December 2014-January 2015 by Healthcare Today

INDEPENDENT PRACTITIONER TODAY

The business magazine for doctors in private practice

In this issue

Paying for your care

Financial guidance on what you can do to help yourself and those whom you love P24

A prophet’s warning

A healthcare trouble-shooter gives his predictions for the sector in 2015 P34

Stop preSS: HM revenue and Customs agrees that consultants can trade as limited liability companies and sell goodwill.

Full details for subscribers only at www.independentpractitioner-today.co.uk

The tricks of the quacks

What the charlatan doctors of yore came up with to relieve the gullible of their money P44

Turmoil over ‘sell-offs’

By Robin Stride

Hospital group HCA enters 2015 unsure whether to crack the champagne or dig in for another costly battle to stop the Competition and Markets Auth ority (CMA) forcing it to sell two flagship London hospitals.

With the judgment of legal hearings awaited as Independent Practitioner Today went to press, it was anxious to give no official response to reports that The Wellington, The Platinum Medical Centre, London Bridge and Princess Grace hospitals were safe.

Hundreds of consultants were, however, assured at a Christmas party that the CMA had backed down and HCA, which has spent £3m£4m defending itself, would not have to sell any hospitals.

It is understood the CMA privately agreed it failed to follow statutory processes and made mathematical formula errors, which flawed the basis of its decision to try and force HCA to sell.

But a CMA spokesman said reports implying it was giving up on the HCA issue, part of its longrunning private healthcare investigation, were inaccurate. It was requesting the Competition Appeals Tribunal (CAT) – which meets to consider two other appeals on 19 January – to reconsider.

In a cagily worded statement,

In association with

the CMA, which has already dropped earlier plans to force selloffs by BMI and Spire, said: ‘It would not be appropriate for us to comment on or disclose the detail of confidential matters that are before the CAT.

‘We can, however, confirm that, in light of certain matters identified during the litigation and in order to ensure fairness to the parties, we have invited the CAT to remit these matters to the CMA so that the parties can have the opportunity to make further representations upon them to the CMA and for the CMA to consider those representations before final decisions are taken. None of this prejudges the ultimate outcome.’

The Federation of Independent Practitioner Organisations (FIPO), which is appealing to CAT over the CMA’s requirement on publication of consultant fees, declined to comment on the HCA issue, but said that a report suggesting the watchdog wrote to it on the subject was inaccurate.

Another appeal is scheduled at the same time from AXA PPP ( Independent Practitioner Today , June 2014).

If the fees requirement is upheld, then the CMA would expect it to be included in the existing timetable. It said that consultants were meanwhile ‘free to make such information available voluntarily’.

Roger Witcomb, CMA private healthcare investigation group chairman, said the information revolution would be ‘the most wide ranging and significant change to result from our investigation into this market’.

He claimed publicly accessible information would make it easier to compare providers and consultants and so increase competition on costs and performance to the benefit of paying patients.

But the CMA ruling that consultants can’t have an interest of more than 5% in a business to which they refer (Independent Practitioner Today, May and October 2014) is proving anticompetitive, accord

ing to evidence from a leading medical accountant.

Ray Stanbridge, giving a personal view, said he knew of 20 consultant owned businesses being sold to private hospitals –effectively the only real buyers around.

As many as 1,000 potential private doctors outside London were also now avoiding independent hospitals due to factors including the CMA’s drive to make them pay for rooms.

Mr Stanbridge added: ‘An attempt to promote competition and economic efficiency in the healthcare market looks like having the completely opposite effect.’

Data chief tries to reassure about accuracy of figures

The boss of the new data body appointed by the Com petition and Markets Auth ority to police publication of better information for private patients has tried to allay consultants’ fears about accuracy.

Private Healthcare Information Network (PHIN) chief Matt James said private doctors were being positive about the opportunity to better demonstrate their quality, but they had concerns about the accuracy of information and

how it will be produced and used.

But he promised: ‘We will work with consultants via their professional associations and hospital operators, taking a measured approach that will lead to the right outcome. We are confident that this will work well for consultants.’

PHIN, as expected, will have the job of ensuring patients can compare and choose between consultants and hospitals by 2017.

➱ continued on page 3

December 2014-January 2015

www.independent-practitioner-today.co.uk

my leap into a war film a surgeon recounts how an investment pitch turned him into a movie adviser P14

come clean when things go wrong next april, all doctors will be under a duty of candour to confess to mistakes P18

7 ways noT to reach your audience our marketing expert highlights 7 areas to be wary of when growing your firm P29

new law will backfire the medical innovation bill risks damaging the doctor-patient relationship P36

‘downsizing’ is really ‘rightsizing’ Financial advice on why asset-rich doctors may choose to move home P40

ethical matters for cancer specialists our ‘business Dilemmas’ series looks at two ethical issues involving cancer patients P42

Plus our regular columns starting a private practice: planning

ediTorial commenT

More or less competition?

Will the Competition and Markets Authority’s rulings actually reduce competition and innovation in the private medical sector? It is starting to look that way.

With HMRC finally conceding that consultants can trade as limited liability companies, and sell goodwill, there’s good cause for New Year celebrations among hundreds of our relieved readers and their accountants who had feared the worst.

But the CMA has put a damper on the party mood. And although it is early days, it now seems its private healthcare inquiry could end up discouraging many consultants from even

trying to set up a private business due to increasing hassle.

As we report on page 1, others are said to be in the process of selling their consultantowned businesses to the only buyers around – private hospitals.

Once these businesses are out of the way, hospitals can use their bargaining power to increase prices. It’s a scenario we’ve seen in the US.

We hear others are now looking to become business people rather than doctors. By owning a medical practice, and not referring patients themselves, they think they will avoid falling foul of CMA rulings.

Tell us your news Editorial director Robin Stride at robin@ip-today.co.uk

Phone: 07909 997340 @robinstride

To adverTise Contact advertising manager Margaret Floate at margifloate@btinternet.com Phone: 01483 824094

To subscribe lisa@marketingcentre.co.uk Phone 01752 312140

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

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

by a staff reporter

Tax and pension changes announced in the Chancellor’s Autumn Statement will bring a boost to thousands of senior doctors’ finances this year – but many on the move will be clobbered.

Stamp duty underwent an immediate overhaul at the beginning of December, meaning that, from now on, each tax band will be used only on the particular portion of the selling price of the property to which it applies – similar to the way income tax is calculated.

Previously, a set tax band was charged against the whole value of a property, meaning substantial hikes in tax between properties costing just a few pounds more.

While critics of the property tax have long argued that the former system was outdated, the sweeping changes will mean that senior doctors buying highend properties will face higher tax charges.

Houses valued above £937,500 will now incur more stamp duty than before. Most properties valued at less than this threshold will pay less.

Under the new rules, no tax will be paid on the first £125,000 of a property, followed by 2% on the portion up to £250,000, 5% on the portion between £250,000 and £925,000, 10% up to £1.5m and 12% above this figure.

Patrick Convey, technical director at specialist financial planners Cavendish Medical, said: ‘This surprise announcement from the Chancellor is in answer to a pro

posed mansion tax from opposition parties.

‘Doctors buying property in London and the Southeast may be paying significantly more in stamp duty.’

George Osborne announced further good news for ISAs, an increasingly popular investment avenue for doctors. Although the contribution limit will be only marginally increased to £15,240, new rules will allow partners to inherit the ISA of a deceased spouse and keep its taxfree status.

Mr Convey said: ‘As the taxfree status of ISAs can now be preserved after death, they could become as popular as private pension schemes to provide additional income in later life.’

Plans to abolish the death tax due on pensions were also confirmed and will now include those receiving annuity income.

Earlier statements had suggested this rule would only apply to those using income drawdown. Currently, pension pots are taxed at up to 55% on death depending on whether the pension has been drawn on.

But in future, when someone older than 75 dies, their heirs will pay income tax at their marginal rate and no tax charge at all will apply if aged under 75.

The Treasury confirmed that the higher rate income tax threshold would rise to £42,385 next year, a 1.2% increase.

Despite the usual prestatement speculation, there were no further cuts to tax relief on pension contributions or savings allowances.

Have your say in How waTcHdogs insPecT you

The care Quality commission is asking doctors for views on its plans for inspecting and rating independent healthcare services. responses are needed by 23 January 2015. you can take part at www. cqc.org.uk/inspectionsconsultation or by using Twitter’s #tellcqc.

TV time for private care

by charles King

The private hospitals’ body, The Assoc iation of Independent Healthcare Organisations (AIHO), has partnered with ITN to create a programme about independent healthcare.

Independent Healthcare Focus is an indepth look at aspects of the role and contribution of independent providers to the UK’s healthcare economy.

It also includes interviews with a range of key stakeholders, such as Stephen Dorrell MP, former chair

man of the Commons’ Health Committee, and Prof Sir Mike Richards, the Care Quality Commission’s chief inspector of hospitals.

The programme, hosted at the website www.aiho.org.uk, aims to challenge current views on independent healthcare.

Chief executive Fiona Booth said: ‘We are very pleased to partner with ITN to create Independent Healthcare Focus . We have managed to profile a great diversity of independent providers, showcasing the latest innovations and

Watch out for HMRC’s social media probing

Independent practitioners have been warned of an increased risk of being targeted for a tax investigation in the wake of high publicity HM Revenue and Customs’ (HMRC’s) court cases against doctors.

Doctors’ advisers say HMRC’s investment in a £45m database that collects information from multiple sources may now start paying off as it starts pinpointing areas and types of businesses where tax underpayment is a problem. But accountants Humphrey and Co warned that there is also a risk that this is resulting in innocent taxpayers being targeted for investigations.

It cited reports that HMRC uses social media to build up a more detailed picture of an individual’s lifestyle, such as social media

boasts about expensive cars or even holiday pictures.

These could trigger an inquiry if they do not fit with the individual’s reported income.

In a message to clients, the Eastbourne firm said: ‘While some of those targeted may be guilty of tax evasion, many more are likely to be innocent.

‘Individuals and businesses may find themselves on the receiving end of a mass mailshot from HMRC asking them to review their taxes simply because they fit a particular profile.

‘More unwelcome still, they may even find themselves singled out for a full investigation on the basis of a snippet of information for which there is a straightforward explanation.’

 See page 6

firstclass care they offer. ‘We hope that as many people as possible will watch the programme on the AIHO website for an indepth look at how the sector works.’

National newsreader Natasha Kaplinsky presents the programme from ITN’s national news studios.

(left) and a scene from the television programme

It is hoped viewers will get an insight into the contribution of independent healthcare to the UK and understand how independent

hospitals deliver highquality, safe diagnosis and treatment to selfpaying, insurance and NHSfunded patients.

London Bridge unit gets top HR award

HCA’s CMA threatened London Bridge Hospital has won the Investors in People gold standard, joining the top 3% of accredited organisations across the UK. It first achieved IIP status – the leading accreditation for business improvement through people management – in 1999. After earning silver status in 2011, the HR team decided to go for gold. The rigorous assessment process

➱ continued from front page

Independent hospitals and private patient units will have to provide it with comprehensive data from 2016 to enable publication of comparative performance measures for hospitals and specialists. These include activity levels, length of stay, patient satisfaction, and rates of unplanned readmis

involved interviews with over 80 randomlyselected employees and the hospital was assessed against nearly 200 standards.

Investors in People head Paul Devoy said: ‘Such a high level of accreditation is the sign of great people management practice and demonstrates a commitment to staff development. London Bridge Hospital should be extremely proud of their achievement.’

sion. PHIN will not get personal data such as patients’ names or birth dates.

The CMA will nominate two non executive directors to join PHIN’s board. Others representing consultants and insurers will be invited to sit alongside directors representing hospitals and patients.

Call for GMC warning to be scrapped

GMC warnings to doctors who stray from its guidance should be scrapped, according to defence body the Medical Defence Union. It said such warnings can have serious consequences for doctors, even though they are meant to be a lowlevel sanction.

The union’s Dr Catherine Wills said: ‘Many employers, contracting bodies and other organisations providing medical services do not understand the intended impact of warnings and assume they are an indication of serious concerns, which they are not.

‘Doctors’ careers can be adversely affected as a result and we don’t think this was what was originally intended.’

The MDU criticised other proposed changes to sanctions guidance, including that fitnessto practise panels should auto

matically consider serious action for failures to comply with certain aspects of GMC guidance. These include failure to raise concerns, bullying, sexual harassment or discriminating against patients. Dr Wills said each case must be judged on its merits.

iTn’s natasha Kaplinsky

Plea to end sales ploys to grow PMI

By Robin Stride

The chairman of the Association of Medical Insurance Inter mediaries (AMII) has called for concerted action from the industry to reverse the falling popularity of private medical insurance (PMI).

Wayne Pontin said the insurance sellers and the insurers should tackle areas to halt the decline and potentially help the market develop growth.

He told members at their 2014 Private Healthcare Summit: ‘From the intermediary perspective –and this is true whatever size you are and whichever sector you concentrate on – stop using commission kick backs to win switch business.’

Mr Pontin said intermediaries should add value and give sound advice to provide sustainable solutions to their clients.

‘Transferring from one insurer to another simply means the mar

ket will stagnate and eventually close to intermediated advice.’

And to insurers, he said: ‘It seems to me illogical that several PMI insurers adopt discount strategies, which effectively result in an escalation of pricedriven decisions and can also mean the end user receives one or more quotes for what they perceive to be the same cover – dual or sometimes triple pricing.

‘If there was clearer exchange of data and more transparency, this would not happen. I contend the insurers are driving a pricesensitive model particularly in the small to mediumsized company sector.

Mr Pontin, speaking at a London conference, said each intermediary would have variable new business acquisition costs and these should be factored into initial commissions.

But there was a ‘very thin line’ which resulted in a tipping point in terms of growth and sustainability.

If the initial commission was too high, it could feasibly encourage ‘churn’ at each and every renewal – at the cost of growth.

Cost-Cutting gets salesmens’ baCking

Controversial cost-cutting measures from insurers – such as open referral, guided referral, fee-approved or non-feeapproved – are ‘vital cost containment measures’, AMII chairman Wayne Pontin claimed. He argued they would ‘enable affordable solutions for the consumer and therefore stimulate growth’.

In the consumer sector, they are encouraging growth of aggregators and comparison sites by agreeing quite large introductory commissions.’

Secret recordings become common

An Independent Practitioner Today warning (September 2014) for doctors to be aware their patients might be recording them has proved to be sound advice.

According to a new survey, as many as one in five doctors say they have experienced patients recording their consultations and, in 40% of these cases, they were unaware this was happening at the time.

Three quarters of doctors told the defence body MPS that they believed they had a right to decline a patient’s request to record a consultation, while 91% wanted more guidance on what to do if a patient asked to record a consultation.

The defence body’s medicolegal adviser Dr Pallavi Bradshaw said:

‘While it would be preferable for recordings to take place with the knowledge and consent of both parties, MPS reminds doctors that a patient does not require their permission to record a consultation.

‘The content of the recording is confidential to the patient and they can share it in any way they wish. However, the doctor should advise them how to protect their personal information. Doctors should always behave in a responsible and professional manner in consultations and, consequently, any recording will provide concrete evidence of that.’

Mr Pontin warned that low insurance premiums designed to win market share only triggered a price war.

‘Potentially, there is an initial win by the clients and consumers as they get lower initial premium. However, if these premiums are

not sustainable and have to be substantially increased at future renewals, this is not a sound trading position and will result in a disillusioned buyer who may turn to selffunding or fixed fees services at the expense of insurance.’ He appealed to his audience, which included insurance, cash plan and protection company members as well as intermediaries, to stop infighting and work together ‘to innovate and plug the inevitable gaps which will develop within the NHS’.

