Don’t let your good name be damaged There are lots of things you can do to accidentally harm your brand P22
Keep your seat belts on How to cope with the rollercoaster ride involved in running a practice in the pandemic P12
By Robin Stride
Private providers’ predictions of ‘strong growth’ in domestic selfpay next year are being downplayed by consultants in private practice.
According to an ‘industry barometer’ survey from the Independent Healthcare Providers Network (IHPN), its members anticipate a 2021 change in fortunes in NHS PPUs and the private sector.
The hospitals and clinics trade body reported: ‘Almost six in ten respondents (58%) to IHPN’s barometer reported to feel very positively or positively about the market environment for providers of NHS-funded services, with a similar percentage (55%) feeling very positively or positively about the domestic self-pay market.’
Respondents were ‘senior leaders’ in the independent healthcare sector, but it later emerged there were just 25 of them and they represented ‘around a 40% response rate’.
The Federation of Independent Practitioner Organisations (FIPO) warned the return of private practice to pre-Covid levels would take years rather than months.
It said: ‘While it is likely that increasing NHS waiting lists will result in an enhanced demand from self-pay patients, it is the confidence of all patients to attend hospital and the necessary limitations caused by Covid safety precautions which will impact on the manner and speed at which the private sector recovers.
‘From various sources, we know that there has been some increase
In association with
in outpatient consultations, although not necessarily face to face, but hospital admissions remain low. This relates to the ability outside London for theatre time for private procedures.
‘How all this will play out will to a large extent depend on how the country copes with the virus over the winter and whether a vaccine will be the game-changer we all hope.
‘With these uncertainties and depending on the general UK economic recovery post-Brexit and Covid, FIPO believes that the return of private practice to preCovid levels will take years rather than months. FIPO hopes that the high-quality expert and individualised care delivered by private consultants will eventually become available again to those that choose to access it.’
The London Consultants Association’ (LCA) said members, deliv-
Consultants must help evolve the changes brought about by the pandemic or look for other ways to supplement their income, business experts say. See their analysis ‘Covid offers chance to revamp private practice’ n Page 44
ering the private sector’s services, also failed to share the IHPN’s optimism.
It told Independent Practitioner Today: ‘This may reflect that independent consultants have not been involved in the contracting processes between the private sector and the NHS.
‘While outpatient activity is returning, albeit often teleconsultations rather than face to face, specialists are still facing difficulties when accessing diagnostics services, trying to admit patients and having access to operating theatres.’
An LCA survey last May showed many established consultants were seriously considering retiring or giving up private practice. A repeat poll due soon will see if attitudes have changed.
Around half of the IHPN’s respondents felt that relationships had improved with NHS organisa-
tions in their local area since Covid-19’s onset, with no respondents reporting any deterioration in their relationships, and others experiencing some relationships improving and others worsening.
The sector’s relationships with the Government had also improved in recent months, with around two-thirds of respondents feeling very positively or positively about the current Government’s attitude towards the independent health sector. Nobody reported negatively.
The IHPN said: ‘While overall there is much positivity in the sector about the coming year, existing concerns around Brexit and workforce shortages, as well as the increased operating costs resulting from the Coronavirus pandemic, loom large for independent providers and were identified as key challenges for the sector.
➱ continued on page 6
TELL US YOUR NEWS. Contact editorial director Robin Stride
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Our Accountant’s Clinic series turns its attention to organisational skills; those vital qualities for ensuring services are maintained during the pandemic P16
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A big ‘thank you’ to the thousands of readers who have been tuning in to our weekly emails bringing you updates about additional news and features on our website.
We have done this during the pandemic to ensure you are kept abreast on information and events that, during these fastchanging times, simply cannot wait for your usual monthly digital issue and we appreciate your positive comments about Independent Practitioner Today’s ‘News Extra’ service.
Although opinions differ about the speed of private practice recovery, as demonstrated on page one, the last couple of months especially have marked a steady increase in activity for many independent practitioners, although it varies enormously depending on location and specialty.
This is reflected in our move up to 11 news pages in this and our last issue – things are hap -
pening out there and there is much to keep up with. New private services are opening again following a freeze on such ventures in the pandemic’s early months.
Consultants and private GPs are re-inventing how they do things and it turns out that patients in London – and presumably in other big cities – are keen to take advantage of seeing their private doctor at the weekends when they feel safer about travelling. This is popular with the doctors that do it, too.
In this issue – see page 44 – Prof Gordon Wishart and Philip Housden argue that consultants must now either help evolve the changes they see in private practice, brought about by Covid-19, or look for other ways to supplement their income.
Check out their analysis of some interesting possibilities for the ‘stayers’ in their feature article ‘Covid crisis offers chance to revamp private practice’.
Use feedback to improve your care
To improve, you need to measure. So Jane Braithwaite shows how to ascertaub patient experience to ensure your customer care is improving P18
When you’re hauled before the GMC In the second of her articles on GMC investigations, Dr Ellie Mein explains how to cope with a fitness-to-practise hearing P24
Three things you have to get right Financial stress can hit all private practices at some stage, so Simon Brignall outlines three problem areas and questions you should address P32
Our safety cultures need a fix Recommendations in last month’s Cumberlege Report could lead to far more information being published about doctors’ financial interests P34
The United States of uncertainty Not all US stocks have gone up in 2020. Patrick Convey explains why it is impossible to predict stock markets despite the US now riding high P36
Start a private practice: Extract the fruits of your labour
Accountant Ian Tongue explores options to extract the funds from your company in a tax-efficient manner P40
Doctor on the Road: Hot hatch is more than a ‘boy racer’
Put back the smile on your face with a drive in this Honda Civic Type R P42
Profits Focus: A nice waxing of profits
ENT surgeons come under the spotlight of our unique benchmarking series on specialists’ finances P49
By Edie Bourne
Doctors are being advised not to wait to receive their pension statement for the 2019-20 tax year from the NHS Pensions Agency (NHSPA) but to actively request it to check their true tax position.
Although the Government last winter agreed to pay the tax charge for some clinicians for this period, few details have been forthcoming.
The ‘annual allowance’ restricts to £40,000 the amount of tax-free pension savings which can be accrued each year. Each autumn, the NHSPA issues statements detailing doctors’ annual pension contributions for the preceding tax year, but only if the doctor has ‘deemed growth’ in their pension pot of over £40,000.
However, as specialist medical financial advisers Cavendish Medical has previously advised, the ‘tapered’ annual allowance for
those with a threshold income of over £110,000 for 2019-20 reduces this figure further, down to as low as £10,000 for high-achieving doctors.
And the NHSPA is not duty bound to issue statements to individuals breaching this particular cap but only to those breaching the standard £40,000.
Cavendish Medical’s technical director Patrick Convey told Independent Practitioner Today : ‘You could easily breach the ‘tapered allowance’ and yet not even realise, as you will not receive official notification from the NHS.
‘The NHSPA is also not able to monitor growth in personal pensions that will also count towards the level of allowance relevant to you, and so the line between who should and should not receive the statements is often blurred.
‘To ensure you are not missed, you should request your own statement as soon as possible. There can
be lengthy delays on responding and you will want to be in the best position to make well-considered decisions before your next tax submission.
‘Crucially, many of the statements we have seen contain small errors in the data, which, if left unchallenged, can cause substantial problems further down the line.’
Mr Convey said statements caused confusion each year because HM Revenue and Customs calculated contributions for a defined benefit scheme, such as the NHS, very differently to that of a private pension.
The figures are based on the ‘deemed growth’ of the pension in that year, with an allowance made for inflation rather than the actual contributions. Statements are therefore difficult to understand and mistakes can easily go unnoticed.
He added: ‘As in all matters
financial, forward planning is the key to avoid unpleasant situations and unnecessary tax bills – particularly when the rules and regulations change frequently.
‘You may be confused about how any tax charge will be paid by the Government for the 2019-20 tax year or how the new 2015 Pension Scheme age discrimination consultation affects you. Taking some time to consider your position can pay dividends.’
Those breaching the annual allowance can apply for the NHS to pay the tax charge under Scheme Pays system in exchange for reduced future benefits.
The application for Scheme Pays is normally 31 July each year, but for the 2018-19 tax year, this was extended to 31 October earlier this year and has now been deferred again to 31 March 2021.
The deadline to apply for Scheme Pays for 2019-20 should be 31 July 2021.
Serious reported patient safety incidents involving insured or self-pay patients in private acute care totalled 21 last year, according to Private Healthcare Information Network (PHIN) data.
Figures for calendar year 2019 show the following ‘Never Events’:
5 episodes of wrong site surgery;
11 wrong implants/prostheses;
2 retained foreign objects postprocedure;
1 mis-selection of a strong potassium solution;
2 administrations of medication by the wrong route.
This is the first time such information has been published in the UK.
PHIN chairman Dr Andrew Vallance-Owen said: ‘The publication of these never events is an important step-change in trans -
parency. This will be helpful for patients when deciding the right provider for their care, but it is also important that the information is available to hospitals, consultants, and others within the sector.
‘Never events have to be reported
so that lessons are learnt and actions taken to ensure they cannot happen again. This means that the reporting, investigation and learning is a powerful safety “call to action” in itself and should always lead to an improvement in processes and quality of care as a result.
‘We hope publication of this information will stimulate that process of continuous improvement.’
Federation of Independent Practitioner Organisations (FIPO) chairman Mr Richard Packard said:
‘Never events, at 21 in approximately 645,000 patient episodes, have been shown to be thankfully rare in the private sector.
‘It is important to note, however, that most never events are caused by system and process failures rather than individual errors.
‘Consultants who work in the private sector are grateful for the efficiencies and safe systems established by hospital providers and will continue to work hard with them to ensure the risk of patient harm is reduced still further.’
Share your experience of what has and has not worked in your private practice. Even if it’s bad news, let us know and we can spread the word to prevent other independent practitioners falling into the same pitfalls.
Contact editorial director Robin Stride at robin@ip-today.co.uk
By Robin Stride
A welcome rise in private healthcare insurer funded activity has been recorded for the summer months.
Some areas returned to prelockdown treatment levels and hospital patient numbers, according to the data from Healthcode, the UK’s official clearing organisation for private medical bills.
It reported that August 2020 saw insurerfunded activity in the sector reach 74% of the level achieved 12 months earlier, while some specialties exceeded their previous year’s performance.
This was the third consecutive monthly rise in sector activity from a low of 29% in May, which represents an average increase of 15 percentage points per month.
The company has also compared the number of unique patients receiving hospital treatment with the same month of 2019.
In June, this stood at just 25% for admitted patients and 41% for outpatients, but by August this had
reached 67% for admitted patients and 77% for outpatients.
Commenting on the figures early last month, managing director Peter Connor said: ‘Healthcode’s data processing role puts us in a privileged position of being able to document the sector’s recovery from the darkest days of the pandemic.
‘Not only have we recorded a rise in activity levels over the summer, but insurer preauthorisation rates are now reaching pre pandemic levels too.
‘Of course, I appreciate this picture is not the same for everyone, because we continue to see significant variations in the rate of recovery between regions, specialties and hospitals.
‘Healthcode has therefore started working with hospital groups to help them understand and benchmark their activity and we will continue to do all we can to support the sector.’
Speaking of September’s figures due soon, he said the outlook remained positive.
England operated at 74% the level of 2019 in August, while Scotland reached 61%, Wales 54% and Northern Ireland 88%. The equivalent figures in July 2020 were 59% for England, 44% for Scotland, 32% in Wales and 82% in Northern Ireland.
London achieved 78% of the activity level seen during August 2019, a 13-point rise on the July percentage. Elsewhere, the East and West Midlands regions showed the strongest recovery with activity at 89% and 84% of 2019 levels (compared with 63% and 65% in July). Every region in the UK passed the 50% activity landmark.
Orthopaedics has been hit hard by the lockdown restrictions, but reached 70% of 2019 activity levels in August, compared with only 49% in July, a 21 percentage point increase.
All the top ten specialties were much closer to the activity levels seen last year, with two surpassing the August 2019 figure. These were oncology (106%) and pathology/haematology (110%). The specialties with the lowest proportion of 2019 activity levels were physiotherapy (48%) and ENT (64%), but both were up on July: 29% & 41% respectively
Hospital activity in August reached 77% of 2019 levels, compared with 56% in July, while non-hospital activity was at 76% (68% in July). Within hospital settings, outpatient activity is up to 79% of 2019 levels, while admitted care is at 68%. This compares with 58% for outpatient care and 46% for admitted care in July.
Source: Healthcode
Admitted care bounced back strongly – 67% of 2019 levels in August compared with 27% in July.
London Consultants’ Association
members were briefed on Healthcode’s private healthcare market activity findings and updated on the company’s plans at a virtual lunch.
Specialists expressed interest in the company’s ambitions to modernise the private healthcare market during these challenging times.
Managing director Peter Connor said the market had been recovering to around three-quarters of its volume, although not necessarily value, for the same period last year.
Although insurers were now authorising similar volumes to last year, this was probably due to catch-up for patients unable to access care
during the Covid pandemic’s lockdown period.
The recovery demonstrated was predominantly due to outpatient activity, with non-hospital billing showing an increase. And there were wide variations both in terms of specialty, geography and even hospital group – so interpretation of what this meant was difficult.
Last year in London, 50% of the market was private insurance patients, 30% self-pay and 20% overseas patients.
The breakdown is currently slightly different and the market is changing rapidly with insurance 60%, self-pay 20%, embassies 20% and
approximately 1% NHS (rounded-up percentages).
Consultants heard that Healthcode’s aim is to support independent practitioners and has ambitions to drive a modernising agenda with a better consumer focus. It recognises that high start-up costs and overheads were a barrier to new consultant entrants to private practice.
Discussion topics included shortfalls and the need to disclose these to patients early on, insurance issues and liabilities associated with employed consultants. Mr Connor doubted the consultant employment model would become common soon.
Bupa UK has launched a remote skin assessment service to provide fast detection of skin cancers from a customer’s home without the need for a GP referral.
It said it hoped the ease and speed with which people could get moles and marks checked would encourage more people to come forward and get help with any concerns.
If the new remote skin assessment service from dermatologists at Skin Analytics is suitable, then customers will receive a kit by the next working day which includes a smartphone and a dermatoscopic lens to take highresolution photos of moles or lesions.
Once a customer uploads the photos to an app on the phone, a dermatologist reviews them alongside their medical history.
Bupa said: ‘If there’s nothing to worry about, they will be sent a report and have peace of mind within 24 hours, which is much faster than the usual time to arrange a face to face appointment.
‘If further investigation is needed, an adviser contacts the customer to discuss next steps. Bupa will then help arrange an onward referral to a specialist.’
The service is the latest addition to Bupa From Home, a package of remote health services that customers can access from home.
Customers are offered the service if deemed suitable for the type of mole or lesion they describe. The service is subject to policy benefits and limitations.
See a video on the new remote skin assessment service: www.youtube.com/watch?v=Yr0Wvzv1bA
By a staff reporter
Independent practitioners’ landlords, The Howard de Walden Estate, is harnessing a range of initiatives to raise the profile of the Harley Street Medical Area (HSMA) here and overseas.
Its property director Simon Baynham told Independent Practitioner Today: ‘The HSMA has many attractions that go far beyond its medical credentials: its centrality, transport links and proximity to the shops and restaurants of Marylebone Village. However, there is plenty more that can be done to increase the appeal to patients.’
He said the estate aimed to promote the enclave as an internationally recognised area of medical and healthcare innovation, excellence and expertise by becoming the first medical Business Improvement District (BID), charging a levy on business rate payers to make improvements within the specified boundary.
Mr Baynham, soon to retire from the estate, will chair HSMAP and work closely with the owners to develop the area. Likely projects include greening, better directional signage, click and collect area consolidation schemes to improve air quality, hard copy and
digital directional maps and area literature as well as lobbying.
Howard de Walden is workingwith the soon to be launched UKhealthcarepavilion.com to provide a shop window and partnering platform for doctors aiming to engage customers worldwide.
It invested in the site to ensure the HSMA has a strong presence and its hospitals, clinics and consultants are represented.
The portal will allow HSMA to run its own live events and it is hoped subscribers will benefit from partnering with it, which, when physical events begin to run again, will allow visitors to organise facetoface meetings and partnering at global congresses and trade shows.
