (refer to Rule 2.1, section on consent for research). 3.1 The multi-professional team Much valuable and necessary information is exchanged within multi-professional team meetings. However, it may not be usual for the patient to be present during such a conference and the patient may sometimes be unaware that such a conference is being held. Research shows that patients do expect sharing of information between team members involved in their care with the best interests of the patient in mind. It is, therefore, important that all members of the team are aware that confidential information is being exchanged. Only relevant and factual information can be divulged and no gossip can take place. It may also be appropriate for meetings to be arranged in such a way that only the professionals involved with the care of that patient are present in the discussion. If a patient and/or his/her carers have not been involved in the conference, a named person should be identified to report back to the patient. 3.2 Requests for information

From the patient


In some cases, patients are unaware of their diagnosis, eg carcinoma or a chronic degenerative neurological condition such as Multiple Sclerosis or Parkinsons Disease. Patients may be unsure as to why they have been referred for physiotherapy and ask the physiotherapist for their diagnosis. Such information should only be given to the patient by the health professional (in most cases this will be the patients doctor) who has overall responsibility for the patient. Rapid contact with the doctor to inform him/her that the patient is requesting this information is essential, if necessary indicating the dilemma faced by the physiotherapist with a patient who does not know the reason for referral to physiotherapy. This also applies to the results of investigations outside those relating to physiotherapy. However, special rules of collaborative practice may apply in some circumstances, such as hospices.

From neighbours and other patients


With patients both in hospital and in the community, the physiotherapist is a frequent and regular presence, and may receive enquiries about other patients and neighbours. Physiotherapists must be vigilant to ensure that they do not disclose any confidential information.

From official sources such as DSS, solicitors, etc


Before disclosing any information, written consent from the patient must be obtained. The Societys Legal Work Pack provides further advice regarding the disclosure of information to members of the legal profession.

From supervisors/managers of employees


Before disclosing any information, written consent must be obtained from the patient.

Other competent authorities


The nature of the authority should be verified and the patients permission sought prior to disclosing information, eg a private health insurance company with whom the patient has a contract. 3.3
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Extraneous information
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The following are some examples of information/knowledge that physiotherapists acquire during the course of practice, and some suggestions as to ways of dealing with them.

Knowledge of criminal activities


A physiotherapist recently became aware, when visiting a patient, of discussions going on in an adjoining room regarding robbing a local bank. After discussion with the line manager the police authority was informed.

Evidence of abuse
Physical, sexual or psychological - either of the patient or another involved party. Immediate discussions with a senior colleague and referral to an appropriate professional, such as a doctor, a health visitor or an agency such as Social Services is essential. The Children Act (1989) provides clear guidance to professionals when abuse of children is discovered.

Environmental issues
Where there is evidence of environmental problems, such as infestation by fleas or mice, or excessive damp or structural damage in a patients home, members should inform their Service Manager, the relevant doctor, or other appropriate authority. 3.4 Security of information Patients clinical records, whether held in paper or electronic format, must be stored in a secure manner. For community physiotherapists who may be unable to attend a base hospital at the beginning and end of the day, arrangements must be made to ensure that any patient records are held securely, preferably in a fire resistant lockable cabinet, or, when being transported, in the locked car boot and not left in a car overnight. The holding of electronic records must comply with local Trust protocols, usually administered by Caldicott guardians and in conjunction with the Data Protection Act (1998). When passing sensitive and confidential information via email, it must be transmitted by a secure server or be encrypted. If a fax is used, ensure the person who requires the information is available to receive it directly, usually by making immediate contact before transmitting the information.