Mr Pontin told the meeting that when he started as a broker in 1983, just over 11% of the UK population had PMI. Thirty years on, market analyst LaingBuisson figures put it at 10.6% – albeit of a larger population base.

Eye group looks to expand

Increased referrals to consultants are the aim of eye hospital group Optegra’s new team of professional partnership managers.

They aim to build relationships with optometrists, GPs, clinical commissioning groups and local strategic partners. Optegra’s interim managing director John Behrendt said: ‘It is important to have a team who focus entirely on developing relationships with the ophthalmic and medical commu

nity local to each of our hospitals. ‘With six hospitals and a number of outreach clinics around the UK, we want to ensure that local medical professionals, both privately and across the NHS, are fully aware of how Optegra can support and treat their patients.’

They are: Julieanne Page, Solent; Katy Ibbitson, Yorkshire; Dee Rana, Birmingham; Leyana Martin, Surrey; Amanda Outram, Manchester and Alan Hopley, London.

Sheffield hospital’s new therapy

Sheffield Foot & Ankle Centre consultants Mr Chris Blundell and Mr Mark Davies are now offering the new Cartiva synthetic cartilege implant at Claremont Private Hospital.

Hospital director Andy Davey said: ‘We welcome exciting new treatments at Claremont and Cartiva offers another choice for foot and ankle patients that may have exhausted other treatment options.’

Wayne Pontin of AMII

Beauty clients shun knife

By Edie Bourne

Cosmetic doctors are reporting an upsurge in non surgical treatments as more patients shun the scalpel.

Non surgical treatments now account for over 80% of patients seen at one London clinic and, with no need for general anaesthetic, no time off work and some sizeable financial savings for patients, the clinic says it is easy to see why.

CosmeDocs of Harley Street said rhinoplasty, for instance, required two hours under the knife and seven days of full rest following the procedure and a potentially more painful price tag of £3,768 on average.

But the non surgical nose job, using fillers injected into the nose, takes just half an hour under local anaesthetic and costs an average of £317, saving patients £3,451.

It reports a 140% increase in inquiries for this procedure in the

past year and similar interest growth over a range of other treatments.

The company has also seen an upward trend for some procedures where there are no non surgical alternatives – breast reduction, abdominoplasty and breast augmentation, which have risen 89%, 39% and 42%.

CosmeDocs’ Dr Toni Burke said: ‘More and more we’re seeing patients going for the “little and often” approach, rather than full surgery.

‘Although cosmetic procedures have a more pronounced and longer lasting effect, concerns over their permanence as well as going under general anaesthetic, and longer recovery times can make people think twice.’

The table below shows the surgical and nonsurgical alternatives for some top procedures, as well as price, length of procedure, downtime required and the increase in inquiries, sourced by private health search engine, WhatClinic.com.

Nuffield Health has appointed a market director to deliver its £60m new flagship hospital (Independent Practitioner Today , July/August 2014, page 2) and wellbeing services in Manchester.

Barbara Baker, formerly hospital director at the charity’s Derby hospital, will oversee the physical development of the site, which is situated adjacent to the Manchester Royal Infirmary, into a tertiarylevel hospital and rehabilitation centre.

She will also be responsible for developing an integrated wellbeing programme designed to improve the health outcomes of those living and working in the Manchester region.

independent Practitioner today, July-august 2014

Nuffield Health purchased the former Elizabeth Gaskell Campus complex from Manchester Metropolitan Univ

ersity in July, and took possession of the site in September.

The fiveacre site will provide scope for a wide range of facilities including rehabilitation and preventative health services.

The new hospital will support Nuffield Health’s other facilities in Manchester –including a planned health assessment centre in the recently

acquired gym inside the city’s Printworks building in Withy Grove and the medical centre at Salford Quays.

She said a major part of her role was dedicated to working with and supporting consultants and health related research at the city’s two universities.

Final designs for the hospital facilities are being developed and Nuffield Health expects to submit plans to Manchester City Council for approval in spring 2015.

Tax-evading doctor jailed

By a staff reporter

A privately-practising doctor has been jailed for 18 months for evading nearly £186,000 in tax.

Dr Michael Summer told HM Revenue and Customs (HMRC) investigators that he ‘wasn’t good with numbers’, yet could afford private schooling, luxury holidays and extensive home renovations.

During a four-year period, he earned over £750,000, yet declared and paid income tax and National Insurance on only half of it.

The evasion was discovered as part of the HMRC Tax Health Plan campaign – reported extensively in Independent Practitioner Today –to tackle undeclared tax and income from doctors and dentists.

After the case, Stuart Taylor, HMRC assistant director of criminal investigation, warned: ‘Suppressing your true income to reduce your tax bill will not be tolerated by HMRC or the public, most of whom pay what is due, when it is due.

‘Michael Summer spent vast sums on a luxury lifestyle – on his home, his holidays and even his car. We will not cease in our efforts to track down those who deliberately, and fraudulently, seek to gain a financial advantage over honest businesses.

‘If Summer had come forward

in 2010 and used the voluntary disclosure campaign to put his affairs in order, it would have been much less costly for him.’

Dr Summer, aged 46, of Main Street, Ratby, Leicestershire, worked in the private sector, preparing medical examination reports for insurance companies and the armed forces.

He did this on a self-employed basis, and submitted a self-assessment tax return through his accountant each year. In his first fraudulent return for 2008-09, he under-declared his annual income by almost £12,000, but by the time of his 2011-12 return, this figure had risen to £195,000.

He was arrested in February 2014, and claimed he didn’t know exactly what he was earning or spending. But he did admit during questioning that he had not provided his accountant with his true income.

Later he admitted four offences of evading income tax at Leicester Crown Court, where he was sentenced to 18 months imprisonment on each charge, to run concurrently.

HMRC said confiscation action will follow to recover the tax Dr Summer failed to pay.

The court heard that he has already made a payment of £100,000, which will be held on

account pending the confiscation process.

HMRC said he under-declared his income by £11,772 in 200809, £103,000 in 2009-10 and £102,462 in 2010-11. He failed to declare £195,224 in 2011-12.

The total income tax and National Insurance evaded was £185,985.

Five years ago, HMRC launched a campaign encouraging doctors and other medical professionals to declare their unpaid tax under more favourable terms.

Those affected had until June 2010 to come forward. To date, the campaign has raised total revenue of over £64m.

Police doctor booked for tax dodge

A London GP who under-declared his income by £700,000 in a tax fraud has been sentenced after an investigation by HMRC.

Dr Khaled Yasin, aged 64, of Pickering House, Windmill Road, Ealing, London, was paid £1.3m for his work as a forensic medical examiner for the Metropolitan Police Service over an 11-year period.

But he only paid tax on £655,955 of that money, which meant he avoided a £300,000 tax bill. He also owes £50,000 in interest.

He was sentenced to two years

imprisonment, suspended for two years, and ordered to complete a 200-hour community punishment order.

Dr Yasin pleaded not guilty, but was found guilty at Isleworth Crown Court of eight charges of cheating the public revenue contrary to Common Law.

The evasion was again discovered as part of the HMRC Tax Health Plan campaign to tackle undeclared tax and income from doctors and dentists.

HMRC investigator David Margree said: ‘Yasin thought he

could get away with the fraud because he had declared some of his earnings – he was wrong. This was a serious breach of Yasin’s professional standards.

‘Had he come forward in 2010, and used the voluntary disclosure campaign to put his financial affairs in order, he could have avoided a criminal record and serious damage to his reputation.’

The fraud took place between April 2002 and April 2011. During this time, Dr Yasin also worked as a GP for a health centre in Brentford, Hounslow.

Nuffield starts menopause drive

Doctors at Nuffield Health have launched a publicity drive to help women who they say get little support, advice or treatment for symptoms relating to menopause and hormonal changes.

Research for the not-for-profit healthcare provider found 47% of women with menopause symptoms said they felt depressed, while 37% said they suffered from anxiety.

Women in the workplace fared even worse, with 72% of female

workers with symptoms reporting they felt unsupported at work –even though one in five said their problems had a detrimental effect on their job. One in ten women said they have considered quitting.

Dr Annie Evans, menopause specialist at Nuffield Health Bristol Hospital, said: ‘Menopause is a condition which is often sidelined as just a fact of life, and not something to be taken seriously. But for many women the symp -

toms are extreme and can have a devastating impact on their life.’

The survey also flags up barriers that may cause thousands of women to miss out on advice, management strategies or treatment which could significantly improve their quality of life.

Menopause and premenstrual syndrome specialist Dr Julie Ayres, at Nuffield Health Leeds, said: ‘The issue needs to be dragged into the 21st century.

‘Increasingly, employers are

beginning to take employee health and well-being seriously, with numerous initiatives to help improve health and fitness, yet clearly, the menopause remains taboo.

‘Until we shine a spotlight on the subject and try to tackle some of the difficulties that women are facing at work, we stand to lose experienced and talented women who should be at the peak of their career rather than facing forced retirement or feeling alienated.’

top private medical secretaries

Nearly 100 doctors nominated their closest staff for the 2014 British Society of Medical Secretaries and Administrators’ Private Medical Secretary of the Year award.

First prize went to Ricky de Faria, of The Priory Hospital, Roehampton, London. His nominator, deputy medical director Dr Phil Hopley, said he had ‘modernised and streamlined the smooth running of the business while retaining all of the aspects of clinical care and patient support that have been valued over many years’.

Winner ricky de Faria (right) is pictured with thirdplace Karolina lason after being presented with their awards by Kingsley Hollis, head of practice management for Helix Health

How the face of medicine is changing

Women are increasingly breaking into traditionally male areas like surgery and emergency medicine and more doctors than ever come to work here from Europe.

These are some of the findings from a GMC report The State of Medical Education and Practice 2014

At the same time, the profession will soon have equal numbers of men and women doctors. Already women account for 44% of all registered doctors and more than half of medical students are female.

Second prize was won by Manju Sharma, nominated by Dr Rowland Illing, director, Leading Interventional Oncology Network (LION), Devonshire Street, London. Unfortunately, illness prevented her collecting the award in person.

Karolina Lason, nominated by gynaecologist Mr Onsy Morris of New Victoria Hospital, Kingston upon Thames, was third. The award is sponsored by practice management software company Helix Health, formerly DGL Solutions. It is open to any medical secretary/ administrator working in the independent sector.

There has also been a shift in the pattern of doctors from overseas coming to work here, with more from southern Europe.

GMC chief executive Niall Dickson said: ‘The face of medicine is changing and it is important that those responsible for workforce planning understand the implications. Of particular concern are the potential shortages in some specialist areas where there are diminishing numbers in postgraduate training and large numbers over the age of 50.’

New site to find doctors

By Leslie Berry

A former flying doctor and paediatrician-turned-MBA is behind a new website aimed at boosting consultants’ private practice by linking them with potential patients.

Patients can use Dr Mark Ratnarajah’s FindMeHealth.com to investigate and evaluate health procedures, try and find the right consultant for them and view actual and guideline prices. They can then book appointments directly with their chosen consultant online. The company said this avoided patients’ sole dependence on a GP or reliance on word-of-mouth, ‘opening up the possibility to book the most appropriate doctor for them’.

Customers can speak to a health adviser on the phone to help them reach an appropriate decision for them.

Dr Ratnarajah, who is initially targeting the self-pay market, said

the idea came after seeing how difficult it was even for him to access the right healthcare after his mother fell ill. ‘I could only imagine how complicated it would be for everyone else.’

He launched his business with capital investment led by Betfair co-founder Ed Wray, with participation from other private investors.

Mr Wray said: ‘Consumers have access to transparent online information in almost every other sector, so why not healthcare? FindMeHealth can help put consumers back in control and thus able to make better choices right now.’

FindMeHealth aims to gather data on clinical outcomes and customer feedback. Doctors pro-

vide availability status, allowing customers to search, compare, book and pay for services online. The service is free for doctors to register and receive online inquiries from FindMeHealth. But it encourages them to upgrade to a premium service which promises higher ranking on search pages, a bigger personal profile and quick online payment with every transaction booked.

There is no upfront payment or membership for the premium service, but doctors pay a transaction fee for every new outpatient appointment booked online. This is ‘less than 2% of the overall procedure plus consultations cost’.

The company said it had 5,000 consultants on its database and 750 on its premium service.

I can’t afford my tax bill

QHelp! I haven’t put away enough tax to pay my bill by the end of January 2015. What’s your advice to help me get back on track?

accountant susan Hutter (right) says:

Your situation is certainly not an isolated case.

there are many doctor practice owners and sole traders who fall into the same trap of spending the profits and find at the eleventh hour that they have insufficient money to pay their personal tax bill/Corporation tax bill.

t hat said, HM r evenue and Customs expects any business owner/sole trader to take responsibility of their finances and will not tolerate thinly-veiled excuses.

i f you do not have the ready cash to pay the tax, you should contact HM r C in good time before the due date to see if you can arrange a ‘time to pay’ settlement.

this can be done by yourself or your accountant. usually, HMrC will want to speak to you as well, although it is generally advisable for your accountant to open the negotiations on your behalf.

if it is a company tax liability, generally speaking, the maximum amount of time HMrC will allow on a time-to-pay arrangement is 12 months.

i f it is a personal tax liability, HMrC will usually want the tax to be paid before the next tax due date.

t his is usually a maximum of six months. i n extreme circumstances, and if you speak to an understanding inspector at the r evenue, you may be able to stretch it further.

Either way, you have to have good reason for running out of money. if you tell HMrC that you have spent your tax funds on an expensive cruise, he will not be impressed.

Examples of the types of reasons that would be acceptable are:

 ill health, either for yourself or a close relative which has meant that you have not been able to work as many hours in the practice as normal and therefore have fallen behind with saving for the tax reserve.

 an unexpected business liability has arisen that you had not budgeted for – for instance, your landlord has reviewed your rent at a far higher level than you envisaged and a large amount of back rent had to be paid.

HMrC is likely to ask you for a personal financial statement to see whether or not there are any assets that you can turn into cash quite quickly, such as isas and/or stocks and shares.

circumstances, you are not personally liable for this tax.

owe money to your company. it is unlikely that they will close the business down if there are not enough assets in the company to pay the tax, as this means they may never receive the money. HMrC does tend to be quite pragmatic about these matters.

Equal instalments a ssuming that a timeto-pay arrangement is granted, you will pay the tax in equal instalments over the time allotted and HMrC usually requests a direct debit to cover this.

also, it may ask if it is possible that you could raise an extra mortgage on your main residence or other property.

Extra time

Generally, you have a good chance of achieving a time to pay arrangement if this is your first ‘offence’. t his means, up until now, you have paid all your taxes, including PaYE, in time and have not asked for an arrangement within, say, the last three years.

sometimes, HMrC will be prepared to give you some extra time to pay – although interest will be mounting up. it very much depends on how you negotiate and the reasons for not being able to meet the liability.

if you trade through a limited company, the main tax liability will be corporation tax. in these

HMrC will therefore look at the company’s assets to see whether or not anything can be sold to raise the money.

they may also ask you if you are able to raise the money personally. However, they cannot force you to do this unless you

if you default on the payments, the arrangement will be automatically cancelled and HM r C will proceed to collect the balance. t he interest on late payment, currently 3% a year, will be charged together with the final instalment.

obviously, it is best to avoid the above conundrum if at all possible, as, apart from anything else, it is a stressful position to be in. to avoid getting into the same tax pickle next year, you may want to consider setting up a monthly direct debit in a separate bank account – which you cannot dip into for personal spending. ultimately, you will have peace of mind and know that the money left over is yours to spend freely.

Susan Hutter is a specialist accountant for the medical profession at Shelley Stock Hutter LLP

There’s a 1-in-4 chance of someone developing shingles during their lifetime.1 The risk increases with age, as does the likelihood of complications. 2

Year 2 of the national shingles immunisation programme started on 1st September 2014* for eligible patients. For full programme details and support items visit www.shinglesaware.co.uk

information.