Paul Benton, managing director at the Association of British Health Tech Industries who is launching the site, wants it to act as ‘the UK’s front door’ for hospitals, clinics, healthcare services and life science companies.
He said: ‘It is fantastic to be working with The Howard de Walden Estate and their HSMA community to unite together worldleading private healthcare providers and caregivers with the UK’s life science industry.
‘For the first time, there will be a global platform that highlights the whole sector – industry, clinical associations and private healthcare providers – highlighting why the UK is a world leader when it comes to healthcare innovation and patient care.’
Mike Davison, head of international at Isokinetic Medical Group, said: ‘Rebuilding the brand of HSMA within the UK and internationally has long term strategic value to the area and tenants.
‘The support we have had from HSMA has been fantastic, helping to profile and spread awareness of the innovation and patient first services available. They have really helped to change perceptions and drive awareness of the true capability of the area.’
Issues arising from remote patient consultations are to be investigated by the BMA’s Board of Science.
The move follows a call by the association’s annual policy-making meeting for an examination of the evidence on how, where and when remote consultations should or could be carried out.
Doctors noted the necessity for remote consultations during the Covid-19 pandemic. But fears were voiced at the BMA annual representative meeting that greater use
➱ continued from front page
Chief executive David Hare said it was ‘hugely heartening’ to see members’ positivity about their prospects for growth and the ability to continue providing high quality services to both NHS and privately-funded patients.
The sector’s role in the NHS had long been viewed as contentious in some quarters but he believed it was promising to see the sector’s relationships with both the NHS and Government improving over the last few months – ‘presenting real opportunities for a new approach to public/private partnership with long term benefits for patients.’
of this type of technology, albeit generally positive, could potentially be detrimental to some patients who require face-to-face appointments.
Board of Science chairman Prof Dame Parveen Kumar said: ‘The use of digital consulting has been essential during the pandemic for reducing the risk of infection for patients and in GP surgeries and hospitals. Digital consulting certainly has its benefits; it’s flexible and can mean more patients are seen.
‘However, we know it’s not for
Are doctors too remote? BMA Board of Science chairman Prof Dame Parveen Kumar (below) says some patients need face-to-face meetings
everyone and some patients should and do need to see a doctor face to face – something we have continued to offer where safe and necessary throughout the pandemic.’
The board will review available evidence to see how valuable an asset the development is in helping doctors understand how and when best to use technology.
It hopes the Government will take account of its findings when pushing for greater use of digital technology in patient care.
A high proportion of surgeons and nurses are suffering from workrelated allergic reactions, including blisters and rashes, according to a global survey.
It says these can be caused by an allergic reaction to products within the operating theatre environment, such as hand hygiene products and personal protective equipment.
The survey by SERMO for medical solutions company Mölnlycke,
found 74% of surgeons suffered an allergic reaction to equipment in the operating theatre at least once a year.
All of those who experienced a reaction were diagnosed with contact or allergic dermatitis.
Researchers looked at the opinions and experiences of 568 surgeons and nurses in the UK, US, Japan and Scandinavia. Survey results at www.molnlycke.co.uk/ biogel.
Compiled by Philip Housden
NHS wants to ‘recover income quickly as possible’ NHS contracts and payment guidance October 2020-March 2021 issued to finance directors last month provides further details of the financial arrangements for the health service for this winter, with reference to ‘system top-up funding’ which includes private patient incomes.
The guidance states: ‘System funding envelopes are based on the expectation that organisations will return non-NHS income to the levels seen in 2019-20 . . . Organisations should make all reasonable efforts to recover income as quickly as possible.’
Private patient revenues for the NHS in England in 2019-20 were around £700m and, as has been previously reported in PPU Watch, the cost of Covid-19 in terms of reduced income from private patient services provided by the NHS is running at around £40m£50m a month.
But how trusts reverse the present closure of PPUs as they prepare winter planning – including capacity for a second wave – is not clear.
Meanwhile, results are coming in to Housden Group from NHS trusts that are completing my company’s second NHS PPU Barometer survey.
These figures combine an up-to-date position of trading performance together with an end-of-year forecast.
The trusts completing the survey represent 51% of the total private patient revenues of the NHS and form a representative and best available view of the market.
Key findings are that 48% of trusts are more than 75% down on private patient revenues at the end of quarter two – end of September 2020. And 56% forecast they will finish the financial year more than 50% down on 2019-20.
A full exclusive report will feature in the next issue of Independent Practitioner Today
Philip Housden is director of Housden Group. See page 44
By a staff reporter
The new GenesisCare Centre for Radiotherapy at Bupa Cromwell Hospital in London is being billed as ‘Europe’s most advanced radiotherapy centre’.
It offers access to radiotherapy technologies such as MRIdian, MR Linac, Gamma Knife Icon and Varian Edge and will specialise in complex and difficult-to-treat tumours including cancers of the abdomen, central nervous system, head, neck and lung, as well as offering the latest techniques for breast and prostate cancers.
Its opening comes as a recent investigation by DATA-CAN, the Health Care Research Hub for Cancer, found that Covid-19 could potentially cause an extra 35,000 cancer deaths due to delays in diagnosis and treatments during the pandemic.
GenesisCare UK general manager James McArthur said: ‘We are
pleased to extend our partnership with Bupa Cromwell to provide a seamless care pathway, adopting the latest techniques essential for achieving the right care outcomes.
‘This is of significant importance right now to ensure cancer patients receive the best care possible and don’t delay essential treatment.’
Hospital director Philip Luce said: ‘As cancer rates continue to rise, it is encouraging that we’re finding new ways to give people access to better and quicker treatment.
‘As a centre of excellence for cancer care, we’re proud to be opening this new radiotherapy facility and to provide our UK and international patients with cutting-edge treatment, resulting in better outcomes.’
The centre’s advanced equipment includes the Varian Edge Linac, designed to deliver stereotactic brain and spinal surgery, stereotactic ablative radiotherapy
UK Government in Wales Minister David T.C. Davies visited Rutherford Cancer Centre South Wales to show support and highlight the contribution independent cancer centres can make in light of the Covid-19 pandemic.
The unit in Newport, Gwent, was the first cancer facility to bring proton beam therapy to the UK in 2018 and now offers the pioneering treatment to adult NHS patients in Wales, making them the first to be offered proton beam therapy on the health service in the UK.
The centre stayed open throughout the pandemic and assisted local
The Varian Edge radiosurgery system is just one of the advanced pieces of radiotherapy equipment at Bupa’s Cromwell Hospital in Kensington
(SABR) – which is used for small tumours elsewhere in the body –and volumetric modulated arc therapy, a highly versatile treatment for a wide range of cancer types. It has the highest dose rate in the industry, resulting in less time in treatment.
It is also home to the latest Gamma Knife Icon. GenesisCare’s neuro-oncology lead specialist Dr Anup Vinayan said: ‘The Gamma Knife Icon is one of the most sophisticated systems for stereotactic radiosurgery (SRS), deliver-
NHS trusts by treating cancer patients who would have otherwise had treatments delayed or cancelled by the effects of the lockdown.
Mr Davies, MP for Monmouth, was welcomed by Rutherford Health chief executive Mike Moran and manager Jamie Powell, and toured the facility to see the 55-ton cyclotron used for the proton beam therapy machine.
He said: ‘Rutherford is a leading example of a firm which is harnessing the expertise which exists in the UK to deliver transformational improvements to cancer treatments and the lives of patients.’
Mr Moran said: ‘Rutherford Health has been at the forefront of pushing for early diagnosis to give patients the highest chances of treatment success. The UK Government urged NHS trusts across the country to utilise independent sector capacity to deal with cancer delays and our centres have risen to the challenge.’
Rutherford Health said its network of cancer centres in Wales, Reading, Northumberland and Liverpool will continue to assist NHS trusts with delays in cancer treatment to try to address the cancer backlog.
ing the highest possible accuracy.
‘SRS targets tumours at many different angles around the body at the same time with the beams meeting at a single point.
‘This delivers a high dose of radiation to the tumour while ensuring the healthy tissue around it receives a much lower dose and reduces the risk of side-effects. It is often called “brain-sparing” surgery because of its ability to protect healthy brain tissue and preserve quality of life for people needing treatment for brain tumours.’
Cleveland Clinic London will have a clinical partnership with The London Clinic to provide comprehensive oncology services to patients at their respective facilities.
The latter’s chief executive, Al Russell, said: ‘We’re delighted to announce this partnership with Cleveland Clinic London. It’s an organisation that aligns with our values and interests, prioritising exceptional patient care above profit.
‘Working together, we will create integrated pathways to support huge numbers of cancer patients in the years to come, all the time learning from each other for the benefit of the patient.’
Cleveland’s boss Dr Brian Donley called The London Clinic an ideal partner to provide its cancer patients with a seamless care pathway ‘that prioritises empathy and clinical excellence’.
By Douglas Shepherd
All doctors are being urged by the GMC to read and familiarise themselves with its new 40-page document Decision-making and consent before this comes into effect on Monday 9 November.
The guidance, following ‘extensive consultation’ with doctors, lawyers, patient groups and others, emphasises that effective decision-making based on conversations between doctors and patients is fundamental to good care.
It aims to help doctors have meaningful conversations with patients about their treatment
and care options, and is designed to be easy to follow, taking account of the pressure doctors work under.
There is a single page summary with key principles doctors need to know, a focus on the importance of taking a proportionate approach tailored to individual patients and information on how colleagues can support decision-making.
GMC medical director Prof Colin Melville said: ‘Doctors are working in pressured environments and in challenging circumstances, impacting on the time they have with patients. It is therefore critical their conversations with patients are meaningful and that they support patients to make decisions that are right for them.
‘Poor practice, such as failing to share information patients need to make informed decisions, can lead to poorer outcomes, more complaints and, in some cases, serious harm. Our guidance provides the key components of effective communication between doctors and patients, which are vital to help patients make decisions that are right for them.’
The updated guidance lists seven principles of decision-making and consent (see box below).
Prof Melville added: ‘Consent and shared decision-making are at the heart of the doctor-patient
relationship. Obtaining a patient’s consent need not be a formal, time-consuming process, but should be part of having good conversations. Our guidance sets out what is expected, and doctors should use their judgement about how to apply it depending on each patient’s individual circumstances.’
Head of MDU advisory services, Dr Caroline Fryar, said: ‘It is important that doctors are able to approach both the patient and circumstance before them in a proportionate way using their professional judgement.
‘The GMC has taken a positive
step in this updated guidance by making it clear that not every paragraph will be relevant to every decision.
‘The inclusion of seven key principles of decision-making and consent is a helpful tool for doctors.
‘Another welcome addition is that only serious or persistent failures to follow the guidance, such as failures which also pose a risk to patient safety or public trust in doctors, will put a doctor’s registration at risk. We are pleased to see this explicit reassurance included.’
The MPS plans new support resources for members. Med ical director Dr Rob Hendry said consent issues were often at the heart of cases against doctors and remote consulting due to Covid-19 had created additional challenges.
‘While we recognise that the core principles of decision-making and obtaining meaningful consent apply in all clinical settings, supplementary guidance addressing the consent challenges posed by remote consultations would be welcome.’
Medical defence specialist MDDUS welcomed the new guidance. Its medical division head Dr John Holden said the guidance was timely, recognising the pressure on doctors of time and resources, which was highly relevant during the pandemic. He was pleased the GMC recognised that not every aspect of the guidance must be met to avoid the risk of a regulatory investigation, ‘rather, the guidance may be applied proportionately, with regard to the complexity and potential impact of an individual decision’.
See box opposite
1
All patients have the right to be involved in decisions about their treatment and care and be supported to make informed decisions if they are able.
2 Decision-making is an ongoing process focused on meaningful dialogue: the exchange of relevant information specific to the individual patient.
3 All patients have the right to be listened to and to be given the information they need to make a decision and the time and support they need to understand it.
4 Doctors must try to find out what matters to patients so they can share relevant information about the benefits and harms of proposed options and reasonable alternatives, including the option to take no action.
5
Doctors must start from the presumption that all adult patients have capacity to make decisions about their treatment and care.
A patient can only be judged to lack capacity to make a specific decision at a specific time, and only after assessment in line with legal requirements.
6
The choice of treatment or care for patients who lack capacity must be of overall benefit to them and decisions should be made in consultation with those who are close to them or advocating for them.
7
Patients whose right to consent is affected by law should be supported to be involved in the decision-making process and to exercise choice if possible.
This is guidance on good practice. It sets out a framework for decisionmaking that will help you practise ethically and in line with the law.
If you’re not sure how the law applies in a given situation, seek advice through local procedures, consult your defence body or professional association, or seek independent legal advice.
You must use your professional judgement to apply this and our other guidance to your practice. If you do this, act in good faith and in the interests of patients, you will be able to explain and justify your decisions and actions.
Only serious or persistent failure to follow our guidance that poses a risk to patient safety or public trust in doctors will put your registration at risk.
By Robin Stride
Patients like seeing their consultants in London at weekends because they feel safer when travelling. That is one of the findings of outpatient clinic London Medical during the pandemic.
The clinic began extending its opening hours on Saturdays and Sundays during lockdown and is offering a full range of clinical services over selected weekends.
Chief executive Tony Graff told Independent Practitioner Today the new service had gone down well with consultants and customers.
He said: ‘Some patients feel safer coming into London at the weekend rather than the week. Some patients are at work and cannot make it to the clinic during the week. Patients can come at weekends for tests and then have remote consultations at another time to suit them.’
The greater availability is also proving an attraction to other specialists who want to offer their services at the weekend. Mr Graff said: ‘These consultants can now apply for practising privileges at London Medical. We are excited to welcome new consultants to our clinic.
‘We have been opening at weekends for the last three months with a very positive response from both patients and consultants. It is not just the convenience, but they can get access to our world-class facilities and exceptional clinical service at a time that suits them’.
The management has redesigned the clinic to be ‘an exceptionally safe environment’ and has made it easier for patients to access its services.
from the safety of their home at convenient times and home-testing meant consultants got the latest clinical data required to give expert advice.
‘Over the last 25 years, London Medical has become well-established as a leading outpatient clinic specialising in chronic conditions including diabetes.
It has continued to provide leading-edge treatments including, more recently, type-1 diabetes patients on closed loop technology, oral rybelsus for diabetes, bempedoic acid for cholesterol and major expansion in child health such as allergies and hormone issues.
Consultants who already had practising privileges have also been pleased because they wanted to provide additional hours from London Medical but have been committed to the NHS during the week.
Surgeons at King Edward VII’s Hospital in the Harley Street Medical Area have performed their first deep inferior epigastric artery perforator (DIEP) flap reconstruction with lymphatic microsurgical healing approach (LYMPHA) for prevention of secondary breast cancer-related lymphoedema.
The innovative dual surgery procedure was performed by Mr Paul Thiruchelvam and Mr Navid Jallali, who recently joined the multi-specialist hospital’s breast unit. With colleague Miss Judith Hunter, they are the only group to undertake these very complex combined procedures in the UK, the hospital said. A DIEP flap reconstruction is a
type of breast reconstructive surgery where fat, skin and blood vessels are transposed from the lower abdomen and moved up to the chest to rebuild the breast mound.
During the complex procedure, which can take up to eight hours in surgery, no muscle mass is removed to recreate the breast. For patients who have undergone a mastectomy, it offers a lower risk of losing abdominal muscle strength and a shorter recovery time compared to TRAM flap procedures.
The pioneering operation was performed for the first time at King Edward VII’s Hospital in combination with LYMPHA, a highly technically demanding microsurgical
Remote working has been expanded and is receiving strong demand from patients and consultants. There is now a simplified booking process and a new specialist app is due shortly.
London Medical is providing comprehensive home testing, including home nurse visits.
Mr Graff said patients loved it, as they talked to their consultants
‘A wide range of leading consultants have appreciated working within its friendly efficient environment, and not having to worry about the admin side of their practice – rent, rates, staff, clinical governance and so on.
‘Since the lockdown, these concerns have become even more onerous and inquiries to practise at London Medical have increased significantly.
‘The clinic’s dedication to safety, drive to weekend working, and development of remote activity are expected to continue this trend.’
procedure requiring close co-ordination between the oncologic surgeon and microsurgeon, and highly skilled nursing support preand post-operatively.
King Edward VII said current clinical evidence showed that the technique reduced the risk of secondary breast cancer-related lymphoedema, which remained a feared complication of breast cancer
treatment, affecting about one in five people.
