November 2014

THE BUSINESS MAGAZINE FOR DOCTORS WITH A PRIVATE PRACTICE

Today INDEPENDENT PRACTITIONER

In this issue

handover

Our resident accountant gives advice on how to ensure a good succession on retirement P10

Huge hospital planned

By Robin Stride

Top independent practitioners are set to be given practising privileges in a palatial multi-millionpound international hospital destined for London.

Early plans for the new-build development, which would aim to be a beacon for high-net-worth self-pay patients from overseas, emerged to some parties two years ago – but then the project stalled.

Now, however, discussions about the scheme are gathering renewed intensity as more concrete proposals take shape.

Independent Practitioner Today has been told the venture has some serious financial backing and the search is already underway for the right team to run the facility.

A source said: ‘It’s back on the cards. I don’t know what the hiccough was. They have gone to the extent of retaining a high-end selection business in the UK for the management team.

‘My understanding is that all the funding has come from a strong UK-based enterprise with United States connections. It is not a medical group, but a strong financial concern.

‘There was a “glitch” 18 months ago, but I think you can expect to hear something further in 2015.

‘If you live in Dubai and you are

not well, you have a choice: The Mayo or this new international hospital.’

As well as from the Middle East, ‘ultra-high-end’ patients will, it is said, also be targeted from India and Africa.

There has been a huge drop-off in recent years in the number of overseas patients coming for treatment in the UK.

Many are going instead to newer and more modern hospitals outside of the UK, which have been marketing themselves strongly around the world ( Independent Practitioner Today , February and April 2014).

Initiatives unconnected to the new international hospital were launched earlier this year to find a way of increasing medical business by promoting the ‘Harley Street’ and the ‘London’ brand to overseas patients.

Although the new international hospital is thought likely to have ‘several hundred’ beds, a large proportion of them would not be for patients but for their accompanying staff and relatives. They can expect five-star hotel facilities, including garaging.

The source said: ‘This would be good for London. The capital is seen as a safe haven in a world of turmoil. The UK is a trusted market.

‘Harley Street used to carry a name abroad, but not so much now.

‘If you arrive here and go big here with a project like this, you can have a big market for yourself for ten years.’

Another source, who has been privy to some details of the scheme, commented: ‘Given the current Competition and Markets

ENGLAND CALL-UP

Spire Liverpool Hospital sports medicine consultant Dr Nigel Jones is the new official doctor for the England rugby union team. He is working as official sports medicine consultant and doctor for this year’s autumn internationals and next year’s Six Nations and World Cup. Dr Jones said it was an immense honour. ‘I have acted as official doctor for the under-19s and under-21s before, but this is a different level of workload and intensity. I intend to enjoy every moment.’

Authority investigation (into private healthcare), if you have got London as a magnet attracting more competition, then it will make it easier for existing major players to continue with the estate they’ve got – because there will be more competition.’

Early estimates from observers put the project costs in the order of £600m.

information overlord What’s being done to help private doctors publish their performance measures P12

measured with the same ruler a new regime for inspecting independent hospitals is about to begin P16 it’s good to stalk our marketing expert explains why you should be a ‘cyberstalker’ too P28 a cunning plan ritical points in the life of a doctor when financial decisions should be made P34 windlers’ list eware of investment scams now that pension rules are about to change P43 ore than just a looker

W 4-series shows the car industry is taking a lesson from beauty surgeons P50

Plus our regular columns

Business Dilemmas:

ediTorial commenT

Made to feel a spare part

Many consultants have enjoyed their time in private practice because they have been free from what they see as dictatorial micromanagement by NHS trust functionaries.

But, for some orthopaedic surgeons, it felt like a flashback to past NHS experiences when they opened letters from BMI Healthcare and discovered the real meaning of the newlycoined phrase ‘Orthopaedic Improvement Programme’.

They might have optimistically expected new kit or more support staff. But, instead, the strategy was to make savings by restricting their access to cer -

tain knee and hip prostheses suppliers and brands (see p5).

Howls of dismay erupted from among those affected.

They question: how will the scheme work, should a private hospital dictate what kit consultants use, who tells a patient they will be operated on with a prosthesis that is new to their specialist, and what retraining arrangements will there be?

BMI has toned down its original plans, selecting four suppliers instead of an initial three. We expect consultants with strong cases to be listened to.

They will surely be the first of many facing similar scenarios.

Tell us your news Editorial director Robin Stride at robin@ip-today.co.uk Phone: 07909 997340 @robinstride

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Publisher: Gillian Nineham at gill@ip-today.co.uk Phone: 07767 353897

Head of design: Jonathan Anstee chief sub-editor: Vincent Dawe 12,000 circulation figures verified by the Audit Bureau of Circulations

Doctors to gain from easing of pension taxes

by leslie berry

Senior doctors have welcomed plans to abolish the harsh death tax due on private pensions.

The easing proposal, announced by The Chancellor George Osborne last month, means that individuals can choose to pass their private pots on to loved-ones free of tax because pensions do not form part of a person’s estate for inheritance tax purposes.

Patrick Convey, technical director at specialist financial planners

Cavendish Medical, explained: ‘A higher-rate tax-paying doctor could contribute to a private pension, enjoy tax relief on the sum and then leave it tax-free to loved- ones if they die before 75.

Currently, pension pots are taxed at up to 55% depending on whether the pension has been drawn on.

But, in the future, when someone older than 75 dies, their heirs will pay income tax at the marginal rate and no tax charge will apply if aged under 75 – subject to them having available lifetime allowance remaining.

While the regulation change will only apply to those who have their pension funds invested in income drawdown rather than in annuities, the new rules will constitute a very attractive proposition for higher-rate taxpayers.

‘If they die after 75, it could be subject to only 20% tax if withdrawn by a basic-rate taxpayer – a very useful inheritance tool, depending on an individual’s circumstances.’

He told Independent Practitioner Today: ‘Some doctors may choose to leave their private pension untouched in a bid to help future generations, but individuals should be particularly wary of the complexities surrounding both pension contributions and pension withdrawals.

‘Remember, there can be financial disadvantages for taking pensions in the wrong order and penalties for contributing above set limits.’

Further details are expected in the Chancellor’s Autumn Statement in December.

Screening offers criticised

A GPs’ leader has called for action to protect patients from companies promoting ‘inappropriate health screening when, in fact, the evidence of benefit is often lacking’.

Responding to the House of Commons’ Science and Technology Committee’s report into health screening programmes, Dr Richard Vautrey, deputy chairman of the BMA’s GP Committee, said

many doctors would share MPs’ concerns.

He said: ‘As the BMA has repeatedly warned, it is vitally important that people being invited for screening fully understand the pros and cons of the procedure.

‘Patients must also be aware that there is a risk that false positive results could lead to unnecessary and potentially harmful further investigations.’

Patrick convey: a director at cavendish medical

Booming beauty expo gets bigger

by robin stride

Wannabe independent practi tioners who see business opportu nities in aesthetics were out in force at Europe’s largest reconstructive, cosmetic and nonsurgical event.

Independent Practitioner Today ’s stand at the second annual Clin ical Cosmetic and Reconstructive (CCR) Expo welcomed a stream of GPs and consultants who aim to get into this area for the first time or to expand their offering.

FROM SYRINGE TO SCALPEL.

A number said they were think ing of leaving the NHS and going fully private into this growing area.

ONE MAJOR EVENT.

The doctors were among more than 3,000 visitors, including aesthetic and reconstructive surgeons, to the London Olympia show and tandem conference streams.

And next year’s event on 8 and 9 October 2015 promises to be far

annual scientific meeting alongside – heralding what is seen as a new age of collaboration among the surgical and non-surgical arenas.

Consultant plastic surgeon and former BAAPS president Mr Rajiv Grover said: ‘This represents a

great opportunity to expose BAAPS members to the teaching and training of non-surgical treatments, an area where they have always maintained a key interest.

‘The ability to invite a wider range of surgical speakers also expands the portfolio of the BAAPS conference.

‘Without doubt, the joint CCRBAAPS meeting will be the premier aesthetic conference in the UK and we are pleased to be part of this unique event.’

More than 155 exhibitors showcased their wares and there was high-profile coverage in mainstream media.

CCR Expo hosted two simultaneous conferences, live demos and lectures on a varied range of subjects from facial rejuvenation, the ‘natural’ breast and new reconstructive techniques to discussions on ethics in female genital surgery and the latest in non-surgical technology.

Doctors agree that patients need more data on prices

Independent practitioners agree that patients must have access to information about fees – and quality and outcomes – to help them make informed choices about their treatment.

Online private healthcare solutions provider Healthcode surveyed a customer sample to gauge awareness of the Competition and Markets Authority’s (CMA) final report and support for its remedies.

Eighty-five per cent thought it right that patients could research private providers’ fees and 94% favoured publication of consultant performance data.

Consultants said this would bring the private sector into line

with the NHS and increase the private sector’s credibility.

One consultant commented that healthcare providers should be like ‘any other industry or service, otherwise it is like getting a menu at a restaurant with no prices listed and being expected to order a meal’.

But there were fears statistics might be misleading without careful explanation and could lead some to practise more conservatively and avoid difficult cases.

Healthcode managing director Peter Connor said that the survey showed most consultants recognised that data transparency was essential for the private health sec-

Patients use EU law to get free private care abroad

Over 600 NHS patients who have had surgery in other European countries have reclaimed their medical costs from the NHS under a new law introduced a year ago. Under the EU Directive on Cross-Border Healthcare, UK patients have the right to receive treatment anywhere in Europe.

Effectively, it means that UK patients who are waiting for treatment can choose to have an operation at a private hospital in Europe and reclaim the cost, provided the treatment is medically necessary and would cost no more than in an NHS hospital.

According to figures revealed by the Department of Work and Pensions under a Freedom of Information request, 855 patients have submitted claims so far. Of these, 621 were successful. They reclaimed a total of £833,491 – an average of £1,342 per claim.

DWP figures, revealed at the request of Operations Abroad Worldwide – a UK provider of treatment overseas, show France, Germany and Poland were the most popular countries for operations.

tor’s success. He understood concerns that published information must be clear, accurate and easy to understand so patients could make truly informed decisions.

This was a priority for his company and it was developing ways to make recording the necessary raw data an easy and efficient process for providers.

Few survey respondents had read the full CMA report, but most backed the information remedies it set out.

The survey, sent to a sample of 813 practice owners, managers and secretaries, was cond ucted from 24 September-17 October.  See www.healthcode.co.uk/cma

The lowest cost for a hip replacement was £4,153.35 – in the Czech Republic – and the lowest cost for a knee replacement was £2,756.16, in France. The DWP said the costs may reflect the requirements of individual patients and therefore not necessarily a standard price.

Ruth Taylor of Operations Abroad Worldwide said: ‘For those who are on NHS waiting lists and considering private treatment, having their operation in Europe means they benefit from prompt treatment and will be able to claim back their medical costs, although they will have to cover their own travel expenses.’

Refunds were limited to the cost of an NHS operation but European medical costs could be up to 80% lower, so treatment in a top private hospital was possible for much less than it would cost the NHS.

Spire and Bupa sign deal

By Charles King

Spire Healthcare boss Rob Roger has hailed a new fixed­price agreement with Bupa UK as a decisive shift to a more ‘partnership­style approach’ of working in all the group’s hospitals.

He said the aim now was for both parties ‘to drive volume growth in independent patient numbers, based on affordable healthcare and great clinical outcomes’.

Starting from 1 April 2015, the agreement has a minimum of four years, with prices agreed for six years until 31 March 2021.

Bupa Health Funding managing director Dr Damien Marmion con­

firmed that the insurer would be looking to work similarly with other hospital providers.

He said: ‘We believe that the new arrangements provide a solid basis to address the affordability of private healthcare while maintaining and surpassing current standards of high­quality care for our mutual customers.’

quality of care and customer experience at Spire hospitals.

‘The key terms of the agreement reflect a desire by both parties to encourage increased private healthcare customer volumes.’

Bupa said a developing quality framework would aim to bring about greater collaboration to improve quality of care and treatment experience for its customers.

SaleSmen’S view

Healthcare intermediaries welcomed the Spire-Bupa price pact.

Claire Ginnelly at brokers Premier Choice Group said: ‘This is excellent news for customers. any move by insurers and providers of healthcare services to work together to control costs has to be welcomed by the market.

The parties said they were trying to address some key challenges faced by their mutual customers.

‘This includes improving affordability, particularly for outpatients, and measures to build upon the existing high standards of

insurer insists 15% cuts are only way to save sector

Bupa Health Funding managing director Dr Damien Marmion has warned the insurer will continue seeking price cuts ‘of up to 15% or more’ from some major providers.

Speaking at the launch of Bupa’s 24 ­ page report Prescription For Growth – issued to the industry with last month’s Independent Practitioner Today – he argued that the sector needed a clear, united vision and commitment to change before it become even more outdated.

‘This report confirms there is an appetite for private healthcare and an opportunity for growth if we respond to customers and deliver more affordable healthcare in a way that suits their lifestyles.

‘We have a vision of consultants growing their private practices, hospital groups better utilising their excess capacity and more customers turning to private healthcare as a whole.’

According to figures in the report, the private paid healthcare

industry has the opportunity to grow by £2bn annually if it collaborates on improving value, accessibility and transparency around quality.

It said private healthcare spending could grow from £3.6bn to £5.8bn a year if it was more accessible and this could see £1.1bn a year of NHS resources freed up by 2025.

Bupa said its report, with research by healthcare analysts LaingBuisson, showed that the risk of a ‘downward spiral of demand’ was a reality, as the number of private healthcare customers continued to decline.

There was still a high demand for private healthcare but the sector was outdated and cost was the biggest barrier to buying it.

Asked whether he thought the figures stacked up, York University professor of health economics Alan Maynard said they were a ‘reasonable assumption’.

Bupa added that both it and Spire were committed to working together to advance these aims and would agree a rolling programme of initiatives for both parties to work on for the duration of the agreement.

‘The cost of Pmi continues to be the biggest barrier to entry. we all need to work together to help grow this market and to make it more sustainable.‘

Reports speeded up

New free software creates thirdparty reports for doctors and automatically redacts non­permitted information from patient records before they are sent electronically.

Intelligent GP Reporting (iGPR) should help cut administrative staff time spent fulfilling thirdparty information requests – and support compliance with the Data Protection Act.

Insurance requests can take an hour or more, but the makers claim this can be reduced to as little as ten minutes per report.

The redaction function automatically removes non­permitted medical information from GP reports provided to third parties.

This includes, for example, details of contraception, irrelevant negative test results and

genetic testing information. Doctors can redact further information manually if required.

The software allows payments to be processed electronically and speeds up the process of the report reaching the third party.

iGPR is funded by the insurance industry. It can be used to create all insurance reports and as insurers adopt the system, reports will be sent electronically. It also supports the creation of reports for solicitors requesting information.

The Association of British Insurers said iGPR would save doctors valuable time when dealing with requests for medical information and maintain the security of patients’ medical details.

The software is available from www.nichehealth.co.uk

HealthFirst, BMI Healthcare’s B2B and corporate well­being division, has given its health assessment centre BMI City Medical in London a £30,000 facelift.

The centre, which serves as a satellite unit to BMI The London Independent Hospital, has renovated the patient reception area,

the clinic’s five consulting rooms, and doubled the clinic’s capacity to provide health assessments.

As well as health assessments, BMI City Medical team also offers private GP services and access to specialists in cardiology, general surgery, gynaecology, neurosurgery, orthopaedics and urology.

Spire Healthcare boss Rob Roger

Radiotherapy centre opens near London Bridge clinic

HCA International has opened a £7m London Radiotherapy Centre, near London Bridge Hospital.

It opens just as construction of a new £100m NHS and private patient cancer centre at Guy’s Hospital next to London Bridge railway station gets underway.

HCA will build a private cancer hospital on four of the 12 floors of the new building.

The London Radiotherapy Centre is equipped with the latest TrueBeam machine offering advanced radiotherapy and stereotactic radiosurgery treatments.

HCA NHS Ventures chief executive Sarah Fisher said it was designed with patients’ convenience in mind. She told Independent Practitioner Today : ‘Firstly, there were no private patient facilities like these in south ­ east London and having surgery, chemotherapy and radiotherapy next door to each other is much more convenient for already anxious cancer patients.

‘When the new cancer centre is opened, we will be able to cater for all cancer patients’ needs under one roof.’

She said HCA was privileged to be working so closely with Guy’s and St Thomas’ Trust and its PPU would generate substantial new funds for the NHS.

The TrueBeam offers many benefits to patients including reduced treatment times and high­dose, pinpoint accuracy, which helps to protect healthy tissue. The machine is also the first in the country with a ‘6 Degree of Freedom’ couch.

London Radiotherapy Centre also has a four ­ dimensional CT scanner and radiotherapy planning facilities, consulting rooms and other patient facilities.

The centre’s 4D computed tomography scanner means that images not only identify a tumour’s location but also capture its movement and the movement of any organs nearby.