Presentation: Vial containing a lyophilised preparation of live attenuated varicella-zoster virus (Oka/Merck strain) and a prefilled syringe containing water for injections. After reconstitution, one dose contains no less than 19400 PFU (Plaque-forming units) varicella-zoster virus (Oka/Merck strain). Indications: Active immunisation for the prevention of herpes zoster (“zoster” or shingles) and herpes zoster-related post-herpetic neuralgia (PHN) in individuals 50 years of age or older. Dosage and administration: Individuals should receive a single dose (0.65 ml) administered subcutaneously, preferably in the deltoid region. Do not inject intravascularly. It is recommended that the vaccine be administered immediately after reconstitution, to minimize loss of potency. Discard reconstituted vaccine if it is not used within 30 minutes. Contraindications: Hypersensitivity to the vaccine or any of its components (including neomycin). Individuals receiving immunosuppressive therapy (including high-dose corticosteroids)

is not indicated for the treatment of Zoster or PHN. Deferral of vaccination should be considered in the presence of fever. In clinical trials with Zostavax ®, transmission of the vaccine virus has not been reported. However, post-marketing experience with varicella vaccines suggest that transmission of vaccine virus may occur rarely between vaccinees who develop a varicella-like rash and susceptible contacts (for example, VZV-susceptible infant grandchildren). Transmission of vaccine virus from varicella vaccine recipients who do not develop a varicella-like rash has also been reported. This is a theoretical risk for vaccination with Zostavax ®. The risk of transmitting the attenuated vaccine virus from a vaccinee to a susceptible contact should be weighed against the risk of developing natural zoster and potentially transmitting wild-type VZV to a susceptible contact. As with any vaccine, vaccination with Zostavax ® may not result in protection in all vaccine recipients. Zostavax ® and 23-valent pneumococcal polysaccharide vaccine should not be given concomitantly

Caution should be exercised if Zostavax is administered to a breast-feeding woman. Undesirable effects: Very common side effects: Pain/tenderness, erythema, swelling and pruritus at the injection site. Common side effects: Warmth, haematoma and induration at the injection site, pain in extremity, and headache. Other reported side effects that may potentially be serious include hypersensitivity reactions including anaphylactic reactions, arthralgia, myalgia, lymphadenopathy, rash at the injection site, urticaria, pyrexia, rash and herpes zoster (vaccine strain). For a complete list of undesirable effects please refer to the Summary of Product Characteristics. Package quantities and basic cost: Vial and pre-filled syringe with two separate needles. The cost of this vaccine is £99.96. Supplier: Sanofi Pasteur MSD Ltd., Mallards Reach, Bridge Avenue, Maidenhead, Berkshire, SL6 1QP Marketing authorisation number: EU/1/06/341/011

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Sanofi Pasteur MSD; reporting form can be found at www.spmsd.co.uk/AE or via telephone 01628 785291

conFESSionS

New life on the other

Newly independent GP Dr Kannan Athreya (left) tells the story of why he finally left the NHS

LET mE take you back to August 2012 – a very challenging time.

I had been a GP partner in an NHS surgery for 16 years, and what began as a wonderful vocation with a good work-life balance had, over successive years, been eroded into a micro-managed, tick-box, underpaying, moralegrinding disaster area.

So I was not happy – and changes to my personal life made me look at my role as a local GP. It just was not an area of stability anymore and I was seriously considering my future as a doctor.

However, like most of my colleagues, ‘I can’t do anything else’ was the recurring phrase that put me behind that desk day after day. And no self-respecting actuary would have given me good odds on making it to the retirement golf course in my early 40s .

Then opportunity knocked. There was a slight glimmer of hope. I would join a group of doctors looking after some fee-paying patients in a private hospital, a change of scene, albeit for one morning per week. So, naturally, I said yes.

Seeing three patients per clinic wasn’t exactly going to get me a hotline to the Porsche showroom. But what a joy – 30-minute consultations; no QOF; free breakfast!

Within three months, not only was I beginning to think like an independent practitioner, but with the migration of colleagues for various reasons, I soon found myself jointly running the practice.

I moved to a three day week with the NHS and two days running the private service, generating interest and patients from my new hospital consultant colleagues.

In the Summer of 2013, I was put in a quandary. I took a call

Doctors as a group, especially perhaps NHS GPs, do not realise how far one can go with that GMC number

from an old colleague who had heard of my foray to the private sector. He himself had been running a small but very successful independent practice for some years, and thought that I would be ideal to take over his clinic and he put the proposition to me.

Move to the ‘dark side’ I wanted to continue my work at the private hospital and would have to negotiate the means to work in both places simultaneously, but it would mean that, after 22 years as an NHS doctor and 18 years as an NHS GP, I would have to give up the NHS altogether. Though it was stressful and worked me to the bone, the NHS did offer that regular monthly salary.

I said yes. I saw my last NHS patient a year ago and my move to the ‘dark side’ was complete. Though fearful of the unknown, there was also a sense of adventure and pride that I was taking this step and, last February, I took over the reins of my very own clinic, Essex Private Doctors, in Shenfield with three staff, two rooms and one hot seat.

What does a private GP with his own clinic have to expect? Initially, I was met with bills . . . rent, rate, staff costs, supplies and sundries, and with not a full clinic list. And so I was left a little reeling.

This is before I even got

other side

involved with applying for Care Quality Commission management approval.

What I did have now though was time. Glorious time. Necessity being the mother of all invention, my next step was to become a businessman and look into different ways of generating an income stream.

This led me down the seemingly inevitable path toward the aesthetic arena, which is growing every moment, it seems.

A course in botulinum toxin and fillers led me to skin peels, dermarollers, radio-frequency assisted body contouring and skin tightening, and facial vein treatments.

I am now fascinated with laser technology and already been preliminarily trained on the use of a CO 2 laser for skin and aesthetic care.

During this time, I also passed the Diploma in Dermatology exam to shore up my skin knowledge – and add more letters after my name.

Same philosophies

Three months into my private venture, a trusted friend introduced me to a Harley Street plastic surgeon and, as we talked, we covered a lot of common ground and it was clear that we shared the same philosophies in health care. He put forward the idea of my working with him with a view to eventually taking over his business – handling the non-surgical aesthetics and being trained in minimally invasive cosmetic work, referring the more involved cases to a partnered plastic surgeon. I felt this was an amazing opportunity to learn from the best and to build up my expertise. But it was to be a major investment in time and money, and would mean that I gave up my

private hospital work to be at Harley Street. more leaping into the dark.

But, again, I said ‘yes’.

So now I split my time between my clinic in Essex and Harley Street. I am steadily building up both my general practice as well as my aesthetic case load and am looking forward to bringing more services in.

With my Harley Street clinic, I am not only building up experi ence in more involved aesthetic care, but I am also exploring the developing field of age manage ment, of which the more I learn, the more my interest grows.

I have appointed wonderful people to help me with public relations and get me involved in using social media.

Now, perhaps ironically, with all of my commitments, attend ing training, meetings and confer ences, I have next to no time – but I’m loving every second of it.

What I have realised is that doc tors as a group, especially perhaps NHS GPs, do not realise how far one can go with that GmC num ber.

There are so many areas that we could explore to rekindle that early love and passion we had for our chosen vocation, before we had that enthusiasm beaten out of us with bureaucracy and work load.

Perhaps the only take-home message I have is that if you have the courage to open yourself to opportunity, opportunity some how seems to find you.

I am so enjoying independent practice and I only wish I had started earlier in my medical life.

Nevertheless, I often wonder what would I do if, in some way, all this turns sour and I was asked to go back to the NHS again.

I’d probably say ‘NO’. 

Resolutions to thrive in

Together, these resolutions could make a big impact on your profit line

New year’s resolutions for your business really could boost your income in 2015. Garry Chapman suggests ten for independent practitioners to consider

It could be losing weight, stopping smoking, reduced drinking, or more exercise.

Yes, with the start of 2015, it is time to make some resolutions. But where did it all begin?

Most sources state that the practice of making moral promises at the beginning of the year dates back to the Roman times and their worship of the god Janus, who had two faces, giving him the ability to look forwards and backwards at the same time. one face would reflect on past events and the other face would look forward into the future.

Romans used the image of this deity of transitions and changes on the first month of their calendars and the name January is derived from him. In the year 153Bc, the Roman senate fixed the start of the calendar new year at 1 January. the tradition has been around for over 2,000 years, so there must be some merit in having your own New Year resolutions. And why not for your business?

Starting now, why not review

the way you operate the financial aspects of your practice? together, these resolutions really could make a big impact on your profit line. Even if you can keep one of them over the next 12 months, it could make an amazing difference.

Here are my suggestions for you to consider including in your financial New Year’s resolutions:

1 Review the way your work is being billed to ensure you are compliant with the rules and regulations that get communicated on a monthly basis from the clinical coding and Schedule development group (ccSd).

2 Ensure you review your procedure fees on a regular basis, particularly if you bill to insurance guidelines, because they are changing all the time.

3 See that your work is invoiced as soon as possible. t his will ensure that you have consistent cash flow and assist with your debt reduction.

Make sure that your price structure/policy is clear and that your patients are made aware of it before commencing treatment, so there is no room for ambiguity when it comes to settling the bill.

Ensure that your practice has a robust process for chasing any outstanding invoices on a consistent and continual basis until they are paid in full. otherwise you will continue to experience a high level of bad debts.

Be aware of any bad payers so that you can decide if you want to continue seeing them while they have outstanding invoices. If you don’t do this, you will end up throwing money away on a regular basis.

Ensure that you have management information on where your patients are referred from and whether they are private medically insured, u K self-pay, from embassies or overseas self-

pay. then you can make informed decisions about your practice for the future.

Make sure that you spend as much time as possible focusing on your core skill set, which is treating and looking after the patient. this will, in turn, make you more money, as you are focused on what you do best.

See that you have a robust infrastructure in place to do all of the above with a secure It system, backed up on a daily basis, to help you achieve this. t hen you will have peace of mind if the tax inspectors come calling.

10 If you find you cannot manage all of the above, you need to consider whether you should join thousands of other consultants who have outsourced this crucial element to a professional billing company. 

Garry Chapman is managing director at Medical Billing and Collection

My leap into a war film

Mr Eddie Chaloner at the premiere of Kajaki with his wife, Dr Ann Rigg, consultant oncologist at St Thomas’ Hospital, London

The ouTline of the incident was familiar to me – a group of Parachute Regiment soldiers guarding the Kajaki Dam in Afghanistan, inadvertently become entrapped in an unmarked minefield – a legacy from the Soviet era. e nsuing injuries lead to the death of the section commander, the serious wounding of several other soldiers – and multiple awards for gallantry.

There were many aspects of the project which resonated with me.

While i was still a junior surgeon, i had done two tours in Afghanistan with the hAlo Trust landmine clearing charity in 1992 and 2000 and further stints in Mozambique, Angola, Sri l anka and northern iraq.

u nusually for a doctor, i had been present on two separate occasions when people were blown up in front of me in minefields.

i had also served in the army as the surgical support to the Airborne Brigade and with 144 Parachute Squadron (Royal Army Medical Corps) – experiencing the rigours of ‘P’ Company selection and the unique bond and cameraderie of the Airborne Brotherhood. i nitially, i was concerned that

It’s not every day one is asked to get involved in making a war film, so when I got an email about the Kajaki movie project, I was intrigued, says surgeon and parachutist Mr Eddie Chaloner

Kajaki, which opened in cinemas on 28 November, recounts the true story of a squad of British soldiers caught in a minefield in Afghanistan

the filmmakers might produce a h ollywood style product which bore little resemblance to the reality of war and do a disservice to the sacrifices made by our soldiers – i need not have worried.

intense commitment

Within a short time of meeting director Paul Katis in a l ondon café in early January 2014, i was impressed by his intense commitment to telling the story, as he had been trying for nearly two years to raise the money to make the film and was determined to succeed.

Although i was approached as a potential investor, during the

A PMN Russiananti-personnel mine, almost certainly the type that causes all the damage featured in the movie

course of our discussion, it became apparent that i had technical knowledge and experience to contribute as well as finance.

i think Paul may have realised this when i produced a PM n Russian antipersonnel landmine from my daysack to show him the type of weapon that caused the injuries on the day.

From the outset, my analytical brain told me that, as a potential investment, this was way beyond a risky proposition – there were so many things that could go wrong that it made no sense at all as a commercial venture.

o n the other hand, i was extremely impressed with the

determination of the film makers to tell the story in a realistic way and finally the subject matter was so intensely personal to me that i decided to let heart rule head and pitched in.

My value to the project ranged from advice about what a live minestrike looks, sounds and smells like close up, to analysis of the injuries caused and the type of weapons that produced them.

For example, explosions are often portrayed on screen as involving large amounts of flame and bodies being thrown in the air, but that’s rarely the case for a minestrike in Afghanistan. There the fireball is suppressed by large amounts of dust and debris and an 80kg soldier usually just falls over after standing on a buried landmine.

Paul was also interested in how injuries look and how to present them to a nonmedical audience in a realistic way, but without making the viewers throw up –not an easy line to tread!

Accurate portrayal

Crucial to the film was an accurate portrayal of the timeline and development of injury from the point of wounding to the evacuation – for example, how long a 15mg shot of morphine is effective and the physiological effects of prolonged bleeding on consciousness and human actions, along with advice about how people react and perform in moments of extreme stress.

Reading the witness statements of the soldiers involved was a sobering experience, particularly when the medic, Corporal hartley, described how, needing to reach one of his comrades but without a mine detector to clear the way safely, he decided to whack the ground in front of him with his rucksack as a way of exploding any buried mines.

if he had hit a mine, he would certainly have been severely injured himself.

Reading his bald account of cold courage and dedication to duty in the heat of the moment brought tears to my eyes.

For his actions that day, Corporal h artley was awarded the George Medal, as was Corporal Mark Wright, the section commander, who died of his wounds.

Reading his bald account of cold courage and dedication to duty in the heat of the moment brought tears to my eyes

MEDIC WITH A MISSION: Former Army surgeon Mr Eddie Chaloner pictured operating in Angola on a patient injured by a landmine (above); with his field surgical team on the tailgate of a Chinook helicopter in Kosovo in 1999 (right); and with a child in Rwanda in 1994 on whom he had operated after she had been shot (below)

That decoration is the equivalent of the Victoria Cross for conspicuous gallantry while not directly facing the enemy.

i would urge everyone to see this movie – and not just because i am an investor in it! in the final analy

sis, it is a tale of ordinary men doing extraordinary things in circumstances beyond the imagination of most people in the uK.

it is a truly remarkable and important portrayal of the realities of the Afghan campaign from the

soldier’s perspective. i am very proud to have played a tiny part in making it happen. 

The Association of Independent Specialist Medical Accountants is a national network of firms advising over 3,000 medical practices across the UK. For some of the best advice available on accounting, taxation and pensions, visit our website and find your nearest AISMA accountant.

Mr Eddie Chaloner is a consultant vascular surgeon at Radiance Vein Clinic in London and Kent

ConsUlTATions onlinE

In touch with patients

Entrepreneurial

software used by Harley Street GPs Dr Fiona Payne and Dr Justine Setchell is now being taken up by other independent practitioners. Here they report on their company’s progress

Back in June 2012, Independent Practitioner Today reported our launch of GPatHome, a software package that enables patients to consult us remotely via a secure web portal.

all of our electronic communication with patients is now done via this system.

Both we and the patients love the ease and convenience of communicating in this way and the patients especially like the extended access. We run the system from 7am-7pm, seven days a week.

Being able to use the system from anywhere in the world is a huge asset for our demographic, as many of our patients either live abroad for part of the year or travel a lot for work.

