Treatment is not followed for many reasons. The expert should establish what was recommended, whether it was accessible, why it was not completed and what difference participation would probably have made. The purpose is not to punish the claimant. It is to provide a realistic opinion on causation, prognosis and future treatment.
“Non-compliance” is often too crude.
The word “non-compliance” suggests that the clinician gave an instruction and the patient failed to obey it. Modern healthcare places greater emphasis on shared decision-making. NICE describes treatment decisions as a collaborative process in which the person is informed about the options, benefits, risks and consequences, including the option of declining treatment.
Neutral language is usually better. “The claimant did not complete the recommended treatment” is more accurate than “the claimant was non-compliant”.
Treatment may not have been followed through choice, misunderstanding or practical difficulty. A claimant may fear that exercise will worsen the injury, experience medication side effects, have caring responsibilities or be unable to obtain time away from work. They may also have been placed on a waiting list but never offered an appointment.
These circumstances are not equivalent to repeatedly missing available treatment without explanation.
Confirm what was actually recommended.
The records may state that physiotherapy was “discussed” without showing that a referral was made. A recommendation in an earlier report may not have reached the claimant’s GP. A referral may have been delayed or rejected.
Before drawing conclusions, the expert should identify who recommended the treatment, when it was recommended and whether the claimant understood what was required. They should establish whether it was available through the NHS, privately funded or dependent upon approval from another party.
The treatment must also have been clinically reasonable. A claimant should not be criticised for discontinuing an unsuitable intervention or one that caused adverse effects.
Ask why treatment stopped.
The reason should ordinarily be put to the claimant during the assessment. They may say that physiotherapy increased pain, medication caused side effects or psychological treatment felt too difficult. They may have improved and believed that further treatment was unnecessary. The explanation may also be vague or inconsistent with the records. The expert does not have to accept every explanation, but it should be recorded and considered.
NICE guidance on medicines adherence recommends exploring beliefs, concerns and practical barriers rather than assuming that failure to take medication reflects carelessness. Some decisions are intentional and informed, while others arise from forgetfulness or difficulty managing treatment.
The same reasoning applies to rehabilitation. The significance depends upon why participation ended and whether the barrier could reasonably have been addressed.
Do not assume treatment would have produced recovery.
A recommendation is not proof that treatment would have worked.
Physiotherapy, medication and psychological therapy have variable outcomes. The expert should consider the evidence supporting the intervention, the claimant’s diagnosis and whether any benefit had appeared before treatment stopped.
It may be reasonable to conclude that participation would probably have improved symptoms or accelerated recovery. It may be possible to say only that treatment offered a reasonable prospect of benefit. Sometimes there is insufficient evidence to estimate what difference it would have made.
The GMC requires medical experts to identify the facts and assumptions supporting their opinions and to make clear where conflicting or insufficient evidence prevents a firm conclusion. Practice Direction 35 similarly requires consideration of material facts that may weaken an opinion.
The expert should not invent a shorter recovery period on the assumption that every recommended intervention succeeds.
Reconsider future treatment.
Failure to follow earlier treatment may affect both the explanation for continuing symptoms and recommendations for the future.
The expert should ask whether the present condition is partly maintained by lack of rehabilitation, avoidance or another unresolved barrier. They should then consider whether the same treatment remains appropriate.
Repeating an unsuccessful recommendation without addressing why it failed is rarely helpful. A claimant who stopped medication because of adverse effects may need a review. Someone who avoided physiotherapy through fear may benefit from clearer advice or graded activity. A claimant unable to attend because of work or caring commitments may need a more practical method of delivery.
The report should explain what treatment is now recommended, its purpose, likely duration and probable effect upon prognosis. Where participation remains uncertain, the prognosis may need to be conditional.
Avoid moral judgement.
A person with capacity may decline treatment, even where others consider it beneficial. The expert may explain the medical consequences of that decision, but should not describe the claimant as unreasonable merely because another patient might have chosen differently. GMC guidance begins from the presumption that an adult has capacity to make decisions about treatment, while NICE guidance recognises the option of choosing no treatment.
Failure to follow treatment is not automatic evidence that symptoms are not genuine. Depression may reduce motivation and organisation. Anxiety may make exposure-based treatment difficult. Chronic pain may produce fear of movement. These difficulties can form part of the condition being assessed. Repeatedly missing appointments, giving inconsistent explanations or reporting severe disability while declining reasonable assistance may affect confidence in the history or prognosis. The effect should be explained without turning it into a character judgement.
Give a conditional opinion where necessary.
A useful report may state that symptoms are likely to improve if the claimant undertakes a defined course of treatment, but that recovery may be delayed if they do not.
For example:
“The claimant has not completed the recommended physiotherapy. A further graded programme remains reasonable. With appropriate participation, improvement would be expected over the following three to six months. Without treatment, the prognosis is less certain.”
Where the reason for incomplete treatment remains unclear, further records may be required. An unsupported assumption should not fill the gap.
Treatment history should never become a shortcut to blame. The expert should establish what was offered, whether it was suitable, what prevented participation and how the absence of treatment probably affected the condition.
The proper opinion is not that the claimant failed a treatment plan. It is an explanation of what the incomplete treatment means medically and what can reasonably be done next.