Director of operations Kate Farrow said: ‘Having successfully undertaken these procedures for patients as part of our support for the NHS during the pandemic, we are delighted that a number of the outstanding team at Imperial College NHS Trust have since joined our team to offer the procedure privately.’
By Leslie Berry
Independent practitioners have been given a valuable insight about how technology will minimise the regulatory burden of the new Medical Practitioner’s Assurance Framework (MPAF).
The requirement, announced in Independent Practitioner Today in November 2019, is being universally adopted by private hospitals, and members of the Doctors Club were given a run down of the implications by online solutions company Healthcode.
MPAF requires hospitals to obtain more information from consultants before granting and maintaining their practising privileges.
These data requirements are now shaping the development of The Private Practice Register (PPR), Healthcode’s central online directory for the independent health sector, to make it easier for consultants and hospitals to comply.
Fiona Booth, the company’s head of external affairs and stakeholder engagement, explained that the MPAF was the product of an advisory group commissioned by the Independent Healthcare Providers Network as part of the sector’s response to the Paterson scandal.
She told the virtual meeting: ‘The basic principle is that problems can be detected early and addressed through effective governance, underpinned by the professionalism of practitioners. MPAF aims to standardise governance systems and processes across the independent sector.
‘All private hospital groups are committed to adopting MPAF. Significantly, it has been endorsed by the Care Quality Commission (CQC), so hospitals will be expected to show evidence of compliance to CQC inspectors as part of the “Well Led” Key Line Of Enquiry.
‘From an independent consultant’s perspective, it is necessary to
engage with MPAF to maintain their practising privileges.
As a technology company working on behalf of the independent sector, she said it was important for Healthcode to align The Private Practice Register with MPAF’s data demands and support providers and practitioners to meet their regulatory obligations and manage their workload.
Healthcode’s product marketing manager Desné Marston said one of the aims of the MPAF is that it intends to build on existing processes and systems.
The PPR complemented this approach because it is an established sectorwide directory that is already being used by over 20,000 practitioners to control their data, thereby saving time and effort. By uploading information to their profile once, they can ensure the correct documents are accessible to those who need it.
Mrs Marston assured the audience: ‘We are actively working to ensure The PPR dovetails with MPAF requirements to make the transition as smooth as possible for everyone.
‘One way that we are doing this is by working to clearly defined data standards so every practitioner’s profile includes essential information in a format that can be shared with other organisations when appropriate.’
We reported on the impact of the Medical Practitioner’s Assurance Framework in November last year
of this valuable information is already included in practitioners’ PPR profiles. This includes DBS certification, ICO registration, names of designated body and Responsible Officer, practice locations and basic professional indemnity information. We are now addressing the gaps in our development roadmap.
To ensure the information held on The PPR is relevant, Healthcode has set up a Data Standards User Group where new standards can be proposed and discussed.
Cross-sector initiative
She was pleased to report that this was a genuinely crosssector initiative, including representation from the BMA Private Practice Committee, the Independent Doctors Federation, the London Consultants Association, insurers and hospital groups.
Data prescribed by MPAF for hospitals to assess practising privilege applications and review them at least every two years includes:
☛ Proof of identity, demographic information, Disclosure and Barring Service (DBS) certification, registration with the Information Commissioner’s Office (ICO), evidence of compliance with mandatory training, evidence of Hep B/ Hep C/HIV status, CV and references, designated body and Responsible Officer;
☛ Locations where a doctor holds practising privileges or works as a doctor;
☛ Valid certificate of adequate insurance cover or medical indemnity;
☛ Scope of practice, including procedure codes, procedures undertaken, volume of work in each area of practice and registries where outcome data is shared.
Mrs Marston explained: ‘Some
‘Under scope of practice, for example, the information required represents a huge undertaking for hospitals and consultants. However, Healthcode’s position as official clearing organisation for private medical bills means we can utilise transactional data to automate aspects of this process, alongside practice information uploaded to The PPR by the consultants themselves.
‘We can organise this data to specify procedure codes; give a 12 month rolling total of procedures undertaken in each hospital where a consultant holds practising privileges; provide a breakdown by patient age group and show how long since the last procedure was undertaken.’
These timesaving PPR enhancements should be available later this year while developmental work on other scope of practice requirements ‘is well under way’.
She added: ‘For thousands of independent practitioners, the ability to control and update information in one place, organised in a logical way, will save time and effort when responding to requests from hospitals and insurers. We are confident that it will be an essential companion service for the MPAF, providing the means to assurance across the sector.’
The Doctor’s Club is a membership organisation, providing events and resources to help doctors and health professionals run a successful practice
By Olive Carterton
The pandemic has pushed back the planned opening of a major new hospital: the under construction Cleveland Clinic London.
Chief executive Dr Brian Donley said: ‘The Covid19 pandemic has brought unprecedented challenges and an unavoidable delay due to lockdown, but we are now making great progress while ensuring the safety of all workers on site.’
Progress is now being made towards a revised completion date for building in September 2021.
The hospital at 33 Grosvenor
Place is expected to open in early 2022 after a short period of commissioning, but will begin seeing patients in its outpatient clinic at 24 Portland Place from Autumn 2021.
Work paused when Covid19 hit to ensure the workforce’s safety and well being. As lockdown restrictions eased in the summer,
site operating procedures were implemented to resume work safely in line with guidelines.
Paul Hamer, chief executive of civil engineers Sir Robert McAlpine, said: ‘We are proud to work with Cleveland Clinic London on delivering this world class healthcare facility in the heart of London.
‘Despite the current challenges of the pandemic which has added significant complexity to the project, the resilience and commitment of the team has been exemplary, allowing construction to resume safely and progress at pace.’
Cleveland Clinic London will
Left: the new Fortius Clinic’s reception in Wimbledon. Below: Surgeons Mr Jonathon Lavelle and Mr Andy Williams
£4.5m
The outpatient, diagnostic and treatment unit offers ‘rapid’ access to orthopaedic and sports injury treatment for local residents and workers.
Consultants for a range of orthopaedic conditions, sports and recreational injuries work from seven consulting rooms at the clinic, open six days a week.
A company spokesman said: that many of Fortius consultants held eminent positions in elite sport and the clinic took care of more elite athletes, clubs and teams than any other provider in Europe.
The spokesman added: ‘Fortius is
an accredited FIFA Centre of Excellence and has over 80 specialists practising at clinics and surgical centres throughout central London. This move out of the central London market marks an important strategic step’.
Chief executive Jim McAvoy said: ‘Wimbledon has been on our radar for some time and we are excited to be providing facilities that will provide worldclass care and first class service to patients and referring doctors.’
Fortius Clinic was launched in 2009 by a group of consultants who set out to create a centre of excellence in the field of orthopaedic and musculoskeletal healthcare.
It operates three outpatient and diagnostic clinics in central London, as well as Fortius Surgical Centre and an orthopaedics partnership with Bupa Cromwell Hospital.
Among consultants holding clinics in Wimbledon are Fortius Board member consultants: spinal surgeon Mr Damian Fahy and knee surgeons Mr Andy Williams, Mr Jonathon Lavelle and Mr Andrew Davies.
Other Fortius consultants include consultant surgeons Mr Giles Heilpern, knee; Mr Simon Bridle, hip; Mr Phil Mitchell, hip; Mr Ali Narvani, shoulder; and Mr Ramon Tahmassebi, hand and wrist.
have 184 inpatient beds, including 29 ITU beds, eight operating rooms, a full imaging suite, endoscopy and catheterisation labs, day case rooms for surgery and a full neurological suite with rehabilitation.
The facility will offer comprehensive medical and surgical services, with a special focus on heart, vascular and thoracic, digestive disease, neurosciences, and orthopaedics.
Most of the existing façade of the building is being maintained and the original entrances to the building will be reinstated.
A second peak of Covid 19 in England this winter is the numberone concern among the medical profession.
Eightysix per cent of more than 8,000 doctors and medical students who responded to a BMA survey said a second peak was likely or very likely in the next six months.
Doctors said the failure of the test and trace system, lack of monitoring and adherence to infection control measures in public places, and confusing public health messages on physical distancing and face coverings, were the main risks to causing a second peak.
When asked about the impact of measures to help prevent a second peak, doctors said a fitforpurpose test and trace system that was accessible and provided timely results, as well as a coherent, rapid and consistent approach to local outbreaks, were the two most important.
8,629 doctors and medical students in England took part in the survey between September 9 and 11.
Keep your seat belt on – it’s not over yet!
Hold tight! It’s been a rollercoaster ride in private practice for over six months now, and the peaks and troughs are surely set to continue, says Jane Braithwaite
THE WORLD of private practice is ever-evolving and this year has been more transforming than ever before. It’s best described as a rollercoaster ride with more fear than thrills.
I am sure many of my colleagues in private healthcare might use slightly stronger language to describe the challenges that we have all faced.
From the perspective of the patient, the impact of Covid has been enormously significant in their ability to utilise the services we offer and many potential patients will be suffering in silence, too anxious to go out into the world to address the symptoms they are experiencing.
Only time will reveal the true extent of this. Many patients who were receiving, or due to receive, treatment in the early part of 2020 have suffered delays in treatment and this is going to be an ongoing problem for some time to come as we struggle to catch up.
The rapid increase in telehealth during lockdown was initially a challenge for many consultants, private GPs and patients, but has been a success in many respects and looks set to continue into the longer term.
I recently discussed this with Mr Nick Panay, consultant gynaecologist in reproductive and postreproductive medicine and director of Hormone Health, which has clinics in Harley Street and Nottingham.
He told me: ‘We kept our Hormone Health service going by offering virtual consultations over lockdown and now at least half our consultations are still by phone or video, as this suits our patients’ requirements.
‘We have also continued to provide helpful information to our women on health-related issues through social media, webinars and podcasts.
‘It has been a challenge being able to fit in the cancelled or postponed consultations and we have seen a particular growth in our requests for new consultations.
‘The pandemic has shown us how important it is for quality of life, hormonal and general health to be maintained during this difficult time. Optimising lifestyle and
The additional overhead of Covid testing is having an impact both in terms of administration, logistics and timing
diet underpins any hormonal interventions.’
Nigel Denby, a registered dietitian who is part of the team of consultants within Hormone Health at 92 Harley Street, supports Nick’s view.
He reflects: ‘I found so many women are more relaxed and able to focus on the advice during video consultation. No travelling or stress trying to find the clinic or get there on time means they are calm, receptive and ready to get on with the job in hand – it’s a win, win.’
I have spoken to many other consultants, who like Nick and Nigel, plan to make virtual consultations part of their ongoing service.
But there are others who feel very strongly that face-to-face consultations are essential for their patients, and this could either relate to the particular specialty, the patient demo -
graphic or perhaps the consultant’s personal dislike of the concept.
To get the most accurate view of how private healthcare is performing, we need to look at the finances and the data published by Healthcode provides us with valuable insights (see page 4).
Its data reports that, during lockdown, invoice numbers were down 60%. But coming out of lockdown the data shows a pickup in the number of face-to-face consultations.
It is particularly interesting, too, that the number of self-pay invoices is increasing and is higher than pre-Covid levels and, sadly, this may be due to longer NHS waiting lists.
On a day-to-day basis, there are numerous Covid-related frustrations. The additional overhead of Covid testing is having an impact both in terms of administration, logistics and timing. The ability to book surgery is a problem in many specialties and at many private hospitals.
There has been significant change in many aspects of private practice with some practitioners finding working in a virtual manner complements their practice and specialties, while others have found it lacking.
Although we are seeing good growth in recent weeks and months and a return in confidence, that is now being threatened by daily reports of increasing cases of Covid.
I am not sure anyone can predict exactly what will happen in the next six months, but it is safe to assume it will continue to be a rollercoaster ride of sorts.
See how Covid will affect your private practice, page 44
Jane Braithwaite (below) is managing director of Designated Medical, which offers business services for private consultants
A look back through our journal’s archives of ten years ago reveals that although times change, some issues are not so new
Researchers working for a new independent healthcare think-tank identified a huge latent public demand for private doctors and hospitals.
Findings suggested the sector’s 10% share of the UK’s total number of patients a year could more than double.
But patients told researchers they wanted the private sector to work in tandem with the NHS.
Richard Jones, chief executive of the H5 Private Healthcare Alliance – encompassing the five largest UK hospitals groups, said: ‘For every person who is currently a user of private doctors and the independent hospital sector there are at least one or two other people who are actively considering or at least positively disposed to using it in future.
‘We think there’s a latent demand. The challenge for our industry is how we can convert
latent demand into active users. That is a much bigger debate about healthcare policy organisation and funding in Britain.’
He told independent Practitioner Today: ‘I hope doctors realise the scale of the opportunity – it is very positive.’
Mr Jones, a former Spire Healthcare commercial director, added (prophetically?): ‘There is a wide recognition in society that the NHS is a very important institution and it is not our role to criticise it.
‘Our role is to say that the private sector, working alongside the NHS, already plays an important role, not conflicting but complementing the health service.
‘We want to work in partnership with the Government and policymakers to help contribute to the debate about how the private sector can help contribute to overall healthcare.’
The alliance was the forerunner of several organisations which have represented private healthcare providers over the years.
Doctors working in private practice and the NHS were heading for more tax turmoil in the wake of nationwide publicity about HM Revenue and Customs’ (HMRC) errors.
Tax officials had ridden a storm of disasters on the PAYE front,
with underpayments and overpayments occurring through their system’s inability to correctly attribute tax codes to allow employers to deduct the correct amounts of tax.
Accountant Vanessa Sanders, of Stanbridge Associates, said that six months into the 2011 fiscal year there was still no code to allow employers to deduct the correct amount of tax from a source of income which should have the 50% applied to it.
‘This means that deductions through PAYE will still not necessarily be accurate if you earn more than £150,000, particularly if this is from more than one source,’ she said.
New private doctors expanding their businesses were being advised to take advantage of a National Insurance Contributions holiday scheme.
Announced in the Budget, it aimed to encourage new business start-ups in key UK regions.
Under the three-year scheme, eligible businesses could take a ‘holiday’ for each of the first ten employees they hired in their first year of business.
Private doctors’ problems with the taxman were predicted to get a whole deal worse thanks to an HMRC plan to cut costs.
We reported that consultants’ and private GPs’ tax advisers might not be copied in on all the letters doctors receive from the Revenue in future, so they would have to rely on doctors letting them know about every piece of correspondence.
If doctors forgot to send a copy of a letter to their adviser, then it could mean more unnecessary trouble for them under the HMRC’s ‘Tax Health Plan’.
Some 2,500 doctors were said to have come forward to declare irregularities to the taxman under the scheme, launched in January, while around 28,000 more who had not responded were waiting to see whether HMRC had them in its sights.
Share your experience of what has and has not worked in your private practice. Even if it’s bad news, let us know and we can spread the word to prevent other independent practitioners falling into the same pitfalls
Contact editorial director Robin Stride at
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• Access to a free counselling service as part of your membership for stress or anxiety that you feel could impact your practice
• Free access to the Croner advice line which provides support with tax and VAT, company law and health and safety support
Independent practitioners’ success in their future business relies on smart and robust organisational skills to ensure that exceptional service is maintained, while also ensuring necessary procedures are in place to make sure practices are Covid-safe, says Julia Burn. Organic growth is also needed to rebuild a practice
Organisation of the practice
One of the main practical ideas for maximising the efficiency of a business in the current environment is to ensure that the practice has excellent organisational skills in place.
You need to make sure enough time is scheduled for consultations while allowing for the additional procedures and cleaning which will undoubtedly need to be in place in relation to the pandemic.
It is important to have an efficient personal assistant (PA) or practice manager to ensure that the day-to-day parts of the practice are running smoothly, managing calendars for both clients and staff.
The consensus across all businesses is that ‘agile working’ is going to become the new norm in society. Agile working allows the workforce to perform part of their duties in the normal office environment, but there is also an element of working from home and an element of people varying their hours of work from the standard 9am-5pm.
For this to work, it is essential that businesses understand how this will affect day-to-day activities. Ensuring that the right people are in the right place at the right time to service clients.
Often in small practices, the PA also gets involved in the accounting function of the business. Where they may be a fantastic PA,
they may not be skilled or trained in book-keeping and this could create issues when it comes to yearend accounting. For example, things may be misallocated in the accounts, which may affect how profits or losses are disclosed – and that could affect future planning.