We did have to add GMT (Greenwich Mean Time) to our working hours on the website though to remind them that we do need some sleep.

Both we and patients love the ease and convenience of communicating in this way and the patients especially like the extended access

Having run the system with our own patients with great success, we are now able to lease the software to other practices to use for their own patients.

Our ﬁrst software licence was to a new start-up private general practice in c ambridge – www. cambridge-private-doctors.co.uk. although the basic framework remains the same, each practice can personalise the website to their requirements.

Other practices may wish to operate the system at different hours – we are in discussion with another practice who may use the system for out-of-hours.

Each site ends up with a bespoke design appropriate to their own needs.

Writing this as we have, makes it all sound very easy and, in many ways, it is. But there were an awful lot of hurdles to jump and bills to pay before we were in a position to lease it.

legal aspects

The most important aspect was probably the legals. We instructed our lawyer – another entrepreneurial female, Jo Tall at www.offtoseemylawyer.com – to draw up a software licence agreement and

We have the GMC’s support for our system, as well as impressive testimonials from patients

one of her colleagues trademarked the company name and logo. Meanwhile, our trusty i T adviser was beavering away in the background ensuring that all the behind-the-scenes i T support was in place. We think we’ve exhausted him over the last few months. not that we’re demanding . . . much!

But it was all worth it in the end and c ambridge.gpat home went live on 1 October. We believe the system has huge potential both for GPs and consultants in private practice.

a s the demand for electronic communication builds, so the need for a secure means to provide that – and get paid – increases.

We have the GMc’s support for our system, as well as impressive testimonials from patients.

and we even had a letter published recently in the BMJ online in response to an article as to whether patients should be able to email their doctors. We say a deﬁnite ‘yes’ with our secure system.

We are very proud of what we have achieved so far and are looking forward to continuing to expand our brand and our business. 

Dr Fiona Payne (left) and Dr Justine Setchell outside their Harley Street practice ‘GP at 92’

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

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

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

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

You have to tell them

when things go wrong

From April 2015, a legal duty of candour will apply to all health providers registered with the Care Quality Commission (CQC), subject to Parliamentary approval.

Independent practitioners who are registered providers with the CQC will be legally obliged to ensure their practice culture and policies support transparency. And clinicians with practising privileges at private hospitals will have a front-line role in ensuring their organisations observe the statutory duty.

The desire to protect reputations and careers and to ignore awkward truths contributed to a catalogue of failings in care at Mid-staffordshire Nhs Trust.

h owever, it was the cover-up itself, as much as these failures, that caused severe damage to public confidence.

Following the recommendations in the Francis r eport, the Government is now making transparency after adverse incidents a legal requirement for the organisations providing care: the statutory duty of candour.

s ome providers will need to overhaul their systems and procedures to comply, but it is important this transformation includes the provision of proper support for health practitioners too.

Dr Mike Roddis (right) looks at how organisations in the private sector can best meet their obligations and support staff

Ethics and law

d octors already have an ethical obligation to tell patients if something goes wrong, as set out in paragraph 55 of Good Medical Practice . But, until recently, healthcare organisations had no corresponding duty to be candid with patients and their families. The introduction of a statutory duty of candour helps to align the

obligations of doctors and organisations and should theoretically limit the possibility of open and honest doctors being ‘left out in the cold’ by organisations protecting their own short-term interests. The new rules require organisations to establish an open and honest culture and impose specific disclosure duties on them when a ‘notifiable patient safety incident’ occurs. The Care Quality Commission (CQC) will oversee compliance through its inspection regime and has the enforcement powers to bring a criminal prosecution against providers that fail to meet these standards. initially affecting Nhs bodies, the Government wants to extend the duty to all providers registered with the CQC, although the necessary regulations must still be approved by Parliament.

This means independent practitioners who are registered providers with CQC will be legally obliged to ensure their practice culture and policies support transparency.

i n addition, clinicians with practising privileges at private hospitals will have a front-line role in ensuring their organisations observe the statutory duty. ➱ p20

ADvice foR DisclosuRe conveRsAtions

 talk to your colleagues about what happened, so you have as much information as possible before meeting the patient and their family

 Don’t rush the meeting and ensure you won’t be interrupted by a colleague or bleep

 Bring in other members of the team, if appropriate – for example, there maybe someone with whom the patient has established a rapport

 think about your body language – sit down so you are at eye level rather than towering over them and avoid defensive postures such as crossing your arms

 show empathy. Allow the natural sympathy and concern you feel for your patient to come through

 use plain english – don’t hide behind medical jargon when describing what happened and the likely consequences

 clearly set out what action has been/will be taken to help the patient in the aftermath of the error

 Allow the patient and their family time to express their feelings and distress. they should be the moral interlocutor and you should not expect them to ‘forgive you’

 Prompt the patient and their family to ask questions

 say sorry. it’s not an admission of liability to say you are sorry that the patient has suffered harm. if a mistake has been made, then saying sorry is the right thing to do

 Don’t speculate about what happened or cast blame – if you don’t know, say so, as it’s better than having to explain you were wrong later and losing the patient’s trust

 explain the next steps: tell them how the incident will be investigated by the hospital/ practice and set out the time-scale

 Make yourself available – let patients and relatives know how to contact you in case they have queries

say sorry. it’s not an admission of liability to say you are sorry that the patient has suffered harm

The practicalities of candour

The main duties set out in the statutory duty of candour regulations are:

 As soon as is reasonably practicable, one or more agents of the organisation must tell the patient or their representative in person about a ‘notifiable’ incident.

 The patient should be offered reasonable support. The CQC says this might include help with understanding what is being said, emotional support, information about impartial advocacy services, and access to remedial treatment.

 Patients or their representatives should be given all the known facts, an apology, and be told what further inquiries the organisation considers appropriate.

 The organisation should also provide a written notification to the patient which sets out the face-to-face discussion and updates them on the results of any further enquiries.

An independent firm offering one to one meetings anywhere in the UK giving advice and help with:

• how to start in private practice

• how to maximise private practice income

• ways to reduce tax payments

• setting up in Chambers/Groups

• limited companies and LLP’s

• financial planning

• record keeping

• computer software

• tax and financial advice re: car purchases

• pensions: NHS, personal and employee schemes

• purchase of consulting rooms and surgeries

• inheritance tax and capital gains tax planning

• VAT

For more information please contact us by: Wilmslow

Phone: 01625 527351

Fax: 01625 539315

Harley Street

Phone: 020 7307 8759

Fax: 01625 539315

Email: info@sandisoneasson.co.uk

Website: www.sandisoneasson.co.uk

 A written record of the notification and any correspondence must be retained and held securely by the organisation.

 Notifiable incidents that trigger the statutory duty are defined in the draft guidance as ‘any unintended or unexpected incident… that, in the reasonable opinion of a healthcare professional, could result in, or appears to have resulted in’ death, severe harm, moderate harm or ‘prolonged psychological harm’.

This reflects the definition used within the current Nhs contract, but the Government has indicated 1 that non-N hs providers will use CQC-notifiable patient safety incident harm definitions – set out in the Care Quality Commission (registration) regulations 2009 – to determine when a disclosure under the d uty of Candour is required.

At the time of writing, the CQC

the MeRits of oPen DisclosuRe

the introduction of a statutory duty of candour is a powerful incentive, but there are already compelling reasons for organisations to champion openness and honesty, including:

1 clinical governance

Mistakes are a valuable opportunity for quality improvement. the Government says that the duty of candour ‘will act as a catalyst to improve the understanding of harm and the learning which flows from it at provider level’. to put it another way, an open discussion by those involved of all the factors which contributed to an adverse incident is usually more illuminating and constructive than looking for someone to blame.

2 Providing effective care and rebuilding trust

A trusting, professional relationship with patients is an important precondition for medical care, whether it is encouraging them to talk about their health concerns or obtaining their informed consent, including an open discussion of risks and (in the private sector) the cost of the available treatment options. if we jeopardise that trust, patients will lose faith in us and it becomes much harder to do our job. conversely, if patients recognise that we are sincere and open with them, it can help to rebuild the damage caused by the original error and restore their confidence.

3 Protecting commercial interests

While occasionally painful, openness and transparency are better for the standing of an organisation than being evasive. Research has indicated that patients and families want to hear an apology and to know that their experience has not been in vain because lessons have been learned. that means complaints and legal action are probably more likely when the victim of error believes they have been deceived. What’s more, social media has given aggrieved patients a powerful voice and allegations of a cover-up can build momentum and cause significant reputational damage to clinicians and hospitals.

Reduction in labour costs and time associated with manual paper filing

Reduction in labour costs and with manual paper filing

Initial data capture of archived patient files, including ongoing processing of live files/data Consultants have remote access to patient data when and wherever they need it

Complies with the national initiatives

www.orsgroup.com/consultants 023 8026 7755 | paperless@orsgroup.com

had just closed a consultation on guidance 2 that suggests how organisations can comply with the statutory duty of candour (regulation 20 of its revised fundamental standards).

This emphasised the need for a board-level commitment to transparency; for providers to take all allegations seriously and consider whether they meet the threshold for notification; and for appropriate training and support for staff so they could recognise when a ‘notifiable’ patient safety incident has occurred and respond appropriately.

While the CQC does not suggest how organisations should support employees, it does propose sanctions. The guidance recommends providers refer staff failing to act in accordance with the candour requirements to their relevent professional regulatory body.

i agree that those who deliberately conceal patient harm or suppress the raising of concerns are acting unethically and this may raise questions about their professionalism. however, if we want to make a real difference for patients, i believe we need to focus on helping staff to do the right thing.

Support for staff

The need to support healthcare staff in the aftermath of a serious untoward event ( s U i ) was an important theme at the second international incident disclosure Conference held at York University earlier this year.3

Among the contributors was dr Jo shapiro, director of the Center for Professionalism and Peer support4 at Brigham and Women’s hospital in Boston, Us dr shapiro explained that disclosure and peer support are inextricably linked and described a range of organisational programmes to help clinical staff to cope and recover following adverse incidents, but where the focus does not waver from the needs of the patient and their family. They include:

 Facilitated group meetings so the healthcare team can discuss what happened and its emotional impact;

 Confidential 1:1 peer support with trained clinicians who have ‘been there’;

 disclosure coaching by doctors, nurses and social workers to prepare

doctors for open and honest conversations with patients and relatives, including how to apologise;

 resources, such as video learning, which explore the rights and wrong approaches to disclosure;

 An employee assistance programme for those finding it difficult to cope with the aftermath of a medical error.

it does not diminish the distress of patients and families to recognise the terrible impact that an sUi can have on the healthcare staff. Previous studies have shown that doctors feel ‘guilty, afraid, and alone’5 when mistakes are made in a culture where failure is quite difficult to accept and can strain relationships with colleagues.

Without adequate support, such as the programmes implemented at Brigham and Women’s h ospital, some clinicians may develop their own coping strategies to help them deal with what has happened.

These may be positive, but responses such as denial or dissociation are clearly damaging to the individual and may hinder their ability to communicate with patients.

i also believe it is a mistake to assume that healthcare professionals are naturally able to conduct conversations about medical error, simply because they are practiced in breaking bad news or broaching difficult matters such as end-of-life care.

in fact, few practitioners have extensive experience in talking to patients about causing them harm because of an error and we’d probably be concerned about those who have.

so while there is no definitive way to conduct a disclosure conversation, there are clear principles to follow (see box on page 20) and it would be a shame if patients are failed again because organisations have not provided adequate advice or training. such training must, in my view, cover practicalities such as who should attend the meeting, how to communicate the facts, avoid speculation and passing blame. it should also stress the need for patients and families to be the ‘moral interlocutors’ following an adverse event, encouraging them to express their feelings or ask questions.

cAse scenARio

A patient with private health insurance has a hip replacement procedure at an independent hospital but later returns to see the orthopaedic surgeon complaining of pain and slight shortening of her leg. An X-ray shows that the joint has become displaced and the patient undergoes corrective surgery. During this second procedure, the surgeon realises that the first artificial hip was misaligned. following her operation, the patient asks the surgeon if he had discovered what had gone wrong the first time. how should he respond?

AnsWeR:

Aware of his ethical duty of candour, the surgeon sits down with the patient and describes what went wrong during the original surgery. After telling her how sorry he is that she has been put through the stress of further surgery, he explains how he has addressed the problem, reassuring her that she will not be billed for any of the additional cost. he encourages her to ask him any questions and gives her his contact details in case she thinks of anything later. he follows this up with a letter.

the surgeon also reports the matter to the hospital as part of its adverse incident procedures and notifies the patient’s insurer. the surgeon carries out an audit and shares the patient’s care and the results of the audit with his colleagues at the local mortality and morbidity meeting. they conclude that the surgeon’s complication rate is significantly below average. the patient later responds to a survey, expressing her satisfaction with the way the matter was handled.

in my experience, many clinicians expect to control the conversation and often want under standing and forgiveness following an admission of error, but this is unfair and unrealistic. By preparing health professionals for disclosure conversations, they are better able to represent their organisation and ensure it meets its new obligations.

i hope the statutory duty of candour helps change the climate within N hs and private health organisations, making it clear there will be zero tolerance for cover-ups.

As i have shown, the emphasis on transparency is right for victims of harm, but it also has advantages for providers, particularly when it comes to rebuilding trust with patients and quality improvement.

however, it won’t be possible to achieve a real culture change without the contribution of healthcare professionals on the front line.

The challenge for senior leaders will be developing systems of training and support within their organisations that will make open-

ness and candour an easier option, as well as an ethical duty. 

A former consultant pathologist and medical director, Dr Mike Roddis is now a specialist in professional development and organisational troubleshooting. His company, MJ Roddis Associates, works with NHS trusts and in the independent sector

References

1. Paragraph 5, Eighth report of the Secondary Legislation Scrutiny Committee, 29 July 2014. www.publications.parliament.uk/pa/ld201415/ldselect/ ldsecleg/42/4203.htm.

2. Guidance for providers on meeting the fundamental standards and on CQC’s enforcement powers, CQC, July 2014.

3. 2nd International Incident Disclosure Conference, held by the Social Policy Research Unit at the University of York, York, 12-13 May 2014. www.york.ac.uk/ inst/spru/IIDC2.html.

4. Center for Professionalism & Peer Support at Brigham and Women’s Hospital. www.brighamandwomens.org/medical_ professionals/career/cpps/default.aspx.

5. Delbanco et al, Guilty, Afraid and Alone – Struggling with Medical Error. New England Journal of Medicine, 2007; 357: 1682-83.

PROBLEMS WITH THE TAX MAN?

HMRC tax investigations and disputes create difﬁcult and stressful times.

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

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

‘Here to help. Not to judge.’ Gilbert Tax Consultants LLP | Ofﬁ ces in London, Leeds and Newcastle T: 0800 734 3333 | E: enquiries@gilberttax.co.uk www.gilberttax.co.uk

Paying for care

Chris Miller looks into the financial and legal aspects associated with care and gives helpful information of what to do when you suspect someone you know needs it

Many people do not think about care until the need is forced upon them.

a nd few people are experts when it comes to knowing the right sort of care required for their loved one.

Is hourly care sufficient or would live-in care be more appropriate? What does a good care home look like? What should I expect to pay for care and how much is provided by local authorities or the nHS?

What is power of attorney and what legal rights does that give me to manage the affairs of someone else?

Doctors and their families are no different to the rest of the population and often experience the same lack of information and advice when it comes to care.