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4
rule

Relationships with professional staff and carers


Chartered physiotherapists shall communicate and cooperate with professional staff and other carers in the interests, and with the consent, of their patient; and shall avoid inappropriate criticism of any of them. This Rule relates to the cooperation and communication which physiotherapists are expected to undertake when dealing with professionals and others associated with the care of their patient. Physiotherapists shall work in such a way as to promote good health in a clinically effective manner with due consideration of cost. This may involve working in various locations and within multi-disciplinary and inter-agency teams. Physiotherapy is an autonomous profession and the responsibility for assessment and subsequent treatment remains with individual physiotherapists. Written or verbal referrals may be accepted from all sources, (eg medical practitioners, other health professionals and self referrals). Chartered physiotherapists are reminded that they are legally liable for the treatment, teaching and advice carried out following assessment. This applies regardless of whether the treatment requested by a medical practitioner is found to be appropriate, following assessment of the patient by the physiotherapist, and is subsequently carried out or not. In some instances, there may be local agreement regarding the limitation of access to the service by operating a medical referral-only system. It should be openly acknowledged that this referral system is not a requirement of professional physiotherapy practice but is employed as a management strategy. Rule 4 does not preclude Chartered physiotherapists from working only from a written medical referral. However, the responsibility for physiotherapy assessment and treatment is that of the Chartered physiotherapist. Opting to work in this way does not lessen this responsibility in any way. It is also acknowledged to be unlikely that any referral to a Chartered physiotherapist can be called inappropriate before assessment is undertaken. This is because the responsibility lies with the physiotherapist to identify whether or not physiotherapy is indicated. Therefore, clinical criteria must be established to ensure that clear objectives are agreed for any intervention. Chartered physiotherapists have a threefold responsibility to ensure that intervention on the basis of their assessment is necessary and appropriate: To the patient; to make sure that expectations are not raised that cannot be fulfilled, and not to waste time or treat patients to whom the treatment would not be beneficial or has ceased to be beneficial. To themselves; by treating a patient who does not require such treatment, a Chartered physiotherapist could be in contravention of a Rule of Professional Conduct. It is morally wrong to give treatment when it is not required or when referral to another agency is necessary or more appropriate. To the employer; whether self employed or employed through a health Trust, private hospital or industrial concern, it is ethically wrong to waste time and money by treating patients unnecessarily.

Referrals received from medical practitioners and other health care practitioners requesting physiotherapy please are dealt with in the above manner and to a large extent raise no problems. If it is decided that physiotherapy is not appropriate, the referrer should be informed. This enhances the understanding of colleagues about the role of physiotherapy. 4.1 Prescriptive referrals

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Some physiotherapy referrals are contentious. Usually, these are prescriptive referrals and tend to fall into three categories: Requests for particular modalities of treatment that would be actively harmful to the patient. Requests for treatment that is unnecessary. Requests for treatment that has doubtful benefits.

Agreed protocols for treatment are not considered in this context.

Actively harmful
Health Circular HC(77)33 Relationships between the Medical and Remedial Professions includes comments by the Joint Consultants Committee. Para.2(ii) states: In asking for treatment by a therapist the doctor is clearly asking for the help of another trained professional, and the profession of medicine and the various therapies differ. It follows from this that the therapist has a duty and a consequential right to decline to perform any therapy which his professional training and expertise suggests is actively harmful to the patient. Equally, the doctor who is responsible for the patient has the right to instruct the therapist not to carry out certain forms of treatment which he believes harmful to the patient. Medical colleagues have, therefore, clearly acknowledged that Chartered physiotherapists have the right to refuse to treat a patient when the treatment requested is considered to be actively harmful. It would be courteous in these circumstances and beneficial to the patient to discuss the matter with the medical practitioner and suggest other courses of management, based on the physiotherapy assessment.

Unnecessary treatment
If it is clear that a request is inappropriate or cannot be justified in the terms of possible benefits or available resources, the referring medical practitioner must be approached and the responsibilities of the therapist explained as set out above. If the medical practitioner persists in making such inappropriate requests, it may be necessary for a more formal approach to be made by a senior clinical physiotherapist or service manager. Prescription of the number of sessions required within or outside a specified time span, to fulfil a therapeutic intervention should also be challenged. An information paper with regard to the rationing of physiotherapy is available from the Professional Affairs Department.