It may be a good time to contact your accountant to discuss how they could assist with day-to-day bookkeeping, cash management techniques and potentially help you with preparing forecasts and budgets.
With the Government measures coming to an end this Autumn, and many deferred liabilities being payable in early 2021, cash flow is critical (See our website story ‘Consultants advised to get advice before seeking Chancellor’s new deal’). Many accountants offer outsourced services that cover some of the day-to-day book-keeping tasks; this would enable key staff to focus on other areas of their role .
As mentioned in last month’s article on the ‘new normal’, cash management is key to the success of a business.
At the start of the pandemic, the Government put a variety of different arrangements in place to assist firms through the crisis, including the furlough scheme, the bounce back loan, the business interruption loan scheme and ability to arrange deferment of HMRC liabilities.
These arrangements are now coming to an end, so it is important to go back to basics with cash management to ensure businesses continue to remain cash positive.
A top tip to consider would be to prepare monthly cash flows. Keeping these forecasts up to date will enable the practice to identify potential cost savings.
It would also be worthwhile to look at customer payment terms and review the practice’s own supplier terms to see if more favourable terms can be agreed.
Cash collection will become a key role. It is going to become harder where people start to feel the pinch of the lockdown, where many businesses were not able to function at full capacity and some of which had to shut their functions down completely.
Payment terms may need to be agreed on a customer by customer basis, which could become a timely and therefore costly exercise.
Most doctors’ businesses have seen some shrinkage in their operations during the pandemic, especially non-urgent medical practices who may not have been able to perform any of their usual procedures for a prolonged period.
The next step will be to try and find ways to bring the business back to the level it was previously. And the first way to do this would
be to promote organic growth –using the practice’s own internal knowledge, contacts and resources to grow again.
Ensuring that clients receive the best possible service in a safe and friendly environment that they will tell their friends and acquaintances about is the best possible way to promote the business.
Repeat business from current clients is also incredibly important and a testament to the fact that, although times are difficult, they are receiving the best form of care from professional, skilled people. It may also be sensible to contact previous clients who have left the practice and see if they require any services.
With the uncertainty of when things will fully return to normal or the extent of the damage from a second spike of the virus, it is important to be organised and knowledgeable about the practice’s finances so that any issues that arise can be identified and acted upon promptly.
It is also particularly important to focus on what your business does best and continue to offer your clients the exceptional service that they are used to.
Julia Burn is a senior manager at Blick Rothenberg and part of the team that advises medical practitioners
‘You can’t manage what you can’t measure’. This well-known quote by management thinker and ‘the founder of modern management’, Peter Drucker, is a great way to set the scene for this month’s article in our series on patient experience.
You cannot know whether you are successful unless success is defined and tracked. To improve, we need to measure. Jane Braithwaite (right) here focuses on how you can measure patient experience to ensure your strategy is working and leading to the improvements you want to make
What are you measuring?
To measure anything requires clear criteria to measure against.
Earlier in the series, as part of defining the patient experience strategy, we discussed the importance of setting your vision, which describes what you want your practice/clinic/hospital to be and also your objectives to ensure you achieve this vision. These will be important, as they will now become the basis for your measurement criteria.
As you set out your measurement criteria, it is useful to think ahead about how the findings will be used. It is important to measure the right things that will allow you to track improvements.
In the US, there are a set of trademarked surveys called CAHPS surveys, which stands for Consumer Assessment of Healthcare Providers and Systems. These have been created by the US Agency for Healthcare Research and Quality and are designed to report on the aspects of patient experience that are important. They are free to use and may well serve a useful purpose within the UK market too.
The measurement criteria you choose will obviously depend on your own vision and objectives, but looking at the questions asked in the CAHPS survey is helpful for
We all know that responding to surveys can be tedious, so your challenge is to ensure patients are surveyed in a manner that encourages participation
inspiration. As an example, if one of your main objectives is to ensure that patients can book an appointment in a timely manner within your clinic or hospital, you may choose a measure such as the following:
In the last six months, when you needed care right away, how often did you get that care as soon as you needed it?
The patient would be prompted to choose from the following answers:
Never;
Sometimes; Usually;
Always.
Another important objective for many healthcare providers is to deliver information in a way that patients can understand and an example measure, seen in the CAHPS survey, might be as follows:
During your recent visit, did your healthcare provider explain things in a way that was easy to understand?
Yes definitely;
Yes somewhat;
No.
This same format of answers applies to other questions asking the patient if the doctor spent enough time with them, listened to them and respected them.
While the CAHPS templates will provide you with assistance, it is important that your measurement criteria measure the aspects of your service that are important to you.
Having defined your measurement criteria, the next step is to decide how you will survey your patients and capture their responses. You will also need to decide whom you will survey. Will you ask every patient or a subset of your patients?
We all know that responding to surveys can be tedious, so your challenge is to ensure patients are surveyed in a manner that encourages participation.
One important factor is to ensure patients are aware why ➱ p20
I would like to make an important point about patient testimonials and reviews. There are several specialist websites that are used to collect reviews and feedback from patients.
These provide an excellent way for patients to check out the credibility and reputation of healthcare providers by reading the feedback from previous patients and I encourage their use, but it is vital to acknowledge that these do not adequately measure patient experience.
They act more as a marketing tool than a comprehensive measure of patient experience. This may change over time, but, in the short term, it is important to gain a much more detailed and quantitative measure of patient experience.
The best way to embrace patient testimonials, reviews and feedback is in the same way that you treat thank you letters and compliments as mentioned on the next page.
Surveys can be designed to give us data that can be presented in graphs and spreadsheets, which are easy to understand and to monitor trends over time to look for improvement
Surveys can be designed to give us data that can be presented in graphs and spreadsheets, which are easy to understand and to monitor trends over time to look for improvement.
The most used survey tool in the UK is Survey Monkey, although there are lots of others. Survey Monkey offers a limited free service, but for a reasonable annual subscription you can access numerous template surveys, some of which are designed for the healthcare sector, including the CAHPS templates described previously.
Using technologies such as Survey Monkey to run your surveys also reduces the burden of analysis, as they contain embedded tools to present the data in manageable ways. If you create and run your own survey, you will need to plan for the overhead of collating the data into a useable format.
There are also specialist companies focusing on the healthcare industry that provide measurement and analysis of patient experience and cater for all sizes of healthcare businesses, from individual consultants through to large healthcare establishments.
they are being asked to take part and how the findings will be used to improve care.
If they understand the impact their feedback will have, they will be more likely to take part. It is also important to use several different means of engaging with patients, as some ways will appeal to some groups more than others.
Technology offers us numerous options including email, SMS messages and the use of a computer tablet within the hospital or clinic environment.
The beauty of using technology is that it reduces the burden on healthcare staff, but you should not rule out good old fashioned paperbased surveys, as these may appeal to some patient groups more than technology, but it will, of course, be more timeconsuming to collate the responses.
Once you have run your survey and the data is captured, it needs to be analysed and presented in a meaningful way to ensure it can be used to develop action plans for improvement
to understand by you and the rest of your team.
It should be in a format that allows for the measurement of trends over time, so ideally in a spreadsheet or a graph. And the more data that can be collected over time, the more informative the findings will be.
The next stage is to use this valuable information to produce improvement plans enabling you and your team to focus on a small number of areas, usually where you have received lower scores or less positive feedback than you would like to receive. For each of these areas, an action plan should be developed to ensure improvement over time, and this will be the subject of next months article.
I look forward to answering the following questions next month: How will your improvement plans be developed?
Who will own the improvement plans?
How will you embed the focus on patient experience in your organisation?
How to make patient experience a top priority for the long term.
As well as surveys, you could also consider more descriptive patient engagement such as patient interviews and focus groups. The information gained will be harder to present graphically, but will undoubtably offer some informative knowledge.
An interview could even be an informal chat that takes place at the end of a consultation or during a ward round, with each patient being asked a consistent set of three questions and their answers being manually collated.
You could also engage your medical PA in the process, asking them to ‘survey’ patients, by phone or email, following their appointment.
Like all businesses, healthcare providers receive complaints from patients, and these can provide valuable insights into your patients’ experience and should be included as part of the data collected.
At the other end of the spectrum from complaints, I am sure you receive ‘thank you’ letters and
compliments from patients regarding the care you have provided. These also provide valuable insights and will highlight the most positive aspects of the patient experience you are delivering.
Once you have run your survey and the data is captured, it needs to be analysed and presented in a meaningful way to ensure it can be used to develop action plans for improvement.
You will need to agree who will do the analysis and presentation and continue to do so on a regular basis. If you are using a survey tool, this may not be a significant overhead, but if you plan to run your own survey, the collation of the data will take some time to manage.
The output produced should be presented in a manner that is easy
Jane Braithwaite is managing director of Designated Medical, which offers business services for private consultants, including medical secretary support, book-keeping and digital marketing
BUILDING A STRONG brand in healthcare has never been more important. Over time, a brand that has been nurtured and taken care of can make the difference between a successful healthcare business and one that is struggling.
With technology and the Covid pandemic driving change across the healthcare sector, patients and customers have never had so much choice. It is therefore vital to invest time and resources in your brand and not to damage it. But if you really don’t want to maintain your brand’s strength in the marketplace, here is a quick check list of actions or behaviours you can do to cause it real harm.
1 First impressions count: Underestimate the power of design and branding
First impressions count in every walk of life and private healthcare is no exception. Investing time and resources in the design of your logo, visual identity and website is vital if you want to make a good first impression with patients, especially if you are positioning your company as a premium brand.
Good design does not need to cost the earth and there are now tools and technology available that can help you such as Canva, Squarespace and WordPress.
Building your brand takes time and there are a lot of ways you can accidentally damage it. Simon Marett shows how you can ruin it all
fully designed and you are attracting lots of new patients through your copy, pricing and proposition, but what about the delivery of the service or product?
If your business operations –technology, processes and people – are not aligned to deliver on that brand promise then you are destined to fail. Patients will ultimately be disappointed and dissatisfied and won’t return.
4
Don’t listen to your customers and patients
If you are not listening to your patients or you do not ask them what they think of the service you are providing them with, how do you know that they’re happy? The answer is you don’t.
Building a simple post-consultation patient survey in a tool like Survey Monkey is a simple way to ensure you are capturing patient feedback, learning what is good about your service and also where you need to improve.
2 Neglect to map your patient journey in detail
Creating, documenting and communicating the journey your patients will go through from preconsultation through to posttreatment is essential.
5 Have complex and poorly communicated pricing
Not investing the time from the outset to detail this journey will only result in confusion, miscommunication and errors that will ultimately result in a poor patient experience and damage your brand.
3 Overpromise and underdeliver
Make this a golden rule never to happen in your business. Your logo and website might be beauti-
Pricing your products and services is never an exact science and there are a number of factors for you to consider, but perhaps simplicity and transparency are the most important.
Nobody likes to get to the point of payment and find that they are being charged 20-30% more than they anticipated. Keeping your pricing framework simple and making sure it is communicated throughout the patient journey is a sure-fire way of reducing customer complaints and preventing your brand being damaged.
Cut corners on recruitment
For independent practitioners and healthcare businesses, hiring and training the right people is key, because so much of a patient’s experience will be determined by the interactions they have with the patient care team, medical secretaries and your practice manager. Cutting corners on recruitment and saving a couple of thousand pounds by hiring a cheaper candidate can prove to be a false economy in the long term if they are not up to the job.
7
Choose the wrong technology partner
Selecting the right technology platforms and patient management systems to build your business on is a headache for any independent practitioner. There are several hundred to choose from and new healthcare start-ups are entering the market each week.
Not doing your research and defining your requirements at the start of the process is a major mistake to avoid that will eventually impact your business through wasted time, energy and money, and a poor practitioner and patient experience.
8
Have poor and untimely communication
Relevant and timely communication with your patients is important, but how do you get it right?
Too little communication will result in poorly informed patients and complaints. But you also do not want to bombard them with too many emails and text messages and annoy them.
Taking the time to map out your patient journey and the information they need and want at every stage is a useful process to go through and can help you achieve the optimal level of communication for patients.
Be hit and miss on social media
Social media – where do you start? Which platforms should you be across and what, when and how often should you post? For many patients in 2020, social media is where they first find out about a practice and also where they go to find out more information and post questions.
Being inconsistent with your activity and leaving a patient’s question unanswered for a few days is a quick way to damage your brand. If you are going to use social media, be consistent and start with a ‘less is more’ approach.
10 Don’t educate and inform your patients
In most fields of healthcare, a patient who is well informed and educated about their own health is often a better patient who achieves better outcomes. They are also likely to trust your
brand and prove a profitable patient over the long term.
So investing time and energy in content such as videos, blogs and infographics to build up their knowledge of their symptoms, treatment options and expectations is a smart move for any independent practitioner.
This list is not finite but covers some key areas. Ultimately, doctors with a brand that is looked after will likely retain happy patients, acquire new ones and build a business destined for success in the future.
Simon Marett (right) is founder and managing director of Ellerton Marketing Ltd, www.ellertonmarketing.com, a specialist strategic marketing consultancy for independent healthcare practitioners
SURVIVING A COMPLAINT
In the second of two articles on GMC investigations, Dr Ellie Mein (left) explains how to cope with a fitness-to-practise hearing
FEAR IS a natural reaction for any doctor notified of a GMC investigation. Many doctors tell us their first thought is of erasure.
Of course, that can happen, but for the majority of doctors subject to a GMC investigation, the prospect is remote.
GMC fitness-to-practise (FTP) statistics for 2018 show fewer than 70 erasures and 101 suspensions.
One of the main roles of medicolegal advisers is to put that fear into context and to explain the procedure along with guiding and supporting doctors with the complexities of the process.
In 2019, at the MDU we resolved 86% of GMC cases, handled by inhouse lawyers, without a formal hearing.
In our article in the September issue of Independent Practitioner
Today , we looked at the GMC investigation process and what to expect at each stage. This time, we will look at what to expect if you face a FTP hearing or receive a warning or undertakings.
Warnings can be issued in cases where allegations do not justify referral to an FTP tribunal, but there is evidence to suggest behaviour or performance has fallen below standard and warrants a formal sanction.
Of the 1,208 case examiner decisions made in 2018, 69 of these resulted in a warning.
Before issuing a warning, the GMC asks for comments. However, if no comments are made or the doctor does not dispute the allegations, two case examiners may agree a warning.
If a warning is not accepted or the case examiners consider it appropriate, the complaint will proceed to an investigation committee hearing. Such hearings are rare, though. It may also decide to issue a warning, conclude a case with no sanction or refer a case to an FTP tribunal.
Warnings will be disclosed to the person or body who made the allegation and any person or body for whom the doctor provides medical services or the doctor’s employer.
Warnings are visible on the online register for two years and remain available to employers indefinitely.
Undertakings may be offered after a performance, health or English language assessment if case examiners decide that a doctor’s fitness to practise is impaired. During 2018, 93 of the 1,208 case examiner decisions concluded with undertakings.
Undertakings might include restrictions on practice or behaviour or a commitment to undergo medical supervision or retraining. Details of undertakings – except where they relate solely to health – will be disclosed to employers and anyone who enquires. They may also be offered for cases relating to conduct, but not if the allegations are so serious that there is a ‘realistic prospect’ of erasure.
A GMC study of cases that were considered by fitness-to-practise tribunals showed doctors who showed insight and said sorry were ten times less likely to be erased than those who did not
The FTP tribunal can take the following actions:
Accept written undertakings;
Impose a period of conditions;
Suspension from the register for a set period;
Erasure from the register. This doesn’t apply in cases with allegations solely about health. The doctor can apply to be reinstated after five years by demonstrating they are fit to practise
Issue a warning if the doctor’s fitness to practise is not impaired.
Publication of decisions
Undertakings, if accepted, conclude a case. However, the case may continue to an FTP hearing if they aren’t accepted, if further concerns arise, if the doctor fails to comply or if health or performance deteriorates.
FTP tribunals are held by the Medical Practitioners Tribunal Service (MPTS), which is an operationally distinct part of the GMC.
Of the 1,208 case examiner decisions in 2018, 280 of these involved referral to a tribunal. It will often take several months for a case to progress to an FTP tribunal hearing, during which time the GMC will investigate further and may ask for expert evidence.