Attendance Allowance

The Government provides funding to help pay for personal care if you are physically or mentally disabled and are over 65 years old. It is non-means tested and is paid at two different rates depending upon the level of care that you need because of your disability. From april 2014-15, the lower rate of £54.45 per week is paid for those who need ‘frequent help or

Few people are experts when it comes to knowing the right sort of care required for their loved one

constant supervision during the day, or supervision at night’, while the higher rate of £81.30 per week is paid for those who need ‘help or supervision throughout both day and night, or you’re terminally ill’. a ttendance a llowance claim packs are available by phoning 0345 605 6055 or going online at www.gov.uk/attendance-allowance/overview.

you could get extra p ension Credit, Housing Benefit or council tax reduction if you get a ttendance allowance – check with the helpline or office dealing with your benefit.

Personal independence Payment (PiP)

pIp is a non-means-tested benefit for those with long-term ill-health or a disability between the ages of 16 and 64.

It is based on how the condition affects you, not just the condition itself, with the amount awarded varying between £21.55 and £138.05 per week.

To make a claim, call the Department for Work and p ensions (DW p ) on 0800 917 2222 or go online at www.gov.uk/pip/overview.

Before calling, please ensure that you have the following information to hand:

 Full contact details and date of birth;

 national Insurance number;

 Bank or Building Society details;

 Doctor’s or health worker’s name.

council tax reduction

Someone with a formal diagnosis of dementia who lives on their own is exempt from paying council tax.

If there are two people living in the house, then the council tax is reduced by 25%. If a council tax single occupancy exemption is being claimed, you will not lose this entitlement if you have a livein carer.

council funding for care costs

people who are elderly, disabled or have a long-term health condition that needs support with dayto-day activities may be entitled to some financial help from their local authority.

However, any financial assistance is means-tested by the local authority, with their social services department determining whether you’re eligible for funding or not.

In e ngland and n orthern Ireland, if you have savings and assets (including property) of more than £23,250 (Scotland £25,250, Wales £23,750), then you will have to pay for your own care.

However, before they can help, your local authority will need to carry out an assessment of your care needs.

It’s called a ‘needs assessment’ or a ‘care assessment’; it’s free and everyone has a legal right to have one.

only afterwards is there a financial assessment to determine who should pay for any services you might need.

The upper capital threshold for means-tested support will rise to £118,000 from 2016-17, which will therefore increase the number of people who are eligible for social service care support.

o ne of the aims of the Dilnot Commission on Funding of Care and Support was to protect people from extreme care costs and that there should be a cap on the lifetime contribution to adult social care costs.

Based on the Commission’s recommendation, the Government has set the cap at £72,000 from 2016. In reality, this figure refers only to the social care cost component.

In other words, individuals will still have to contribute to their own living costs, which is a not unreasonable expectation. However, the cost cap is not a cap on what is actually spent on someone’s long-term social care but rather the amount that a local authority would spend on the individual if they were eligible for care through the means test criteria.

This means that a self-funder residing in a more expensive care home will only see their personal cost of care increase each week by the amount that the local authority would spend on them, causing them to spend considerably more on care before they reach the cap limit of £72,000.

nHS continuing Healthcare funding

This is a package of care that is arranged and funded solely by the n HS for individuals who have

complex ongoing healthcare needs in a non-hospital setting.

The service is free, non-means tested and can be delivered at home or in a care home. To be eligible for n HS Continuing Healthcare you must have a complex medical condition and substantial, ongoing care needs.

Just because you have a disability or if you’ve been diagnosed with a long-term illness or condition does not necessarily mean that you’ll be eligible for n HS Continuing Healthcare. you must have a primary health need where your main or primary need for care must relate to your health, not just having a condition or disability.

There is no definitive list of health conditions or illnesses that qualify for funding and not everyone with ongoing health needs will be eligible. The assessment is usually very strict, and being elderly and frail isn’t enough to qualify.

However, if you are eligible for nHS Continuing Healthcare, the n HS should pay 100% of your fees. There is an organisation called Care To Be Different that helps support eligible families secure n HS Continuing Healthcare funding even when it has been previously declined.

Care To Be Different was set up by angela Sherman after her marathon three-and-a-half-year battle with the n HS to secure Continuing Healthcare funding for both of her parents. Go to www.caretobedifferent.co.uk.

Financing options for care

people, there remains significant concern around the poor quality of care delivered, which has received extensive coverage in the last few years.

While the Government has stated the importance of care choices, there is still an alarming lack of awareness of the choice available to people as care needs arise.

Surveys show that most people want to stay in their own homes and have care delivered in the home environment.

The Good Care Group (www. thegoodcaregroup.com) is a national provider of 24-hour livein care for people in their own homes. It understands how worrying it can be when planning the financing of long-term care, particularly at a time when you are already facing difficult and highly emotional decisions about care.

It works with Symponia (www. symponia.co.uk), who are specialists in financial care planning for the elderly through a network of around 150 independent financial advisers around the country. If your capital and savings and/ or income push you over the means-test thresholds for state funding, you will generally need to be responsible for funding.

However, with careful planning it may be possible to structure your finances without having to worry about the future.

immediate care plans

Immediate care plans – otherwise known as immediate care annuities – are dedicated tax-efficient financial policies specially designed to cover all, or part, of the cost of your spouse, parent or relative’s care fees. The plan will pay an agreed tax-free amount at regular intervals, directly to the care at home or home care provider, for the rest of their life.

Benefits can increase over the years to help keep pace with care fee increases. a lump sum is required to purchase such a plan and this is calculated individually on age and health.

you may be able to financially benefit from releasing an amount of equity in your home. It’s a realistic way to raise capital, income or a combination of the two while continuing to live in your home.

Despite this recent focus on the funding mechanism for social care, making it a fairer system for ➱ p26

Symponia will be able to advise on both immediate care plans, specific investments and/or equity release. a ssuming that there are no unexpected complications, this process should take between four to six weeks.

care fee insurance

The association of British Insurers has stated that the new cost-cap being introduced by the Government in 2016 is unlikely to generate a pre-funded insurance market for long-term care, despite a ndrew Dilnot’s objective that more people should pre-plan for potential care needs.

This type of insurance has been offered before but with limited success due to lack of demand.

While there is still uncertainty regarding an individual’s future care needs and their associated costs coupled with an unfounded belief that the state provides care free, people are unlikely to take out a pre-funded insurance product to cover long-term care.

lasting power of attorney

a lasting power of attorney (lpa) is a formal legal document that lets you appoint one or more people known as attorneys to help you make decisions or make decisions on your behalf.

Setting up an lpa gives an individual more control over what happens to them should they have an accident or illness and can’t make decisions at that time.

There are two types of lpa:

1 Health and Welfare LPA.

This gives an attorney the power to make decisions about matters such as a daily domestic routine, medical care or life-sus-

taining treatment. It can only be used when the person concerned is unable to make their own decisions.

2

Property and Financial Affairs LPA. This can be used as soon as it is registered, but only with the permission of the donor. It gives the attorney the power to make decisions about money and property, such as managing a bank account, paying bills, collecting benefits or a pension or even selling property including your home.

lpa s can be made through a solicitor or a registration form can be obtained from the office of the public Guardian at www.gov.uk/ government/collections/lastingpower-of-attorney-forms.

The donor needs to sign a certificate to say that they understood what they were doing when they signed the form and that there was no coercion of fraud when the lpa was set up.

Before an lpa can be used, it needs to be registered with the o ffice of the p ublic Guardian which costs £110 and can take up to ten weeks.

If you need help or advice in setting up an lpa, you can contact the o ffice of the p ublic Guardian on 0300 456 0300. p lease note that you can cancel your lpa if it is no longer required or you choose to make a new one.

Enduring Power of Attorney a n e nduring p ower of a ttorney (epa) is the legal authorisation to act on someone else’s behalf in a legal or business matter. However, on 1 o ctober 2007 the epa was replaced by the two types of lpas detailed above.

Case study: Paying For Care at hoMe

Based on clients of the good Care group eric and alma had been married for over 65 years and, since the end of World War ii, they had rarely spent a night apart.

sadly, eric’s deteriorating health meant that a move into a care home seemed an inevitable end to their life together. alma and the family wanted him to stay at home, but knew that this wouldn’t be an easy decision, as eric needed specialist personal care and alma was unable to provide this.

as a potential solution, the family considered having a live-in-carer and they both arranged a meeting with the good Care group. Following a care assessment, a home care package was arranged to meet their needs.

expert advice from symponia to help them explore the best way to fund the care, they talked through the option of equity release with their local symponia member, who suggested that the whole family became involved in the discussions.

exploring an immediate care plan

to help the family gain additional peace of mind, the adviser suggested that they explore the possibility of an immediate care plan. they calculated the income and compared that to the expenses, which had to take account not only of the household costs – which largely remained unaltered – but the care costs of £1,175 each week.

this bespoke calculation left a deficit of just under £22,800 a year which was submitted to the underwriters for consideration.

after assessing eric’s health and mortality, the cost of the immediate Care Plan with a built-in automatic 5% annual escalation was £92,000. eric and alma used equity release to buy the immediate care plan. as their property was valued at over £500,000, the release of equity was just under 18.5% of the total value.

the family also consulted with a solicitor with expertise in equity release who ensured that they understood all the implications of the transaction.

a lasting power of attorney is a formal legal document that lets you appoint one or more people to help you make decisions or make decisions on your behalf

as such, no new epas can now be drawn up. However, one signed before 1 october 2007 and not yet registered may still be registered through the office of the public Guardian.

The epa gives the attorney the power to sell property, manage financial affairs, sign documents and make purchases on behalf of the individual, but not to make decisions about personal care and welfare.

Deputyship under court of Protection

The Court of protection is a specialist court for all issues relating to people who lack capacity to make specific decisions. The court makes decisions and appoints deputies to make decisions in the best interests of those who lack capacity to do so themselves.

a deputy would take control of a person’s affairs in the absence of an lpa/epa or where you have reason to believe that someone is in

immediate danger or at risk if you did not act on their behalf. For further information or to download an application form, contact www. gov.uk/court-of-protection.

The court will usually issue your application within one week of receipt and you will receive a letter telling you what to do next.

For standard applications to the court, you should expect to wait to be notified of the court’s decision within 16 weeks of them receiving the application.

a pplying to the court costs £400, which must be paid at the time of making the application. The applicant may be exempt from paying the fee if they are in receipt of certain benefits.

you can send urgent enquiries via email to courtofprotectionenquiries@hmcts.gsi.gov.uk or call 0300 456 4600. There may be an emergency situation that needs an urgent decision, such as when you want to stop someone who

too often, we believe that the person concerned can ‘soldier on’ or we do not wish to face the likelihood of their deteriorating health

lacks mental capacity being removed from where they live. In these situations, you should ask to speak to the ‘Urgent Business officer’, who will discuss the case with you and make arrangements to receive your application and present it to a judge.

In conclusion, don’t ignore the potential care need for a spouse, partner or other family member.

Too often, we believe that the person concerned can ‘soldier on’ or we do not wish to face the likelihood of their deteriorating health.

Warning signs

We are all invariably busy in our own lives that we tend to put off making a decision on care until we are faced with an emergency. look for the warning signs; for example, an increase in the level of forgetfulness where the individual wanders out of the house and can’t find their way home; an

increase in falls around the house; not eating or drinking properly leading to weight loss or loneliness and depression.

a s a first action, I would strongly recommend carrying out research into possible care even if you don’t need it for months or even years.

Consider the options of hourly care, live-in care or a care home. e xplore the costs involved and how to fund care over several years.

Review the need for a l asting power of attorney. Discuss these matters among the family and in particular with the person who may need care to ensure that, wherever possible, they are comfortable with and participate in choosing care for themselves. listen to their opinion and act accordingly. 

Chris Miller (left) is head of development at The Good Care Group, London

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

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

Dear Reader,

Subscribing to Independent Practitioner Today is the only way you can be sure you will see every issue. Don’t risk missing out. Our personal subscription for doctors and managers is only £75 a year and £200 for organisations. But you can cut this to just £60 (only £36 after tax for higher-rate payers) and £175 respectively if you pay by direct debit. So take advantage of this offer now for our unique business magazine dedicated to supporting you in your private practice. We’re confident your subscription will repay itself many times over!

Editorial director

Name and full address of your bank/Building Society

Name(s) of account holders Branch sort code

banks and building Societies may not accept Direct Debit instructions for some types of account

Debits

Banks and Building Societies may not accept Direct Debit instructions for some types of account To: The Manager

post your application (no postage required – uK only) to: independent practitioner today Subscriptions Department, FreepoSt, po box 36, plymouth, pL1 1br

Please post to: Proact Ltd Subscriptions Dept., 12 Mary Seacole Road, The Millfields, PLYMOUTH PL1

or subscribe online at www.independent-practitioner-today.co.uk

ways not to reach your audience

Surgeon Mr dev Lall believes there are seven particular areas to be wary of when you are trying to grow your private practice in 2015…

Marketing, to many people, is not only something of a black art but also very ‘hocus pocus’ in nature.

a bit like alternative or complementary medicine, it all seems a bit ‘pseudo’, with no evidence base or underlying common sense or basis in reality.

there appears to be few, if any, rules and the only commonality you seem to find are terms flying about the place such as ‘engagement’, ‘branding’ and ‘getting your message out there’.

a nd yet the truth is actually quite the opposite. t here are a number of well-founded, evidence-based principles of human behaviour that underpin successful advertising and marketing.

Does it work?

i ndeed, good marketing is actually pretty scientific, with controlled trials, statistical analysis and so on.

e ach marketing effort is, or should be, evaluated for efficacy – in other words, did it work? Did it generate more business? even more pertinently, did it generate more income than it cost?

When creating your marketing strategy, it is equally important to consider how you will measure and track its effectiveness when you are trying to grow your practice.

Like homoeopathy, crystal therapy and other complementary therapies out there, the common problem from which i would

the aim of your advertising is to get the potential patients out there to lift the phone and book an appointment

argue the seven marketing areas below suffer is an inability to reliably measure, track and demonstrate the efficacy of approach.

1 image advertising

i think this is probably one of the worst possible ways to market anything. the idea is that you

use images to attract attention of the potential customer and to associate your product/service/ business with certain values.

Frequently, companies use unexpected images that catch you by surprise in their image advertising, such as a red umbrella in a sea of black umbrellas, or a brightly

coloured penguin in a line of black-and-white penguins.

Such strategies, while good for big advertising agencies because they can be fun to craft and even win awards, are unlikely to be of any value in growing your medical practice.

2 brand advertising

Brand advertising is very closely related to image advertising and the idea is again to create a unique name and perception of a company through advertising campaigns and business material with a consistent theme.

So you might have a nice logo, a consistent use of imagery and colours on your website, stationery and advertising.

While it is a good idea to have consistency purely from an aesthetic perspective, this is actually of no value when it comes to growing your private practice.

Marketing companies love brand advertising – but, again, the problem is one of demonstrating that it has worked and actually brought in new patients for you.

For this reason, the best strategy is always direct response marketing. in your advert or marketing piece, you ask viewers to do something in particular: say, to ring a dedicated phone number.

i n this way, there can be no doubt that the patient came to see you as a direct result of that marketing approach.

if you are looking for assistance in growing your practice and the response you get focuses on ‘branding’, then run away. Fast.

3 logo

ah, the logo. Fun and nice to have, but completely pointless. Do you ever take a company’s logo into consideration when deciding whether you are going to do business with them?

no. and neither does anybody else. Only three people in the entire universe have any interest in your logo. You, the guy who designed it for you and your mum. and she’s only pretending because she wants you to be happy. Forget about the logo.

4 social media marketing there are two ways you can promote your private practice on social media.

the first way is with paid advertising on platforms such as Facebook and Linked i n. Paid advertising like this is a great idea when targeted correctly. i t is effective at generating patients, is scalable and trackable, and because of this, you can show that it is generating more income

for you than it costs to implement. that is not what i am referring to here, though. the pointless social media marketing i am referring to is Facebook ‘likes’, fan pages, ‘tweets’ on twitter, blog posts, Pinterest ‘pins’ and the like.