Treatment of dubious benefit


Many modalities of physiotherapy, although appearing to have a beneficial effect, have not been evaluated or researched. It is the responsibility of each individual physiotherapist to keep up to date in respect of the research and evaluation of modalities and approaches to the care of various conditions. As research and evaluation develops, many treatments considered to be safe or efficacious are now proving to be less so. Indeed, the claims for some treatments are regarded as discredited. It is therefore important that the therapist can demonstrate knowledge and refer to these findings when dealing with requests for treatments of dubious benefit with the referring medical practitioner or a patient. It is important that the physiotherapist is regarded as the expert about the body of knowledge that is considered to be, or classified as, physiotherapy. Much of the above explanation deals with relationships with medical colleagues.
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Physiotherapists, however, work with a wide range of health and social care practitioners, as well as with teachers, relatives, informal and formal carers and patients. At all times, these working relationships must be directed for the benefit of the patient and his/her family to provide as high a quality of care as possible. Information relating to the care of the patient must only be divulged in accordance with the guidelines set out in Rule 3. Multi-professional care plans, protocols and pathways which benefit the care of a patient individually or collectively are part of communication and cooperation as set out in this Rule. Physiotherapists are also expected to work closely with other physiotherapist colleagues. Full communication must exist in the best interest of patient care. Physiotherapists taking over the treatment of a particular patient may, following assessment, decide to change the treatment radically. This could be construed by the patient as a criticism of the previous therapist and should be fully explained, (eg different level of skill/area of expertise). Guidelines are available to members from the Professional Affairs Department in respect of patients seeking care in both the private and public sector. Members are expected not to criticise publicly any colleague, either verbally or in writing, to the patient, to any member of the health care team or to others. The consequences of such criticism can be far reaching. This does not, however, preclude members from giving expert evidence in court about the alleged negligent activities of a colleague. Such members are expected to be objective and able to support their evidence by appropriate references. If a member, however, feels the evidence presented by an expert witness or a colleague, has caused damaged, that member can take action through this Rule. 4.2 Whistle blowing It is essential that all Chartered physiotherapists are aware of mechanisms which are available to them regarding whistle blowing. Members employed in the NHS should be aware of the nominated officer within their Trust, and should feel comfortable to seek advice should untoward circumstances present. All staff are protected in these circumstances. Outside the NHS, physiotherapists should seek advice from the CSP, the Organisation of Chartered Physiotherapists in Private Practice or the Association of Chartered Physiotherapists in Independent Hospitals and Charities, as appropriate. Whistle blowing must not be used to resolve personal, partnership or business disputes. In these cases, any areas of concern must be raised with the individual therapist first.

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5
rule

Duty to report
Chartered physiotherapists have a duty to report, to an appropriate authority, circumstances which may put patients or others at risk. Chartered physiotherapists work within a variety of environments, both within and outside the hospital setting. All environments can present risks for the patient, carer and therapist, from the obvious (eg steep stairs without grab rails in the home situation) to the less obvious (eg poorly lit areas in a physiotherapy department). Members are expected to be aware of health and safety rules and procedures and to ensure that both their patients, colleagues and they themselves comply with these. In the course of treatment, patients are encouraged to take calculated clinical risks to take forward the rehabilitation process and reach their maximum potential. Physiotherapists are expected to assess the risks, to explain them to patients, supervise practice and to record where appropriate. Further details regarding risk assessment in relation to Manual Handling are available from the Professional Affairs Department. Risks relating to other personnel caring for the patient are also the responsibility of a physiotherapist. This may include the levels of staffing required for maintenance of a rehabilitation programme, including the safe manual handling of a patient. This must be safe for both the patient, the carers (general fitness and suitability of a home carer) and the physiotherapist. The physiotherapist is, therefore, required to assess all risks relating to the overall physiotherapeutic care of the patient. In the NHS, any risks identified that cannot be dealt with by the physiotherapist or the therapy service must be reported by the therapy manager, usually in writing, to the appropriate authority. In the private sector, any risks identified that cannot be dealt with by the physiotherapist should be directed to the referring clinician or appropriate authority. Senior medical practitioners have been suspended by the General Medical Council for not reporting the known and acknowledged incompetent level of practice of a colleague. The Secretary of State for Health has supported the action of colleagues reporting incompetent behaviour to the appropriate authority. Members are therefore advised to ensure that they maintain their own competency as advised in Rule 1, assist colleagues to maintain their own standards and levels of practice and to report incompetent practice to the appropriate authority in the best interests of patient care. Much has been written and discussed in the past few years regarding whistle blowing in the NHS. Members are reminded that if they have a concern regarding staffing levels, rationing of care or other Trust activities which they believe endangers patients or discriminates in some way, they must take it through the Trust procedures before going public. More detail is given in the explanatory note of Rule 4.