FTP tribunals have three members, including at least one medical and at least one non-medical member. Most hearings will have a legally qualified chairman who advises on points of law. Some cases may also have a legal assessor.
The tribunal has three stages:
1
Evidence is heard and the panel determines whether the facts are found proved. If not, the case will finish.
2
A decision on whether admitted or proven facts amount to impaired fitness to practise. The panel will take into account any evidence of remediation since the misconduct occurred.
3
Decision on any sanction, if fitness to practise is impaired. The tribunal takes into account patient protection, public confidence in the medical profession and the need to uphold standards of medical practice. Mitigating factors, such as the doctor showing insight or steps taken to address the problem will also be considered.
FTP tribunals and their outcomes are public and unfortunately can attract negative media attention, adding to the distress of those involved. The MDU has a dedicated press office that is experienced in helping you mange media attention, however.
Decisions are also published on the GMC and MPTS websites except if they relate to confidential information about physical or mental health.
Insight and remediation
Demonstrations of insight into the causes of the incident that led to the complaint, and providing evidence of remediation to put things right, can be persuasive that a doctor is fit to practise.
The MDU or your own medical defence organisation can guide you on how to demonstrate this.
A GMC study of cases that were considered by FTP tribunals – but not cases relating to health or convictions – showed doctors who showed insight and said sorry were ten times less likely to be erased than those who did not.
A GMC investigation can be a distressing experience for any doctor. However, it is important to be aware that, with the support of your medical defence organisation, most cases will be concluded in their early stages. This is also a reflection of the way in which the GMC has changed its FTP procedures and its approach to FTP investigations over recent years.
Nevertheless, it is vital you involve the MDU or your own medical defence body as soon as you receive notification of a concern being raised about you.
Dr Ellie Mein is an MDU medico-legal adviser
As people and businesses start to return to normal, those who were thinking of a move will be firmly putting this back on the agenda, but some things have changed while we have been in lock-down. Even before the review of capital gains tax promised by the Chancellor, some tax perks have been lost already, warns Vanessa Sanders (below)
PPR is a relief available when individuals dispose of their only or main residence.
PPR eliminates or reduces – if you have not lived there for the whole period of ownership – any gain arising on the difference between the purchase price and the selling price.
But major changes to PPR relief took place with effect from 6 April 2020 as set out below.
Previously, there was an exemption from the time-apportioned gain accruing in the final 18 months of ownership. This period has been reduced to nine months, except for those property owners with a disability or resident in a care home, who will remain entitled to a final exemption period of 36 months.
Those who were planning to sell within their final nine to 18 months of ownership prior to 6 April 2020 but who have had to delay due to Covid-19 will be caught by this reduction.
Despite the impossibility of selling a home during the lockdown period, no concessions have been announced concerning the extension of the final period.
This is in contrast to stamp duty land tax (SDLT), when the period allowed is 36 months between disposals of main residences, and a further concessionary period has been announced due to the impact of Covid-19.
Prior to 6 April 2020, letting relief applied where the only or main residence was let as residential accommodation for part of the period of ownership.
On disposal of the property, owners were entitled to claim a very generous letting relief at the lower of:
The amount of gain attributable to PPR relief ;
The amount of gain arising from the letting;
£40,000.
➱ p28
This relief was in addition to the PPR relief.
Up to 5 April 2020, there was no requirement for the individual owners to occupy the dwelling while let. But for disposals since 6 April 2020, letting relief will be available only for periods when the individual owners have shared occupancy with their tenants.
Reporting requirement dates have changed as has the date when the liability to pay the CGT arising on such gains.
With effect from 6 April 2020, any disposal of a UK residential property not wholly covered by an exemption or relief must be reported to HM Revenue and Customs within 30 days of the disposal together with a payment on account of the tax liability. This includes a disposal of a PPR where the PPR relief is not 100% of the gain.
However, there has been a soft landing on penalties for failure to report until 31 July 2020 because of the current pandemic. The penalties are £100 for the first six months, but interest runs on the tax owing from 6 April 2020.
It is not a straightforward report that can be made direct through a tax agent, because the individual must first register for a digital tax account and then authorise their agent to make the disclosure on their behalf.
All of this takes time, which is not on the taxpayer’s side. This is the case even if the residual gain is small and results in minimal tax liability.
There are different ways that you either can or must report your capital gains depending on:
Since 6 April, letting relief will be available only for periods when the owners have shared occupancy with their tenants
Whether you are resident or nonresident;
Whether you are in or out of self-assessment;
The level of gain and how much of your annual exemption you have to cover any gain.
But to ensure the correct amount of tax has been applied – 18% for basic-rate taxpayers and 28% for higher- and additional-rate payers – it is easiest to use self-assessment.
The amount of PPR relief deductible before any letting relief is calculated by multiplying the gain by the period of occupation over the total period of ownership.
The individual’s period of occupation can be actual or deemed occupation. Deemed occupation are periods during which the individual is absent from the property, but for PPR relief purposes is treated as living there.
In addition to the final period of ownership set out above, examples of deemed occupation periods include:
construction/alterations/decorations or a delay in selling their previous main residence, this would qualify as a period of deemed occupation, provided this period does not exceed 24 months and the individual immediately moves once the reason for the delay ends.
Given the reduction in the final period from 18 months to nine months, it is now beneficial to remain in an existing main residence until it is sold rather than moving to the new property, as this extends the overlap period in which two properties are owned and full PPR relief is available from nine months to 24 months.
The following periods of absence must be preceded and followed by a period of actual occupation to qualify as deemed occupation.
☛ Abroad by reason of employment
If an individual has been absent to perform duties of employment overseas, this period will be deemed occupation. There is no time restriction on this.
☛ Reason of employment
If an individual has been absent due to conditions imposed by their employer, requiring them to reside elsewhere, this period would also be a deemed occupation although it has a limit of four years.
☛ Any period of absence Any absence not exceeding three years is considered a period of deemed occupation.
From 6 April 2020, where an individual has purchased a property but is unable to move in immediately due to the completion of
Vanessa Sanders is a partner with accountancy, finance and tax advisory medical specialists Stanbridge Associates Ltd
Sarah purchased a property in Lincoln in February 1998 and sold it 22 years and six months later in August 2020.
From February 1998 until December 2004, it was her principal private residence (PPR). This is six years and ten months
In January 2005, Sarah relocated by request of her employer to Liverpool. This secondment finished in June 2008, so her absence ‘by reason of employment’ lasted three years and six months.
She returned to live in Lincoln until June
2010 when she was deployed by her employer to work in the US. This period of actual PPR is two years.
While in the US, she let out her property, but left employment in June 2013 and travelled round for six months, after which she returned to Lincoln, resuming occupation of her PPR in January 2014 and remaining in Lincoln for six years and eight months until the house was sold in August 2020.
So she was abroad by reason of employment for three years and her travelling amounts to six months’ absence ‘for any reason’.
Thus, Sarah’s total period of ownership would be 22 years and six months.
In this example, the whole period of ownership would therefore qualify as periods of occupation. As a result, the whole gain would qualify for PPR relief, reducing the gain to nil with no need to disclose the sale or pay any tax.
With many doctors, this may not be the case, as the period of time spent abroad is unlikely to be a requirement of the employer – unless on secondment – and the letting relief for PPR qualification has now changed.
Surgeon Mr David Sellu (left), convicted for gross negligence manslaughter of a patient – overturned on appeal after a 30-month prison sentence – continues his story from last month
DR LINDSAY CROCKETT asked me to take a seat. ‘I am afraid I have to have my two nursing colleagues sit with me during consultations. Prison rules. I hope you do not mind,’ she said apologetically.
‘I don’t mind.’
‘I have been reading your notes and I see you are a doctor.’
Dr Crockett listened sympathetically as I explained why I was in prison and I summarised my medical condition.
‘I heard about your case and I
must admit the medical world was shocked by your imprisonment,’ she said, to my surprise. ‘We will do all we can to support you through this difficult time.’
Reasoned discussion
I could not have wished for better treatment. The doctor had a reasoned discussion with me about the choice of medications: I would take it for about two months for my blood pressure to come down, during which time I would visit
the health centre once or twice a week for blood pressure checks.
One day, I went to collect my medications. They had been ordered the previous week on repeat prescription and it took two to three days to be delivered from the pharmacy in Watford.
I took my ID card with me, as, understandably, the staff in the centre were not permitted to hand over medications without the recipient showing valid identification.
The healthcare assistant who
gave out the medication sat in the small office that doubled as a dispensary and was doing paperwork when I knocked on the window of the hatch. I told her I had come to get my medications and showed my card.
‘We only give out medications between seven and eight in the morning and between 2.45pm and 4.15pm Monday to Friday and 7pm to 8pm at weekends.’ I had arrived at 11am.
‘I didn’t know that; I’m sorry,’ I replied but, before I could say any more, she handed me a printed sheet with this information.
‘Come back in the afternoon; I am busy,’ she added.
‘But it only takes two minutes or less for you to give me these tablets, I know they are in that cupboard I can see over there,’ I said.
‘They probably are, but I don’t have the time right now.’ She gave me the package when I called back at 4pm.
On another occasion, I made the mistake of taking a powerful water tablet before visiting the health centre. I desperately wanted to go to the toilet, having been waiting half an hour, but was told that under no circumstances were inmates allowed to use staff toilets in the health centre. I was bursting to go. I barely made it to the gym in time.
I give Dr Lindsay Crockett and her team at Hollesley Bay prison credit for bringing my blood pressure under control by the time I was discharged, albeit with four medications and their potential side-effects. Some of these I have suffered have been life-changing, but I am learning to live with them. The swelling of my legs largely cleared, but the exact cause was never diagnosed.
My status had been elevated to ‘enhanced’, which meant that the number of visits I was allowed increased to one every weekend. If the visitors’ forms were handed in by lunchtime on Wednesday, the visit was practically guaranteed that weekend.
Unlike at Belmarsh and Highpoint, visitors did not have to ring
the prison beforehand to confirm the visit.
As Hollesley Bay prison was scattered over such a vast area, prisoners from wings that were some distance from the visiting hall were picked up by prison van and brought to the hall.
Prisoners in blocks that were just a few doors away were allowed to walk. Prisoners came in through one door and had a yellow-coloured band attached to their wrists, to differentiate them from visitors who had bands of a different colour.
The seating arrangement was similar to those at Belmarsh and Highpoint South, but the atmosphere was much more relaxed and informal. Snacks and drinks were sold in the tea bar, run by an onsite company that also taught catering to inmates; prisoners largely ran the tea bar.
There was no prospect of release from the first two prisons I was in. I also knew that prevailing rules dictated I would serve exactly half of my 30-month sentence behind bars and be released home on licence at the halfway point. Naturally, I welcomed any hope of temporary release during those first 15 months.
On my new unit, I submitted an application to be considered for early home release on tag, the socalled Home Detention Curfew. Under this scheme, an eligible prisoner serving a 30-month sentence could be released about four months earlier and serve those four months at home under stipulated conditions.
If successful, the prisoner would be required to wear an electronic device around his ankle to monitor his movements and he would be required to spend every night at the agreed address until the order was served.
I discussed this with my family, who were excited at the prospect of an early release, but as it turned out, my application was refused on the grounds that people serving a sentence for manslaughter were not eligible.
I had also applied for town and home leave, but, under the new regulations, I had to attend a board meeting whose members I had to convince that I stood to gain from my temporary releases from prison.
This meeting was clearly important and I had been warned that I could be called for it at any time without prior notice, so I gathered all the paperwork I had, verifying that I had been a peer mentor, was now a cleaner and was complying with all prison regulations. I placed them in a folder that I kept in my room.
On the morning of my meeting, I finished cleaning the unit, as I did every day, and was getting ready to head off to the gym when an officer knocked on my door. He informed me that I was wanted in the boardroom. I grabbed my folder and made my way over there.
There were three officers conducting the meeting and one of them, a woman, was the governor’s representative. I had been warned that she was unpleasant and would do everything in her power to humiliate inmates. My first impression was that she looked as though she had slept in her uniform the previous night.
‘You have put on your application that you want to be allowed to do a town visit on the twentysixth of July,’ she bellowed at me.
‘Tell the board what you propose to do that day and why this request should be granted.’
‘We have not decided what we are going to do, as none of us knows this part of the country at all. I suppose we will go to Ipswich, which I believe is within the allowed radius of 40 miles,’ I said as firmly as I could.
‘That tells us nothing about how
you wish to re-engage with your family and you have not mentioned anything purposeful so far,’ she said.
‘Well, I have kept in touch with my family throughout my imprisonment and we have kept our relationship strong. They stood by me throughout my trial and they have been visiting me every weekend. They are very supportive. I propose to continue with the engagement in our relationship.’
‘You have not told us what you will and won’t do. I see here that you were working as a surgeon before you came to prison. We have a reputation as a prison to uphold,’ she said. I could see she was in an aggressive mood from the way she was waving her right index finger in my direction. ‘We would not want the press to know that you have been let out to roam the streets. You can just imagine the headlines: “Dr Death seen wandering in town”.’
Hurtful statement
That was a hurtful statement. It was the first time in my life that I was made to feel ashamed of being a surgeon, a profession where, if you got it wrong, you could be branded a killer.
‘That is an unfair comment about my position. I did not set out to hurt anyone and I was trying my best for a sick man.’
‘Well, you did not do a good job. I see here that you also applied for a tag. What makes you so sure you will get one?’
‘Once again, a patient died under my care; I had no malice towards him and I had no intention for him to come to any harm. People die even with the best medical care.’
I paused before proceeding to tell them how I had a busy surgical practice in West London and an untarnished career spanning 40 years. I believed I had saved many lives but had been punished on account of a single incident, which I, of course, accepted was a serious event.
‘That was a matter between you and the courts. We are here to carry out our duties to incarcerate you and if you have any arguments about why you are here you should take that up with the law outside.’
This line of argument was getting me nowhere, so I decided to
It was the first time in my life that I was made to feel ashamed of being a surgeon, a profession where, if you got it wrong, you could be branded a killer
address the original question about re-engagement.
‘One of my sons works in Oman, in the Middle East, and he will come over as soon as I have a Release on Temporary Licence (ROTL) date. The rest of my family are in the UK. If I am granted permission, he and our other children will join my wife and me at home.’
I told them my son had qualified from medical school, but having witnessed my difficult trial at close quarters, he was so traumatised that he was undecided whether to continue as a doctor. He needed my help and encouragement to continue a medical career.
There was a long pause as they took notes and then they commanded me to wait outside.
Fifteen long minutes later, I was summoned back inside.
‘The board will grant you a ROTL, but under strict conditions,’ the woman officer said. ‘Any infringement of the rules imposed will result in this facility being withdrawn.’
Once again I felt humiliated and angry. However, I was desperate to be let out, if only for a few hours, and to be with my family, so I stayed silent.
26 July 2014
Preparations began to ensure the success of my town visit. I heard stories in the prison about leaves being cancelled for the most trivial of reasons.
One inmate told me that on the day he was to be picked up by his wife and son, their car would not start, so they asked her brother to give them a lift to the prison.
When they arrived, the visit was cancelled due to the car’s registration number not being the one given, and so they had to make the three-hour journey back home again without seeing each other.
Visits to pubs or any shop or restaurant that sold alcohol were for-
bidden. Public places such as football matches and swimming pools were out of bounds and engaging in activities such as golf was considered elitist and also banned. Inmates were required to state where they were going to be throughout their town visit and there might be officers in plain clothes monitoring their whereabouts. We were not allowed to take any items out of prison and would be subject to severe punishment if we were caught bringing anything back. No food, no clothes, no newspapers or books; nothing.
I spoke to my wife Catherine excitedly on the phone the night before the visit. She would drive with our daughters Amy and Sophie; they were planning to leave at 5.30am to ensure they got here before the 9am pick-up time.
An officer had recommended that we go to a pretty village called Aldeburgh on the Suffolk coast, as that would be ‘just up my street’. Moreover, this village had one of the top ten fish and chip shops in the UK.
I was up at 6am. I ironed my shirt and trousers and did not bother with breakfast but had a coffee instead. I took a shower and sat in my room reading and writing. I had to fill in a form that I had to hand in at the main gate telling the officers exactly what I was wearing that day and what I had in my possession. A belt and glasses were allowed but nothing else.