While these can be made to work in some circumstances, i would emphasise the ‘can’ and ‘some’. in general terms, it is a lot of work for unpredictable and untrackable outcomes and with little, if any, demonstrable benefit. and while it is free to perform for yourself, it is also a massive time sink and distraction from other more important activities such as treating patients and marketing your business in ways that are proven to work.

5 search engine optimisation

good old SeO. When you search for any content on google or any of the other search engines, you get two results: a dverts or ‘Sponsored Listings’ at the very top, right-hand side and bottom of the page; and natural search results which comprise the main body of the results shown.

the higher up you appear in the natural search listings – ideally in the number one position on page one of the search – the more likely the person performing that search is to visit your website.

this, in turn, increases the chance they will call you to book an appointment and become a patient. this is, of course, a good thing. take the results of a g oogle search for ‘glaucoma’ – see screengrab below. t he results in the green box are natural search results, those in the red boxes are ‘sponsored listings’ – in other words, adverts.

the principle behind pay-perclick advertising is that you pay the search engine to get your website to the top of page one when people are performing relevant searches.

the idea behind search engine optimisation is to try and get your website coming as high up on page one of a g oogle search as possible without paying google to do so – to come to the top of the natural searches.

t here are several problems to overcome, not least of which is obvious from the example. there are 2,850,000 web pages relevant to the search term ‘glaucoma’ and getting to the number one spot with 2,849,999 competitors, many of which are trying to do the same, is difficult, unpredictable, can take months and is expensive.

and even if/when you do get to the top of the search rankings, the amount of patients you get as a result can be surprisingly low, because the ‘quality’ of the clicks is low – in other words, visitors to your website are not necessarily interested in becoming private patients.

and never forget that the visitors you do get could all disappear literally overnight when google next changes the way it ranks web pages.

6 your website

Paradoxically, your website could be helping very little to grow your practice.

t hat is because most doctors’ websites are very poorly designed. t he primary purpose of your website is to generate private patients, and most are simply ineffective in doing so.

the key thing is to drive visitors to contact you by phone or email

to make an appointment. to that end, every aspect of your website must be designed to encourage people to do that one thing. Most consultants’ websites are either the online equivalent of a glossy brochure or a CV. neither is effective at generating patients.

7

marketing without a ‘power calculation’

t he most important thing with any marketing strategy is to get your name and practice out there in front of people who have the potential to become patients of yours.

not only that, but it has to be financially worthwhile for you. Yes, it sounds obvious, but you would be amazed at the number of times people make a mess of this one.

When you are doing research, you have to consider the incidence and prevalence of a given condition, the sensitivity and specificity of the test for that condition. then you perform a power calculation to inform the study design, duration and numbers of subjects required. in the same way, you also need to consider comparable variables when it comes to creating a marketing campaign. Sure, the assessment is generally much simpler, but you do have to do some basic sums and so inform your strategy before you start. and just like clinical research, you need a defined, measurable end point. How do you know if the marketing approach you have chosen is working? You need to be able to track and measure the method by which patients find you.

How many patients has the campaign generated? How much income does this equate to? How does that compare with the costs of the campaign?

and when you take in the lifetime value of each patient in terms of income for you, how much are you willing to spend on marketing per patient generated? Yes, it is all common sense when you think about it, but –sadly – most people don’t think about these things at all. 

Mr Dev Lall is an upper-GI surgeon and runs a specialist private practice consultancy www.PrivatePractice Expert.co.uk

Celebrating our 22nd year in Business

www.medbc.co.uk

Come and join the hundreds of other consultants who use MBC and experience the following benefits:

• Bad debts of less than 0.5%

• Increase in net income by up to 25%

• Freedom for the consultant and secretary to focus on the medical side of the practice

• 24/7 online access to both your financial and practice management data

• Having a service tailored to your needs with your own Account Manager

• Our fees are only charged on the money that we collect for the practice and NOT on what we invoice which means we share the same objectives

Special offer:

To celebrate our 22nd year in business we are for a limited period of time offering all new clients an introductory discount of 20%*

Further information:

MBC – More than just a billing company

Please visit www.medbc.co.uk for more detailed information or phone 01494 763999 and speak to Garry Chapman to establish how we may assist your practice.

*Terms and conditions apply

Hospital’s first steps

The £95m Kent Institute of Medicine and Surgery (KIMS), the county’s first and only tertiary care hospital, opened doors to its first patients in the Spring. Leslie Berry reports on its progress

Independently-owned , patient-focused and clinician-led, KIMS offers private healthcare services as well as services to the nHS.

It will provide high-quality complex procedures and acute care in areas such as cardiology, cardiac surgery, neurology, neurosurgery, complex orthopaedics and surgical oncology.

the hospital has one of the largest cardiology departments in the UK and is the first and only institute in Kent equipped to carry out open-heart surgery.

Complex neurosurgery is also available for the first time in the county, as is reconstructive surgery, made possible by the most sophisticated imaging and operating departments in southern england.

In addition, complex orthopaedics, surgical oncology and routine elective surgery are available.

‘ to open a large organisation from ground zero is a complex task, and one I believe we have managed well,’ says dr Anthony Hammond, chairman of the KIMS Medical Board.

performing well

‘ yes, there have been teething problems, but they are milk teething problems; nothing has really bitten us at all. the theatres are up and running, as are the diagnostics, the day wards, the HdU and ItU units and the spinal surgery team.

‘the building is performing well both technically and as a patientcentred environment. the clinicians who have started work here report very positive experiences of the clinical services we offer in KIMS.

‘ t he feedback we are getting from patients has all been very positive and we are already hearing about patients asking to be referred to KIMS because of what they have heard about us.’

Some 180 consultants have practising privileges at the hospital and, by the winter, the hospital says more than 100 of them had started working there.

dr Hammond adds: ‘our administration processes needed building from the ground up. As always, the devil is in the detail and this takes a little time to get right. But we are aware that this is probably the most public-facing side of our business and we are working hard to implement pro-

cesses that enhance the patients’ experience.

‘But the big picture is looking very good. we have good people working very hard and who are focused on making patients better.’

Medical director dr Chris thom is equally positive, while acknowledging a slightly slower than anticipated ramping up of activity initially.

Complex hospital

‘we have safely and successfully planned the opening of an incredibly complex hospital,’ he says.

‘Activity is picking up nicely and the patient experience, as reported to us, has been very

good, as has that of the consultants practising here.’

He says that, at the outset, patients were coming to KIMS that would otherwise have gone to other local providers, such as the private BMI and Spire hospitals in Maidstone and Chatham.

‘the next stage is to start bringing in work that would otherwise have gone to a range of london hospitals,’ d r t hom adds. ‘ we have already begun that process with spinal surgery, brought here by a team from King’s, and cardiac interventional cases in our new robotic catheter labs.’

phase 1 of KIMS has generated approximately 180 whole/fulltime-equivalent jobs. t hey inc -

The entrance at KIMS Hospital, near Maidstone, which opened for both NHS and private patients in April

lude clinical professionals of all disciplines, hospitality personnel, porters, security and reception, building and grounds maintenance, It technicians, administration, financial and procurement

KIMS has plans to develop two further phases that may include bespoke facilities for rehabilitation and oncology services.

Frustrated plans

A new planning application will be needed, as the original approval would have lapsed for these two plots. t he plan is to introduce future phases of development over a ten-year period.

Chief executive Jayne Cassidy explains that plans to treat nHS patients at KIMS were being frustrated by nHS england’s moratorium on recognising new providers and the local clinical commissioning group’s inability to contract

new Any Qualified providers outside of the commissioning year

‘we have been, and continue to be, pressing n HS e ngland and local commissioners to talk to us about what we can offer,’ she says.

‘Meantime, we are carrying out spot theatre work for local n HS trust hospitals to help them manage waiting list breaches, and we are in the planning stage with other trusts to assist with winter pressures and support the local critical care network.

‘Since the KIMS concept was born, the aim has been to provide a high-class tertiary hospital serving private and n HS patients across Kent, east Sussex and South east london and that continues to be our aim.

‘there is still work to do, but we have made an excellent start and the clinical and non-clinical teams continue to build on that.’ 

...cuts into lost fees!

“MidexPro thinks like a doctor, not a computer exper t”

All you need to run your private practice including document management, diary, clinical data, even test ordering and lab reports from TDL.

From paper billing (incl VAT) to electronic billing (EDI) to management of bulk purchase contracts.

Grow seamlessly from a small solo practice through to a large group practice, remote access network system

MidexPro is the cost effective practice management system with support second to none.

Free download of the full working package (30 day limited) from www.midexpro.com or call for a CD.

Try it for yourself with no sales pressure.

“MidexPro

has revolutionised our lives; it is just so easy”

Chief executive Jayne Cassidy

The hospital boasts one of the highest-resolution PET/CT scanners

The ‘living wall’ at KIMS Hospital

whAT 2015 mighT bRing

A prophet’s warning

Sean Sullivan (pictured above) is one of the UK’s leading business transformation specialists with a strong reputation for tackling challenging healthcare assignments. We asked him to look into his crystal ball and predict what lies ahead for the sector

warning

Sean Sullivan gained national recognition as Turnaround Pract itioner of the Year 2014 due to his work for Castlebeck – the owners of Winterbourne View, the private hospital near Bristol that was forced to close after a BBC TV Panorama programme in 2011 revealed widespread abuse of patients.

This is alongside his other accolades, including those from the Institute for Turnaround.

Sean works with both private and public sectors, including investors and lenders. We caught up with him in London and asked him to look into his magic crystal ball and give us his business forecasts for healthcare in 2015.

Short term: next three to six months

No service provider can stay at the zero price increase plateau they have been on. Over the New Year and certainly by April 2015, we will see a slew of price increases from the private sector into the NHS and local authorities: 2-4% looks likely.

With greater than 50% of NHS trusts – both foundation trusts and trust development authorities – now facing stressed situations, expect to see your own NHS trust exert downward pressure over an ever widening range of situations to keep on track with both financial and operational targets.

When it comes to public and private sector financial and operational restructuring, beware the ever-growing army of well meaning, but unqualified turnaround wannabes who are having a go at grappling with inexperienced hospital clients.

No special pleading here, but there is nothing wrong in asking for their bona fides.

Longer throughterm: to 2016

Coming to a lender for your business soon: a softer, more cushioned approach to dealing with the fall-out from covenant breaches and repayment failures. Banks will be increasingly seeking to actively encourage client transformation rather than the more traditional threat of waving a foreclosure notice.

Why would the above point be of interest? Well, if you or your business has debt of any size and with the Bank of England base rate being static at 0.5% for all this time, any upward interest move after next year’s election may cause some pain.

Two interest rate hikes may start to prove fatal for ‘zombie’ entities hanging on with whatever appendages they have.

Expect to see a number of exits – or at the very least some reworking of debt – by those in this category unable to withstand a return to more normal interest rates.

Expect upwards pressure on wages. If the annual NHS wage increment under the NHS’s Agenda for Change and the Knowledge and Skills Framework do not do it – and the NHS pension can be substituted – then prepare for an ever increasing number of nursing and paramedical staff choosing to move over to the private sector.

By this time, we should be seeing a significant increase in private GP-owned and run walk-in GP practices on the High Street with £50-£120 per consultation and minor surgery fee range. GMS and PMS GPs, do you see yourself here?

We should be seeing a significant increase in private GPowned and run walkin GP practices on the High Street with £50£120 per consultation and minor surgery fee range

looking to install their own CCTV to head off trouble at the pass as quickly as they possibly can. This will, of course, have to be limited to public areas: receptions, dining, sitting rooms and corridors. As we all expect, stories of this flavour are not finished yet.

Sooner or later

We should, by this stage, be seeing a result in all the speculation that US investors are focusing on the UK healthcare market with a couple of purchases coming to realisation, possibly at either ends of the quality spectrum.

Those involved in aspects of providing residential care who consider themselves at risk of exposé by secret filming will be

Somebody is going to see the wisdom in funding a meaningful dementia service in the UK that is more than merely ‘elderly care plus’, making full use of the fastadvancing technology and understanding the concept of being fairly paid for a service fairly delivered.

The increasingly sorry affair that is domiciliary care contracting will finally find its real value to society with more realistic expectations for provision of services, time with users and travelling arrangements for carers.

New law will backfire

The Medical Innovation Bill is an unnecessary risk, warns Dr Marika Davies. Here she argues that the proposed law will greatly increase patient expectations and risk damaging the doctor-patient relationship. And pressure will be put on doctors to go against what they consider to be in their patient’s best interests

It Is natural that those who have very sick relatives or friends, suffering with what is thought to be an incurable disease, would welcome innovative treatments that may save the life of a loved-one.

the Medical Protection society welcomes the debate the Medical Innovation Bill has ignited, but we believe that because innovation is so important, further research is needed to determine whether there are barriers to innovation and, if so, how they may be overcome.

In a modern medical system, we must ensure responsible medical innovation can happen. If there are barriers, they should be removed. But we are not convinced that this proposed bill is the way to do it.

t he Medical Innovation Bill aims to encourage responsible innovation in medical treatment and to deter innovation that is not responsible.

the bill has public support and its stated purpose seems sensible, if not commendable.

It is supposed to encapsulate what is already best practice. so why have we and many others, including Cancer Research UK, raised concerns?

t his bill would mean that if a doctor wishes to depart from the existing range of accepted medical treatments for a condition, then they must obtain and take into account the views of at least one doctor with the appropriate expertise and experience, relevant to the condition.

treatment cannot be carried out for the purpose of research and must be in the best interests of the

patient. the bill applies to both the NHs and private healthcare.

As the bill progresses through Parliament, amendments have been proposed that we believe could introduce safeguards and limit any risks created.

For instance, Lord saatchi has made a commitment to consider exclusions from the bill which we welcome as an important step towards greater clarity.

The bill is not necessary

We are not aware of any evidence that doctors are prevented from innovating because of a fear of litigation.

Current law allows doctors to undertake responsible medical innovation. A doctor who tries an unproven experimental treat -

ment may do so provided they are satisfied that it would be supported by a responsible body of medical practitioners (the Bolam test) and would withstand logical analysis (Bolitho).

this does not mean a treatment needs to have been used already by others, simply that there is a level of professional support for it that has a logical basis.

If a need for more clarity is warranted over the current law, this should be addressed with education and not further law-making, which will only complicate matters further and risk increasing litigation – see the case study on the opposite page.

t he bill adds unnecessary bureaucracy to current good medical practice. At present, if doctors

wish to depart from NICE guidance, they may do so on the basis of their professional judgement, in line with the Bolam-Bolitho tests. GMC guidance, Consent: patients and doctors making decisions together (2008) , recognises and allows for innovation. t he bill may require future innovative decisions to be referred to colleagues as a matter of course, with more hurdles to treatment than there are at present.

Doctors may be falsely reassured by Lord s aatchi’s claims that if they follow the process outlined in the bill, they will be supported and protected by the courts. this is incorrect in law: it will always be open to patients to challenge doctors through the courts and it is simply not possible for the bill to give doctors reassurance ahead of any court decision.

If there are barriers to medical innovation, it is likely that a number of complex and interrelated causes, not just fear of clinical litigation, are the cause.

t hese should be investigated and addressed in a sensible and proportionate way, not by simply introducing new laws.

The bill has risks

Independent practitioners will face particular challenges if the bill becomes law. In light of the high media profile, the expectations of patients may be higher, and the process of departing from standard guidance potentially more burdensome.

t he bill may, in fact, increase litigation over the meaning and

scope of the bill, decisions not to try innovative treatments or failure to warn of risks.

there is also a risk that patients will misunderstand and overestimate what this bill would do. Lord s aatchi claims the bill will ‘empower patients to demand that every possible route should be tried’.