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6
rule

Advertising
Chartered physiotherapists shall ensure that advertising in respect of their professional activities is accurate and professionally restrained. This Rule sets out the parameters within which members can advertise. An advertisement must be professionally restrained, accurate, legal, decent, honest and truthful. Because of the importance of the maintenance of the patient/therapist relationship, it is unethical to appeal in person to potential patients, whether such appeals are made face-to-face or by telephone. However, advertising via a website, leaflets, or advertisements in free newspapers which can be accessed directly by potential patients is acceptable. Advertisements, whether written or audio-visual, should not be false, fraudulent, misleading, deceptive, self-laudatory, unfair or sensational. This also applies to the use of qualifications and titles. It is undesirable (but not unethical) to use too many qualifications; three are considered acceptable. Claims of superiority over other practitioners in respect of personal skills, equipment or facilities must not be made. Members may, however, call themselves specialists if they fulfil the criteria identified by the CSP. Further information is contained in an information paper available from the Professional Affairs Department PA23 Specialisms and Specialists: Guidance for Developing the Clinical Specialist Role. Physiotherapists should publicise the profession and the practice of physiotherapy but they should act in a restrained manner in respect of their personal professional practice.

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7
rule

Sale of services and goods


Chartered physiotherapists shall not sell, supply, endorse or promote the sale of services or goods in ways which exploit the professional relationship with their patient. Chartered physiotherapists should only sell or supply goods or services in clinical practice after they have satisfied themselves that the item in question is appropriate to the individual patients condition. Any handling charge on the sale of goods or services should be reasonable. Chartered physiotherapists should not accept commission from a third party for recommending, when practising, the purchase of goods or services. Primarily, physiotherapists working outside the public or employed sector are selling the services of a Chartered physiotherapist. Members are therefore expected to ensure that, following a detailed assessment, appropriate care is given. Patients must be informed of the likely length and cost of that intervention and the fees charged must be reasonable. See the threefold responsibility of Chartered physiotherapists as set out in Rule 4. Excessive charging or over treatment could facilitate a complaint alleging contravention of this Rule. This Rule refers expressly to the clinical context and the supplying of appliances, supports etc to patients and to charging for them. Within the NHS, there are clear guidelines set down for the supply of these goods and the charges to be made. Within the private sector, it is reasonable for a handling charge to be added to the cost of an item. It would, however, be unethical for a mark-up to be made that was so high as to constitute exploitation of the relationship with the patient and to go beyond normal commercial good practice.

7.1

Setting up a business supplying equipment Increasingly members are setting up businesses, including e-commerce, supplying a whole range of equipment and services. Often this is done in addition to continuing to practise. It is important that these two activities are kept separate and that the recommending or supplying of any equipment to a patient fulfils the criteria set down in these Rules and is not seen to benefit the physiotherapist commercially.