Part of the reason for giving a description of what an inmate wore was that if they were to abscond, the prison authorities
would be able to give the police as accurate a description as possible to help them trace absconder. The other reason was obviously because they did not want them to return in different attire with drugs hidden in secret compartments.
At 8 am, I stood by a window on the unit overlooking the street my family would drive up to reach the pick-up point at the main gate. When I saw them drive in shortly afterwards, the feeling of anticipation was immeasurable.
I went to the unit office and handed in my room key and waited to be called to join them. It was nearly 45 minutes before my name was announced asking me to proceed to the main gate to be checked out.
The officer in the office took the form I had completed and read me the rules and then allowed me to join my family, who were waiting in their car in the car park outside. They all jumped out of the car, we hugged and soon I was in the front seat with Catherine driving out of Hollesley Bay. This was the first time I had been in private transport for over eight months and was allowed to leave prison premises without a prison escort. I felt elated.
Adapted from Did He Save Lives?
A Surgeon’s Story, £9.99, Sweetcroft Publishing ISBN 9781912892327 from Amazon. His story continues in Indepen dent Pract itioner Today next month
Financial stress can hit all consultants’ private practices at some stage – as recent events have highlighted. Simon Brignall (right) outlines the three key problem areas and the questions you should address
BEDROCK OF THE PRACTICE: Medical secretaries are expected to wear many hats, including receptionist, personal assistant, sales ledger clerk, insurance guru, credit controller and debt collector
OVER THE years, I have been asked a wide range of questions during my meetings with consultants, the most common being on how they compare with their colleagues and ways that they can improve their practice.
They are generally referring to their turnover and you can now add to this mix questions I’m asked about how I feel their practice is recovering from the impact of Covid19.
These seem like simple things to ask, but they often have complex answers that can be impacted by any or all of the following:
How much time you devote to your private practice?
How long you have been in private practice?
Where is your practice located?
What is your fee schedule, patient mix and specialty?
Levels of distress
It is important to realise that every practice is different which is why, at Medical Billing and Collection, we tailor our services to the needs of each consultant.
As most consultants who come to us are in various levels of distress, the second most common question I get asked is: ‘Am I in worse shape than my colleagues?’ My response is always polite and understanding, as often there are a range of factors that have contributed to the position that they currently find themselves in.
It is important to realise these
are factors that can plague both small and large practices and also established consultants as well as new entrants to the field.
I have taken on a consultant who had close to £400,000 outstanding as well as a couple of clinics that were owed over £1m. We were able to assist all of them to retrieve most of their outstanding funds and make appropriate tax adjustments for what was left.
We achieve bad debts of less than half of one per cent, but we regularly see examples in private practice of bad debt between 5% and 10%.
Let us explore the three commonest causes why most doctors who seek our help are in some form of distress with their financial affairs.
The following are in no particular order. However, the challenges are probably something most consultants face at some stage during their private practice life cycle.
One of the first challenges a consultant comes across when they set up in private practice is to put in place the correct infrastructure to ensure it is run soundly.
This means having a robust auditable system to facilitate the practice’s financial elements and would include the ability to raise invoices and reconcile payments. Remember to ensure that it meets the latest regulation requirements such as General Data Protection Regulation.
You should have the facility to chase outstanding invoices through a mixture of methods such as phone call, email and letter, and a system to collect payments from selfpay patients via a range of payment options including card payments. At MBC, we have the facility to collect money 24/7 through our online payment portal.
I often see practices being run on a mixture of spreadsheets and word processing documents, sometimes combined with folders stuffed with paper copies of clinic and theatre lists.
To make matters worse, these software programmes are being run on laptops and PCs that are never backed up. So if the device is either lost or the software becomes corrupt, then the entire practice
Ensure your financial infrastructure is robust, auditable, secure and backed-up. The financial consequences of not doing this do not bear thinking about and if you are ever investigated by the HM Revenue and Customs, it could get even worse
See that your practice is not too dependent upon one person. No matter what business you are in, it is not good practice to rely on a key member of staff
Understand your billing and know what your debt is at any given time. Establish how much you are owed, how old the debt is and make plans to resolve it. Do not ignore the problem.
Whatever the size of your private practice, take the opportunity to review it based on the challenges outlined and take action promptly or it may be something you regret not doing
Alternatively, outsource your medical billing and collection through a professional organisation which will take care of each of the above challenges in one stroke
data, including its financial information, is put at risk.
It does not matter about the size of the private practice. If the consultant does not have the correct infrastructure in place to support the financial aspects of private practice, then this needs to be addressed immediately because every day that passes, they are placing their income at greater risk.
Once a practice becomes established, the next key challenge is to appoint the right secretary to assist the consultant in growing the practice. The medical secretary is the bedrock of any successful practice and is often the busiest person.
Medical secretaries are expected to wear many hats, including receptionist, personal assistant, sales ledger clerk, insurance guru, credit controller and debt collector.
Few individuals have the combined skill set required to complete all these tasks perfectly as well as find the time to fit them all into a working week. The explosion in email and other digital methods of communication from patients means they are often just running to keep up.
That is why it is an almost
We regularly see examples in private practice of bad debt between 5% and 10%
collection to experts. This ensures practice finances are in good order with the added benefit that the secretary has more time to look after the other elements of running the practice.
It also is good to split the medical and business side of the practice, so that the conversations with patients are compartmentalised, leaving the secretary to manage the patient’s clinical needs. Then, if the secretary leaves, the replacement process will be less stressful and from a financial perspective will have minimal impact.
impossible task for one person to cope with, especially as the practice grows. In our experience, once the practice reaches a certain size, the secretary is so busy dealing with the patients and the medical side of the practice that the billing and collection is the area that often gets neglected.
When a good secretary has been with the practice for some time, they can appear to have everything under control. But if they leave or retire, then the impact on the practice can be devastating, particularly financially.
Unfortunately, this tends to become apparent only later when the practice starts suffering from poor cash flow because the billing and collection is behind or, even worse, invoices are not raised correctly, resulting in a loss of income.
The consultant often thinks the new secretary can cope in the same way as the previous one, but, in our experience, this is rarely the case.
In general business, it is not a good idea to be reliant upon one key individual. ‘Key person dependency risk’ in medical practice is mostly unavoidable, as most consultants are sole practitioners.
A good solution can be to outsource the medical billing and
If you have the above areas under control, then probably the biggest challenge is to ensure correct billing and keeping the outstanding debt under control. Few practices achieve this feat consistently. I still regularly come across practices that either are making mistakes with their invoicing or are underbilling.
But probably the most common issue I find when talking to consultants is that they do not know how much they are owed or how old the debt is. You cannot begin to tackle a problem if you have no visibility about its size and scope or, even worse, do not know you have a problem.
Ensuring that you have up todate accurate information around outstanding debt is vital. We provide our clients with 24/7 access to their practice data, which allows them to run an array of reporting, including a report detailing their outstanding debt.
Once you have visibility on your aged debt, it is important to ensure you put in place robust procedures for chasing and collecting outstanding bills. Procedures are only effective if routinely followed –and that is rare.
All these elements are controlled if the medical billing and collection is outsourced. It means a strong and consistent cash flow and alleviates much stress when it comes to paying HM Revenue and Customs. Most problems can be resolved if decisive action is taken once the financial problems appear.
Simon Brignall is director of business development at Medical Billing and Collection
Two recommendations could lead to far more information being published about individual practitioners’ areas of clinical accreditation and financial interests. Michael Rourke (right) reports
INDEPENDENT MEDICINES and medical devices’ safety were examined in a report First Do No Harm in July by Baroness Cumberlege.
In a letter to the Health Secretary accompanying the review document, her overall conclusions are summarised bluntly: ‘The healthcare system – in which I include the NHS, private providers, the regulators and professional bodies, pharmaceutical and devices manufacturers and policy-makers . . . is disjointed, siloed, unresponsive and defensive.’
This report, coming so soon after the publication of the Paterson Inquiry earlier this year, has highlighted a number of failings in healthcare.
While it will be for the Government to determine what, if any, steps to take, these two publications together with the repercussions from the Covid-19 pandemic, may place healthcare reform –both NHS and private – higher on the agenda than usual.
The review was asked to investigate what had happened in England in respect of two medications and a medical device: hormone pregnancy tests, sodium valproate and pelvic mesh implants.
The review considered that the system cannot be relied upon to identify and respond promptly to safety concerns.
While acknowledging that innovation in medical care ‘has done wonderful things’, the review has concluded that ‘innovation without comprehensive pre-market testing and post-marketing surveillance and monitoring of outcomes is, quite simply, dangerous’.
It highlighted that for the interventions it was reviewing, the system simply could not answer how many women who had been treated or affected have had negative outcomes.
Two recommendations could lead to far more information being published about individual practitioners’ areas of clinical accreditation and financial interests.
As the report acknowledges, these are three disparate interventions governed under two separate product regulatory frameworks.
The review expressly did not cover other medications or devices where concerns had been raised –although it states that the list is long. Notwithstanding this, the conclusions of the report clearly apply more broadly than these three treatments and potentially to the other UK jurisdictions.
The review is long and detailed, amounting to 267 pages, including 12 appendices and a further 12 annexes. It is not an easy read for anyone involved in healthcare.
It includes 12 ‘themes’ and accompanying actions for improvement alongside nine recommendations for the Government.
The report is aimed at the Government and introducing systemic changes to improve patient safety. If implemented, the changes could well be widespread.
In the longer term, the recommendations such as to overhaul the Yellow Card and improve datagathering systems can only be welcomed.
(GMP) requirements which chime these recommendations.
GMP requires you to ‘recognise and work within the limits of your competence’ and to ‘take prompt action if you think that patient safety, dignity or comfort is or may be seriously compromised’.
This includes reporting colleagues who may be unfit to practise. While a more easily accessible register may increase knowledge about accreditations, it is fundamental practitioners should not endanger patients by practising in areas outside of their competence.
Recommendation 7 concerns the creation of a central database of implanted devices. Within the detail of this recommendation, the review notes that identifying individual clinician competencies is not presently an easy task.
The recommendation is that the GMC expands the details of registrations to include all doctors’ clinical interests and accreditations.
Recommendation 8 is that the GMC register should also include a list of all financial and non-pecuniary interests for all doctors, and mandatory reporting of all payments made by pharmaceutical and medical device industries to clinicians and others.
This recommendation was linked to Theme 7 of the review: Conflicts of interest – ‘we deserve to know’. This sets out the potential conflicts of interests of clinicians in practice, in the governance of panels reviewing safety issues –where participants may have interests – from manufacturers and in research.
Individual practitioners may, in future, be required to provide more details of treatments undertaken to a form of central database and have expanded details of practice accreditation and both financial and non-financial interests.
However, while these recommendations may or may not be implemented by the Government, practitioners will already be aware of their existing duties under the GMC’s Good Medical Practice
This is also linked to Theme 8 of the review (Holding to account –Guidelines and Quality). The recommendations from that theme apply to both NHS and private hospitals, emphasising that both should encourage clinical audit and have systems for monitoring quality at board level.
GMP requires practitioners to have honesty in financial dealings. This requirement forbids practitioners from allowing financial considerations to affect the way you treat, refer or commission services for patients.
Practitioners must be open about financial interests and declare these. Any inducement, gift or hospitality that may affect or be seen to affect the way you prescribe for, treat or refer patients or commission services for patients is also prohibited.
There are elements of the 12 themes which practitioners can consider now to improve their own practise. The most directly applicable to individual practitioners are found in themes 1, 2, 3, 5 and 6.
1: ‘No one is listening’ The review sets out that large numbers of the women interviewed about their experiences did not believe they had been listened to when describing their experiences to treating doctors.
In Hempsons’ experience, such experiences by patients can lead to complaints, even where there is no clinical wrong or legal complaint. Ensuring that patients are listened to and any clinical conclusions or recommendations clearly explained can reduce the risks of complaints or litigation.
Recommendation 8 is that the GMC register should also include a list of all financial and nonpecuniary interests for all doctors
THEME 2: ‘I’ll never forgive myself’ – Parents living with guilt
The review was, of course, looking at poor outcomes for children and this theme highlighted the guilt felt by parents for the harm caused unwittingly by them.
However, this theme, while rightly noting that the parents and women were not themselves at fault, again links to Theme 3 and consent.
THEME 3: ‘I was never told’
One of the most important themes from a medico-legal perspective is Theme 3 concerning informed consent. The law of informed consent is now set by the case of Montgomery v Lanarkshire Health Board.
We have previously written about this decision in ‘Keep It Legal – informed consent –Montgomery Five Years on’ (www.hempsons. co.uk/news-articles/keep-it-legalinformed-consent) and the importance of informed consent.
In summary, patients need:
To be given all the information they require to make a decision;
In a manner that they can understand;
The information should be tailored to the specific concerns of the individual patient;
Should include the options and risks of adverse outcomes;
If adverse outcomes are unknown, this should be explained to the patient.
Reviewing how you obtain consent to procedures, the information that you provide – and
ensuring that this includes information about alternative options and risks – and how you document what has been consented to is a key requirement in modern medicine. The last issue of recording work clearly, accurately and legibly is a requirement of GMP.
The review, however, calls the sheer variety of consent forms now in use as ‘bewildering and a major source of confusion’. The review indicates that, where appropriate and with the agreement of the patient and doctor, conversations about consent should be audio or video recorded.
In the longer term, the review has recommended that a single patient-decision aid should be produced for each surgical procedure or medical intervention and that NICE should take the lead on facilitating this. Pending this, a point to consider is whether, if you are using these forms, they are clear and appropriate.
The forms introduced in the wake of Montgomery could be refreshed and improved. Whether video or audio recording of con -
sultations will become commonplace will need to be seen. If this is to be undertaken, aside from the issue of consent, thought will need to be given to issues over the safe and secure storage of these to comply with data protection requirements.
THEME 5: ‘We do not know who to complain to’ –Complaints
This theme raises the issue that patients find navigating complaints systems for healthcare confusing and difficult. In both the private and NHS sector, there should be clear details of how to complain.
In the private sector, there are fewer avenues for complaint, but as noted under Theme 1, ensuring that patients are listened to, and complaints dealt with appropriately, can reduce the risk of complaints escalating.
For providers registered with the Care Quality Commission (CQC), having an effective complaints system is a regulatory requirement.
THEME 6: Duty of candour –Preventing future errors
The review notes that patients considered that there was a lack of open conversation when things had gone wrong.
The theme highlights that there is a professional duty of candour on practitioners, including a statutory duty for CQC-registered providers. The review highlights that identifying breaches of this, and enforcement of it, has not been ‘entirely effective’.
Linked to Theme 5 and Theme 1 above, listening to patients and dealing with patients concerns openly is likely to be a greater concern of regulators and employers in the future.
Themes 4 and 7 to 12 contain detailed and important comments and recommendations on the resolution of issues for the interventions considered and the systemic failures concerning patient safety.
Recommendations include wider data gathering – including registries and databases, a Patient Safety Commissioner, improved assurance processes and amending the regulatory approaches governing the Medicines and Healthcare Products Regulatory Authority.
It will need to be seen how these recommendations are taken forward, but on the back of two reports highlighting safety concerns in the private and NHS sectors, at least some of the recommendations are likely to be adopted.
Michael Rourke is a partner at Hempsons
Not all US stocks have gone up in 2020. Patrick Convey (below) explains why it is impossible to predict the markets
THIS YEAR has been a strange one so far for equity investors; the early gains of global equity markets in the first couple of months turned into material – and rapid falls – in all equity markets.
Yet, as we sit here in the early days of Autumn, global markets are more or less back where they were at the start of the year, although the UK is a laggard. Thank goodness for diversification.
Across the Pond, the US market has rebounded strongly and the tech stocks such as Apple, Google, Amazon and the electric vehicle firm Tesla have appeared to defy gravity.
Hands up all who wish they owned more US tech stocks?
Sometimes the disconnect between what is happening in the economy and what is happening on Wall Street is hard to reconcile in one’s mind.
However, we need to remember that the market looks well beyond our current challenges and discounts all future earnings into prices.
To those who believe markets work, this represents the best guess of the value of a company today, given the information we have available to us.
To others, it may feel like ‘bubble’ territory – rapid escalation
before it bursts – and a big momentum play into a few companies getting lots of media attention and investor dollars.
An estimating process
We also need to remember that trading in the markets – buying Apple – is not as simple as saying that Apple is a good company, so the price should go up. It is rather a process of estimating whether the market has over- or underpriced just how good Apple is.