But this will give patients false hope and may put pressure on doctors to provide inappropriate treatments that go against their medical judgement.

sadly, the reality of most cases where the bill could apply is that there is seldom time to try all possible treatments, neither is there likely to be funding for these. the use of one innovative treatment may also preclude the use of another.

t he bill gives the impression that all innovative treatments are readily available, and that all doctors have an understanding of

every possible treatment with an obligation to provide them once the legislation is passed. this is not the case, and it will be for the doctor to explain otherwise and risk damaging the doctorpatient relationship. Potentially, the bill could lead to fewer patients taking part in clinical trials, thus holding back responsible innovation and limiting risks.

Issues of funding and the possibility of a complaint to the GMC remain and so the bill may not achieve its intended aims of increasing innovation.

the proposed legislation is open to interpretation and the risk of abuse, which will put patients who are desperate to try anything at risk of harm from unsuccessful, ineffective and possibly harmful treatments. 

Dr Marika Davies (right) is a medico-legal adviser at the Medical Protection Society

this will give patients false hope and may put pressure on doctors to provide inappropriate treatments that go against their medical judgement

a case in point

a 23-year-old patient with stage iii cervical cancer sees a gynaecologist privately, attending with her parents devastated by the diagnosis. they have heard of the Medical innovation Bill and want to discuss an experimental drug they have read about on the internet.

the gynaecologist is sympathetic. she has many years of experience and a special interest in this condition, and so spends time with the family discussing the patient’s care.

However, to the family’s disappointment, she is not prepared to prescribe the drug they want: she considers there is insufficient evidence to suggest the drug could have any beneficial effect, that there are considerable risks to the patient and that overall the treatment is not in the patient’s best interests. the doctor receives a letter of complaint soon afterward and the family refuses to pay her fee, as they are dissatisfied with the service she provided. the patient’s condition deteriorates and she dies a few months later. the parents bring a claim against the gynaecologist alleging that her failure to consider innovative treatment denied their daughter an opportunity to treat her cancer.

Making bad debts good

Chasing bad debt is always ethical for independent practitioners, argues Martine Reuben (right)

We often hear from our consultants that they do not feel ‘comfortable’ chasing unpaid invoices. the key to dealing with this problem is not whether you chase these patients, but how you chase these patients.

What we refer to as ‘gentle chasing’ is always appropriate. But what is gentle chasing? for us, this is an initial phone call to introduce ourselves as the accounts manager and explain that there is an outstanding invoice.

t he manner has to be nonthreatening and soft – more of an inquiry to check they are aware of the debt. Always make a plan to speak again on a particular day and time and make sure you constantly follow this up.

Most consultants would rather write off a payment than get involved with chasing for the money. We always advise our consultants that ‘no debt is a bad debt’ because everyone has the right to be paid for the service they provide.

Clearly, this simplistic statement has many grey areas when it comes to outstanding invoices for consultants.

o ften the situation is very sensitive. the patient may have recently undergone a life-threatening operation and, in some cases, the patient may be deceased. We are often faced with such a situation and certainly do not see this as an occasion where gentle chasing is inappropriate. on the contrary, is not chasing for pay-

ment an admission of responsibility?

Just because something feels uncomfortable, it doesn’t make it unethical. In this particular case, our advice is to wait a respectful length of time and then call the next of kin directly to express your sympathy and give a gentle reminder.

often you will need to wait for probate and go through a solicitor, but it is worth sticking with the process, as payment will eventually be made.

As a general rule, there is absolutely no need to threaten patients with debt collectors. If chasing is handled correctly, then this need never be an option.

Having a third party on hand, who is emotionally unattached to the patients, is a very cost-effective way to handle this uncomfortable area.

Reminder phone calls to a patient’s mobile phone that are consistent, gentle and friendly are incredibly effective. Ask for a BACS transfer or take a credit card payment over the phone, rather than asking for a cheque to be sent.

Most importantly, always get a mobile phone number and an email address at the initial booking and on the hospital registration form. We find that those who have the best cash flow are those who take the most thorough information from the start.

there are five main reasons why patients do not pay invoices:

The patient confuses the consultant’s bill with the hospital bill. When a patient goes to a private hospital, their credit card details are requested, but no payment is taken, as it is used as a guarantee for hospital payment –blood work, X-ray, theatre costs or nurses. t he patient makes the assumption that this covers the consultant’s bill also, so the invoice is discarded.

2 The patient has simply forgotten. Human error prevails and the invoice is put to the back of the drawer with intention to pay that never materialises. t hese patients need a gentle nudge and usually pay immediately accompanied by flowing apologies for the delay.

There is absolutely no need to threaten patients with debt collectors. If chasing is handled correctly, then this need never be an option

Patients are not aware of an excess. o ften insurance companies do not inform patients that some or part of the bill will be the patient’s liability. t he patient is therefore left in blissful ignorance that the full bill has not been covered by the insurance company.

The patient may also hope that they never get chased for the money . . . and, in many cases, they never are.

There is sometimes confusion over private hospitals self-pay package schemes. Private hospitals will often offer a package for procedures, which include either an initial consultation and the procedure or the procedure and a follow-up consultation. often this is not communicated to the consultants, so they, in turn, bill for the consultation without realising the patient has

already paid for this within their package. In this case, payment needs to be chased from the hospital as opposed to the patient. Generally, most invoices are left unpaid due to practice inefficiency. It is impossible to bill efficiently and create good cash flow if the invoicing process is chaotic. Approach private practice like it is a small business and the patients are your customers. You have to take responsibility for taking the proper information from your patient to be able to invoice effectively. this means employing the correct systems and procedures from the very beginning. Ultimately, no independent practitioner – no matter which specialty they practise in – needs to assume a financial risk when treating a patient. 

Martine Reuben is co-owner/director of medical billing company MediAccounts

Upright Positional MRI

A new concept providing real benefits to patients

• Weight-bearing scans and variable patient positioning enables a more precise diagnosis

• Truly open system is a solution for claustrophobic patients without compromise in image quality

Going

Is it time to ‘rightsize’ your home? Simon Bruce explores why asset-rich doctors may choose to make a move

Taking T he decision to downsize your property is never easy.

But many recent empty-nesters no longer want the responsibility of living in a large property with high running costs and expensive gardens to maintain.

Your choice may be based on logical and prudent thought, but an emotional attachment to the family home can be difficult to assess until the time comes to leave it behind.

according to research, around 55,000 households downsize each year, releasing equity of around £7bn.

a lmost half of home-owners who plan to sell in the next three years are looking to move to a smaller property. There is even a new marketing term – ‘rightsizing’ is now used to reflect that people may have different housing needs at various life stages.

a t the same time, many have enjoyed substantial hikes in the value of the family home, becoming asset-rich yet relatively cash and income poor in comparison to working years.

The majority of your wealth is usually tied up in illiquid bricks and mortar – your main residence may be a good wealth accumulator, but is less practical as a source of income when your combined nh S salary and private practice stops.

in selling up, many consider a more convenient property, with smaller annual household bills,

Your main residence may be a good wealth accumulator, but is less practical as a source of income when your combined NHS salary and private practice stops

down

and use the profits to supplement pensions and other investment income.

Whether this means keeping a cultural bolt hole in the capital plus a rural retreat, or a ‘lock stock barrel’ move to the coast, the options are only really as limited as one’s imagination.

Your energy and drive may be more bountiful in early retirement with plans for frequent business class trips to far-away places, but the cash needed to enjoy a higher quality of life could be locked in a high-value property.

Delaying the decision for ten or 15 years can mean you have less control over the eventual move and less time to reap its benefits.

Understanding

your annual running costs

nhS Pensions, when being paid out, increase annually by the Consumer Price i ndex (CP i ), which is a composite index of basic goods and services compiled by the government.

The annual pension increase is linked to the September CPi figure, but is not subject to the ‘triple lock’ protection awarded to the state pension.

i n 2015, nh S Pensions will increase by just 1.2%. When compared with the rapidly increasing costs of the goods and services typically consumed by a Cavendish client, the CPi really bears no resemblance.

Leaving behind familiarity and 30 years of memories can be an emotional wrench

in a low-interest-rate environment, this means that the level of personal funds required to support the good life is often underestimated.

When income is not a concern, there is less pressure to really understand what we spend, whether this is on the house, the kids or on holidays. a side from the very wealthy, the reverse is often true in retirement where savings cannot be easily replaced once spent.

Time to reflect?

however, while ‘rightsizers’ might celebrate the liberation of their less encumbered lifestyle, leaving behind familiarity and 30 years of memories can be an emotional wrench.

i ndependent think-tank the i ntergenerational Foundation conducted a study into the motivational factors behind downsizing for those aged 65-75.

i t showed one of the biggest concerns for would-be movers is their attachment to material possessions – particularly when connected to bringing up their children – and specifically, how these might be accommodated in a smaller property.

Those who had taken the leap had endured tough lessons about their personal effects during the moving process; they may treasure them, others may not.

Those questioned were also apprehensive of sharing a smaller

living space with their partner –particularly if both were due to retire with much more time to spend at home – and worried if there would be room for the grandchildren to visit. i n reality, downsizers saw no change in their ability to enjoy family occasions.

Helping the children

For many senior medical professionals, a potential factor in downsizing is a desire to make an altruistic gesture – unlocking funds to help with an offspring’s property purchases, whether this is a first flat or moving up the ladder to accommodate a growing family.

Older ‘boomer’ generations now hold the concentration of housing wealth as few twentysomethings have the financial resources or income to raise a big enough mortgage on their own.

Former generations may have climbed on the property ladder with loans of just three times their salary, but today the ‘bank of mum and dad’ is often left to fund

the considerable deposits needed, particularly in London.

First-time buyers – dubbed ‘generation rent’ – now receive £18bn of parental help with their deposits, up from £8bn five years ago.

Tax liabilities

Reducing your exposure to inheritance tax ( ih T) could also be a driving factor in choosing to downsize at the right time.

The tax is levied at a fixed rate of 40% on estates worth more than £325,000 per person or £650,000 per couple. any gift you make to your children will be exempt from inheritance tax if you live for a further seven years.

i n this situation, you must ensure your future security is still your number one priority. Do not be too quick to give away the roof over your head. Will you have enough funds to buy a suitable property and still make the most of a modern, ‘fruits-of-yourlabour’ retirement?

e arlier last year, London’s mayor Boris Johnson called for older people who downsize from

their family home to be exempt from paying any ih T on their profits in a bid to help solve a housing shortage in the capital. Other political parties are still considering a mansion tax on high-value properties, which, if eventually introduced after next year’s general election, would encourage movement in this prime housing market.

Considerations

The opportunity to downsize must be assessed as part of your overall retirement plan. h ow much equity will be released and what level of income could this create given current interest rates? h ow will the agents’ fees and stamp duty detract from your lump sum?

Your life continues to evolve –preparing early for a change and leaving enough time to adapt will surely help you to flourish in new circumstances.

Furthermore, for the adventurous, there is always the opportunity of downsizing to a boat – as we congratulate Sir Robin knox-

Johnson (aged 75) completing one of the fastest and toughest single-handed yacht races: the transatlantic Route du Rhum from St Malo in France to guadeloupe in the Caribbean. 

Simon Bruce (right) is managing director of Cavendish Medical, specialist financial planners helping senior consultants in private practice and the NHS

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

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

Ethical matters for cancer specialists

While dealing with an ethical dilemma, doctors should also take into account how their actions might affect a vulnerable patient. MDU medicolegal adviser Dr Sally Old (left) considers two private practice scenarios involving patients who have been diagnosed with cancer

Take Control

Dilemma 1 GPs have missed several cancers

QA designer in his 40s came to see me because he was concerned about a mole on his shoulder that had been bleeding. He had seen his GP the previous month, who told him that this was probably due to his rucksack rubbing on his shoulder, but he had not been reassured and self-referred to me for a second opinion.

On examination, the mole was asymmetric with a raised border and patchy in colour. Histology later confirmed that it was a malignant melanoma.

I’m worried that the GP could have overlooked such obvious symptoms. It’s a particular concern because the same practice referred another patient last year with a suspected melanoma, but only after she had returned to her GP several times.

What action should I take and should I raise a concern about this practice? Should I tell my patient to make a complaint?

AIt is understandable that you feel troubled about this and, of course, all doctors have a

duty to raise concerns if they feel patient safety is being compromised.

In the first instance, you could write to the practice, explaining that you wanted to notify them of the diagnosis, and diplomatically explain your concern that this diagnosis could have been missed. Make sure you ask them for a response, as you have a responsibility to ensure that your concern has been addressed appropriately and keep a record of your concerns and the action you have taken.

The practice should have a process for investigating adverse incidents and learning lessons from what went wrong. In this case, you might expect them to carry out a root cause analysis of the incident and, if necessary, an audit of the dermatology cases to confirm that no other patients need to be called back for review.

The doctor involved might also need to undertake some additional continuing professional development in relation to der

“

matology. Finally, the practice would usually be expected to notify the Care Quality Commission about any incident that led to the shortening of a patient’s life expectancy.

If you are satisfied with the practice’s response, it would be reasonable to leave the matter for them to manage.

If, however, you receive no response or an unsatisfactory one and you remain concerned, then you could write to the NHS England Local Area Team, who have the power to investigate these concerns and take action if they deem it necessary.

K&D offers a new type of personal language for self expression of feelings and thoughts by children and

Dilemma 2

She’s declined a chaperone offer

Q“ K&D offers a new type of personal language for self expression of feelings and thoughts by children and parents following family breakup or divorce and during the period of positive reconstruction of their new

I am treating a woman with metastatic lung cancer. She has just called to arrange an appointment after returning from a business trip because she has been experiencing back pain and her foot drags when walking.

Who We Are

Ekel Ltd is a UK based industry leader, developing interactive story based animation apps

I suspect she may have cauda equina syndrome and explained that I might need to carry out a rectal examination to be sure.

Kids and Divorce. K&D helps children and parents negotiate the challenging transition following family breakup or divorce through to family reorganisation.

Ekel’s ﬁrst app is called Kids and Divorce. K&D helps children and parents negotiate the challenging transition following family breakup or divorce through to family reorganisation.

ﬁrst app is called Kids and Divorce. K&D helps children and parents negotiate the challenging transition following family breakup or

that you broach the subject sensitively so she does not feel pressurised into something that she would not otherwise have chosen. However, ultimately, you need to prioritise her clinical needs over your own feelings. Bear in mind that the patient might require urgent referral for an MRI scan, so any delay would almost certainly adversely affect her health and comfort. This means it would probably not be appropriate to refer the patient to a colleague who would be prepared to proceed without a chaperone.

If you carry out the examination, make a careful record of your reasons and note that a chaperone was offered and declined.

Finally, if your practice does not already have a chaperone policy, it is a good idea to produce one for your website or practice literature. This will help to manage patients’ expectations and may make it easier to meet their needs. 

You also have a duty to be open and honest with your patient, but bear in mind you do not yet have all the facts. It is likely he will already be angry and distressed that an earlier opportunity to make a diagnosis was missed. If this is the case, it might be reasonable to suggest that he raises his concerns directly with the practice.

After an incident with an amorous patient a few years ago, I always insist on a chaperone for all intimate examinations, but the patient has now told me that she doesn’t like having someone else in the room. Should I go ahead with the examination without a chaperone, despite my misgivings?

reorganisation.

However, it is important that the patient does not feel the responsibility lies entirely with him, so explain that you are going to write to his GP practice yourself about his diagnosis and ask for his consent. You might also want to offer the patient the chance to speak to a counsellor.

AYour patient’s refusal of a chaperone should be respected, but, clearly, it leaves you in an uncomfortable position, especially given your past experience of a patient behaving in a sexualised way.