7.2

Inventing or adapting equipment Physiotherapists have often been inventive and, with manufacturers or on their own, have developed new pieces of equipment, appliances or supports and have gone on to manufacture, promote and sell these items. This again is perfectly legitimate and can be an appropriate activity for Chartered physiotherapists and will not contravene this Rule in any way, if not linked with direct clinical practice which exploits the professional relationship with individual patients. Members should, however, be aware of the legal limitations when adapting or modifying equipment and be aware of any obligations in respect of product liability.

7.3

Endorsing a product Manufacturers are always looking for endorsement and promotion of their products and to be able to advertise these. Naming a Chartered physiotherapist who recommends wide use of a piece of equipment, cold pack, support or other device, is very useful to them. Members are therefore advised to think very carefully before involving themselves in any trials etc. Negative results are rarely if ever published. It is important to be clear as to how a members name, practice or hospital could be used in subsequent advertising and also what reward they may receive for such a trial or suggestion for a change of design. If, however, the product has merit and the therapists/departments would like their names associated with it, this would be ethical. Promoting or selling the product to patients as

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part of clinical practice and receiving a commission would not be ethical. If members have any doubts about any activity concerning this issue, the acid test is will this affect the patient/physiotherapist relationship; is it exploiting the direct clinical practice situation? If so, it is unethical. If not, it is probably ethical but it is always wise to be very clear how your involvement will be used. If you have any further doubts contact the Professional Affairs Department at the Chartered Society of Physiotherapy who will be happy to discuss the situation with you.

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8
rule

Personal and professional standards


Chartered physiotherapists shall adhere at all times to personal and professional standards which reflect credit on the profession; behaviour, approach and dress should not cause offence to the patient and carer. This Rule has been deliberately framed as a general statement, recognising that it is impossible to specify in precise terms everything that could be considered to be professional misconduct now and in the future. The following provide examples of incidents that may be brought to the attention of the Chartered Society and which could lead to the professional disciplinary procedures being invoked.

8.1

Conviction by a Court Any conviction of a member by a court of law may be evidence that a physiotherapists continued practice may imply some risk to the public. In addition it may reflect adversely on the profession. It is therefore appropriate for the Society to consider all the circumstances leading to such a conviction. There will obviously be cases of a minor and/or personal nature where no action by the Chartered Society is required. When such cases are drawn to the CSPs attention, they will normally be dealt with informally. If the member believes he/she has a defence, it is important that a member who is charged with a criminal offence should not plead guilty. The acceptance by the court of such a guilty plea would (at least without legal advice) lead to a conviction, and subject the member to the professional disciplinary procedures.

8.2

Disciplinary procedure by the State Registration Board Any adverse findings by the Physiotherapists Board of the Council for Professions Supplementary to Medicine (CPSM), the Health Professions Council (HPC) from April 2002, will be reported to the Chartered Society and will render a member liable to disciplinary proceedings in line with the Societys own regulations. Matters raised before the Physiotherapists Board (HPC) may also be raised as a breach of the Societys Rules of Professional Conduct.

8.3

Disciplinary proceedings by an employer Disciplinary proceedings by an employer culminating in dismissal from employment may also lead to a charge of professional misconduct. This applies even if the member has been involved in related court proceedings which have not resulted in conviction. Disciplinary proceedings by an employer leading to punishment short of dismissal (eg a reprimand) will not normally give rise to disciplinary action by the Chartered Society unless the circumstances are sufficient to find a complaint under another section of the Rules of Professional Conduct.

8.4

Personal conduct derogatory to the reputation of the profession Personal conduct which does not lead to conviction by a court of law or disciplinary action by an employer may give rise to disciplinary action by the Chartered Society if such conduct is judged to be derogatory to the reputation of the profession, (for instance, dishonesty and indecent or violent behaviour). Abuse of alcohol or drugs will normally be dealt with as a health matter, but could also be the subject of disciplinary proceedings.