Surgeons attack BMI implant cap

By Robin Stride

Surgeons have voiced concern over a new BMI policy to boost profits by selecting only four knee and hip suppliers for most operations.

The hospital group has told them other brands will be highly restricted across the group ‘due to significant cost differences’.

Its move came after analysis revealed a large variation in spend on over 80 hip and 35 knee brands from 20 suppliers.

BMI told consultants this was diluting its ability to benefit from better commercial terms and leaving it open to clinical risk due to the fact that staff had to train for more products.

The effectiveness of its ‘Orthopaedic Improvement Programme’ (OIP) will, according to The British Orthopaedic Association (BOA), depend on the extent of genuine engagement through a transparent and comprehensive dialogue with consultants, including any relevant training.

The BOA said: ‘Their professional perspective is crucial to ensure selection of the best implant for each individual patient.

‘Moreover, enforced use of particular implants carries a greater risk of complications and errors as surgeons take up new implants, as there is a learning curve during which complications are more likely to occur.

‘To illustrate this point, a recent study from Finland suggested that there would be a 50% increase in significant complications within the first 15 cases when a surgeon changes implant.’

Consultant orthopaedic surgeon Mr Ian McDermott, of London Sports Orthopaedics, said: ‘The main difference between private healthcare and the conveyorbelt NHS style of “care” is that

is the answer to pressures in the independent sector really to dumb down services and to try and emulate the mistakes of the nHS?

Orthopaedic surgeon mr ian mcDermott

patients should have access to the best treatments from consultants of their choice, and those consultants should be free to make the best clinical decision for each patient based on their particular needs.

‘Some patients might just want any knee/hip replacement from any consultant at any private hospital. However, increasingly, such patients are becoming rarer, as people’s awareness of the variability of standards increases.

‘And more discerning patients understand the importance of being seen by the best possible person – first time, rather than just for revision work.’

‘Is the answer to current pressures within the independent sector really to dumb down services and to try and emulate the mistakes of the NHS?’

He claimed OIP would encourage some consultants to take their patients to alternative providers.

But BMI said other hospital providers as well as itself were under intense pressure to reduce total episode costs. It was working hard on internal cost aspects, but consultants had to work with it to tackle the areas that both influenced together.

A spokesman told Independent Practitioner Today: ‘If we do not do

this, we will all be under further pressure on fees, as we need to find these savings one way or another.’

He said OIP was piloted at two BMI hospitals earlier this year and is now being rolled out across the group for hip and knee prostheses. ‘The vast majority of our hip and knee consultants will be unaffected.’

Better commercial terms could now be negotiated, but clinical quality remained a priority.

‘We have completed a rigorous clinical and technical assessment of all the hip and knee brands we utilise across the group, using Orthopaedic Data Evaluation Panel (ODEP) ratings and survivorship data from the National Joint Registry. We have selected clinically equivalent, branded items that are fully supported by major manufacturers.

‘The transition to the new arrangements will be a phased implementation, with sites prioritised into waves. It is important to emphasise that BMI Healthcare hospitals are committed to providing the highest standards of care to all patients and therefore will continue to work with consultants to ensure that this is not compromised.’

BMI said it would work with consultants and the preferred suppliers to ensure surgeons were supported for change. Suppliers were committed to providing consultants ‘with whatever training and support they may need to use their products’.

At Symbios, one of the suppliers not selected, managing director Justin Quick said: ‘Our concern is that BMI has selected the four largest global orthopaedic companies to buy from. They are all US­based. Smaller UK­based businesses like us with innovative products are being excluded.’

GMC probes boost stress

By Edie Bourne

Independent practitioners facing GMC investigations are likely to experience mounting stress.

A defence body survey of 180 doctors investigated by the organisation in the last five years found nearly three-quarters of them thought their experience harmed their mental and/or physical health.

The Medical Protection Society survey also revealed:

 Respondents’ involvement in GMC investigations impacted on their stress/anxiety (93%), personal life (76%), health and wellbeing (74%), confidence (69%) and professional reputation (52%);

 Almost half of respondents (47%) did not believe they received enough support in looking after their health throughout the investigation;

 70% of respondents said the GMC should offer more support to doctors facing an investigation.

The survey – which included consultants with private practices – also revealed that more than a

quarter of respondents (28%) considered leaving the medical profession as a result of their experience. Eight per cent changed their roles and 2% left the profession.

MPS senior medico-legal adviser Dr Richard Stacey said: ‘Although these insights into the impact of GMC investigations on the health of doctors are alarming, they are, unfortunately, not surprising.

‘The attributes that make a good doctor – for example, being caring, kind and conscientious – can also make them particularly vulnerable if they become the subject of a GMC investigation.

‘A doctor can experience fear when they receive a letter from the GMC informing them that they are the subject of a GMC investigation. The GMC do provide information about their procedures to doctors who become the subject of an investigation; however, the correspondence can appear formal and legalistic.

‘While MPS acknowledges that the GMC has recently taken steps to soften the wording of corre -

GMC rEaCtion to MPS’s findinGS

GMC chief executive niall dickson said: ‘Patient safety has to be our first priority, but we also recognise that we have a duty of care towards doctors involved in our investigations. our procedures will always be stressful and, of course, some of the doctors who are referred to us are already under considerable strain or have mental health problems.

‘the MPS recognises the steps we have taken to make our procedures less stressful. We have an ambitious programme to speed up the process, disposing of more cases without the need for a hearing and setting up the Medical Practitioners tribunal Service, a separate adjudication tribunal, headed by a judge, committed to fair and effective decision-making.

‘We also fund the BMa’s doctors for doctors service to provide free advice and support for doctors in our procedures and we fund a witness support programme for anyone appearing at the tribunal.

‘at the same time, we accept there is more we can do and we will work with the defence organisations, the BMa and others to find ways to support doctors and reduce stress where we can. We must never do anything which undermines patient safety, but, with that proviso, we must strive to handle every case as quickly and sensitively as we can.’

spondence with doctors being investigated, the results suggest that more needs to be done.’

Dr Stacey said it was important that doctors suffering with mental or physical problems relating to stress and/or anxiety got help early.

He said it was re-assuring to see that 77% of respondents to the survey sought help or support for their health issues from family or friends, and 62% sought assistance from colleagues.

 See page 8

New depression treatment on offer

Nightingale Hospital, London, is claiming a UK first with the launch of a repetitive transcranial magnetic stimulation (rTMS) service for depression. It is also the first to be using the very latest ‘H coil’ technology.

rTMS has been fully licensed by the Food and Drug Administration in the US since 2008 and is routinely used to treat depression in many first-class international hospitals; for example, the Johns Hopkins Hospital, Baltimore, US. It is increasingly used across Scandinavia and other European countries and is now covered by many international healthcare insurers.

Dr Michael Craig, lead consultant psychiatrist of the service, said the very latest in rTMS technology – the H coil – was developed fol-

lowing research at the National Institute of Mental Health, US, and had been reported to be significantly more effective than previous models.

‘Trials have shown that even in patients who failed to respond to one to two antidepressants, almost 40% of patients have been found to get better in proper randomised controlled trials.’

Nightingale’s managing director Martin Thomas said they were very excited to be the first hospital in the UK to deliver this treatment.

‘Depression can be a debilitating condition and rTMS is a significant treatment option for patients. Nightingale Hospital continues to be committed to delivering the latest evidence-based treatments and the very highest levels of psychiatric care to patients.’

rtMS iS thE latESt EffECtivE, non-invaSivE, non-PharMaColoGiCal, outPatiEnt trEatMEnt for dEPrESSion

it works by targeting short magnetic pulses over the scalp to produce electrical currents in specific brain regions that regulate mood. in extensive trials across 20 global centres, it has proven its efficacy, particularly for the third of patients that have failed to respond to cognitive therapy and drug treatments.

approximately a third of patients with depression do not respond to medication or psychological therapy. they consequently have to endure its debilitating effects on their lives.

Many patients also find they cannot tolerate the side-effects of medication, which can include poor sleep, weight gain and reduced sex drive. for these patients, rtMS is seen as a significant treatment option. unlike with electroconvulsive therapy (ECt), no anesthesia is required, there is no memory loss and normal activities can be resumed straight after treatment. the treatment can also be used in conjunction with medication and talking therapies.

the magnetic pulses increase prefrontal and limbic function within the brain, which supports functions including emotion, behaviour, motivation and long-term memory, to relieve depression. Some studies indicate that rtMS also increases levels of dopamine and serotonin, helping to push more ‘feel-good’ chemicals round the brain.

2014 WinnErS

legal adviser: Jasy loyal, hCa international ltd Management Consultancy: GE healthcare finnamore

Best use of technology: accedo Gr. healthcare outcomes: Ph Care team, total Community Care ltd innovation: Christian day, Bupa Cromwell hospital

Public Private Partnership: the Practice

Excellence in risk Management: Ellie Cornelius, BMi healthcare

Excellence in training: Partnerships in Care and Mark Elsworthy, Bupa Cromwell hosp. Medical Practice: Jackie Portsmouth and alastair Bovell, Bupa Cromwell hospital

nursing Practice: Catherine farr and Jenny apted, Shepton Mallet nhS treatment Centre, Care uK

Primary Care & Community

Services Provider: Sarah Bricknell, inhealth

Mental health hospital Provider: Bestwood hospital Management team, Eden futures home healthcare Provider: adam Mason, Brighton and Sussex Care Extra Care Provider: tracy Paine, Belong villages

residential Care Provider: Greensleeves home trust team

Entrepreneurial achievement: london Management team, Green Surgery ltd

Management Excellence: Samantha Yates, Cygnet healthcare

outstanding Contribution: Phil Coombes, raphael healthcare

l&B industry Choice award: Blossoms healthcare, hCa

The cream of the industry

Market analysts laingBuisson’s independent healthcare awards 2014 showcased the innovation and excellence that just carries on growing. Broadcaster huw Edwards hosted the glittering awards evening at london lancaster hotel and presented the 19 prestigious accolades to leading lights in the industry sector.

huw commented on the importance and value of the independent healthcare sector, noting that the biggest news stories were often those involving health.

laingBuisson chief executive William laing said this year’s finalists represented ‘the best of the best’ in the sector. the awards were supported by Spire, aspen, ramsay and daC Beachcroft. also supporting the evening was Sparks, raising awareness for children’s medical research.

Two top accolades for HCA

HCA International Limited won two top prizes at the LaingBuisson Independent Healthcare Awards in recognition of its industryleading work and services. Blossoms Healthcare, a part of the company that offers primary care and occupational health to leading corporate clients, was recognised with a special Industry Choice award for service excellence and innovation.

Attendees at the ceremony

voted on the night for this category. Blossoms was recognised by its industry peers from a pool of 46 healthcare providers. The award was collected by commercial director Magnus Kauders.

Jasy Loyal won legal adviser of the year in recognition of the wide range of legal services she provided with her very small, diversified team. The services included a revalidation programme and implementation of a

The

face of information revolution in private care

ground-breaking risk management and compliance programme to deal with the Bribery Act. Her team contributed significantly towards helping HCA become the first UK independent hospital group to put these regulations in place. Judges noted they were ‘blown away by the breadth and diversity of services provided in-house’ by the company, adding that her work was ‘a clear winner’.

The Private Healthcare Information Network (PHIN) has appointed Sam Meikle ( right ) as director of operations to speed up its plans to publish high-quality information for patients about private healthcare.

She said: ‘I am driven by what I would want to know for my family or for me before any of us started treatment. Making patients more equal partners in planning their care is a major goal and PHIN has a central role in making this happen.’

PHIN is building its capabilities in anticipation of being approved by the Competition and Markets Authority (CMA) as the information organisation charged with ensuring consultants and private hospitals move rapidly to publishing a wide range of information covering both quality and fees.

Ms Meikle is a prominent leader in the area of health information and public engagement.

In 2012, she founded London Connect, on behalf of the London Academic Health Science Centres, to boost the care patients receive by improving the use of information, working with patients, the public, professionals, academics, policy-makers and industry.

She also led London’s bid for the international Bloomberg Philanthropies’ Mayors Challenge, which focused on empowering patients with diabetes to improve self-management through the better use of information.

PHIN chairman Dr Andrew Vallance-Owen said: ‘Sam brings a wealth of expertise in public engagement on complex health issues and in presenting information in ways that are both accessible and actionable.’

 See ‘Information overlord’ on page 12

Accused doctors require support

Over the past decade as a medico-legal adviser, I have assisted many doctors who have been investigated by the GMC. having your practice put under a microscope can be a very stressful time for doctors, and it can have a significant impact on their personal health, irrespective of the merits of the complaint.

In fact, a recent MPS survey of 180 doctors investigated by the GMC in the last five years found that almost three-quarters (72%) believed the investigation had a detrimental impact on their mental and/or physical health.

the attributes that draw a doctor to a career in medicine and make them a good doctor – being caring caring and conscientious –also mean that they can be particularly vulnerable when they are the subject of a GMC probe.

More than a quarter of respondents (28%) revealed they had considered leaving the profession as a result of a GMC investigation, 8% changed their roles and 2% left the profession. So we must ask the question: why is this happening?

negative connotations

Many people may not understand the impact a letter from the GMC can have on a doctor, but it can be significant.

I recently spoke to a doctor involved in an investigation and after reading their initial correspondence from the GMC, their first thought was that they would be ‘struck off’ and that consequently they would have to sell their house and consider a career outside medicine.

I was able to reassure them that the complaint would not result in them being erased from the medical register, but that did not prevent the sleepless nights for the doctor before they contacted us.

GMC investigations tend to move at a slow pace – sometimes for reasons that are outside the GMC’s control – and often take many months.

While a lengthy investigation can be stressful in itself for doctors, it is not until the conclusion of an investigation that the GMC

By Dr richarD stacey senior medico-legal adviser at the Medical Protection society (MPs)

provides the doctor with the allegations, to which they are invited to respond within 28 days.

While the GMC will consider applications for extensions of time, this is a relatively short time-frame considering the many other professional and personal commitments that doctors have, and it can significantly add to the amount of stress and anxiety that they experience.

imposition of interim orders

During an investigation, the GMC may invite a doctor to appear before its Interim Orders Panel. this panel can impose an order on the doctor’s registration, which may consist of specific conditions or a suspension on an interim basis, pending the outcome of the investigation. this can have significant consequences for doctors in private practice, as it could lead to their practising privileges being withdrawn.

the financial impact of such a decision, together with implications for the viability of sustaining the future of a private practice, can also add to what is already a difficult and stressful time.

Furthermore, GMC correspondence can sometimes appear formal and legalistic, despite the fact it has reviewed and improved the way it communicates with doctors.

We are urging the GMc to review some of its current procedures to create more avenues and opportunities for supporting doctors subject to an investigation

information from their friends, family and colleagues – who otherwise would be in a position to provide valuable support – due to feelings of professional embarrassment and not wanting to concern others.

Supporting doctors should therefore be a priority during this difficult time.

having worked in general practice for ten years, I know that all a health professional wants is to provide the best care for their patients, and I can empathise with a doctor’s feelings of disappointment and sadness if something does not go as expected.

An example of this is when the ‘realistic prospect test’ is used. this is a test that case examiners apply when deciding whether or not a case can be closed with no further action or, alternatively, whether another action is indicated – such as the offer of a warning, the offer of undertakings or referral of the case for determination by a Fitness to Practise Panel.

While the GMC does provide an explanation as to the nature of the ‘realistic prospect test’, the wording can appear cumbersome, leaving the doctor feeling that they may still be considered guilty but that it can’t be proved.

t he doctor will usually infer that the GMC’s decision to not take further action is based on having insufficient evidence to demonstrate that their fitness to practise was impaired, rather than because the investigation found their practice to be adequate.

Dysfunctional strategies

Sadly, for all the above reasons, the findings of MPS’s survey do not come as a surprise to me.

And it is also disappointing to see some doctors lose their clinical confidence and adopt dysfunctional strategies that can lead to feelings of isolation.

It is not uncommon for doctors who are the subject of a GMC investigation to withhold this

We fully understand the impact that GMC investigations have on doctors and our wide experience of cases – from an alleged delay in diagnosis of a carcinoma to doctors with health problems – means we are in the best position to alleviate concerns as soon as possible. If a member seeks our advice in relation to a GMC investigation, the case will be allocated to a medico-legal adviser – a doctor who has undertaken relevant legal training – who, in addition to corresponding with the GMC on behalf of the member, can be contacted at any stage of the investigation for support.

Depending on how the case progresses, the team assisting the member may evolve to include a solicitor and a barrister – all of whom can provide advice in relation to the GMC investigation.

MPS also provides access to an independent and confidential counselling service from trained psychologists, which is available 24 hours a day, seven days a week. As a result of our survey, we are urging the GMC to review some of its current procedures to create more avenues and opportunities for supporting doctors subject to an investigation.