Did Apple’s market value double from US$1 trillion in August 2018 to $2 trillion in August 2020 because the discounted earnings were expected to be far larger than the market thought or are we in bubble territory?
If you are hoping for an answer, then you will be disappointed; no one really knows.
If we look beyond these gravitydefying stocks, we see that the returns from the vast majority of
Do we know what happens next with any certainty? Let us be honest – we do not know, you do not know and nor do any professional fund managers
US companies is less than stellar, perhaps reflecting more closely how many feel about the current economic environment.
In fact, 335 stocks in the S&P 500 – the stock market index that measures the performance of 500 large companies listed on US stock exchanges – sit below the market average for the year of around 12%. Half of all stocks have actually lost money, although maybe some of them will be future winners. Fortunately, if you are a systematic, long-term investor, you will
have avoided the full brunt of the UK’s woes and picked up some of the benefits of owning US tech stocks.
Could we have predicted this outcome? Do we know what happens next with any certainty? Let us be honest – we do not know, you do not know and nor do any professional fund managers.
All we can really do is to remain well diversified, try to avoid the feelings of wishing we had more in the US tech stocks and be patient. Investing using the rear-view mirror is never advisable.
If history tells us anything, it is that today’s winners are rarely tomorrow’s winners.
With a longer-term perspective and a disciplined approach, we can sit back confident in the fact that we will participate in tomorrow’s winners as we own them today, somewhere in our richly diversified portfolios.
Patrick Convey is technical director of Cavendish Medical, specialist financial planners helping 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.
Independent Practitioner Today has joined forces with leading healthcare lawyers Hempsons to offer readers a free legal advice service.
We aim to help you navigate the ever more complex legal and regulatory issues involved in running and developing your private practice – and your lives.
Hempsons’ specialist lawyers have a long track-record of advising doctors – and an unrivalled understanding of the healthcare system as a whole.
Call Hempsons on 020 7839 0278 between 9am and 5pm Monday to Friday for your ten minutes’ of free legal advice.
Advice is available on:
Business structures (including partnerships)
Commercial contracts
Disputes and litigation
HR/employment
Premises
Regulatory requirements and investigations
Michael Rourke Tania Francis m.rourke@hempsons.co.uk
A patient who wants a consultant’s letter excusing him from wearing a face covering raises a number of issues, tackled here by Dr Ellie Mein (right)
QI am a private respiratory consultant who recently had a request from one of my patients with sleep apnoea. The patient had sent an email and called my secretary several times to ask for an urgent letter stating that, due to his underlying condition, he was unable to wear a face covering at work.
In one of his emails, he stated that his workplace was insisting he wear a facemask despite his explanation that he was exempt, as he had a breathing problem.
I feel uncomfortable about writing such a letter, as I do not feel the patient’s condition prevented the use of a face covering. What should I do?
AAs I write, face coverings are compulsory on public transport, in shops, supermarkets, shopping centres, takeaways, transport hubs, banks and a significant number of other settings, including museums, galleries, cinemas, hair and beauty salons and places of worship.
As a result, doctors are receiving an increasing number of requests for letters excusing patients from wearing them.
In addition to those environments where face masks are mandatory, the Government strongly encourages the wearing of face masks in other enclosed public spaces where social distancing might be difficult. Many of the requests come from people who are expected by their employers to wear masks to prevent the spread of Coronavirus in the workplace.
The reasons for such requests vary from patients having one of the legitimate reasons listed in the government guidance to patients with no co-morbidities reporting
they feel faint or short of breath if they cover their nose and mouth: ‘Face coverings: when to wear one and how to make your own’ .
As the list of indoor settings where face mask use is mandatory has grown, so too has the list of circumstances when people might not need to wear a face mask including:
Children under 11 years of age;
If you have a physical or mental illness or impairment, or a disability that means you cannot put on, wear or remove a face covering; Employees of indoor settings or transport workers;
Police officers and other emergency workers, given that this may interfere with their ability to serve the public;
If putting on, wearing or removing a face covering would cause you severe distress;
If you are with, or providing assistance to, someone who relies on lip reading to communicate;
To avoid harm or injury, or the risk of harm or injury, to yourself or others – including if it would negatively impact on your ability to exercise or participate in a strenuous activity.
There is also a list of when it is acceptable to remove a face mask indoors such as to eat or drink; take medication; or for identification purposes, among others.
With regard to face coverings in the workplace, there is no overarching guidance for workplaces due to the variation between different work environments and industries. But there are 14 guides available from The Depart ment for Business, Energy and Industrial Strategy which advise on how to make workplaces secure.
These guides address different types of work environments, recognising that some employers will need to rely on several of the guides to cover different types of workplace within their organisation.
The majority of these guides currently conclude that ‘face coverings
are not a replacement for the other ways of managing risk, including minimising time spent in contact, using fixed teams and partnering for close-up work, and increasing hand and surface washing.
‘These other measures remain the best ways of managing risk in the workplace and the Government would therefore not expect to see employers relying on face coverings as risk management for the purpose of their health and safety assessments.’
It’s in the guidance
For clarification, the current Government guidance contains confirmation that ‘no person needs to seek advice or request a letter from a medical professional about their reason for not wearing a face covering’.
So if the patient’s request relates to a letter for their workplace, they can be directed to the guidance specific to their industry as mentioned above. It is then for them to discuss with their employer and occupational health department how best to resolve a difference of opinion on this subject.
If the request relates to not using face masks on public transport or other indoor settings, they can be reassured that they are able to selfdeclare their legitimate reason.
Of course, if the legitimacy of their reason is challenged, they may require evidence of their condition. It is possible that at this point doctors would be asked for a brief letter or an excerpt of their notes to confirm the relevant diagnosis.
In this scenario, we would advise that any letter simply states the diagnosis the patient relied on without an opinion on how this might prevent face covering use.
The GMC is clear in Good Medical Practice (2013) that doctors must recognise and work within the limits of their competence. As such, doctors will need to be aware that if they offer an opinion that a medical condition prevents covering the face, they may be asked to justify their expertise in face coverings and their impact on various diagnoses.
In short, there is no reason for doctors to produce letters to explain why a patient should be exempt from wearing a face covering.
Dr Ellie Mein is a medico-legal adviser with the MDU
private psychiatrist is asked not to disclose information to a patient’s GP. Dr Kathryn Leask (right) gives advice
QI am a private psychiatrist and have been seeing a patient with ongoing mild to moderate symptoms of anxiety and depression. The patient was referred by her GP, at the patient’s request, following her marriage breakdown. She was not reported to have any other significant psychiatric history.
During the consultation I noticed that the patient had palmar erythema and a number of spider naevi, both of which she said had developed over the last six months to a year. I asked her about her physical health and about alcohol and drug use, both of which she denied.
I discussed my concerns about the physical signs I had noticed and that I felt that some investigations were necessary in case there was an underlying cause that needed treatment. I said I would write to her GP to let them know so that relevant investigations could be arranged.
The patient specifically asked me not to mention this in my letter to her GP. I explained that this could negatively impact on her health and her future care, however, she remained adamant that she did not want me to share this information.
Should I go ahead and share this with the GP?
AYou have been placed in a difficult position and you have understandable concerns about not providing the GP with clinical information important to the patient’s future health. In its guidance Confidentiality (2017), the GMC set out a doctor’s obligations when a patient objects to their personal information being shared in relation to their own care.
Where a patient with capacity to
make their own decisions objects, for example, to information being disclosed to their GP, you should not disclose unless it would be justified in the public interest. But if a patient was to lack capacity to make decisions for themselves, you would need to consider what was in their best interests.
The guidance says you should explain to the patient the potential consequences of their decision not to allow personal information to be shared with others providing care. It may be possible to reach a compromise with the patient. If, after discussion, a patient who has capacity to make the decision still
objects to the disclosure, you should respect this and make it clear to them that they can change their mind at any time.
It is important to carefully document your clinical findings –and your assessment of the patient’s capacity to make a decision about the sharing of her clinical information. You should also document the nature of the discussion you had with her with regards to the consequences to her future health of her not allowing you to disclose the information to her GP.
Dr Kathryn Leask is a medico-legal adviser with the MDU
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A PRIVATE PRACTICE – Our series for doctors embarking on the independent journey
Trading as a limited company for your private practice has been a popular choice for many years and increasingly so following the introduction of the tapering of the pension annual allowance.
Ian Tongue explores options to extract the funds from your company in a tax-efficient manner
AN IMPORTANT factor to understand when trading as a company is that it is a separate legal entity from you personally.
This means that the company has to produce accounts separately from you, file a tax return and pay corporate taxes. You will have two relationships with your company: firstly as an owner (shareholder) and secondly as a director (officer).
One of the key advantages of trading as a company is the flexibility that it offers for the extraction of profits.
It is the control over the extraction of the profits which allows you to decide how much taxable income you have to declare on your personal tax return.
Accessing the funds for your dayto-day needs and ensuring that this is tax-efficient are key considerations. Your circumstances will be different to others and therefore a tailored strategy is the best option. Your accountant should discuss this with you and make sure that you keep them updated on your personal circumstances.
As a director of the company, you can receive a salary for your services. A salary is treated as an expense of the company and is tax-deductible.
Most consultants do not pay a salary due to already having an NHS salary, but, for those who are fully private, it is important to be paying a salary at a level at or above the National Insurance threshold to ensure that you continue to accrue years for your state pension.
For those where a spouse is involved in the business, it is common to pay them a salary provided that it is tax-efficient to do so. If your spouse has no other earnings, it is important that the salary is set at a tax-efficient level.
For those with older children, if you can get them involved in the
One of the key advantages of trading as a company is the flexibility that it offers for the extraction of profits
business, they could also receive a salary from the company. As with paying a spouse, it is important that the salary paid is commensurate with their services provided. Depending on the level of salary paid and whether the employee(s) have other earnings, you may need to operate a PAYE scheme. Your accountant should be able to advise you further based on your individual circumstances.
A dividend is a distribution of profit from the company to its shareholders (owners) and is therefore paid from the taxed profits of the company – that is to say, the dividend paid is not taxdeductible.
The recipient of the dividend declares this as income on their personal tax return and the appropriate level of income tax is paid. It is important to note that while dividends are subject to income tax, the rate of income tax paid is lower than self-employed or employment tax rates.
It can be confusing to understand the tax rates when you have the company paying corporation tax, currently at 19% of profits, and personal income tax on the dividend paid. It is tempting to add them together to work out the overall level of tax, but this would be incorrect.
The current income tax rate payable together with the effective rate of tax when taking into account the corporation tax is shown in the box below
As can be seen from the above, for those needing to extract all of
the profits, the tax efficiency of the company will depend on how much can be extracted at the lower tax rates, as the effective rate of tax in the higher and additional rate bands are in the region of three per cent higher. Your accountant should assess your circumstances and advise you on the optimum strategy for you.
Not everyone needs to take all of the money out of the company and when this happens, the funds – retained earnings – start to build up.
For those in this position, they should be able to work on a strategy to liquidate their company upon retirement and pay capital gains tax on the funds distributed rather than income tax.
Provided that the various criteria are met, this strategy can be very effective, as you may only have to pay 10% tax on the distribution of funds at the end.
This strategy requires planning and therefore you should discuss your individual circumstances with your accountant if you are considering this option.
If you would like the benefit of using the company’s money but do not want to take a salary or dividend, you could consider a loan from the company.
Loans to directors are tax-sensitive and it is important to understand the implications.
If a company lends money to a director or employee, you have to consider the impact for the recipient and the company itself.
From the recipient’s perspective, if the loan carries less than HM Revenue and Custom’s standard interest rate, currently 2.5%, a benefit in kind arises and income tax is paid on the element of interest not paid. If interest is applied to the loan, no benefit in kind will arise. Additionally, if the loan is less than £10,000, no beneficial loan arises even if interest is not charged.
From the company’s perspective, the loan is reported on the company tax return and if the loan is not repaid by the time the corporation tax for that period is paid (nine months), an additional amount of tax is payable by the company.
This is not an additional tax on profits and is effectively a holding tax which is repayable when the loan is eventually repaid. The tax is charged at 32.5% of the loan, which is no coincidence that this is the income tax dividend tax rate.
Often, taking loans can be useful in the short term, but in the longer term it can be problematic and careful planning is required.
For the consultant, it is unlikely that you will have capacity to pay more into pensions if you have remained an active member of the NHS Pension Scheme. However, spouses who are usually directors in the company often have capacity to pay into pensions.
Therefore, you could consider making a pension contribution from the company as part of a director’s remuneration package. Provided that the overall package of salary and dividends is reasonable, tax relief is available on the contribution made.
Aside from extracting profits and paying expenses personally, it is possible for the company to provide other benefits to the directors or employees. This can be a good way to make the company’s funds work well for you, particularly if you are trying to restrict how much you extract by way of profits from the company.
A popular choice is a company car now that electric vehicles have been given very favourable tax treatment. Other benefits such as health insurance may not save tax overall but can be beneficial from a cash flow perspective.
Extracting profits from your company can be a challenge and create a mindset of having to pay a lot of tax when doing so.
However, there are strategies to minimise the tax payable and these should be discussed with your accountant and tailored to your individual circumstances. Next month: Working in groups
Ian Tongue (right) is a partner at Sandison Easson accountants
Put back the smile on your face with a drive in this. It certainly worked for our grinning motoring correspondent Dr Tony Rimmer (right)
WITH THE essential travel restrictions imposed on all of us during recent times, it has become apparent to us medics who enjoy cars and driving just how much we have missed a good drive on a great road just for the sake of it.
It can be fun and stimulating and there is no doubt that many of us would benefit from the positive therapeutic effects to combat work stresses.
However, the realities of family life dictate that few of us can afford the luxury of an impractical sports car in addition to a family car, so we seek out cars that can operate in a dual-purpose way.
This, of course, was the reason why the market for the ‘hot hatch’ took off massively after Volkswagen released the original Golf GTI to the world in 1975. Nowadays, every major manufacturer has a sporty variant of its big-selling family hatchback in its line-up.
Hot hatch
Surprisingly Honda , despite being heavily involved in Formula One since 1964, were late to the game. Their first sporty Civic called the Type R was released in 1997.
Although the early cars were not really serious competitors to European rivals, we are now on the
fifth generation and the current car has serious ambitions to be the best hot hatch available.
Before we go any further, I must address the elephant in the room.
The styling of the Type R with its additional spoilers and large rear wing is something you will either love or hate.
The standard Civic is already a very angular design and the bodywork addenda give an overtly aggressive and perhaps ‘boy racer’ look to the car. In my view, making an instant judgement would be a great shame because many medics may dismiss it without experiencing its positive attributes.
Based on the very practical and useful five-door Civic body, the Type R has a 2.0 litre four-cylinder turbocharged engine that produces 320bhp, front-wheel drive, sophisticated sports suspension and is only available with a manual six-speed gearbox.
As with most Japanese cars, it has a very high-standard specification, so there are only two trim options – the £32,320 Standard and the £34,320 GT. The GT model adds zoned climate control, parking sensors and a better sat-nav system.
The driver and front-seat passenger are treated to really comfortable and supportive sports seats and the driving position is excellent
Sitting on the standard 20-inch sports alloys, the Type R looks low and fast even at a standstill. Honda claims that all the additional bodywork features have real aerodynamic benefit and, with a potential top speed of 169 mph, I have no reason to doubt them.
The driver and front-seat passenger are treated to really comfortable and supportive sports seats, the driving position is excellent and the steering wheel has a thick leather rim.
The rear seats are roomy enough for two adults with three at a squeeze and the boot is as large as in any family hatchback.
I was itching to get my test car on the road and as I took off, it became very quickly apparent that I was not going to be disappointed. The response from the throttle, the positivity of the gearbox and the feedback from the steering is really top notch.
What I was not expecting was the quality of the ride.
The standard adaptive dampers allow three variants: Comfort, Sport and Plus-R. The default is Sport mode, but flip it into comfort and, although still firm, the ride is as comfortable and controlled as any normal hatchback.
On my favourite twisty A and B roads, the Type R displayed an agility and pace that would impress any Porsche driver. The fact that it does this with such composure is enough to bring a smile to any keen driver’s face.
Although modern paddle-shifting dual-clutch gearboxes are almost faultless, you still cannot beat selecting each ratio by hand using a manual box on a great road.