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Conclusion
The information and advice given in this document supports and expands the Chartered Society of Physiotherapys Rules of Professional Conduct. The advice and examples given are not exhaustive and members, if in doubt, can seek further advice from the Society.

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Appendix 1
Disability Discrimination Act (1995)
Section 21 of the Disability Discrimination Act (1995) requires all service providers, including providers of health and social care services, whether within or outside the NHS to: take reasonable steps to change practices, policies or procedures which make it impossible or unreasonably difficult for disabled people to access a service provide auxiliary aids or services which would make it easier for, or enable disabled people to use a service overcome physical features which make it impossible or unreasonably difficult for disabled people to use a service by providing a service by a reasonable alternative means.

The NHS Executive issued Health Service Circular HSC 1999/156 in July 1999. This sets out the action that all NHS employers are expected to take to implement Section 21. It includes a report entitled: Working in Partnership to Implement Section 21 of the Disability Discrimination Act across the Health Service. This report provides a framework of good practice and includes a detailed checklist and audit tool to help service providers ensure that they have covered every area of their service. The CSP has also produced Guidelines on Disability which set out the Societys stance on disability issues and its promotion of best practice in this area. This is available from the Industrial Relations Department.

Human Rights Act (1998)


The Human Rights Act (1998) came into force in the UK on 2 October 2000. Potentially, this legislation could have enormous implications for the rights of all people, although the full extent of its impact will not be known until test cases have come before the courts. Among the most relevant for physiotherapy service providers will be: Article 2, the right to life Article 3, which includes the right not to be subjected to inhuman or degrading treatment Article 8, the right to respect for private and family life, home and correspondence Article 9, the right to freedom of thought, conscience and religion, including the right to manifest religion or belief in worship, teaching, practice and observance Article 14, the right to enjoy all other Convention rights without discrimination on grounds such as sex, race, colour, language, religion, political or other opinion, national or social origin, association with a national minority, property, birth or other status.

Sex Discrimination Act 1975 (amended 1986)


The Sex Discrimination Act (SDA) and Sex Discrimination (Northern Ireland) Order make it unlawful to discriminate on grounds of sex. Discrimination is not allowed in employment, education, advertising or when providing housing, goods, services or facilities. It is unlawful to discriminate in employment or advertisements for jobs because someone is married. The Equal Pay Act (EPA) (1975) (amended 1984) states that women must be paid the same as men when they are performing equal work. Discrimination is defined as: Direct discrimination: treating someone unfairly because of sex. Indirect discrimination: setting unjustifiable conditions that appear to apply to everyone but in fact discriminate against one sex.

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Victimisation: being treated unfairly for trying to exercise rights under the SDA, Order or EPA. Employers must not discriminate against a person because of their sex or because they are married. This applies to recruitment, treatment in the job, chances for promotion and training, dismissal or redundancy.

Race Relations Act (1976) as amended by Race Relations (Amendment) Act 2000
The Race Relations Act (1976) makes it unlawful to discriminate against anyone on grounds of race, colour, nationality (including citizenship) or ethnic or national origin. The Race Relations (Northern Ireland) Order also includes religious belief or political opinion. It applies to jobs, housing, training, provision of goods, facilities and services, housing and education. Discrimination includes: Direct racial discrimination: when someone is treated less favourably on racial grounds than others in similar circumstances. It includes racist abuse and harassment. Indirect racial discrimination: when people from a particular racial group are less likely to be able to comply with a requirement or condition and the requirement cannot be justified other than on racial grounds. Victimisation: where someone is treated less favourably because they had complained about racial discrimination or supported someone else who had. The Act covers all employers, irrespective of number of employees, and gives protection to most employees including self employed and those working for someone else on a contract. It also applies to anyone providing goods, facilities or services to the public which must not be refused or provided on less favourable terms than offered to people of other racial groups. The Race Relations (Amendment) Act (2000) extends the Race Relations Act (1976) to prohibit discrimination in all functions of public authorities. Anyone whose work involves functions of a public nature must not discriminate on racial grounds while carrying out those functions. This means that all functions of public authorities, including the NHS, will be subject to the Race Relations Act (1976). The Act will also apply to any private or voluntary agency carrying out any public functions, such as providing services for NHS patients. All such activities must be free from racial discrimination. Public authorities such as the NHS must also have due regard to the need to eliminate unlawful discrimination and promote equality of opportunity and good race relations in carrying out their functions. They will be expected to consider the implications for racial equality of everything they do, for example, opening or closing a hospital. The Commission for Racial Equality will be issuing Codes of Practice to provide practical guidance to public authorities on how to fulfil their general and specific duties.