I would also encourage any doctors going through a GMC investigation to seek professional assistance at the earliest possible opportunity, share their feelings and experiences with people they know and trust, and remember that they are not alone. n

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A smooth handover

‘I am planning to retire from my practice in the next five years. I don’t have an obvious successor, but am keen to reap the benefits of what I have built up. What is your advice?’ Susan Hutter (right) responds to the big questions on hundreds of independent practitioners’ lips

There are a number of ways to tackle this issue.

Firstly, through the course of your career, think about any ‘young hot-shots’ you have met operating in the same field.

If you can target someone who has been a consultant for, say, five years who has just embarked on building up their practice, it may be worth having discussions with them.

You could explore the possibility of taking them into your practice and gradually passing it over to them. The ideal scenario would be for him or her to buy you out in a few years.

another alternative is to reverse into a larger practice of the same specialty with a view to eventually selling out to the others. apart from anything else, it is often possible to reap the benefits of economy of scales regarding overheads. This is especially the case if, for example, you are leaving your premises to work out of theirs.

Specialist teams

It now seems to be the trend for medical companies to put together a team of similar specialties – for example, a centre of excellence in, say, urology or orthopaedics – and/or have a number of specialties in the same building. But note that this would not include a company who owns a hospital, as this is likely to break the strict rules on competition. This works particularly well if all the specialties use the same

expensive equipment, such as imaging equipment, as the costs can be shared.

Some medical companies are even offering buy-out packages which typically last a five-year period and the individual being bought out would then go on a salary for the rest of the term of his or her contract.

If you do sell out your practice following any of the above methods, you should be able to obtain what is known as ‘entrepreneurs relief’ for capital gains tax (CGT) purposes.

You would be selling your goodwill if you trade as a sole trader, or if you are a limited company, the shares in your trading company, to the third party. Both of these methods are regarded as a disposal of a trading asset for CGT

purposes and therefore the effective rate of tax on the capital transaction would be 10%.

If you continue working for the purchaser for some time after the sale, even on a reduced hours basis, this would probably be on a salary which would be subject to income tax and National Insurance. It is recommended that specialist tax advice is taken here.

Pension issues

If you are thinking of retiring within the next five years, then you should also look carefully at your pension.

It is worthwhile taking specialist advice, especially if you can afford to maximise your personal pension, which would be a private pension scheme.

You will need to look at how

this interacts with the N h S Superannuation Scheme, irrespective of whether you have retired from the NhS or not. The pension rules are quite complex and forward planning is essential.

For the last five years, the market for buying and selling medical businesses has come into its own and consultants are now selling their practices, and buying others, in the same way that dentists have done for many years (see feature on page 10 of October’s edition).

It is a good time to make the most of the sale of a practice. 

Susan Hutter is a partner at Shelley Stock Hutter LLP. She provides specialist accounting, taxation and business advice to the medical and healthcare industry

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Information overlord

Consultants in private practice will be legally obliged to publish performance measures from April 2017. Matt James reports on what is being done to prepare for this

Last month, I exp lained that the Private h ealthcare Information network (PhIn) is likely to be the organisation charged with the task of helping the sector to respond to the information ‘remedies’ arising from the Competition and m arkets a uthority’s (Cma) recently­concluded investigation of the private healthcare market.

those remedies include requirements for both hospitals and doctors to publish a range of performance indicators by april 2017. there is a separate requirement for publication of consultant fees but, as this is still the subject of a legal challenge, I will concentrate on the performance measures for now.

the only sensible place to start is with the Cma’s Private healthcare market Investigation order, and the list of mandatory performance measures it sets out at article 21.1 (see box on the right).

Valid concerns

Right at the outset, let me acknowledge that you are likely to have a number of concerns about the validity and deliverability of these indicators, particularly as they apply to individual specialists. Fair enough; as do we. s ome of these indicators are relatively straightforward; some will need a lot of work; some will, at best, not be applicable to many specialties or procedures.

You are likely to have a number of concerns about the validity and deliverability of these indicators, particularly as they apply to individual specialists

Don’t worry; there is time to get this right, and we will involve consultants throughout.

a s you can see, data doesn’t need to reach the information organisation until s eptember 2016 – nearly two years away.

In practice, that date has little bearing on most consultants, since you are not expected to produce the data, which will come from hospitals, registries and existing collections – for example, adverse events via the Care Quality Commission and infections data via Public h ealth England.

We will work with the professional specialist societies, consultant representatives and the hospital operators to consider what data can and should be published, moving on to how it should be presented to make it meaningful for patients, and a fair representation of both hospitals and consultants.

ArtIcle 21.1 of the cMA’s PrIvAte heAlthcAre MArket InvestIgAtIon order 2014

every operator of a private healthcare facility shall… supply the Information organisation, quarterly from a date no later than 1 september 2016, with information as regards every patient episode of all private patients treated at that facility, and data which is sufficiently detailed and complete to enable the Information organisation to publish the following types of performance measures by procedure at both hospital and consultant level:

a) volumes of procedures undertaken

b) Average lengths of stay for each procedure

c) Infection rates, with separate figures for surgicallyacquired and facility-acquired infection rates

d) re-admission rates

e) revision surgery rates

f) Mortality rates

g) Unplanned patient transfers – from either the private healthcare facility or private patient unit to a facility of one of the national health services

h) A measure, as agreed by the Information organisation and its members, of patient feedback and/or satisfaction

i) relevant information, as agreed by the Information organisation and its members and, where available, from the clinical registries and audits

j) Procedure-specific measures of improvement in health outcomes (ProMs), as agreed by the Information organisation and its members to be appropriate

k) frequency of adverse events, as agreed by the Information organisation and its members to be appropriate

In parallel, we will take the available data, assemble it into a view of your practice, and ask you to check it.

First things first – let’s try to get the data right. I expect that work to begin in earnest in 2015, and to continue right through to the point at which publication is required, in april 2017.

We expect that you’ll find the data useful. We’ll assemble records from both private practice and the nhs to give a whole­practice view, mapped into nhs coding so that you can compare apples with apples, with relevant benchmarks where that is valid and helpful.

t he data will be certainly be useful for appraisal and revalidation and for managing your practice, with good information on referral patterns, patient demographics and so on, in addi­

I believe that, in the end, this will work and, moreover, will work to your benefit, while being genuinely useful to patients

secure website, and only you, or people you explicitly authorise, will be able to see details of your whole practice.

Case mix adjustments

Perhaps more importantly, once the hospitals start to apply ICD10 diagnostic coding to records – also mandated by the Cma – we will, for the first time, be able to undertake comprehensive case ­ mix assessment and adjustment to our indicators.

as has been often observed, it is vital that analysis reflects complexity so as not to deter doctors from treating difficult cases.

Even so, we’ll want to agree an approach, possibly varying by specialty, for how to deal with cases assigned to responsible consultants in the nhs, where they were not the surgeon who performed the procedure.

Improve your workflow

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sultants, part ­ time consultants and so on.

at this stage, let’s assume that these problems are capable of being solved.

I believe that, in the end, this will work and, moreover, will work to your benefit, while being genuinely useful to patients.

If it helps patients to understand and trust private healthcare and gives them confidence to make decisions, then it will encourage them to buy private healthcare. and that’s good for you.

In a future edition of Independent Practitioner Today, we will start to look at the individual measures, and how they will be constructed and presented.

It’s an interactive process, so do get in touch if you would like to be involved. 

Matt James (left) is chief executive of

Transparency is a picture of health

The key to providing quality healthcare is to be open and transparent. That way, a learning culture is developed and all professionals can learn from events and data, says Manisha Shah

patient safety and high-quality care are central to every healthcare story and at the forefront of everyone’s minds. a nd yet the debate continues – what does the highest quality of healthcare look like and how is it best delivered?

in my view, the key to providing complex tertiary care at the highest quality is a team effort. We have learned that events happen at the sharp end of a process and, therefore, it is essential to have a multidisciplinary team with a commitment to co-ordinated care and a drive to improve care through learning.

a learning culture begins with a willingness to be transparent, accept what the data tells us, learn from all events and to share the learning widely.

improving safety an acceptance that human fallacies are inevitable and a willingness to emphasise learning is the essential first step.

it is a universal truth that things go wrong in the delivery of healthcare and mistakes are made. Back in 1999, the institute of Medicine estimated that a staggering 44,000 to 98,000 hospitalised patients died annually in the Us and that more than one million patients were injured as a result of an error.1

t he biggest learning has been that often an error is due to systematic issues that can be addressed. Guidance that deals with these systematic errors has been implemented and tools to deliver care have been introduced, yet there is still work to be done.

t he Health s ecretary Jeremy Hunt recently stated that unsafe care is currently costing the nHs between £1bn and £2.5bn every year. 2 a nd medical errors aren’t isolated to the nHs according to figures from the Centre for Health and the p ublic i nterest (CH pi ), between October 2010 and april 2014, there were 802 unexpected deaths and 921 serious injuries reported by private hospitals.3 t herefore, like a number of industries that have gone before it – such as airlines, railways, nuclear power and car manufacture – healthcare must lead the charge on improving care processes. this includes independent hospital providers, who are seeking ways to become ever more patient-centric and to continue to communicate and share quality information better.

Examples of how we are driving improved outcomes: t here are a number of ways to drive towards improved outcomes. Here at HCa, our founding principle is ‘putting the patient first’, which guides us in how to deliver the best patient experience, and exceptional outcomes. Quality of care requires patient centredness and patient safety to be at the core of everything we do. aside from investing heavily in technology to improve outcomes and quality of life, we have taken additional steps:

 Transparency – the key to delivering quality healthcare. as an organisation, a culture of learning is central to our thinking. We have a robust governance structure, strategy and both a hospitallevel and a central reporting system, allowing us to provide group-wide analysis and shared learning across our network.

 as part of the culture of learning, openness and reporting of incidents is encouraged. t his takes courage, as it may make incident rates look worse in the short term, but it is the only way to drive up standards.

 Communication is crucial to safe care – that includes engaging all clinical and non-clinical members of the team.

 e ach of our hospitals has a medical director for medical leadership and our staff is sup -

ported by resident medical officers, often by specialty, 24/7.

 MDMS (advanced data management), research and links to academia allow our staff to continually learn from the most recent evidence.

What we have learnt is that quality improvement relies heavily on good leadership. Being visible is very important and manage ment engagement that starts at the top is essential.

One example of this is that we have introduced ‘unit-based safety rounds’ where executives each sponsor a ward and work with teams on the floor to gather intelligence about improvement opportunities. t he executive is then responsible for ensuring the delivery of that improvement.

external assessment is a big part of ensuring our internal methods are effective and driving improvement. a lthough there are some restrictions on independent sector involvement, we engage in national audits and external accreditations – such as CHKs and isO – as much as we are able to. each year, we publish a quality booklet to share the results of these audits and other clinical outcomes with our patients, consultants and healthcare staff.

Communicating good care

the nHs has done a lot more data collection, data gathering and data emphasis. the independent sector may have done so internally too. However, as a sector, we are looking to show that we are providing the highest-quality and the best patient outcomes possible and are becoming more transparent.

We have many opportunities for systematic improvements such as electronic health records, transparency across the sector and a format to communicate better and bring in a level of openness that allows us to continue to drive up standards.

Most important of all, we need to consider transparency from a patient perspective. Because outcome measures reflect what is most important to patients, it’s critical that they are developed with patient needs, values and preferences in mind.

as private healthcare providers, we are often compared on cost, but the conversation needs to be

As private healthcare providers, we are often compared on cost, but the conversation needs to be about quality and safety and the best possible route for the patient

about quality and safety and the best possible route for the patient. e ssentially, the very best in patient care. 

Manisha Shah (right) is vice-president of Clinical Services and Patient Safety at HCA International

References

1. Kohn L.T., Corrigan J.M., Donaldson M.S., editors. To err is human: building a safer health system. Washington DC: National Academy Press, 1999.

2. Jeremy Hunt: Message to NHS staff on ‘sign up to safety’ campaign. Department of Health. www.gov.uk/government/ speeches/jeremy-hunt-message-to-nhsstaff-on-sign-up-to-safety-campaign, published 24 October 2014.

3. Patient safety in private hospitals – the known and the unknown risks. Centre for Health and the Public Interes t. http:// chpi.org.uk/wp-content/uploads/ 2014/08/CHPI-PatientSafety-Aug2014.pdf, published August 2014 (See Independent PractitionerToday, September 2014, p18).

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NEw CQC iNspECTioN REgimE

Measured with the same ruler

A

new inspection regime for all private hospitals has been needed for some time. Now that the watchdogs are descending on their targets, Fiona Booth (right) gives the independent sector’s response

This auTumn, eight independent hospitals will be inspected by the Care Quality Commission (CQC) under a new approach specifically modelled for the independent sector.

Those hospitals will be awarded ratings from a pril next year, which will be directly comparable to their nhs counterparts.

The new inspections mark a new phase of a large work programme involving the regulator and the sector.

i t has become clear over the past couple of years that a new inspection regime for all hospitals is needed.

a t the same time, the Competition and m arkets a uthority (C ma ) has highlighted that the independent sector needs to do more to publish data in a directly comparable format to the nhs – a critique fully accepted by the sector. s o the publication of these ratings, following the new inspection regime, is doubly welcome.

The sector worked with the CQC from the point at which it realised a new regime was needed.

We contributed, under the banner of the i ndependent h ealthcare a dvisory s ervices (now aihO), a response to the consultation and helped shape the inspection regime to ensure that it reflected the critical differences between independent and public sector hospitals.

The new inspection protocol will judge whether independent hospitals, like their nhs counterparts, are safe, caring, effective, well ­ led and responsive to people’s needs – clear indicators which will help clinicians, regulators and the public understand the quality of care being offered.

Of course, independent­sector hospitals are already inspected by the CQC and have been for a number of years, so this is not a radically new announcement.

Comparable to NHs

The sector welcomed the CQC’s State of Care report last year, which rated independent hospitals very highly overall.

But across the independent sector we believe the new inspection

inspectors’ eight

the first eight independent hospitals to be inspected under the new cQc regime are:

 Baddow hospital, essex

 BMi Mount Alvernia, guildford, surrey

 the Lister hospital, London

 the London Welbeck hospital

 nuffield health tees hospital, stockton, co Durham

 oaklands hospital, salford, greater Manchester

 peninsula nhs treatment centre, plymouth, Devon

 spire southampton hospital, hampshire

regime is a key development, as we want our hospitals to be comparable with nhs institutions, and we want to participate in the process of mutual exchange and learning with the public sector. We are aware that there are gaps in the amount of information we publish, which is why the sector came together in 2008 to start producing it.

That project became the Private healthcare information network (Phin – see page 12), which has started to publish a range of data and whose work will considerably expand in the coming years. ultimately, the patient is at the centre of this whole debate – nhs, self­paying or insured.

m ore than 10m patients have the choice of using the independent sector, and they deserve to have the critical information to take important decisions about their care.

We accept that, as many aihOmember hospitals provide services into the nhs, those patients should have access to the same information as they do about nhs hospitals.

Those patients who choose to use the independent sector, either via insurance or through direct payment, should have all the detail they need to give them re ­ assurance and comfort that their care will be of the highest standard.

P hin is working towards that goal and needs further collaboration from the public sector – in the form of the health and social Care i nformation Centre – to ensure that we can publish the right information in the right format. Furthermore, independent hos­

We want to participate in the process of mutual exchange and learning with the public sector

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pitals want to be judged by the same standards as their nhs counterparts.

The sector has recently been criticised for not reporting incidents to the national Reporting and Learning s ystem ( n RL s ) in the same way that the nhs does.

We take this criticism on board, and have been working with the nhs and other bodies to rectify it.

Collaborative projects

But it has also taken public sector colleagues and bodies some time to help us do so by running trials and approving budgets for collaborative projects.

Of course, with the nhs budget under severe pressure, it is unknown what the future funding settlement for such collaboration will be, but the sector is firmly committed to reaching this goal.

The eight hospitals being inspected (see box above) are in a variety of locations and offer a huge range of services. Designing an inspection protocol that will accurately reflect standards across all of them has, at times, been challenging.

But we very much look forward to the outcome of the pilot inspections and the work we can do following them to further refine how independent hospitals are scrutinised.

We are committed to ensuring that all patients are given all the information they need to make the right decisions about their own care. 