Also, and cleverly, Honda has successfully minimised torquesteer; a feature of many powerful front-wheel drive cars.
I had a wide grin after every drive in the Type R and it boosts the mood like very few modern cars can.
As a daily drive for any keen independent practitioner, it hits the bullseye. A Golf GTI may be more understated, but it is no better to drive and is more expensive.
I completely understand if the styling is too much for some, but my advice would be to ignore the extra body kit and just try the Type R on the road.
I guarantee that you will be impressed.
Dr Tony Rimmer is a former NHS GP practising in Guildford, Surrey
HONDA CIVIC TYPE R
2.0 vtec turbo
A Golf GTI may be more understated, but it is no better to drive and is more expensive
Body: Five-door hatchback
Engine: 2.0 litre four-cylinder turbo-petrol
Power: 320bhp
Torque: 400Nm
Top speed: 169mph
Acceleration: 0-60mph in 5.7 seconds
WLTP combined economy: 33.2mpg
CO2 emissions: 178g/km
On-the-road price: £32,320
Consultants must now either help evolve the changes they see in private practice, brought about by Covid-19, or look for other ways to supplement their income. Prof Gordon Wishart (left) and Philip Housden (right) analyse some interesting possibilities for the ‘stayers’
AGAINST A BACKGROUND trend of increasing costs to run a private practice, and with more resources required to comply with clinical and information governance, many consultants are considering whether it is worth restarting. Their decision may be influenced by the recent renewed rise in Coronavirus cases and the uncertainty about how long nonCovid clinical services will continue to be disrupted.
For those who perform surgery or other invasive procedures for private patients, the requirement for additional hygiene measures and PPE will result in decreased productivity that will challenge the previous level of reimbursement per unit of time in the independent sector.
With a massive backlog of NHS patients requiring diagnosis and treatment during the next few years, many consultants with a busy NHS trust post may find they have less time to devote to private practice as they struggle to balance other commitments with research, service development and their family.
For many more newly appointed consultants, and those with smaller practices, these additional restrictions and safety measures will perhaps be a step too far and they choose to discontinue their private practice.
Many will be tempted by other
options – including medico-legal work or consultancy/advisory roles in pharmaceutical and healthcare companies or the regulatory healthcare bodies – to augment their earnings without the significant additional costs of private practice management.
This trend could lead to offers of alternative part-time contracts to work for independent sector hospital groups. We believe these could become a viable career move in England for the first time, and not just for a very few in central London.
This may appeal to more senior consultants, many of whom already take early retirement to access their pension then return to a reduced-hours NHS contract, and also to junior consultants at the beginning of their careers.
Estimates predict NHS waiting lists will reach 10m patients by the end of 2020, so the service will be unable to manage the backlog without significant independent sector help.
With £10bn of NHS contracts now being let for the next four years and an overall shortage of doctors in the UK, there has never been a better time for consultants
to change their working practice to take advantage of opportunities.
For private hospitals, there is now a period of guaranteed funding to allow a review of how healthcare is delivered in the independent sector.
There is an opportunity to consider whether to employ consultants directly or to employ subconsultant grades to allow consultants to focus on income generating services and – for some – to focus on increased specialisation.
For anaesthetists and consultants in specialties suited to waiting list initiatives, such as orthopaedics, general surgery or ENT, the prospect of additional work covered by crown indemnity may be more attractive than a return to their own private practice.
And, for many NHS hospitals, this may also be the time to review the present closure of private capacity and consider launching or exp anding a private patient unit on their NHS campus.
For the NHS trust, this secures additional revenues at a time when budgets are less flexed with activity.
A more flexible approach to NHS and private activity within a trust contract may also be more attractive than traditional private practice for some consultants.
So what will be the major challenges postlockdown for those doctors who decide to return to private practice in local independent hospitals, and how can they be mitigated?
They will have to get used to additional pre-operative assessments that may include Covid-19 antigen testing and temperature/ symptom screening, and decreased productivity in the operating theatre.
Consultants may require regular testing themselves to ensure a Covid-light environment is maintained. Outpatient consultations may continue to be by phone or video for a considerable time, which will prove more difficult for certain specialties such as cancer diagnosis.
While none of us can predict when the pandemic will end, it is likely that an effect of Covid-19 will be to accelerate a change forever in the way independent healthcare is delivered.
During lockdown, consultants have already been exposed to remote phone or video consultations and an increasing reliance on digital healthcare. There is now increased Government funding to accelerate this digital healthcare revolution and they will need to embrace this challenge in the independent sector.
Moreover, with the planned investment of £10bn of NHS activity with the independent sector during the next four years, many consultants could be attracted to working two to three days weekly in the NHS, with the remainder in an independent hospital group.
This would, by default, introduce an Australian-type system where a consultant’s time is more evenly split between public and independent sectors.
This change, however, will require UK independent hospital groups to consider employing consultants directly, either part-time or full-time, in a similar way to London’s Schoen Clinic and the planned Cleveland Clinic.
A second obstacle to a return to private practice is whether insured patients will be able to access private hospitals that may also have
many NHS inpatients and outpatients.
Without that core insured business, there is likely to be a major drop in profitability that will not be compensated by a likely increase in self-funding patients.
Lack of access to private hospitals for private patients may result in a reduction in the number of patients who have private medical insurance or insurers adjusting their policies to better suit the new healthcare landscape.
It seems likely that insurers will continue to drive a policy of working with a smaller number of consultants in each specialty, or consultant partnerships who can deliver a certain level of clinical service for an agreed price, with the intention of this also driving up quality.
In fact, AXA PPP Healthcare successfully utilised these consultants and partnerships to help triage insured members to access urgent services during lockdown and this pattern seems likely to continue as insurers move towards a strategy that will deliver value-based healthcare.
So, what is value-based healthcare and what can consultants do to make their private practice more attractive to insurers?
Increased demand for audit and outcome data
Value-based healthcare is the equitable, sustainable and transparent use of available resources to achieve better outcomes and experiences for every person.
So insurers will be looking for evidence from private practitioners of better clinical outcomes by use of clinical audit, patientreported outcome measures (PROMs) and, for cancer treatment, outcome measures such as local recurrence and survival data.
Collecting this type of data can be time-consuming and expensive for sole practitioners, which may on its own be a good reason to consider joining a partnership where these costs are shared. An alternative would be to work with a referral partner who collects audit data on behalf of consultants.
As an example, Check4Cancer manages and audits diagnostic pathways for breast, skin and pros-
it is likely that an effect of Covid19 will be to accelerate a change forever in the way independent healthcare is delivered
tate cancer and plans to expand the audit process to capture the final treatment summary and fiveyear outcome data in its breast cancer pathway.
It was able to provide face-toface consultations for patients in all three pathways throughout lockdown by close collaboration with insurers and consultants.
The increased engagement and the ability to refer patients during lockdown has led to additional consultants applying to join the breast network. But they will have to comply with rigorous criteria established by the company, including membership of the Association of Breast Surgery, running a one-stop breast clinic with a radiologist present, core biopsybased diagnosis, pathology results within five working days and no ultrasound screening.
This type of approach, with rapidaccess best practice and streamlined pathways, could be extended to other non-cancer specialities.
In recent years, development of private cancer treatment centres has provided the opportunity for surgeons and oncologists to invest in purpose-built facilities providing cancer diagnostics, radiotherapy and chemotherapy. This approach, pioneered by Cancer Partners UK, has been successfully continued by Genesis Care since acquisition.
The initial investment for consultants can seem high, but the returns can be large, and many consultants and consultant partnerships have chosen this route to increase their annual revenues from private practice by directing patients to their own centre.
Indeed, the partnership approach has been particularly successful in central London with the Fortius and One Welbeck clin-
ics, the latter providing access to consultants in gastroenterology, endocrinology and orthopaedics.
The Covid pandemic and the healthcare system’s response to it has initiated and accelerated a change in the delivery of healthcare in the UK and is likely to bring about lasting changes for consultants, UK insurers and independent sector providers.
Many of these changes will benefit patients, with increased use of video or phone consultations by private GPs and consultants, greater use of digital healthcare and AI clinical developments and access to streamlined pathways for diagnosis and treatment.
Insurers will be looking to work with smaller numbers of consultants and consultant partnerships who can deliver value-based healthcare to achieve better outcomes and experiences for every person.
Consultants will therefore be expected to collect much more outcome data, PROMs and patient feedback and this will require increased administrative support and entail additional costs.
The private hospital groups can see this as an opportunity to change the way they work, with direct employment of consultants on a part-time or full-time basis and increasing subspecialisation in specific hospitals rather than trying to provide all services in every network hospital.
They will also face the challenge of balancing the management of both private and NHS patients in the foreseeable future and perhaps beyond.
What is certain, however, is that private practice is already changing from the traditional approach that has persisted for decades.
Consultants must either embrace these changes, and get involved in directing how this should evolve or look for other ways to spend their time and supplement their income.
Prof Gordon Wishart is chief medical officer at Check4Cancer and visiting professor of cancer surgery at Anglia Ruskin School of Medicine. Philip Housden is managing director of Housden Group healthcare consultancy
New plans to train doctors in the independent sector are welcomed by Dr Howard Freeman (right), clinical director of the Independent Healthcare Providers Network
THE CORONAVIRUS pandemic has undoubtedly transformed relations between the NHS and independent healthcare sector and those that work in it, and indeed has shed a light more broadly on how the two sectors work together.
Due to Covid, there has been excellent partnership working that has taken place over the last few months, enabling hun-
dreds of thousands of NHS patients to access the urgent care they need in independent sector hospitals.
Worthwhile ambition Covid-19 has also provided real impetus to resolving a key issue that the health system has been grappling with for a number of years – how to ensure that independent healthcare providers
are able to play their part in training the next generation of medical professionals.
While a significant number of private hospitals already support the education of junior doctors, the sector, along with other key bodies such as the Royal College of Surgeons, have long been calling for there to be widespread provision of training in the independent sector.
And with whole NHS teams transferring across to their neighbouring independent hospitals to deliver services throughout the pandemic, what has been a longstanding worthwhile ambition for the sector to host trainees has now become a necessity.
This ambition has also been helped by the Care Quality
Junior doctors will hugely benefit from these new opportunities
Commission (CQC) implementing a new fast-track process for granting practising privileges for those clinicians who do not work in the independent sector.
Undertaking a significant programme of work alongside the Independent Healthcare Providers Network (IHPN) and the relevant deaneries, NHS England-Improvement and Health Education England have recently published an agreed set of principles and guidance to increase training in the independent sector for those providers under the national agreement with the NHS. And the deal allows opportunities for this to be
• Completely open scanner that is well tolerated by claustrophobic patients
• Weight-bearing scans for spine and joints enable a more precise diagnosis
• Patients who are large or cannot lie down can be accommodated
extended further into the sector in the coming year.
These key principles will ensure junior doctors get the highest possible standard of training and includes the need for trainees to always be supervised by a consultant who is a recognised clinical or educational supervisor in the NHS.
The agreed principles also ensure that training will be open to trainees regardless of level, including core trainees, with appropriate levels of supervision, tailored to meet their needs.
NHS indemnity must also be in place for the doctor in training to work in the independent sector site for the NHS work undertaken.
With over 80% of independent sector hospitals rated as good or outstanding by the CQC, junior doctors will hugely benefit from these new opportunities, and allow them to see the benefits of working in the independent sector and the high-quality care they provide to patients.
Indeed, where the supervision of trainees has been piloted in a number of independent sector hospitals, the experience has proved incredibly positive for all those involved.
Junior doctors have had the chance to treat patients with a
wide range of conditions, providing not only an essential practical experience for the trainees but also the chance to learn about teamwork, management and the broader culture of healthcare in independent hospitals.
More broadly, the opening up of training in the independent sector reflects the welcome move towards taking a more ‘system-wide’ approach to key clinical workforce and safety issues.
In just the last few years, independent providers have rightly been brought into the fold around key safety initiatives, with barriers broken down to enable independent providers to submit data – for example, to the National Reporting and Learning System and its successors – as well as launching a new pilot with Healthcare Quality Improvement Partnership to ensure private providers can contribute to national clinical audits.
With significant long-term pressures facing the health service and the need for highly skilled and adaptable clinicians like never before, it is right that, as part of this, the independent sector is able to play its role in training the next generation of clinicians who are so vital in keeping our nation safe and healthy.
Good
RESULTS OF our latest benchmark show that the gross private practice income of an average doctor in this specialty has increased by 4.5%, going up from £175,000 in 2017 to £183,000 in 2018.
Costs, on average, fell by £1,000 from £68,000 in 2017 to £67,000 in 2018. As a result, taxable profits rose by 8.4% from £107,000 to £116,000 – all in all, a creditable performance.
We have noticed continuing growth in self-pay in the ENT market. This growth is probably higher than in other sectors.
Self-pay growth is particularly
for non-urgent procedures where waiting times on the NHS are increasing.
Insurance company pressure on fees continued during the year, but perhaps to a lesser extent than in previous years where insurers were particularly aggressive.
Over the range, costs for a typical ENT practice have remained similar to 2017 levels.
Consulting room rental costs have risen for several consultants, reflecting higher levels of activity and increasing compliance with
AVERAGE INCOME AND EXPENDITURE OF A CONSULTANT ENT SURGEON WITH AN ESTABLISHED PRIVATE PRACTICE
We have noticed continuing growth in selfpay in the ENT market. This growth is probably higher than in other sectors
Competition and Markets Authority (CMA) rulings.
There has been some increase in professional indemnity costs. In a number of cases, this represented a ‘catch up’ of undeclarations in previous periods. We note that ENT surgeons, by and large, have remained loyal to their existing insurer rather than seeking possible cheaper alternatives in the market.
There was some decrease in phone costs and expenditure on courses and conferences, but this is not significant. Such expenditure does vary considerably from year to year.
Other costs – primarily marketing and IT – did show a reduction. As previously reported, most ENT surgeons who wish to acquire a website have by now already done so.
A preliminary peep at 2019 figures suggests that ENT surgeons have continued to do well.
The interesting observation will be how they have performed in 2020-21, given the impact of the Covid-19 virus to their businesses. There are interesting times ahead.
As readers will be aware, our sample of ENT consultants is not ➱ p50
Year ending 5 April. Figures rounded to nearest £1,000
Use
statistically significant but tries to take a view of what is happening in the marketplace with this particular discipline.
As established readers will know, our sample includes those who:
Have at least five years’ private practice experience;
Are seriously interested in pursuing private practice as a business;
Are earning at least £5,000 a year in the private sector;
Hold either a maximum parttime or a new consultant NHS contract;
May or may not have been incorporated or be a member of a group.
Readers will also know that, during the period we have been reporting our survey, there have been many structural changes in the industry.
There has, for example, been a growth in the number of consultants incorporating, a growth of groups – which tend to generate income enhancement, ongoing pressure from insurance companies, a growth in self-pay and perhaps some unforeseen effects of some of the CMA rulings on how consultants undertake their practices.
All these factors, and others, have affected our results and may lead to a distortion.
Next month: Orthopaedic surgeons
Ray Stanbridge is a partner with accountancy, finance and tax advisory medical specialists, Stanbridge Associates Limited
Orthopaedic surgeons
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Coming in our November issue:
The Coronavirus pandemic has resulted in a significant increase in seeing patients online. While video consultantions may be convenient and ease time pressures, Dr Sharmala Pranklin, deputy head of underwriting at the MDU, discusses how private practitioners can reduce the risks associated with remote consultations
A private psychiatrist asks for advice in our Business Dilemmas feature after being asked to attend an inquest remotely, using video. He has given evidence at an inquest before, in person, and has been carrying out video consultations with patients. But he feels uneasy about giving evidence to a court by this route
Lawyer and doctor Dr Tania Francis looks at new guidance the GMC has published for its staff to assess the risk posed by a doctor facing allegations of impaired fitness to practise in a clinical setting during the Covid-19 pandemic
Prompt payment. Good communication. Clear instructions. Plenty of notice of deadlines and court dates. Acknowledgement of work done. Constructive feedback. Is this how you would characterise your experience of working with lawyers? Caren Scott explains how a better understanding of what is involved in complex clinical negligence case management can help improve communication between medical experts and lawyers
We reveal the results of the second NHS PPU Barometer survey, an exclusive snapshot of performance providing valuable insights into the sector during Covid-19
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