The Children Act (1989)


This Act brings together and consolidates both public and private law relating to children and young persons. The Act repealed large areas of pre-existing law and set up a new framework for the protection and care of children with the establishment of clear principles to guide decision making in relation to their care. The overriding principle is that the childs welfare shall be the Courts paramount consideration. The principles which the law should take into account are as follows: The welfare of the child must be the paramount consideration in court proceedings.

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Wherever possible, the child should be brought up and cared for in his/her own family. Courts should ensure that delay is avoided, and may only make an Order if to do so is better than making no Order at all. Children should be kept informed about what happens to them, and should participate when decisions are made about their future. Parents continue to have parental responsibility for their children, even when their children are no longer living with them. They should be kept informed about their children and participate when decisions are made about their childrens future. Parents with children in need should be helped to bring up their children themselves. This help should be provided as a service to the child and his/her family, and should:

a. be provided in partnership with parents b. meet each childs identified needs c. be appropriate to the childs race, culture, religion and language

d. be open to effective independent representations and complaints and e. draw upon effective partnership between the local authority and other agencies including voluntary agencies. This involvement of the child in the decision-making process is also a major principle. Whilst the considerations set out below apply to specific decisions to be made under The Children Act (1989), there are good reasons for physiotherapists to follow these same considerations in the care of a child, namely: the ascertainable wishes and feelings of the child concerned (considered in the light of his age and understanding) his physical, emotional and educational needs the likely effect on him of any change in his circumstances his age, sex, background and any characteristics of his which the court considers relevant any harm which he has suffered or is at risk of suffering how capable each of his parents, and any other person in relation to whom the court considers the question to be relevant, is of meeting his needs the range of power available to the Court Order, this Act in the proceedings in question.

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Appendix 2
Members of the Review Group
Sue Ashworth LLB MCSP SRP Jane Beard MSc MCSP SRP Coralie E Chinn JP GradDipPhys MCSP SRP Sue England GradDipPhys MCSP SRP Frances Harris MCSP SRP Ruth Hawkes MCSP SRP Kate Moran Rachel Pope MCSP SRP Sally Roberts MCSP SRP Penelope R Robinson MA MCSP SRP Sue Sleeman Claire Sullivan MCSP Maggie Ward MCSP SRP

Members of the External Review Group


Julia Botteley MCSP SRP Professor Norma Brook FCSP SRP Thelma Harvey MCSP SRP Jean Kelly FCSP SRP Vincent Lyles MCSP SRP Owen Moore MCSP SRP Erica Nix MCSP SRP Jane Owen Hutchinson MCSP SRP Philippa White MCSP SRP

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Appendix 3
References and bibliography
Access to Health Records Act (1990) Access to Medical Reports Act (1988) Access to Personal Files Act (1987) Chronically Sick and Disabled Persons Act (1970) Consumer Protection Act (1987) Data Protection Act (1998) Department of Health HC(77)33: Relationships between Medical and Remedial Professions Disability Discrimination Act (1995) EEC Workplace Regulations (1992) Health and Safety at Work Act (1974) Human Rights Act (1998) Mental Health Act (1983) NHS Act (1999) Prevention of Harassment Act (1997) Professions Supplementary to Medicine Act (1960) Race Relations Act (1998) The Children Act (1989)