Fiona Booth is chief executive of the Association of Independent Healthcare Organisations

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Holistic approach to dementia care

Doctors are increasingly seeing patients – or their own loved ones – who have dementia. Zoe Elkins (right) gives a briefing on the condition for Independent Practitioner Today readers and suggests some top tips for supporting them

Dementia can affect a person of any age, but is most common in older people. age and female gender are associated with a higher prevalence, with one person in 1,000 aged 40-65 years, one in 20 aged over 65, and one person in five over 80 having a form of dementia.

i t is estimated there are now 800,000 people aged over 65 with dementia in the UK. this number is forecast to rise to 940,110 by 2021 and 1,735,087 by 2051, an increase of 38% over the next 15 years and 154% over the next 45 years.

t hese figures do not include people with learning disabilities or people with dementia in nHS continuing care facilities. the UK has set out a wealth of initiatives, guidance and policy statements in the last ten years, including Our NHS, Our Future ; Putting People First: a shared vision and commitment to the transformation of adult social care (Department of Health [DoH] 2009); the national i nstitute for Health and clinical excellence (nice); Quality Standards ( nice 2010); the Carers’ Strategy (DoH 2008) and the End of Life Care Strategy (DoH 2009).

the national Dementia Strategy, Living Well with Dementia (2009), set new standards for dementia care and was supported by the Government announcement of £150m of additional funding in local services to deliver it. it set out 17 recommendations that the Government wanted the nHS, local authorities and others to take forward to improve dementia care services. they are focused on three key themes of:

 Raising awareness and understanding;

 early diagnosis and support;

 Living well with dementia.

the Prime minister’s Dementia challenge was launched in march 2012. it sets out plans to go further and faster in improving dementia care, focusing on raising diagnosis rates and improving the skills and awareness needed to support people with dementia and their carers.

i t also has details of plans to improve dementia research. the challenge recognises that while it is very common, dementia is not very well understood.

stigma attached

People often don’t ask for help because there is still a stigma attached. t hey may wrongly think that the symptoms are a normal part of ageing and that nothing can be done. to reduce stigma and raise awareness, the challenge has set targets to work with a range of different organisations to create dementia-friendly communities. Fiona Lowry, chief executive of the Good care Group – one of the signatories to the Pm’s Dementia c hallenge – says: ‘We feel very privileged to be involved in the Pm’s Dementia care and Support compact, as it sets the benchmark for high-quality, relationshipbased care for people living with dementia, ensuring that their lives are enhanced through the best care delivered by well-trained care professionals.’

t he UK Government has also pledged to increase funding of

dementia research to around £66m by 2015.

Until relatively recently, dementia was commonly referred to as ‘senility’ and accepted as part of getting old. today, this is no longer considered to be the case, with dementia understood as a set of symptoms caused by damage to the brain.

e xamining the psychosocial approach to dementia reminds us that a person with dementia is no less a person than anyone else and efforts should be made to maintain and improve quality of life by respecting and preserving the individual’s personhood.

The patient’s perspective to develop this further means that we take the perspective of how the person with dementia views their life rather than our perspective of how they should lead their life. a s tom Kitwood argued, the dementia is not the problem; the problem is ‘our’ –individual, carer, professional, society – inability to accommodate ‘their’ view of the world (Dementia Reconsidered: The Person Comes First, 1997).

therefore, there is a danger of creating/maintaining a ‘them’ and ‘us’ dialectic tension that has become reinforced over the years by the socially constructed and devalued status of someone who is ‘dementing’.

People with dementia and their families will be involved with a multitude of professionals during the course of their illness and caring role.

a multi-agency, professional approach can help the person with dementia and their family stay well and to live at home for longer, giving time to work through issues like loss and grief.

But most people, if they feel that their independence is being removed from them, will wish to remain independent at whatever cost. the relationship that homecare workers develop with their clients can be instrumental in supporting the person with dementia and gradually building a care package to support them.

Dementia is best understood as the increasing failure to store the facts of what has just been happening, while storing feelings in the normal way, as explained by

A multiagency, professional approach can help the person with dementia and their family stay well and to live at home for longer

CAsE study: stEvE

steve is an 88-year-old retired pilot who has vascular dementia.

He lives with his wife Anne, who is his primary care-giver. some time ago, steve was highly anxious and easily agitated. He was insecure and attached to Anne, who could barely be left alone even to visit the toilet.

As soon as she was out of sight, he would become paranoid and aggressive – convinced she was leaving him. Anne was becoming burned out by the demands of 24/7 care. soon, Anne was at breaking point. steve was prescribed anti-psychotic medication, which failed to reduce his episodes of challenging behaviour while adversely affecting his cognitive and physical abilities.

using the sPECAL method – explained on page 20 – we explored steve’s past and found that he could still access many positive memories of his time as a pilot. When we referenced aeroplanes or flying, steve would swing his arm in a wide arc and say with pride: ‘I flew around the world, you know.’

using verbal cues, we found we could quickly and easily take steve back to his flying days, and when he was held in this good place, he was no longer an elderly frightened and frightening man with dementia, but became a 30-something dashing pilot, king of his world.

However, steve would still become very upset and angry if he felt that Anne had gone somewhere without him, and this posed a great challenge to the care team. she needed a decent break and we had to facilitate this without upsetting steve.

using information from the distant past, we found that Anne had once owned her own floristry business. Although steve had always been incredibly proud of his wife’s achievements, his own position as Md of a large international company had ensured that he was never particularly concerned about Anne’s comparatively ‘small’ enterprise.

the next time steve asked where Anne was, the carer explained she was sorting out a problem at the shop. steve smiled fondly and rolled his eyes as if to say ‘thank goodness I’ve not been dragged along’.

Once the twin themes of steve’s flying and Anne’s need to solve problems at the shop had been shown to be entirely acceptable to steve, Anne was able to take a two-week holiday in France with her daughter while our carers held the fort with steve.

the sPECAL method is designed to work positively with dementia, rather than trying to defeat or ignore it and has been shown to enable people to stay at home for longer, experience increased levels of wellbeing and take less medication.

steve continues to live in the comfort and familiarity of his own home. He no longer takes antipsychotic medication and his former outbursts of agitation rarely occur. Anne is no longer a worn-out care-giver; she takes a regular day out with her daughter and enjoys an occasional holiday abroad, which enables her to recharge her batteries and sustain her role as steve’s loving wife.

Anne told us: ‘the Good Care Group has enabled me to make time for myself, meaning that when I spend time with steve, I can give him the love, care and attention that he deserves. the approach that they have taken through sPECAL has really worked for steve.’

the SPECAL Photograph Album (Garner P., The SPECAL Photograph Album, 2008, 3rd edition; Windrush Hill Books, Hawling, Gloucs).

Since we can only recall what has already been stored, the person’s ability to recall the facts around what they did yesterday or what they had for lunch today is increasingly compromised. Yet people with dementia will possess memories from many years ago that remain potentially available and useful to them.

Change of location

a ny family member should always bear in mind that a dramatic change of location from a family home that has been lived in for many decades to an unknown and unfamiliar environment will not be in the person’s best interest.

it is therefore important for the care package to include a proactive outline plan for a future move into care, just in case this should become either desirable or necessary.

Far from accelerating the person’s move into care, this part of the care package has been shown to increase the time the person will spend at home – something that everyone wishes to achieve –and minimise distress should they ever have to move. (‘ a multimethod evaluation of a service for people with dementia’, Pritchard e.J. & Dewing J., Royal college of nursing institute [Rcni] Report no.19, 1999)

t here are several companies that provide 24-hour live-in care for people with dementia in their own home. i work for one of them. Some people live alone, while others still have their partner, who is loving and supportive but just doesn’t have the care skills, patience and understanding to look after someone with ever-advancing dementia.

the Good care Group’s aim is to support people with dementia to stay safely and happily in the familiarity of their own homes and communities for as long as possible. Our dementia strategy is underpinned by an understanding of The SPECAL Photograph Album, an innovative use of analogy to explain the experience of the person with dementia.

treatment and management of

the relationship that homecare workers develop with their clients can be instrumental in supporting the person with dementia

IntErEstEd In tAkInG PArt In A CLInICAL trIAL?

re:Cognition Health (45 Queen Anne street, London, W1G 9JF) is the largest group of cognitive and brain health experts in the uk. It’s London Centre also undertakes international final-phase clinical trials for new medicines for a range of neurological conditions including medications to slow down the progression of Alzheimer’s and other types of dementia.

Anyone who is clinically eligible can participate in a clinical trial at no financial cost to the individual. this year, re:Cognition Health has been enrolling for a number of international trials for those with mild and moderate symptoms of Alzheimer’s disease and also behavioural variant fronto-temporal dementia. during the study period, all participants are randomised to active drug or placebo. But, as the studies offer an open label extension, all participants can expect to receive the active drug at the end of the study period.

Enrolment is competitive, globally, and re:Cognition Health is currently one of the top recruiters for Ad trials, internationally; giving as many uk patients as possible a chance to take one of the places on the trial.

double-blind randomised international trials currently in progress at re:Cognition Health: 1. Condition: Mild Alzheimer’s disease (MMsE 20-26) study LZAX Expedition study. study Period: 82 weeks. study closing for enrolment: 31 december 2014

2. Condition: Behavioural variant fronto-temporal dementia (MMsE 20-30) taurx 007. study Period: 52 weeks. number of visits: 10. study closing for enrolment: december 2014

3. Condition: Mild-moderate Alzheimer’s disease (MMsE 12-22) study Lu AE58054. study Period: 28 weeks. number of visits: 8. starting enrolment: december 2014

4 & 5. Condition: Mild and moderate Alzheimer’s disease (MMsE 14-26) studies: taurx 005 and 015. study Period: 82 weeks. these two studies are no longer enrolling. Additional, new international trials are coming soon.

What’s involved in participating in a clinical trial?

those participating in a phase 3 clinical drug trial are provided early access to new treatments and require the patient and their carer to adhere to the trial protocol, which includes attending regular prescribed appointments for between 12 and 18 months so their response to the treatment can be measured.

re:Cognition Health provides information on its website for general inclusion/exclusion criteria and one of the re:Cognition Health consultants guides patients as to which trial is most suitable for them.

typical entry criteria include:

 A confirmed or suspected clinical diagnosis which fits the study objective

 test results within a specific range – for example, MMsE score or ACE-r score. these are both paper-based memory tests

 Other health, lifestyle and family factors

 Other medications the patient may be taking

For more information or to register interest, email the research team at clinician@re-cognitionhealth.com and visit the website at www.re-cognitionhealth.com.

At dementia provides information on assistive technology that can help people with dementia live more independently. see www.atdementia.org.uk

tOP tIPs FOr MEdICAL PrOFEssIOnALs suPPOrtInG PEOPLE

SPECAL’S

ThrEE GoLDEn ruLES (JAmES o., ConTEnTED DEmEnTIA rAnDom houSE GrouP, LonDon, 2008)

WItH dEMEntIA

 note that, for the person with dementia, feelings are much more important than facts. People with dementia struggle with storing new information or memories, but will always know how they are feeling. this has been borne out by neuro-imaging studies from the university of Iowa. (Feinstein J.s. et al, ‘sustained Experience of emotion after loss of memory in patients with amnesia’, Proceedings of the national Academy of sciences, 2010, vol.107 no.17. university of Iowa) these findings provide direct evidence that a feeling of emotion can endure beyond the conscious recollection for the events that initially triggered the emotion. www.pnas.org/cgi/doi/10.1073/pnas.0914054107.

By fostering a sense of self-esteem and confidence and at all times avoiding causing distress, worry, frustration or confusion, the person’s well-being will remain protected, enabling them to function at a higher level.

 Avoid asking too many direct questions. Questions put huge strain on people with dementia. While some questions may be unavoidable in a diagnostic setting, by reducing the amount of unnecessary questions, you will help to put the person at ease, bolstering their confidence which, in turn, will positively impact on their ability to supply the medical practitioner with the information they require.

 Listen to the person with dementia – everything they say and do has huge significance. Even with word-finding deficits and other cognitive difficulties, the person retains the ability to express their thoughts and feelings. Although the content of their message may be hard to interpret, it should never be ignored.

 do not contradict. People with dementia have to make sense of their reality in a slightly different way to us and will increasingly use past memories to make sense of the here and now.

this, combined with language difficulties and other cognitive issues, can lead them to say things that may not make sense to us or that we may perceive to be ‘incorrect’.

Correcting a person with dementia and informing them of their ‘errors’ serves no good purpose, since their failing short-term memory means that they are unlikely to store the ‘correct’ information that you have given them.

Any ‘common-sense’ attempt to correct them will leave them feeling foolish, upset or even angry – possibly without even knowing why they are.

dementia has developed threefold over recent years. i t is now widely understood that the use of the biomedical model without recognition of other approaches to understanding the construction and meaning of dementia means that neither the person with dementia nor those in supportive roles are seen as being active contributors to care. the person with dementia can be viewed as not having a sense of self or identity when using the biomedical model in isolation. it is recommended that a blended approach of psychosocial techniques is employed by any care provider, and these are integral to the SPecaL method of managing dementia.

The SPECAL Photograph Album was developed by the contented Dementia trust (www.contenteddementiatrust.org). the trust aims to promote lifelong well-being for people with dementia and is grounded in the principles of person-centred care which were first described by Kitwood in 1997.

Change of perspective

The SPECAL Photograph Album introduces a very important change of perspective for both professional and family care-givers and offers them a completely different way of looking at the condi-

tion, leading to ways of interacting with and responding to the person with it. We call this ‘SPecaL sense’ – something which flows from engaging with the experience of dementia as demonstrated by The SPECAL Photograph Album additional treatment options for alzheimer’s disease are medication based on the ‘cholinergic hypotheses’, which maintains that, as a result of underlying pathological processes, neurons that use acetylcholine, critical to memory and learning, are affected.

Recent advances have seen the production and prescribed use of acetylcholinesterase inhibitors. these drugs increase the amount of neurotransmitter available by inhibiting the action of the enzyme responsible for its deterioration.

nice provides practice guidance related to the use of this medication ( nice 2006). For the other dementias described, treatment options using medication require a careful balance to manage symptoms of the dementia and the side-effects of the prescribed medication (nice/Scie 2006).

 next issue: What to do legally and financially to prepare for care

Zoe Elkins is head of care strategy at The Good Care Group

your prActice

Innovative technology builds developing

A leading provider of physiotherapy services explains how a novel, cloud-based phone system has allowed it to expand and tailor its services to time-strapped, tech-savvy clients. The cloud-based technology is also a boon to professional staff, who often work remotely. And, as Dean Payne explains, the system saves the firm money to boot

I founded o pt I mum Healthcare Solutions Group in 2003 when I identified a huge gap in the market for end­to­end treatment and rehabilitation.

In my 20 years of experience as a senior physiotherapist, I have worked with a number of clients who often fail to continue with their prescribed gym sessions and complete their rehabilitation process properly.

As a result, I formed optimum Healthcare Solutions Group – a one­stop­shop for individuals and large corporations that incorporates four integrated departments:

 optimum physiotherapy;

 optimum neurotherapy;

 optimum fitness;

 optimum elite fitness.

All of these departments work together to provide full assessment, treatment, rehabilitation and performance continuum for all our patients. It is now one of the main regional healthcare providers in the uK.

the business has grown rapidly since day one because of the services we’ve brought under one roof and because of the partnerships with insurance companies, which now refer their clients onto us.

the loyalty we’ve formed with these companies has been built on our ability to turn each case around efficiently, while providing the best possible care. As a result, we now operate 23 clinics providing specialist care across seven uK counties.

As the business grew, communication with stakeholders and across clinics was absolutely vital.

f rom the get ­ go, we required technology that would not only enable us to provide flawless communications with all stakeholders, but would also adapt to the rapid growth of the business – and RingCentral’s cloud­based phone system hasn’t let us down.

the personal touch

As one of the biggest physiotherapy companies in the u K, we wanted to ensure that our customers still received the best customer service and personalised treatment possible.

But with our previous on­premise pBX telephone system, we had just four incoming telephone lines and around 500 inbound and outbound calls a day. this meant that customers were

To improve the patient experience even further, we’ve introduced a smartphone app, which delivers exercise programmes straight to our patients’ smartphones and tablets

kept on hold for much longer than they needed to be.

As a company that thrives on the best customer service, we are driven by key performance indicators (KpIs). But we realised we weren’t achieving these for the time taken to answer customer calls.

We considered getting more ISdn lines on our existing system, but it meant we’d be spending three to four times as much and, as a small business, this just wasn’t financially feasible for us. But thanks to the cloud­based phone system from RingCentral, we now have 32 lines for the price we used to pay for just four ISdn lines.

to improve the patient experience even further, we’ve intro ­

Optimum Physiotherapy provides a number of services to ease discomfort, including acupuncture and Pilates

builds a healthy business

duced a smartphone app, m y physio App, which delivers exercise programmes straight to our patients’ smartphones and tablet computers.

p eople don’t leave messages anymore – they just hang up if they can’t get through to someone quickly. that’s why we ensure patients can quickly make an appointment online or by calling in, making all interactions with us as easy and efficient as possible.

efficient and easy to use technology

With our previous on ­ premise phone system, the biggest challenge we faced was the complexity of using it, which required external engineers to administrate and maintain it. As a result, we researched alternative technology that would be easy to use and program for the senior management team.

I’ve personally been a huge advocate of cloud technology such as RingCentral’s cloud tele­

phone system ever since I was a lone practitioner in 2005. t he technology enabled me to divert calls from my office to my home very easily and meant I could take customer calls and remain professional regardless of my location. one of the biggest advantages of using cloud technology is that it’s so easy to implement and use. All our staff are much more comfortable using the cloud ­ based phone system we have in place, and can even reprogram it without any additional technical support.

one team, one cloud

With 32 staff distributed across 23 clinics in seven counties across the uK, our workforce is very dispersed, so it’s essential that internal communication is at an all­time high.

Some of my physicians run our clinics on their own. But information­sharing across all our clinics is vital, especially in our line of work where communicating a

customer’s medical history is necessary if they visit physicians in a number of our clinics.

future growth through innovation

At optimum Healthcare Solutions Group, we fully embrace cloud technology and plan to continue exploring new technology to gain a competitive edge.

So it’s essential all staff still feel they are a part of a wider team. We use cloud technology to connect all our staff and share information easily. our phone system allows staff to contact colleagues in different locations through an allocated extension number, and we also use a cloud­based clinical system to securely share notes. Staff retention is important and I’m a huge advocate of cloud technology that enables staff to lead flexible lives. this means they can work from home or remotely when they need to and still be securely connected to office. for instance, an employee has recently had to relocate to Germany for her husband’s job, but thanks to our cloud ­ based phone system, clinical system and the cloud desktops we’re about to launch, she can still remain employed by us and work remotely via the cloud. For further information on RingCentral, please call 0800 098 8136 or visit www.ringcentral.co.uk

We already have a p hysio Advice Line in place, where customers can call in and seek advice from physicians if they can’t make it into their nearest clinic for a face­to­face consultation.

We are now planning to experiment with video and allow patients to send in videos of strength and conditioning work they are doing at home to seek further advice from physicians.

We see huge potential in telemedicine and want to stay at the forefront of the healthcare industry. In the next couple of months, we’re looking to take the work we already do in this area even further and are very excited at the prospect of experimenting with Hd video conferencing as a way of connecting our physicians to patients remotely for real­time consultations.

I’ve built my business from the ground up and I want to be the best at what I do. I want to be the best employer; I want to provide the best possible customer service and lead the evolution in this sector. If this means putting my head on the block to achieve a business edge then, so be it.

It’s easy to sit in a comfort zone and stick with what you know, but businesses need to be prepared to take a risk to move forward and embrace new suppliers and new technologies. 

Dean Payne is managing director of Optimum Healthcare Solutions Group

Getting positive

feedback

Private doctors who market themselves using patient testimonials may find they reveal more than they think they do. Catherine Harriss has some advice

A testimoniAl is an account of how a person valued your service, both good and not so good.

At the very least, it is a method by which you can improve your service.

At best, it is the single most valuable marketing tool that you can obtain and use, and with very positive effect.

We live in a very social world. We always have done. Just as we once used to talk over fences and with our friends, discuss whom to see, whom to ask and whom to seek information from, we still

seek information today, but in a much more public arena. Reputations have made or broken an individual. We can all think of many examples and, in medicine, it is no different.

Why UsE TEsTimoniAls

1

Build trust testimonials can be so valuable in conferring to the reader that you effectively ‘do what you say you will do’. But they must be freely given, announcing the ben-

A testimonial is the single most valuable marketing tool that you can obtain and use, and with very positive effect

efits gained with a time-scale in which they were received and other physical properties relieved or removed or a condition improved.

2 Don’t sell

A genuine testimonial is written from the heart and, consequently, the passion emitted from this can be very persuasive and so encourage others to visit the same practitioner to obtain the same feelings and results. Potential patients will want to feel the same through obtaining the same results.

3 overcome objections When a testimonial is received from an individual who is very surprised that they had a positive experience because of their circumstances, then this too can be very persuasive for others in similar circumstances.

s tatistics and researched outcomes are not as powerful as finding people in similar circumstances who have experienced success.

WhAT TEsTimoniAls Do

1 Announce benefits there is nothing better than reading a testimonial from someone who is so happy at the outcome, explaining why and how it has made an improvement on their life.

this should be seen in full, with all their grammar and spelling mistakes. there is no need for any editing of any kind. indeed, editing implies that there could be an element of making the words sound good.

t hey are not seen in context. therefore, for a testimonial to be believed, it needs to be shown in full with all poor grammar, if necessary.

2 substantiate your claims

if your service aims to eradicate, reduce or cure a certain condition or problem, then this is what your testimonials should reflect. i t should not simply be a short sentence; there should be detail and expression.

3 help relate to other people

When a testimonial writer provides detail of how they came to arrive at your door, and then receive your fantastic service that led them to live normally/better/ happier, then others reading this will project themselves and imagine that they could have the same outcome.

4 help your credibility testimonial writers may impart some information as to how they found you and why they chose you, which indicates that there was a significant thought process that led them to see you.

5

Endorse the key benefits of your product/service o ften in the medical world, we hope that patients come and visit us for a single treatment, whether that be a course or a single-visit procedure and that there is no need for them to return.

t his is very different to many business models where you are thinking of ways to encourage repeat business. if the testimonial indicates that they came to you with a problem and you provided a solution and it worked, then you will have done well.

if the patient provides information about added benefits, then even better. it reinforces that your treatment will help them find the solution they have been looking for.

6

Audience can compare it is never good to hear that individuals have had a poor experience elsewhere, but this can happen and it does happen for many different reasons.

Again, if the writer explains that they came to you because they had this bad experience elsewhere then this really helps to build your credibility.

i n our experience, the writer never specifically mentions past names, as the most recent treatment had the most positive effect and that is the focus they are grateful for.

The law in the UK, Consumer Protection From Unfair trading Regulations 2008 states that ‘falsely representing oneself as a consumer’ (in the

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Editorial director

ObtAining genuine testimOniAls

the key is to make it easy to receive testimonials and there are many ways to gain a positive reputation.

they can be obtained in many different ways and are rarely, nowadays, received in letters through the post.

in my company, we help establish easy pathways for ‘users’ to send their thanks, opinions and outcomes about care received.

there is no need to edit them, for all the reasons we mention in this article. they need to be as complete as possible.

We always advocate the removal of names mentioned and any word that could be identifying and break patient confidentiality. A complete testimonial conveys the message that the sender wanted to give.

A genuine testimonial cannot be obtained under any duress. this is why asking patients to complete a hospital questionnaire about their care is nOt a testimonial and should never be used as such. these are easily spotted, as they are often short comments with no benefits or gains mentioned. to me, they are a clear sign that someone has tried to bolster their image, as they are often added to a website before the real testimonials come through.

there are many review websites which encourage users to write testimonials about their experience. but these are often a double-edged sword, as there is no right of reply.

these sites are necessary in spreading the word about you and your service, but if someone feels that they need to give you a negative review, it is not possible to stop them or, for that matter, to respond to them.

Knowing that this can happen, whether it be in a forum, or any social media website, the impetus for you to provide the best care should be paramount, so ensure that your team are all supporting you with this end point in mind.

Our consultants know that their team could be mentioned in any of their testimonials and highlighted for special thanks. so testimonials should be received spontaneously and your practice needs to encourage this by being attentive, caring and communicative and providing a high quality of care.

this also means that the team that you work with needs to be ‘on board’. they need to know the standards you expect and work with you to ensure that these standards are kept.

staff education should be a high priority along with your treating your staff with the care and gratitude that they deserve. this all makes for happy employees who all help to ensure that the patient has a positive experience.

Receiving and using testimonials remains the single most powerful tool that you can use to enhance and build your reputation and set you apart from your competition.

Fake testimonials are not fair, legal, decent, honest nor truthful

context of promoting a product to consumers) is deemed to be ‘unfair commercial practice’.

t he false practice of business trying to get grass-roots support from non-genuine comments or recommendations is called ‘astroturfing’, which is a criminal offence for which the maximum penalty is two years in prison and/or an unlimited fine.

All this is policed by the office of Fair trading and trading standards.

t he Advertising s tandards Authority’s UK advertising code says that ‘marketers must hold documentary evidence that a testimonial or endorsement used in a marketing communication is genuine, unless it is obviously fictitious, and holds contact details for the person who, or organisation that, gives it’. Fake testimonials are not fair, legal, decent, honest nor truthful.

The GmC

According to the G m C’s Good Medical Practice , April 2013, the core of medical practice is for patients to be able to trust doctors with their lives and health. the guide states that patients need good doctors and that ‘good doctors make the care of their patients their first concern’.

the vast majority of clinicians follow this advice closely and so feedback of care should not be a problem to receive.

taking into consideration the Advertising standards Authority UK code, and the G m C Good Medical Practice code, it is vital to get the right message across to the right people in the right way. 

Catherine Harriss (right) is the founder of MultiWorksMarketing. co.uk specialising in medical private practice marketing and management

It’s good to

stalk

‘I’m a cyberstalker,’ admits our resident marketing guru Mr Dev Lall (right), who explains here why you should be one too

WhIle A WeBsITe is a wonderful thing, not everyone who visits it is going to pick up the phone and book an appointment to come and see you.

This may come as a shock to you, but really it shouldn’t.

What might well come as a shock, however, is the appallingly low percentage of visitors to any given website who do anything at all. Most people arrive, look at a page or two . . . then leave, never to be seen again.

It’s not called ‘surfing’ for nothing. People flit about cyberspace looking for something that grabs their interest. If the web page they find attracts their attention, great. If not, they’re off.

Research has shown that you have at most 11 seconds to grab your visitors’ interest – and if you don’t, they’re gone. For good. This is also true of your own website.

In previous articles in Indepen­

dent Practitioner Today, I’ve talked about the importance of getting your website found by patients and some of the many ways you can do this – pay-per-click advertising, forum marketing, article marketing, videos and so on – so we won’t go over that now.

But what we do need to look at is what happens when those potential patients arrive at your website.

The ‘heat map’

In medicine, hard data beats opinion every time, and this is no less true in marketing and promoting your practice. Using software such as the freely available Google Analytics, you can generate a ‘heat map’ of your website. In other words, see where people are coming from, how long they spend on your website and on what pages, among other valuable information.

If you do this – and I strongly

recommend that you do – you will be shocked to see that 90%+ of the visitors to your website leave within a few seconds, never to be seen again.

And they’re not reaching for the phone to book an appointment, either. Why do people behave this way?

The main reason is because most websites are designed with no thought as to their actual function. The consultant has decided roughly what he wants it to look like and has enlisted a web designer – who knows nothing about marketing – to design it for him.

he spends a couple of grand and ends up with a pretty website and waits for the patients to roll in to his practice. And a few months or years later, he’s still waiting. Not good.

And when you consider that you have paid for many of the visitors to your website to get there in the first place – with

now you can pursue visitors even after they have left your website. it’s time to start cyberstalking. The official term is ‘remarketing’

Google AdWords or pay-per-click marketing – then that makes it harder to bear still.

So what’s to be done?

The first step is to consider what exactly you want visitors to your site to do. Typically, you want them to pick up the phone to make a clinic appointment. There are other things you can get them to do which are far better, but let’s stick with picking up the phone for the present.

Next, you need to look at your website through the prism of that function: if you want people to pick up the phone and book an appointment, you need to make sure that every element on that page is steering them in that direction.

Write your content clearly, concisely and persuasively, explaining in terms the patient/visitor can understand. Why should they consult a doctor about a given

The ‘reMarkeTing cycLe’

condition, why they should do so now, and why should the clinician they choose be you?

Anything that gets in the way of answering those key questions in the visitor’s mind is, at best, a waste of space – nobody cares in the slightest about your CV or that Fellowship you did – and, at worst, counterproductive; for example, superfluous links to Facebook, Twitter and so on.

If you do this, you will find that you get far more visitors to your website turning into patients –they will pick up the phone and make that appointment to see you.

But that’s just the start. Because when you go back and look at Google analytics to see what people are doing on your revamped and refocused website, you’ll find that many more people are making appointments to see you.

You may well have doubled or quadrupled your conversions. But a very large percentage of visitors

are still leaving your website and doing nothing, disappearing for ever. Now what?

Until recently, there was not much you could do about that. The vast majority of visitors to even the best and most focused website still disappeared into the ether, never to be seen again.

The first step is to move ‘upstream’, so to speak, when it comes to paid-for traffic. By fine tuning your keywords and adding negative keywords into your Google pay-per-click campaign to ensure you don’t attract irrelevant and unwanted inquiries – and then split-testing your ads to deliver the highest possible clickthrough rate, you could deliver only those people most likely to be interested in your expertise.

That remains both important and necessary, but, over the last few years, things have got seriously interesting. Because now you can go downstream.

National Conference & Exhibition

Figure 1: how your online research re-appears on the Telegraph website

Figure 2: how your online

This all sounds a bit complicated, but it’s really very simple and you will already have seen it in action, even if you weren’t aware of it at the time

Now you can pursue visitors even after they have left your website. It’s time to start cyberstalking. The official term is ‘remarketing’ and this is how it works: You place a snippet of code on your website which itself connects back to Google.

When a visitor lands on your website, a cookie – a string of text – is placed on their computer, in effect telling Google that they have visited your site but not taken any action.

As the visitor surfs away from your website and randomly flits around the internet, they will inevitably end up on a website that is either owned by Google or part of the Google display network. If that site is remarketing enabled, it can recognise the cookie on the visitor’s computer and will serve up an advert that was previously created by you.

These adverts are served up for free by Google, but if the visitor clicks on it, they are taken back to your website and you are charged a small amount of money (perhaps £1-£2). This is very much analogous to pay-per-click marketing that we have discussed before.

How remarketing works in practice

This all sounds a bit complicated, but it’s really very simple and you will already have seen it in action,

An easy to use software system, which fully supports the clinician and office staff and makes the whole process of running a busy Practice a lot easier.

Call now for a chat and ask about a free, no obligation demonstration of our comprehensive system that has been designed to save your Practice time and money.

Figure 3: how your online research re-appears on a

even if you weren’t aware of it at the time. see the flowchart of ‘the Remarketing Cycle’on page 29.

A practical example

There’s a piece of software I use in my business called Infusionsoft, and the company use remarketing to grow their business. so when I visited the Infusionsoft website and left without taking any further action, they recognised that and metaphorically started to ‘stalk’ me. later that day, I visited several other websites and you can see what I saw:

 Figure 1 (on page 30): screenshot of remarketing on the Daily Telegraph website;

 Figure 2: screenshot of remarketing on YouTube;

 Figure 3: screenshot of remarketing on a technology website. It’s worth stopping to consider for a minute the magic of what you have just witnessed. I have vis-

ited the website of a company which sells a product I’m interested in, but I’ve left the without buying. As a result, when I go to other unrelated sites that are part of the Google display ads network – and there are an awful lot of these – I get adverts served to me about that product I first looked at.

The circles in green on the screenshots on the right show that you can see these adverts on sites as diverse as YouTube, The Daily Telegraph and Tomshardware.com (a technology website).

If I didn’t know better, I would assume these guys were a huge company throwing vast amounts of money to advertise in big-name places such as YouTube, Amazon and the Daily Telegraph

Yet, the truth is the adverts are free and only cost them a small amount of money when I click on them and get taken back to the parent website.

Their logic is that by repeatedly

reminding me of their software, I am far more likely to go back to their site and become a customer. And they are correct. That really is incredibly powerful – and you can use this for your skills as a doctor too, at very little cost. It is now possible to capture the lost visitors from your website and encourage them to return –and book that appointment to see you.

Cyberstalking is now a reality.

‘Oh, it all sounds a bit . . . technical. And unnecessary.’ This is something I hear a great deal, from consultants who do not understand the power of remarketing.

Yet, think about it: if, say, 2% of visitors to your website contact you to make an appointment and you increase that to 4% by running a remarketing campaign, that has literally doubled the income from your website.

And once it is up and running, you don’t need to tinker with it. You should, of course, try to improve the numbers of people who click back to your website –but you don’t have to. And the ads are served for free, unless someone actually clicks.

What’s not to like?

Targeting is the key to success in promoting your private practice. And if you’ve been smart in how you drive traffic to your website, those visitors are highly targeted. It would be criminal to let them go without a fight. Woo them. e ntice them back by reminding them of how you can help them. Major players like Amazon do precisely this: If you’ve browsed on Amazon and not bought that item, you will have seen adverts for that product popping up on all sorts of other websites. That’s remarketing in action. Why do they do it? They do it because it works. Perhaps you should, too. 

Dev Lall is an upper­GI surgeon and runs a specialist private practice consultancy www.PrivatePractice Expert.co.uk

it would be criminal to let these visitors to your website go without a fight. Woo them. entice them back by reminding them of how you can help them

is continuously updated based on the latest medical research to bring you current evidence-based recommendations.

Our unparalleled team of physicians and editors places new research in the context of the existing body of medical knowledge using their professional expertise and first-hand clinical experience.

This combination of Evidence & Experience is invaluable in crafting point-of-care recommendations trusted by more than 850,000 clinicians worldwide.

To learn more or to subscribe risk-free, visit learn.uptodate.com/EXPERIENCE or call +1-800-998-6374 | +1-781-392-2000.

A cunning plan

Understand your financial life cycle. Adam

Martin (below) discusses the critical points in the life of a medical professional when important financial planning decisions should typically be made

Like most people, doctors usually make financial decisions based on their needs at a particular point in time, without paying much attention to where they are in the ‘financial life cycle’.