Chartered Society of Physiotherapy publications


Advice for the Management of Physiotherapy Assistants Bullying at Work IR5 (Red) Chartered Physiotherapists Working as Extended Scope Practitioners PA29 Criteria for the Delegation of Tasks to Assistants PA6 Equipment Safety and Product Liability PA4 General Principles of Record Keeping and Access to Health Records PA47 Guidelines of Good Practice for New Entrants CPD2 Guidance to Members on Chaperoning and Related Issues IR24 (White) Health and Safety Law IR1 (Pink) Legal Advice and Assistance Scheme Leaflet Legal Work Pack Living Wills JB3 Many Happy Returners CPD1 Patients seeking treatment in the Public and Private Sector PA5 Physiotherapists and Insurance PA32 Reports for Legal Purposes PA1 Risk Assessment Policy Statement and Guidance IR3 (Red) Specialisms and Specialists: Guidance for Developing the Clinical Specialist Role PA23 Standards of Physiotherapy Practice 2000 Stress at Work IR1 (Red) The Human Rights Act 1998 IR18 (Blue) The Scope of Physiotherapy Practice PA44 Thinking of Private Practice PA7 Violence at Work IR2 (Red) Working Outside the Scope of Physiotherapy PA21

Department of Health (DoH) documents on informed consent


Health Service Circular HSC (2001) 023: Good Practice in Consent 12 Key Points on Consent: The Law in England Good Practice in Consent Implementation Guide Reference Guide to Consent for Examination Seeking Consent: Working with People with Learning Difficulties

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Working with Older People Working with Children

Guides for Patients: Consent What you have a right to expect Adults Children and Young People People with Learning Disabilities Parents Relatives and Carers

Consent forms are available from: Department of Health, PO Box 777, London SE1 6XH NHS Response Line 0541 555 455 website http://www.doh.gov.uk/consent

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Glossary of terms
Assault Autonomy Balance of probabilities Beneficence A threat of unlawful contact. Autonomy or self-rule or self-determination is based on the principle of respect for the person. The standard of proof in civil proceedings. The principle of beneficence implies the duty to do good. In the negative sense, this is interpreted as preventing harm, in the positive sense it means producing benefits of some kind. The test applied by the courts (taking its name from the case of Bolam v. Friern Hospital Management Committee) on the standard of care expected of a professional in cases of alleged negligence, ie that of the ordinary skilled man exercising and professing to have that special skill. The law recognises that a duty of care will exist where one person can reasonably forsee that his or her actions and omissions could cause reasonably foreseeable harm to another person. A duty of care will always exist between the health professional and the client, but it might not always be easy to identify to which people such a duty extends. Children under 16 years old who have sufficient understanding and intelligence to be capable of making up their own minds can give a valid consent to treatment, which signifies a child who has the maturity and competence to make a decision in the specific circumstances arising. This is the most common tort, being actions brought in situations where the plaintiff/claimant alleges that there has been personal injury or death, or damage or loss of property caused by another. Compensation is sought for the loss which has occurred. To succeed in the action the plaintiff/claimant has to show the following elements: that the defendant owed to the person harmed a duty of care that the defendant was in breach of that duty that the breach of duty caused reasonably foreseeable harm to the plaintiff/claimant.

Bolam test

Duty of care

Gillick competent

Negligence

Tort Vicarious liability Whistle blowing

A civil wrong excluding breach of contract. It covers negligence, trespass (to the person, goods or land), nuisance, breach of statutory duty and defamation. The liability of an employer for the wrongful acts of an employee committed whilst in the course of employment. This is the term which refers to a person (usually an employee) who draws attention to concerns which have health and safety implications.

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Further reading
Legal Aspects of Physiotherapy Bridgit C Dimond 1999 Blackwell Science ISBN 0-632-05108-6 Your Guide to the NHS DoH 2000

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