While everyone has different circumstances, the concept of the financial life cycle is useful in understanding the ‘accumulation’ and ‘distribution’ phases that most people pass through during their lives and the types of investments and financial planning that may be suitable.

o ne of the advantages of the life cycle approach is that it factors in the changing nature of risk over the passage of time (see the illustration at the top of the opposite page).

the accumulation phase generally covers the period in your life when you are working and you are generating and storing wealth, including your home and pension funds. For most people, these are the largest assets to call on during the distribution phase. typically, the later working years just before retirement are the most beneficial for wealth creation, when your largest financial burdens such as mortgage payments and supporting a family are usually decreasing.

Retirement covers the bulk of the distribution phase, when sav-

ings are generally used to maintain lifestyles.

taking these two phases in turn, it’s useful to look at some of the key points in the life cycle and some of the challenges that need to be addressed.

AccUmUlATion phAsE starting out

For many people in the medical profession, studying hard for a number of years was rewarded by above-average starting salaries and earnings potential.

According to highfliers.co.uk, the average starting salary for a medicine graduate was £29,146 in 2012, second only to dentistry (£31,143).

For any younger doctor readers, or for those who find their children are following in your footsteps, at this stage in life it is, of course, crucial to answer some important questions about the financial life cycle, which will help with planning over the short, medium and long term:

 Short-term – is there a fund for emergencies? i s it worthwhile paying back student debt as a lump sum or maintaining the borrowing and using resources to invest elsewhere?

 Medium-term – How will savings need to be made for a deposit on a property?

 Long-term – eligibility for the NH s Pension s cheme and what impact will this have on retirement planning? should a private pension be considered?

house purchase

Property is usually the largest purchase doctors make, so it is always sensible to get specialist advice on affordability of borrowing and repayment of capital.

short-termism is one of the biggest risks – current conditions may lead to purchases beyond repayment means if interest rates increase rapidly.

For example, in the 1980s, there were base rates of more than 13%, which many people have either never experienced or forgotten about.

marriage

Being upfront about finances, including spending habits, the need for joint or separate bank accounts and even thinking about pre-nuptial agreements may save difficult conversations later. once married, it is important to review wills and the ownership of your assets.

For example, it can sometimes be more tax efficient to transfer the ownership of higher-yielding assets into the name of the lower earner.

starting a family s aving for your children’s – or grandchildren’s – future, whether it is to help with a house deposit or to pay for school fees, can take many forms.

starting to save for a child from birth may seem early, but even modest amounts can make a huge difference further down the line.

Current options include Junior isAs and bare trusts.

Junior isAs replaced Child trust Funds (CtFs) in 2011. CtFs can be converted into Junior is As in 2015. Junior isAs have an annual limit of £4,000 and provide a taxefficient wrapper.

the benefit of this may be offset by the restriction that once cash is put into a Junior isA, it can’t be removed from the wrapper. Children get full control of the assets when they reach 18.

Bare trusts offer more flexibility for investments and withdrawals and can be a good option for saving for school fees.

However, they do not have the same tax advantages as is As, albeit that a non-parental bare trust – where assets are gifted by anyone other than the parent –typically allow the child’s full income and capital gains tax allowances to be utilised. ensuring that you are protected against an unexpected loss of

income becomes more important, hence guidance on insurance should at least be considered for one or both parents.

Divorce

thinking about the financial lifecycle can be particularly useful when unexpected or unplanned events occur. i n difficult times such as divorce, it can be useful to break down financial needs into the following categories:

 Immediate concerns – How do you keep things going financially?

 Medium-term – What will happen to the family property? Are maintenance payments due?

 Long-term – What happens to pensions and savings?

i n later years, these assets are likely to play a much more central role in your financial decisions, so this may have a big impact on how you structure your investment portfolio.

DisTRibUTion phAsE

Retirement planning

one of the most crucial stages of the financial lifecycle, and probably the most difficult, is approaching or at retirement.

if, as well as being an independent practitioner, you are employed by the NHs, it is important to understand the nuances of your pension scheme.

Defined benefits pension schemes may also have inflationlinking properties, which, in peri-

ods of even mild inflation, can be beneficial over time.

i f you have a private pension fund (see feature article on p36), you will require specialist advice on lump sum arrangements and other important factors such as death benefits.

You will also need to review your spending pattern to ensure its sustainability over the long term and think about whether you are willing and able to draw on capital.

At this stage in life, it may also be worth reconsidering wills and the ownership of assets, as large changes to earnings may change the outlook on both fronts.

i n summary, financial planning, particularly for the long term, is not always straightforward. However, thinking about savings and investment in terms of your financial lifecycle can help you make better short- and medium-term investment decisions that make long-term planning simpler.

 By necessity, this briefing can only provide a short overview and it is essential to seek professional advice before applying the contents of this article. No responsibility can be taken for any loss arising from action taken or refrained from on the basis of this publication. Details correct at time of writing

Adam Martin, investment management partner at Smith & Williamson, the investment management and accountancy group

Take Control

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Online access to all your billing information

Your significant other

Making spouse pension contributions via your company could not only save tax now, but also boost your family wealth in retirement. James Gransby outlines what you need to know

With the rules on withdrawing pension becoming more flexible, now could be the best time to start saving.

Of course, doctors with a private practice and operating through a limited company very often make a tax saving by paying their spouse for their involvement in running the practice.

But if conditions allow, then making employer pension contributions on their behalf may

be one of the most tax-efficient strategies of all, not only saving tax now but also in retirement.

A not so unusual scenario take the example of a consultant still working in the NhS and having been in private practice for a few years now. they have built up a practice generating £50,000 profit a year via their limited company.

t heir spouse is a 50% shareholder and director and his or

her only income derives from this company. t he spouse receives an open market rate salary of between £8,000 and £10,000 a year.

When dividends are declared, they are kept at a level so as not to push the spouse over the basic-rate tax band. therefore, the spouse has no personal tax liability, their salary being covered by the £10,000 personal tax allowance, and the gross dividend doesn’t incur a tax

liability, as it is entirely within the basic-rate tax band.

t his is basic planning and very tax-efficient. But there are still options beyond this. if the market rate remuneration for their involvement could be argued as being higher than the salary they are getting, then there is scope for making employer pension contributions from the company on their behalf.

Justifying their overall remu-

neration package is fundamental to passing the ‘wholly, exclusively and necessarily’ test for tax relief and so advice should be taken on what an appropriate level may be.

so why make spouse pension contributions?

Justifiable pension contributions on behalf of an employee/director are a tax-deductible expense of the company, so a £10,000 contribution would cost the company £8,000 after the corporation tax saving is factored in.

Looking ahead to retirement is where another benefit, namely higher family income, is also gained.

Whether retirement is imminent or in the more distant future, any situation whereby one spouse is likely to pay a higher rate of tax than the other makes equalisation of income-generating assets sensible tax planning.

This is easy with most assets –

Making employer pension contributions on behalf of a spouse may be one of the most taxefficient strategies of all

such as buy-to-let properties and cash balances held outside of an ISA – as there is automatic nil gain, nil loss capital gains tax treatment between spouses for any assets changing hands. That makes the shift relatively painless.

But pension pots cannot be split between spouses at will – except on divorce – and so, with more careful planning, it is important that each individual builds up a pension in their own name.

The tax benefits of doing so can be large. If one spouse is paying 40% tax on their pension, while the other is not using their personal allowance or basic-rate band, then far less tax would be payable if part of the pension was in their hands.

Another consideration when making contributions is that if the spouse is already over 55 years of age, then the money is not being tied up for very long at all. Immediately, 25% can be taken

out as a tax-free lump sum and, from next year, the remainder can be drawn down under flexi-access drawdown.

After the lump sum has been drawn – known as crystallising the pension – then a maximum of only £10,000 can be paid into their pension per year in the future, but this may still be enough for decent ongoing tax planning.

The premiums paid are totally flexible, subject to the pension input limits of £40,000 a year in 2014-15 with a three-year carry forward for any unused excess.

And provided the amount is physically paid into the scheme before the company year-end, it will get corporation tax relief in the year in which it is paid.

The amount of pension paid each year can be varied and just because a payment was made in one year does not mean it must stay the same in future.

What if my spouse is paying into a pension elsewhere?

If the spouse has an occupational pension elsewhere, then independent financial advice should be taken, as it may be preferable for them to increase contributions into this scheme rather than setting up a new personal pension.

In fact, financial advice should be taken before any pension payments are made on their behalf.

How a spouse pension allows you to retire earlier – or later With the new 2015 NHS Pension Scheme on the horizon, the retirement age in the NHS is rising from 60 to match state pension ages , which will be rising to 68 in the mid-2030s.

To take a pension and lump sum from your NHS Pension early would incur some quite substantial actuarial reductions to income and lump sum levels.

For those with a personal pension, and based on current legislation being enacted, they could access their whole personal pension fund up to ten years earlier, 25% of which will be escaping tax on withdrawal (see the opposite page for the article on flexi-access drawdown).

This could assist in wealth planning, as it could mean that the NHS pension can remain untouched for longer and preserve the amount while family income, by virtue of the income from the spouse’s pension, rises.

The NHS scheme member may choose to retire earlier – as family income has been boosted – or remain in the NHS scheme for longer for the same reason.

But what if we divorce?

Along with any other assets that the individuals hold, pensions would also be split. This is known as ‘pension sharing’.

Given a scenario of a married couple where one has an NHS pension and the other has no pension provision, then a percentage of the NHS pension’s deemed value would be transferred to the spouse.

If the spouse had built up a pension pot in their own name, then this should be taken into account and more of the NHS pension would be preserved by the NHS Pension Scheme member than if

To take a pension and lump sum from your NHS Pension early would incur some quite substantial actuarial reductions to income and lump sum levels

the spouse did not have any pension in their own name.

The NHS pension carries with it other very valuable benefits such as death in service and ill health retirement cover, which the other pension would not have. And so, by the spouse having a pension in their name, then the NHS scheme member will also keep more of this valuable cover.

Life insurance policy

A personal pension can act like a supplemental life insurance policy.

If the spouse with the private pension were to die, then if they have not yet drawn down any of their pension, it would be paid to their heirs without deduction of inheritance tax or any other tax charges, in the same way as a life insurance policy written into trust would be paid out.

The Chancellor has now announced that the previous 55% tax charge applied to a retirement pot being used to provide a pension will be abolished. This allows a pension to be passed tax-free to inheritors in this scenario too.

Flexibility to avoid tax

Other key factors affecting the NHS Pension Scheme include the tax charge for those exceeding the annual input amount, over which the member has very little control – except ceasing any added years or deferring membership altogether.

But these are much more controllable with a private pension, where the amount paid in each pension year can be tested against the annual limit. The NHS scheme inputs are based on a more complex calculation of deemed growth. If the new Lifetime Allowance (LTA) limit is going to be exceeded by the NHS scheme member, then the spouse having a pension in their name will bring with it flexibility over planning options in relation to overall family income.

The LTA limit has already fallen from £1.8m to £1.5m and now to £1.25m, so more and more members of the NHS Pension Scheme are being caught within this net. There is no guarantee that the limit may not fall further than £1.25m. As a rule of thumb, the final pension, multiplied by a factor of 23 (20 + lump sum) gives the LTA amount – i.e. a £45k pension gives a deemed pot of

£1,035,000, which is starting to get close to the £1.25m limit and could be exposed if the limit falls further in the future, subject to any pension protections in place.

Making personal pension contributions from taxed income instead of the firm A non-taxpayer is permitted to make pension contributions of up to £2,880 without the need to have any earnings and one spouse can pay the contribution on the other’s behalf if so desired.

If the NHS consultant is paying contributions on behalf of a nonearning spouse, then because this payment is coming from taxed income, it is quite tax-inefficient compared to making the same contribution from the company. This is because the 20% basicrate tax uplift applied to the personal pension contribution is only going part way towards recompensing the tax paid by the (40% taxpayer) on the net disposable income in the first place. Company contributions nearly always outperform personal contributions in terms of tax saved.

Auto-enrolment is coming

‘Nobody is forcing me to do this, so I may not get round to it’. Wrong. In coming months, any business employing staff, including a spouse, will receive a letter about auto-enrolment (See p48).

This is a mandatory process by which employers will need to pay pensions on behalf of their employees unless the employee chooses to opt out.

When you receive that letter, it should not be ignored and if you have not considered it before, don’t just discard it: this could work out very beneficial as I have explained. Financial advice should be taken before making pension contributions and tax rules may change in the future. But if after proper consideration and if the numbers stack up, then paying your spouse a pension contribution from your company now could make you both wealthier. 

James Gransby (left) is a partner at MHA MacIntyre Hudson, whose Maidstone and Leicester offices are members of the Association of Independent Specialist Medical Accountants

Better access to your

pension

The draft Taxation of Pensions Bill, published last August, suggests next year will be momentous for pensions, writes

Paul Gordon

APrIL 2015 will see the arrival of flexi-access drawdown which will give you the ability to access entire pension funds initially from the age of 55.

The first 25% will be tax-free –subject to the fund size and previous pension benefits in payment – with the remainder of the fund considered as income and taxed accordingly.

Individuals could therefore look to draw the fund as a one-off lump sum or could stagger the withdrawals over several years to increase tax efficiency.

nHs Pension scheme

We are likely to also see further change to the NHS pension with retirement being linked to the state retirement age rather than the 60 or 65 in the schemes currently available.

If you had more than ten years until your normal retirement age in April 2012, you will enter the 2015 version of the NHS Pension Scheme from April 2015.

There is to be transitional protection for those that were within ten to 13.5 years of normal retirement age in April 2012, which will mean a later entry into the new scheme.

The calculation of pension benefits will also change. At present, the 1995 Section of the scheme

provides a pension of 1/80th of your final salary (best year in the last three years) for every whole year of ten programmed activities worked, along with a lump sum, which is three times the pension amount.

The 2008 Section provides a pension of 1/60th of an average of your best three consecutive years in the last ten years. No automatic lump sum is provided, although pension can be commuted at a ratio of 1:12 for a lump sum.

The 2015 scheme will provide a pension based upon career-average revalued earnings from the date of entry until retirement, but at an improved accrual rate of 1/54th for each year of membership, again with no automatic lump sum.

Lifetime and Annual Allowance

The start of the current tax year saw a reduction to the Annual Allowance from £50,000 to £40,000, which will cause potential issues for pensions to those with any increment awards, clinical excellence awards or any other increases to pensionable income.

Note that the £40,000 allowance is not the amount you contribute to the NHS Pension Scheme,but the deemed growth throughout the year and will also

need to include any private contributions being made.

The Lifetime Allowance (LTA) is now £1.25m, down from £1.5m previously. Upon drawing benefits, if they exceed the LTA, a recovery charge will be made of:

 25% if taken as income;

 55% if taken as a lump sum.

It is important to outline where you stand currently, including all pension benefits. So requesting the following information from the NHS Pensions Agency – and coupling it with any private pensions you hold – will allow calcu-

lations against both of the reduced allowances:

 Membership statement;

 Accrued Benefits as of 5 April 2014;

 Annual Allowance figures for the most recent growth period. There are currently delays in the sending of information from the NHS Pensions Agency and therefore it is imperative requests are made sooner rather than later.

Paul Gordon is an independent financial adviser at MacArthur Gordon in Hythe, Kent

TREATing Billing pRoBlEms

Intensive care for unpaid bills

Not being paid for work you have done is a huge pain for many consultants in private practice. Robin Stride visits a ‘financial hospital’ where specialists go to have their medical billing and collection woes cured

Ouch! There is one shared ailment driving patients to this particular ‘clinic’. Financial distress.

It can be a few thousand pounds, or tens of thousands and even hundreds of thousands.

h ere, the patients’ case notes have a common theme of identity – they are all consultants, from all specialties and all parts of the uK.

And they are all seeking the same cures – recovery of unpaid invoices for their private work, a

review of their billing and then a dose of the correct medicine to allow them to focus purely on the medical side.

I am being given a conducted tour of the newly-opened larger premises of Medical Billing and collection, just off the north-west side of the M25 motorway in leafy Bucking ham shire. When the patients keep coming, the clinic grows – and this company is no exception.

They don’t like to say how much they have got back for doctors – their competitors are reading this – but it is running at tens of millions of pounds a year and they think all the signs are that this is set to increase in the years ahead.

We never saw any doctors when we were there because their individual treatment plan does not necessitate a personal attendance. It is more likely they will get their

own consultation at a location and time of their choosing to discuss their own personal ailments. What we did see was the bulk of the now 35 full-time staff beavering away at computer screens and on the phone as they did their daily rounds of curing consultants’ existing billing ailments and preventing new symptoms from rearing their head.

intensive care

It was explained that when someone new comes to the clinic, they are placed in ‘intensive care’ until the immediate issues and nuances have been resolved and they are ready to be passed over to their own account manager.

We also saw a lot of empty space ready for the new employees who are expected to be joining. Medical Billing and collection (MBc) has space to double its workforce to cope with the consultants that are joining them on a weekly basis.

r esearch suggests that only about 10-15% of consultants in private practice currently use a company to sort out their billing, which means that there is a lot of potential for growth.

The people at MBc see this figure changing all the time as more and more specialists take action to improve business performance and to treat what are often longterm sicknesses that have built up

They do not have a sales force. Word of mouth has always been the big driver for their clinic –like it is for many consultants in private practice

to crippling proportions over a number of years.

Another reason for the optimistic growth outlook is the number of ‘NIPs’ – new independent practitioners – who call in a firm to do their billing for them right at the very start, so they and their medical secretaries can concentrate on the business of seeing patients.

Battling with the books

It appears they are far less inclined than the previous generation of consultants to go back home late at night after seeing patients and to then spend more hours battling with the books.

This is how many have run into their financial problems in the first place. DIY billing was not cost-effective and so was often not done properly, leading to late payment, underpayment or worse – no payment.

We never saw any one from the sales force on our visit either. It turned out they do not have a sales force. Word of mouth has always been the big driver for their clinic – like it is for many consultants in private practice.

Getting consultants’ bills settled can be touch and go, though, especially with patients from abroad who manage to slip out of the uK without settling up. Once they are out of the country, then consultants can expect to kiss their money goodbye.

One of the more unusual and effective ‘cures’ for an apparent imminent bout of overseas payment blues involved a more dramatic intervention than usual, and going the extra mile.

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Managing director Garry chapman recalls: ‘I got a phone call from one of our consultants saying he’d seen this patient and learned he was going to be disappearing out of the country in two days.

‘We sprang into action. One of my team then spent the entire afternoon chasing an interpreter and phoning the patient’s hotel.

‘ e ventually, on that Monday evening, I drove from the office to meet the patient by the r iver Thames in London. There I collected £7,000 in £50 notes – in exchange for an invoice and receipt.’

One of the biggest reasons for the company’s success has been through the development of its own software which can be quickly adapted to the way that the market changes. This includes coping with the fee shifting patterns in the private medical insurance market and so ensures doctors receive the correct reimbursement.

Customised service

Another key factor is that consultants are cared for by individual account managers and each one, whether in a group or as an individual independent practitioner, gets a customised service based on their particular needs.

This will be governed by the type of work they do – for instance, some consultants only do foreign embassy work while others will specialise in the most complex cases.

Some might only see self-pay patients. Due to the variable nature of each practice, the account manager provides services tailored to its needs. An example of this can be where the practice is self-pay only and all the money is collected in advance prior to treatment.

On average, MB c says it achieves bad debts of less than half of one per cent across all its clients. Mr chapman says: ‘It is a statistic we are extremely proud of and we work very hard at maintaining year on year.’ he says they only charge on what they collect so that they share the same objectives as the practice.

When asked about other ailments, Mr c hapman explains: ‘Most private practices we go to

We’ve had many people who didn’t realise that the price per insurance company could be so different

see don’t bill correctly. That could be through lack of knowledge about how to use the codes or they may not know they can bill for a local anaesthetic, say, when they do a procedure.

‘It can also be a lack of understanding about how much to charge for a particular procedure, as the fee can differ by up to 100% for a particular ccSD code. We’ve had many people who didn’t realise that the price per insurance company could be so different.

‘We have increased their revenue by up to 25% in some documented case studies. The majority of clients that join us have a backlog. We are typically very successful at collecting the majority of it.

‘ e verybody’s different, but to give you an idea, I’ve had single practitioners coming to me with a backlog of £50,000, £150,000 and £400,000. The consultants quite often don’t know how much they have outstanding until something happens that focuses their attention on it and that makes them call us in when they realise they are in financial distress.’

On the day we met, he had just been dealing with a practice which was owed more than £300,000. There is no such thing as an average, but bad debts can run between 5%-20% among many private practices and the roots of the trouble often go back years. They can get into difficulty at any time, from when they start in private practice or even 20 years later.

Varied symptoms

The ‘symptoms’ that force consultants to take stock of their finances and call for treatment are varied, but might include changing circumstances, such as mounting school fee bills, large tax bills or even a divorce.

As well as getting money back for clients – a huge amount of it by card payments which patients can do online 24/7 – the consultants’ account managers also get involved in many aspects of the practice when dealing with either insurers, hospitals and patients. u ltimately, they all revolve around collecting the correct amount of money on behalf of the practice.

Account manager Lynne Glasson negotiates with insurers about charges for complex sur -

‘Financial Hospital’: Medical Billing and Collection’s headquarters in Amersham, Buckinghamshire (above)

gery and liaises with both them and patients to see fees are agreed before treatment. She tells Independent Practitioner Today: ‘I’ve done a couple in the last week where the insurer was offering £5,000 but agreed to pay £8,000.

‘Another insurer was offering the consultant £3,000 but the consultant wanted to bill at £5,000. We settled at £4,250 and the consultant was happy with that.

‘As long as you can justify the complexities before the operation, then I find the insurers generally OK with the amount that you are asking for.’

Fellow ‘fixer’, account manager Sarah Barratt, estimates as much as 70% of her call time is taken up with patients compared to 20% with insurers and only 10% with doctors and their secretaries.

There might be the worried spouse of a patient who has died, someone who was unhappy with their treatment and does not want to pay, or someone who has run out of insurance benefit, or a patient complaining about the lack of cover under the insurance policy that they have.

General manager Garry Nials says: ‘A lot of consultants come to us for our general expertise in the market – what can they bill for, how much and, just as important, what they cannot bill for. Often we have found they have been charging too low; for instance, using one insurer’s schedule for all their patients, whereas it can differ from insurer to insurer.

‘With some of the backlogs, it makes one wonder how they made any money in the first place. So often they have done the work – and then just not followed it up.’

Swindlers’ list

Caveat emptor!

Doctors are targets and should always be aware of the possibility of being caught up in one of the latest investment scams –especially after the imminent changes to pension pots, warns Patrick Convey (right)

Y O u MAY not have heard of it, but ‘graphene’ is the latest wonder material.

Lighter than a feather, stronger than steel and more conductive than copper, it was first reliably produced by two u niversity of Manchester scientists, Andre Geim and Konstantin Novoselov, a decade ago.

While the inventors went on to receive the Nobel Prize for physics for their efforts, the miracle matter has been involved in some dubious investment ‘opportunities’.

Individuals running ‘boiler room’ scams have been promoting investments in graphene

despite agreement from researchers and scientists alike that mass production in the commercial world is still some way off.

The Financial c onduct Authority (F c A) warned that most firms selling graphene investments are not authorised by the regulator – meaning there is no access to compensation via the financial ombudsman.

Riskier alternatives

Tracey McDermott, its director of enforcement and financial crime, added: ‘...finding an accurate price for graphene is very difficult, and its value is expected to fall over the coming years.’

With interest rates failing to beat inflation, normally riskaverse investors can find their attentions turning to riskier alternatives.

And to satisfy this growing appetite, there has been an influx of alternative investments coming onto the market; from virtual currencies and unmined gold to overseas land and vintage wines.

But among the genuine offers are bogus schemes which have proved dangerous for even seasoned investors.

u K investors lose around £200m a year to high-pressure ‘investment boiler rooms’. Some

Online PASSWORdS

TiPS FOR keePing yOuRS

SAFe

 Think of a phrase that is very familiar to you, eg: Jack be nimble, Jack be quick, Jack jump over the candlestick. now take every third letter of this sentence: cemeceijkmvtcdsc.

At first, it may not be easy to remember the sequence, but you will remember how to arrive at the password. Over time, you will commit it to memory

 use capital and small letters, numbers, special characters and spaces, in any order

 Make intentional grammar mistakes eg ‘tommorow’

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A PASSWORd iS WeAk iF iT:

 is already used for another purpose (an email account or mobile phone). it will be known to other, possibly insecure, software

 is a real word. Hackers can run through digital dictionaries in minutes

 Consists of a birth date or a name. Hackers will have this information already

 is less than eight characters

10,000 victims lose an average £20,000 each.

Bogus stockbrokers – often based in ‘boiler rooms’ abroad –cold-call investors after taking phone numbers from public shareholder lists. They offer to buy or sell shares with the promise of big returns, only for victims to discover the shares are worthless. using high-pressure sales techniques, the stockbrokers offer free ‘secret’ stock tips or research reports into a company the investor already holds shares in.

share scams

The F c A says it receives almost 5,000 calls a year from investors who believe they are victims of share scams, by which point around 10% have already handed over their money.

Often the scammers demand cash immediately, warning that the ‘brilliant’ opportunity will otherwise be lost. Fraudsters tend

to target affluent men, with amounts of up to £250,000 being taken in one hit.

Now investments involving ‘carbon credits’ – a certificate which represents the right to emit carbon dioxide – have hit the headlines.

Sold with the promise of a viable secondary market to sell or trade the permits, in reality, individuals discover that trading on the carbon credit markets requires experience and time – both difficult to achieve if you have a professional career outside finance.

The companies involved are usually based overseas and, as such, are outside the jurisdiction of u K authorities, although the FcA has already launched over 75 enquiries into carbon credit firms.

Other investors are duped into buying fine wine, by the case or barrel-load, which is either overpriced or does not exist. The accompanying glossy brochures

The Financial Conduct Authority says it receives almost 5,000 calls a year from investors who believe they are victims of share scams

promise ‘guaranteed profits’ and make the deal seem legitimate. The end result can be a cellar full of cheap plonk.

It is easy to be wise after the event, but many experienced investors can be duped by ‘getrich-quick’ or indeed ‘get-richquicker’ schemes.

Notorious fraudster Bernie Madoff is serving 150 years for operating the biggest ever Ponzi scheme, whereby a fraudulent rate of return was promised to entice investors. The fund lost around $50bn by redirecting cash to earlier investors with money from later clients.

Many people still question how Madoff was able to dupe well-educated investors. Baron Jacobs of Belgravia – one of Britain’s richest men – was one of his most highprofile British victims. The peer has enjoyed a long and distinguished career in business but allegedly lost tens of millions of pounds.

he said: ‘I went into some detail with him of how it worked. What makes me look so foolish is that I was a fairly savvy investor. It may not look like it now, but I really was.’

Ask questions

Madoff himself claims his victims were ‘sophisticated people who should have known better’. ‘People asked me all the time, how did I do it? And I refused to tell them, and they still invested,’ he said. ‘Things have to make sense to you. You should ask good questions.’

however, new economic developments bring new opportunities for those involved in scams to strike.

Next year’s pension rule changes, which will allow retirees to withdraw their pension pot at 55, could force a rise in ‘pension liberation’ stings.

Louise Baxter of the Trading Standards Institute explains: ‘More 55-year-olds could be targeted by cold-callers to take their pension out, in exchange for a kickback, and they will think it’s been re-invested when it hasn’t.’

Other schemes will offer to help release cash from pensions before the investor turns 55, claiming it is simply borrowing money from their own pension fund.

4

The caller may ‘chat’ to break down resistance

They will fall back on usual sales lines such as ‘i’ve been given the green light to release the investment’ to ‘selected investors’ 5 They may say the investment is so good they have invested their own money in it – or their mother’s 6

They promise to post or email details, but the information never arrives, so they have a reason to call you again to reinforce the message

PROBLEMS WITH THE TAX MAN?

Doing so before that crucial age will actually generate a tax bill of 55% of the amount accessed. If it is not declared to h M r evenue and c ustoms, the tax bill increases with a penalty to 70% of the amount claimed in cash.

Similarly, as the u K’s housing shortage continues, fraudsters have jumped on the chance to sell land-banking schemes. They section plots to sell on to investors keen to make a profit once the site is ready for development; except it later transpires that the land cannot be developed – a scam which has cost uK investors some £200m.

Other schemes include plots of trees or crops for sale abroad. The investment is dubbed ‘low-risk’ with ‘guaranteed returns’: two phrases which can never be linked. e very investor would like a product that offers a fail-safe high

return with a minimum level of risk. The truth is that such a product does not exist. Successful investors are those who understand the very real relationship between risk and reward. 

Patrick Convey is technical director of Cavendish Medical, specialist financial planners helping senior consultants in private practice and the NHS

 The content of this article is for information only and must not be considered as financial advice. Cavendish Medical always recommends that you seek independent financial advice before making any financial decisions.

Levels, bases of and reliefs from taxation may be subject to change and their value depends on the individual circumstances of the investor. The value of investments and the income from them can fluctuate and investors may get back less than the amount invested.

HMRC tax investigations and disputes create difficult and stressful times.

As an award winning firm of tax experts, our highly experienced partners specialise in resolving problems relating to tax investigations and disputes with HMRC.

To find out, in confidence, how we can help call 0800 734 3333.

‘Here to help. Not to judge.’

Dilemma 1 Patient needs to be restrained

QI am a consultant psychiatrist at a private secure unit for people with mental health conditions.

Recently, a nurse reported that one of the long-term patients, a man in his late 30s with severe autism and limited communication skills who was detained under s3 of the Mental Health Act, had been holding his stomach and looked in some pain.

The patient had lost his appetite and she noticed what appeared to be blood after he had vomited.

I want to refer the patient to a gastroenterologist for further examination, but his behaviour is quite challenging and getting worse because of his ill health. It is likely the patient will need to be restrained if we are to investigate what is actually wrong and treat him.

What should I do?

AThe Mental Health Act does not provide for the treatment of physical conditions entirely unconnected to the mental disorder, so you will need to apply the legal principles set out in the Mental Capacity Act 2005 (MCA) to determine your patient’s capacity and best interests.

The patient’s capacity should be assessed and documented in accordance with the MCA. If, as seems likely in this case, the patient lacks capacity to make

Doing what’s

Former consultant psychiatrist and now MDU medicolegal adviser Dr Beth Durrell (right) considers two psychiatry scenarios where important medico-legal principles are at stake

this specific decision, the MCA requires a decision to be made in his best interests.

A meeting of the healthcare professionals involved in his care, and his family or Court of Protection-nominated deputy, would discuss the relevant issues to determine his best interests.

It may be helpful to involve the gastroenterologist and the ambulance service at an early stage, especially if transfer to

another site – for example, for investigations – is likely to be required.

If the patient does not have any friends or family and there is no one with the legal authority to speak on his behalf, an Independent Mental Capacity Advocate (IMCA) should be instructed to represent him.

This is the responsibility of the NHS organisation funding the patient’s care and is a legal

requirement where ‘serious medical treatment’ is proposed.

The ‘best interests’ meeting should cover the available options for the investigation and treatment of his symptoms, and the risks and benefits of these.

The complexities of transferring him and the need for chemical or physical restraint should also be considered.

Under the MCA, anybody proposing to use restraint must be able to show that the person being cared for is likely to suffer harm unless proportionate restraint is used (para 6.44).

Proportionate response means using the least intrusive type and minimum amount of restraint to achieve the object, in the best interests of the person lacking capacity (para 6.47).

Should there be dispute regarding his best interests or if it becomes clear that a number of complex decisions will be required, you may wish to discuss the matter with your defence organisation.

Dilemma 2

I think she seeks assisted suicide

QA woman in her early 50s attended my clinic requesting a medical report about her mental state. The patient has breast cancer which has now spread to her bones and liver.

She told me she had watched her mother and sister die from the disease and remarked that

best, yet lawful

she does not want to suffer the same way.

The patient has not said so, but I suspect that she intends to travel overseas for an assisted suicide. I do not want to facilitate this or break the law, nor do I want to turn her away. How should I respond?

AYou are right to be concerned about the potential consequences. Assisted suicide is illegal in the UK and the GMC stresses that ‘respect for a patient’s autonomy cannot justify illegal action’.

The council also acknowledges that ‘doctors face difficult challenges in responding sensitively and compassionately to a patient who seeks advice or information about hastening their death, while ensuring that their response does not contravene the law’.

The difficulty is that the patient’s request is ambiguous. If she had specifically asked you about assisted suicide, the GMC’s guidance on assisted dying1 states you should explain that it is a criminal offence to encourage or assist a patient to commit or attempt suicide.

This does not prevent you from listening compassionately to the patient’s concerns and developing a care plan which meets her needs.

For example, you could discuss whether she would benefit from counselling or support to help her adjust to her diagnosis.

She may have unanswered questions about the progression of her disease and the availability of palliative care.

It is important to document everything that has been discussed in the patient’s medical

records and to inform the patient’s GP, in line with GMC’s guidance.

In your letter to the GP, it is reasonable to include your conclusions regarding her mental state and her decision-making capacity, but you may wish to avoid providing opinion on whether she has the capacity to make decisions relating to ending her life.

References

1. When a patient seeks advice or information about assistance to die, GMC, 31 January 2013

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STARTINg A PRIvATE PRACTICE: AUTomATIC PENSIoN ENRolmENT

All workplaces must

With all of the recent publicity, it is hard to have not heard the term ‘auto-enrolment’. Most consultants are likely to think that it does not apply to them, but many may get caught out with penalties if their obligations are not understood. Ian Tongue explains how it works

So what is auto-enrolment?

Auto-enrolment or ‘automatic enrolment’ is new legislation aimed at tackling the future pensions crisis of people living longer and not making adequate provision for retirement.

The scheme forces employers to pay pension contributions for their employees, assuming that the employee actually wants to contribute.

It effectively forces an eligible employer to provide and contribute to a workplace pension.

The scheme will take several years to be fully implemented, with businesses having different dates to commence the scheme, and there is a tiered contribution rate for both employees and employers increasing in three stages.

How does this affect me?

1. NHS Employment

Most NHS consultants will be active members of the NHS Pension Scheme and therefore they are already part of a workplace pension.

For those that have left the NHS scheme and are under state pension age, they will no doubt receive correspondence from their employer setting out options including recommencing contributions or ‘opting out’.

Therefore, a consultant’s own pension position should remain unaltered, assuming that they are an active member of the NHS Pension Scheme.

For those that have retired and left the NHS Pension Scheme but returned to NHS employment –e.g. have taken 24-hour retirement – and are under state pension age, they will receive correspondence from their employer setting out options including recommencing contributions or ‘opting out’.

The NHS is legally obliged to still provide pension options to

those who meet the above criteria even though they have already drawn down their NHS Pension.

Deferred members of the NHS Pension Scheme – that is to say, those that have left the scheme and not activated their pension –often have elected for some form of tax protection in relation to their Lifetime Allowance.

Care must be exercised to ensure they are not inadvertently re-enrolled into a scheme that may cause them to breach their pension protection.

How does it affect me?

2. Employees within a private practice

Many NHS consultants have employees within their private practice. This could be an actively involved spouse or third party employed by the business or indeed could be any consultant employed by his orher limited company.

For these people, action is likely to be required.

Additionally, consideration must also be given to those employing a nanny or housekeeper, as any person under your employment is affected.

How does it work?

If you are employing people who are earning more than the lower earnings limit for National Insurance, currently approximately £480 per month, you should be operating a PAYE scheme by law. Depending on your PAYE reference as an employer, this will determine your business’s ‘staging date’.

The staging date is the point where you must start automatically enrolling your staff and paying contributions.

Therefore, before this date, preparation work should be carried out to primarily identify the following:

 Who needs to be enrolled;

 System changes to cope with auto enrolment;

 A suitable pension scheme.

have a pension

You are able to postpone the staging date by up to three months for numerous business reasons.

Five months after your staging date, you must notify the Government through the online Gateway system that you are compliant. Non-compliance or delays could lead to fines.

Which employees do I need to auto-enrol?

There are staff who should be auto-enrolled and there are others who can ‘opt in’ to the scheme. Both types should be identified before the staging date.

The table below illustrates the earnings level and action required.

* SPA = state pension age

Monthly earnings (October 2014) Age

Is this compulsory?

Yes, and you are breaking the law if you do not apply the legislation and confirm this to the Government.

Can my employees ‘opt out’?

Yes, but you cannot suggest this to them or steer them in this direction; it must be their decision. You should not therefore encourage or advise on this course of action.

For those running their own business employing their spouse, you may already be paying into a pension scheme or decide as a couple on the best course of action following advice from an independent financial adviser. As an ‘opt out’ is largely seen as

From 16 to 21 From 22 to SPA* From SPA to 74 £481 and below Has a right to join a pension scheme

Over £481 up to £833 Has a right to opt in

Over £833

Has a right to opt in Automatically enrol

Has a right to opt in

In determining how much salary is pensionable, the employer chooses how to work out your ‘qualifying earnings’. This can either be the entire salary or the portion that sits between the National Insurance lower earnings limit (currently £5,772) and the higher rate tax threshold (currently £41,865).

Contribution rates

The rate of contributions payable increases between now and 1 October 2018. The minimum contributions for the employer and employee are:

It is not just large businessess that are affected by these changes and it is vital that you understand your obligations to avoid finaicnal penalties

the wrong thing to do (by the Government), the rules state that you must enrol an eligible employee before they can opt out. This is to ensure that they were provided with the terms and conditions and details from the pension scheme to allow them to make an informed decision.

There is a time-scale for ‘opt out’ and this is usually one month from enrolment, but could be longer depending on enrolment date and official ‘opt-out period’.

It should also be noted that an employee who has ‘opted out’ must be re-enrolled on a threeyearly basis. Therefore, the monitoring of ‘opt outs’ is an ongoing process.

Additionally, those that accept auto-enrolment or are eligible to ‘opt in’ who decide to ‘opt out’ can opt back in again in the future.

So what does this all mean for me?

For anyone employing someone in any capacity, you need to understand your obligations. It is important that you communicate with your employees at the earliest opportunity and ensure that you are prepared well in advance of the staging date.

This article covers some of the basic points to consider on the automatic enrolment of employees into a pension.

It is not just large businesses that are affected by these changes and it is vital that you understand your obligations to avoid financial penalties.

If you are employing anyone, you should discuss your position with your accountant or payroll provider.

 Note that this article covers the basics and does not cover all possibilities. As always, you should seek the advice of your accountant.

 Next month: Pre-year-end planning tips

Ian Tongue (right) is a partner with accountants Sandison Easson and Co

More than just a looker

The car industry is taking a lesson from the aesthetics market, reports Independent Practitioner

Today’s motoring correspondent Dr Tony Rimmer

Private medicine has always catered for treatments not normally available from the n HS. taxpayers and the public purse should not be paying for nonessential surgery and the vast majority, if not all, of us would agree with this principle.

Outside of the nHS, independent practitioners are – as was evident at last month’s ccr expo at Olympia – increasingly involved in the healthy market of aesthetic surgical intervention.

a s humans, we seem to feel happier and more self-confident if we think we look better to ourselves in the mirror and others in the outside world. We are prepared to pay for this.

this is not really surprising, as throughout our history we have always valued and treasured beautiful-looking objects. Put two equally practical objects side by side and we will inevitably choose the more attractive, better looking option.

Dressed up the car makers have been aware of this for years. When we walk into a showroom, we don’t drive or ride in the cars; we look at them, sit in them and touch them. We will part with our cash more readily for a handsome, stylish car.

So, basically, what B m W has done with the very successful

3-series is to dress it in a very smart and more dapper suit to create the 4-series.

available as a two-door coupé and convertible, it is now available in five-door guise in direct competition with the 3-series saloon: this is the 4-series Gran coupé.

i nitially available with a choice of three petrol and three diesel variants, the Gran coupé is also available with the X-drive option, which is BmW’s four-wheel-drive system.

i t competes directly with a udi’s a 5 Sportback. i have been driving several versions of the new Gran coupé just to see if it is worth considering as a

looker

real alternative to the excellent class-leading 3-series.

First of all, there is no doubt that good looks count and, in this case, first impressions are lasting ones. to my eyes, the Gran coupé is really pleasing to look at and could easily be mistaken for the 4-series coupé on which it is based.

bmw 4-seRies

Easy access

Unlike the coupé, however, it is far more useable. rear doors allow easy access to rear seats that have extra leg- and headroom. t he only bugbear is with the rear middle seat which is perched high and would not be a great place to sit for long journeys.

r ather than the coupé’s boot,

GRan Coupé

body: Five-seat hatchback engine: 2.0 litre four-cylinder or 3.0 litre six-cylinder diesel. 2.0 litre four-cylinder or 3.0 litre six-cylinder petrol power: 141bhp to 309bhp

Torque: 270nm to 560nm

Top speed: 132-155mph acceleration: 0-62mph in 9.1 secs to 5.2 secs

Claimed economy: (Combined) 34.9mpg to 70.6mpg on-the-road price: £29,425 to £45,045

The Gran Coupé has a standard electrically powered hatchback allowing access to a load space that is only 200L less than the 3-series Touring

the Gran c oupé has a standard electrically-powered hatchback allowing access to a load space that is only 200L less than the 3-series touring.

my large dog would love it in here and you couldn’t say that about the boot-only coupé. remember, this is a car with identical dimensions to its two-door sibling.

One of the reasons we buy BmWs is that we expect a sporty drive and excellent road manners. t he 4series Gran coupé does not disappoint. Handling is excellent, aided by the 50:50 weight distribution.

t he £700 adaptive damping option is definitely worth paying for, but the £200 variable sport steering option is unnecessary, as

the standard set-up actually feels more precise.

Be careful with the rest of the options list, because you can, as with most German executive cars, end up spending much more than you think if you get a bit carried away.

Added traction

But a worthwhile option to consider is the superb £1,500 X-drive system. although it adds 75kg to the car’s weight, the added traction and security in difficult conditions is very impressive.

t he power available and the economy achievable entirely depends on which engine you choose.

The diesels are more economical, but the quieter and smoother petrol units make more sense

t here are two sizes of petrol engine: a 2.0litre four-cylinder in the 181bhp 420i and 242bhp 428i models, and a 3.0litre six-cylinder in the 302bhp 435i flagship model.

t here are also two sizes of turbo-diesels: a 2.0litre four-cylinder in the 141bhp 418d and 181bhp 420d models, and a 3.0litre six-cylinder in the 245bhp 430d and the 309bhp 435d. confused? Well you can always ask approved tuner alpina to sell you a d 4 with 345bhp or even nudge B m W to make a 425bhp m4 Gran coupé – they only make the two-door at the moment. the diesels are more economical, but unless you are doing big mileages, the quieter and smoother petrol units make more sense.

i was a bit disappointed by the roughness of the 2.0litre diesel engine i tried in a 420d model. t his engine works well in the 90kg lighter 3-series saloon and has excellent economy (61.4mpg), but i expect a more refined drive in a premium car.

the fantastic 3.0litre six-cylinder diesel engines are better: silkier, a lot more powerful but not so economical.

the new 4-series Gran coupé is a perfectly sized, stylish, practical high-quality premium car. there is an engine and drivetrain to suit all budgets and tastes.

i can see this car being a very popular choice among us medics and quite rightly so. Our aesthetic surgery colleagues will approve too.

Dr Tony Rimmer is a GP practising in Guildford, Surrey

ProfITS focuS: orTHoPaEdIc SurgEoNS

A cut above the others

Profits continue to rise for some of private practice’s biggest earners – but Ray Stanbridge finds the figures are being greatly boosted by the high level of NHS work.

Additional reporting by Martin Murray

Typically, orThopaedic surgeons are top of the earnings scale for consultants in private practice – save for plastic surgeons. a nd this trend seems to continue.

our survey shows that average incomes have risen by 7.4%, going up from £162,000 in 201112 to £174,000 in 2012-13.

But costs have spiralled, too, showing an increase of 14.2% over the year from £49,000 on average to £56,000.

as a result, pre-tax profits have shown an increase of 4.4%, rising from £113,000 to £118,000.

So how has all this come about?

The growth of income, on average, seems to have been distorted by the large rise in NhS income for orthopaedic consultants, particularly those outside of london and the M25 belt.

Impact of NHS

While market analysts l aingBuisson estimate that N h S expenditure now accounts for up to 29% of the total private practice market, for some orthopods, the N h S content of their practice exceeds 50% of total income.

aveRage incoMe and eXpendituRe oF a conSuLtant oRthopaedic SuRgeon With an eStaBLiShed pRivate pRactice

We need to repeat here what we say with other specialties we put under the financial microscope. There are significant problems in effecting any meaningful comparisons between consultant income on a trend basis.

This is due to a number of factors: the growth of groups, the impact of incorporation as a trading practice and, as reported above, the growth of NhS income in the private sector.

These trends have changed the face of private orthopaedic practices over the last ten years.

We have had to make sensible adjustments to our data to obtain the best meaningful comparisons, but this is proving to be increasingly difficult and readers should take serious note of our caveats and also check out the box below, showing who our consultants are.

although our results are not statistically significant, we hope they do still show outline trends of what is happening in the market. in the old days, the vast majority of orthopaedic consultants enjoyed a successful NhS practice. This pattern, too, is changing and also will influence our results if we include consultants who are wholly private. orthopaedic surgeons have been in the forefront of the trend to leave the NhS. While income has risen between 2012 and 2013, costs incurred by the average orthopaedic surgeon have shown a rising trend. Staff costs have, on average, increased from £16,000 to £17,000. This figure is an average of ‘family’ and ‘professional’ staff. The upward trend does correlate with the growth in personal allowances.

Who ouR oRthopaedic SuRgeonS aRe

our sample of orthopaedic surgeons is restricted to those who:  earn at least £5,000 a year gross from private practice  have at least five years’ private practice experience

 are seriously interested in private practice as a business  hold either an old-style or new-style nhS contract

 May or may not work through a group, a limited liability partnership or a limited liability company

Source: Stanbridge Associates Ltd. Additional information: Sandison Easson and Co

consulting room hire costs have shown a slightly upward trend. We expect this to continue following the publication of the competition and Markets authority (cMa) rulings in april 2014. We would expect a further increase in these costs as providers charge ‘market rates’ to comply fully with cMa rules.

p rofessional indemnity costs have shown an upward trend. What we have not yet reported on is the growth in market share of cheaper new providers.

There is always a long time lag in our figures. For some consultants, indemnity costs have fallen

significantly in recent months as they take advantage of new rates.

Whether these new providers will last in the longer term is a matter of conjecture, but, in the short term, those orthopaedic consultants without a claims history who have searched the market have found benefits.

‘Use of home’ costs have shown some increase and motor expenses have remained consistent and, in some cases, fallen.

This is primarily the result of the impact of the Samadian car mileage tax case. We would expect increased cost claims to be made by those orthopaedic consultants

who have a bona fide study/working facilities at home.

Finally, ‘other’ costs have shown some increase. orthopods were among the first to embrace marketing/pr support and these cost rises reflect an increasingly heavy use of these services.

What of the future? We have commented several times previously that the situation for consultants in private orthopaedic practice is interesting.

Some orthopaedic groups have been transferring themselves into formidable businesses, with a strong brand image. Members have done particularly well. other consultants have focused on what seems to be an everexpanding NhS spend in the private sector. yet others are seeking to ‘add value’ from diagnostic and other services. however, we have yet to see the full impact of the cMa’s rulings in this area.

e arly figures for 2014 suggest that orthopaedic surgeons are holding their own and will continue to be at the top end of the earnings league for private medical consultants. This trend will surely continue.



Next time: ophthalmologists

Ray Stanbridge runs an accountancy, finance and tax advisory service specialising in the medical profession. Martin Murray is a partner at Sandison Easson & Co, specialist medical accountants

How arE You doINg?

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years ending 5 april Source: Stanbridge Associates Ltd

what’S in oUr december-JanUarY edition

Make sure you don’t miss our next issue, published on 2 january 2015. only subscribers to the magazine are guaranteed to receive every copy and we don’t think anybody who is serious about continuing private practice in the future, when there is so much happening that will affect them, can afford to miss any issue. coming up next month:

 ten new year resolutions for consultants

 in a powerful piece, consultant surgeon Mr eddie chaloner, medical adviser for the new war film Kajaki – released this month, relates some of his experiences

 are centres of excellence the way to go for the private medical profession?

 profits Focus puts the microscope on ophthalmologists’ earnings

 Why it is always ethical to chase your bad debts

 We look at progress in a newly opened, independently owned and clinician-led private hospital

published by The Independent Practitioner Ltd. Independent Practitioner

Today is editorially independent and thanks Bupa for its assistance with distribution. printed by Williams press Material is governed by copyright. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form without permission, unless for the purposes of reference and comment. Editorial layout is the copyright of the publishers. If you wish to use it for promotional purposes on websites or for reprints, we would be happy to discuss licensing the copyright to you.

© The Independent Practitioner Ltd 2014

Registered office: 7 Lindum Terrace, Lincoln LN2 5RP

Write to Independent Practitioner Today PO Box 198, Cranleigh GU6 9BB

 our motoring correspondent dr tony Rimmer takes the audi a8 on test for the whizz to his medical school re-union

 From april 2015, a legal duty of candour will apply to all health providers registered with the care Quality commission, subject to parliamentary approval. dr Mike Roddis looks at how private healthcare organisations can best meet their obligations and support staff

 Business dilemmas: the Mdu’s dr Sally old answers your questions arising from patients who have been diagnosed with cancer

 plan to take good care of yourself and your family. We look at the financial and legal aspects surrounding long-term care

 From nhS to private – my journey, by private gp Kannan athreya

 Seven areas to be wary of when you grow your private practice

 pre-year-end planning tips

 time to downsize your property?

adveRtiSeRS: the deadline for booking advertising for our combined december 2014-january 2015 issue is 28 november

editoRiaL inQuiRieS

Robin Stride, editorial director

Email: robin@ip-today.co.uk

Tel: 07909 997340

adveRtiSing inQuiRieS

Margaret Floate, advertising manager

Email: margifloate@btinternet.com Tel: 01483 824094

publisher Gillian Nineham Tel: 07767 353897.

Email: gill@ip-today.co.uk

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to guarantee your copy of independent practitioner today by taking out a subscription (at the rates shown on the left), phone 01752 312140 or send off a subscription form on page 26 or email lisa@marketingcentre.co.uk or go to the ‘about’ page of our website www.independent-practitioner-today.co.uk

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