You could try explaining to the patient why you want a chaperone present, although it is important

Professor Michael Lewis Executive Chairman, The Riverston Group

Chairman, The Riverston Group

Professor Michael Lewis Executive Chairman, The Riverston Group

The tricks of the

quacks

The prospect of patients with money to spend has historically proved a happy hunting ground for charlatans trying to cash in on the good name of skilled doctors. Leslie Berry uncovers the various fortunes of quacks from bygone eras

Where there is cash available, you can expect criminals – and medicine has been no exception.

Quacks have been in no short supply over the years and in the Victorian era and run-up to World War 1 they enjoyed a heyday.

‘No cure – no payment.’ t hat might even be an attractive marketing line for independent practitioners today.

But this advertising claim cer -

tainly worked wonders for the makers of Figuroids, tablets billed as a ‘gentle, scientific, natural and absolutely safe obesity cure’.

It was claimed they would start a scientific process in the body that would allow the patient to breathe, sweat, wee and poo their fat away.

the man behind the tablets was qualified doctor Dr George Dixon – whose patent medicines busi -

nesses were reportedly making an average yearly profit of £10,500 by 1908. they worked no wonders –and no wonder.

sophisticated advertising

As an analysis by the BMA revealed, the tablets were made up of bicarbonate of soda, tartaric acid, sodium chloride, phenolphthalein, hexamethylinetetramine, talc and gum.

t he perennially successful advertising message that drew young women to these attractively presented pills, observes author Caroline rance in a fascinating new book, is ‘you are not good enough’.

The Quack Doctor, Historical Remedies For All Your Ills , delves into the colourful history of quackery and marketing promotions the charlatans used, and some sophisticated advertising that went with it.

It is largely a bawdy and gruesome story, but often funny and sometimes moving too. t here was London ‘Doctor’ John Gardner, who made a fortune from ‘worm medicine’ in the first quarter of the 19th century. h e convinced patients at his shops in Long Acre and Shoreditch that their every symptom was the result of worms.

Beasts expelled

And his adverts gleefully recounted the various beasts his medicine had expelled from the human body:

‘Worms, from 1 inch to 130 in length, some with 150 suckers; others in the form of caterpillars; another species like woodlice, 12 feet to each, a wolf of the stomach, expelled from a lady at h oxton, who had nearly fallen victim to its ravages!!’.

h is museum bottled and displayed all manner of animals ‘for the education and terror of the potential future patient’. t hey were pointed to the particular beast that was supposedly nibbling away inside them and causing all manner of ailments.

Cures cost thirty shillings (£1.50) – but the specimens, some of them chicken guts and helpings of vermicelli – were, as the author observes, enough to convince patients to ‘do whatever it took to get their unwanted passenger out’.

For matters outside the body, the 1890s saw an advertising boom for commercial arsenic products aimed at complexion.

‘Dr MacKenzie’s harmless Arsenic Complexion Wafers’, advertised in the London press, promised ‘the most Lovely Complexion’ that the imagination could desire, no matter what condition it may be in now.’

there was also an ‘arsenical toilet soap’ under the same brand, introduced sneakily into the market through a personal advert: ‘Dearest Cora, have you noticed how much Georgie’s complexion has improved lately? he has been using Dr MacKenzie’s arsenical toilet soap. have you tried it? It is simply delicious. Yours with fondest love, Martha.’

It proved hugely popular. When shares in the mother company were released for subscription in 1897, the prospectus stated sales had reached an annual 340,000. But nobody died from using the soap and when chemists were taken to court for selling arsenical soaps, the offence was that the product did not contain arsenic.

‘Analysis of samples collected by secret shoppers showed that arsenical soaps contained either negligible quantities of the metal or none whatsoever, and the product could not therefore be considered “of the nature, substance, and quality” demanded by the purchaser.

‘In their defence, the chemists claimed that the soap simply had a “fancy name” intended to appeal to the prevailing interest in arsenic as a beauty aid.’

One chemist came up with the argument that Sunlight Soap contained no sunlight either. h owever, this proved ineffective in his defence and he was fined.

then there was Baron Spolasco, who practised as a physician and surgeon. he claimed his abilities included ‘the Consumptive cured – the Cripple made to walk – the Deaf to hear – the Dying to live –the Blind to see, and every other affection treated incidental to the human frame’.

he sold his own range of patent medicines and, when practising in Bristol, conjoured up business by advertising how difficult it was to get to see him: ‘In consequence of the number of sufferers who

Conditions were often blamed on masturbation or sexual excess, such as intercourse more than once a week

daily crowed around Baron Spolasco’s consulting rooms, he has found it necessary, in order to save his valuable time, to charge an admission fee of 5s, which admission fee, if the patient be poor, will be received as consideration for the Baron’s advice, the wealthy will, of course, have to pay the usual fee of a guinea.’

It was noted that, whoever the patient and regardless of what was wrong with them, in return for 22s 6d, he supplied two pills folded in pink and blue paper, and some powder folded in white paper.

Too embarrassed

Conditions were often blamed on masturbation or sexual excess, such as intercourse more than once a week. the conmen could latch onto these causes and defraud victims of large sums of money for cures – relying on them being too embarrassed to tell anyone.

One notorious practitioner, ‘Dr henery’, instilled fear and shame into young men who consulted him in a state of mental and physical infirmity.

h e wrote: ‘I have found it a work of much time and difficulty

to effect a complete cure – to snatch them from death – from the early graves to which they were hastening.

‘Some of these were afflicted with distressing wasting dreams, nervousness, unfitness for duty or business, trembling, dizziness, restlessness, palpitation of the heart, pains in the loins, and a constant sense of weariness, starting during sleep, failure of memory, frequent headache, dimness of sight, indifference to life, its hopes and pleasures, fear of insanity, and silent wretchedness from fear of impotence. the symptoms in almost all cases are from the ghastly curse – the fatal habit of self-abuse.’

Luckily his ‘Life-Preserving Drops’ and skill with galvanic electricity were available, at a price, for the needy.

Piddle-tasters

Dr Cameron, near Oxford Street, London, in the 19th century was one of the piddle-tasters, or waterquacks.

h is adverts said: ‘No surer method can be found to ascertain the nature and cause of Inward Complaints, than by inspecting and analysing the urine. It is by a sedulous study of this important discharge and its various changes and relations, that after an experience of 25 years, Dr Cameron has been enabled to perform cures when the first names and abilities in the profession have failed.’ the more successful water-doctors were able to use underhand methods to find information out about patients and then present it back to them. they might do this

using a maid who would listen out for useful snippets of information as patients chatted in the wating room and tell the doctor.

Dr Cameron primed patients in the waiting room to take his advice on board, employing chatty people to pose as other patients, get the real patients talking, and say they were suffering from the same trouble but the good doctor’s treatment had already worked wonders.

Cancer ‘specialist’ Maria Owen, a representative of the Ladies Medical Association, conned patients with lines like: ‘If you will trust in me and the Lord, take a few drops from this bottle, and pay me half a guinea down and undertake to pay half a guinea in six weeks’ time, then you will soon be a different woman.’

then she would disappear. the Ladies Medical Association did not exist and her medicine was a solution of vinegar and soap in water.

At other times, she tried to convince the well that they weren’t. In 1890 in Aston, she got cash from a woman whom she told had terminal heart disease and obtained 4s 6d from another woman whose nose had been disfigured by cancer.

‘If I don’t put a new nose on your face in six weeks’ time, I’ll refund the money,’ she told her. No nose – nor refund – ever materialised. 

The Quack Doctor, Historical Remedies For All Your Ills, by Caroline Rance, £12.99 hardback. ISBN 978-0-7524-8773-1

Plan to minimise tax

With the tax year end of 5 April fast approaching, Ian Tongue says it is a good time to take stock of where you are up to and consider any action points before this date

There are many allowances available each tax year and per taxpayer, so it is certainly worth considering your options.

This article looks at a number of key areas and is not a complete list nor does it constitute investment advice. as always, your individual circumstances should be discussed with your accountant or independent financial adviser.

Savings

With the current unprecedented low rate of interest and no signs of rises despite monthly rumblings, savings rates are generally low. Coupled with interest being a taxable income, it makes sense to consider a tax-efficient place to put your savings. For many years, the Individual Savings a ccount (ISa) has been a popular choice, as the income generated is free of income tax and capital growth is free of capital gains tax.

Changes to IS a s early in 2014 now refer to them as a New ISas or NISas. There are differences between the old ISa and NISa, primarily around flexibility.

Previously, you could only invest half of your annual allowance in cash, but now you can decide how much is in cash and how much is invested in stocks and shares. It can be any combination.

The amount that can be invested has increased to £15,000 a year (2014-15) and, importantly, this is per person, so your spouse’s allowance will double it up to £30,000 as a couple. But remember, any unused allowance does not roll over to the next period. Your decision whether to invest in cash or shares should be made following advice tailored to your circumstances. Banks and advisers can provide a NISa, so shop around.

We know the pressure you’re under

There’s no pressure quite like the pressure you face as a consultant. The MDU is run by doctors for the purpose of supporting other doctors – something we’ve been doing for longer than any other medical defence organisation.

When you choose the MDU, you’re not only getting guidance, support and defence from the largest medico-legal team in the UK, you’re putting your livelihood in the hands of people who understand just how precious it is.

For more information visit themdu.com or call our membership team on 0800 716 376.

another avenue you could consider is your current account. h istorically, very low rates of interest are applied to current accounts. But the high street banks are battling for your custom and many offer headline-grabbing rates of interest on your current account.

e ach one has a cap on how much you can have in your current account attracting the higher rate, for obvious reasons. The interest applied to accounts such as these is taxable and it is important that you declare this to your accountant each year to include on your tax return.

investments

There are a number of tax-efficient vehicles to invest in out there, with the most common ones being Venture Capital Trusts (VCTs), e nterprise Investment Scheme (eISs) and a newer Seed enterprise Investment Scheme (SeISs).

These types of investment allow an income tax deduction based on the amount invested. There are limits to how much can be invested and the tax relief ranges from 30% for VCTs and e ISs to 50% on SeISs.

These types of investments are generally riskier than others and the schemes were introduced to encourage investing in businesses in the start-up and growth stages of their life. It is important that the risks are explained fully.

There are others types of investments and schemes available, and many of them can carry significant risk for the potential benefit of significant tax relief.

hM revenue and Customs has well publicised new measures to tackle tax avoidance and many aggressive tax avoidance schemes have been shut down. This is a specialist area and a full consideration of the risks is essential. a s always, it is vital that any

investing activities are discussed with an appropriately qualified professional adviser who is authorised to provide such advice.

pension

Pensions for doctors has been a particular hot potato for the last few years with soaring contribution rates, proposals to make members work longer and potential watering down of the benefits.

Coupled with the above scheme changes, there have been important changes to the tax relief offered on annual pension contributions and the overall amount that a pension pot(s) can reach before a tax charge arises.

The rules are complex, but, at present, you can pay £40,000 a year into a pension scheme and obtain tax relief.

For most workers who are not employed by the N h S or other public sector body, this would be straightforward, as most will be in

‘money purchase’ pension schemes where you are effectively buying an investment that may go up or down.

For those consultants in the NhS Scheme, the pension is not worked out based on what you have put in, but by reference to earnings level and length of service. a significant pay rise from an increment point or clinical excellence award could result in a substantial ‘notional’ contribution being calculated. Thankfully, where you have exceeded the limit, you can look back three years and any unused relief can come to your aid to hopefully extinguish any tax charge.

Due to the complexity of the above, the ability to pay further amounts into a personal pension scheme may be limited. a dditionally, paying into personal pension schemes may breach any pension protection that you may have in place. It is

important that you consult your IFa before making any additional pension contributions.

There have, however, been significant reforms to personal pensions recently, allowing far greater flexibility on what can be done with the funds on retirement.

Previously, the most common position was that an annuity (annual income) was purchased with the funds, but now you can draw down on the fund, subject to certain criteria.

For a spouse who may not have as good a pension in place for their retirement, this may be an option to consider. an adviser can discuss the changes and your own circumstances in more detail.

gifts and gift Aid

Inheritance tax rules allow you to give away £3,000 of your estate each year (not from income). If you have not used the prior year allowance, this can be doubled up

to £6,000. There are certain other special occasions, such as marriage, and the figures are per donor not receiver.

Gift a id is the Government scheme where tax relief is available for both the donor – assuming they are a higher-rate taxpayer –and receiver.

Making a gift before the 5 april 2015 will ensure that you receive the tax relief at the earliest opportunity. For a claim under the scheme to be valid, the recipient must be a UK registered charity.

Asset disposals

each year you are allowed to make gains on the disposal of an asset(s) and not pay capital gains tax, up to an annual limit. For 2014-15, this is £11,000 per taxpayer. as a result, you should consider the timing of disposals to either maximise the relief or defer disposals, where possible, to use the following year’s relief.

There are usually other considerations with capital disposals and if you are considering any, it is advisable to discuss matters well in advance with your accountant.

Dividends

For those trading as a limited company, it is worth considering the timing of dividend payments. It may be beneficial to pay dividends before 5 april 2015 or indeed delay payment, depending on your circumstances. Discuss matters with your accountant well in advance of the tax year-end.

The above covers some of the areas that should be considered in advance of the tax year end of 5 a pril 2015. a s always, taking advice tailored to your individual circumstances is essential.

 next month: A recap on record-keeping

Ian Tongue is a partner with Sandison Easson & Co chartered accountants

doCToR on ThE RoAd: AUdi A8

Like a lounge in

a luxury hotel

Independent Practitioner

Today motoring correspondent Dr Tony Rimmer finds Audi’s largest saloon akin to a hotel on wheels

IT WAS the invitation to my medical school re-union that did it. A graduate of Liverpool, but living near London, meant I had a weekend of travelling.

Taking the train may have been an option, but I was going to pick up an old friend along the way and he lives in the picturesque town of Stamford. So it made sense to go by car.

The mostly motorway trip needed a vehicle that was going to transport us in comfort and could deal with everything our crowded road system would throw at us.

Having recently tested a couple of excellent 4x4 sports utility vehicles (SUVs) that work well for luxury travel, I got to wondering what a normal four-door saloon would be like, given that I would not be needing highly technical

and sophisticated engineering to go off-road.

Like many things in our medical practice, keeping things simple and well suited to the job in hand is not only efficient but satisfying too.

An S-Class Mercedes would do the job and they have only just released the latest version, but it is somehow too obvious.

More subtle

The S-Class is the default chauffeur-driven limousine in London and I preferred something that would appeal more to a private medical practitioner driver/owner. Something a little more subtle. This is where the Audi A8 comes in.

Although the largest current Audi saloon, it is instantly recog-

nisable of the marque looking like a bigger version of the A4 and A6 models.

The conservative looks suit it well and the A8 does not attract unwanted attention; a bonus in this modern world. Stepping inside is like settling into the executive lounge of a luxury hotel. The materials used for the seats, dashboard and door trims are all top-notch and the build quality is impeccable.

Passenger space is suitably generous. As one would expect with a car like this, rear passengers are spoilt.

There is plenty of leg room and you could quite easily sit back and get on with some work if someone was driving for you. However, that doesn’t mean that the driver suffers; far from it.

The steering wheel, driver’s seat and pedals are perfectly placed for comfort and efficiency. The boot is huge and can easily accept three large suitcases with room to spare.

The available engines for the A8 stretches all the way from a 3.0litre turbo-diesel with 258bhp up to the stonking 520bhp 4.0litre V8 in the S8. All come with an eight-speed automatic transmission and Quattro four-wheel drive as standard.

There is a 2.0litre petrol hybrid version available, but this is frontwheel drive only. My test car was the appropriate base 3.0litre diesel model and I was interested by the claimed fuel consumption of 47.9mpg overall. Could it equal this on my trip to Liverpool?

Great control

Well, the first thing that struck me about the car was the smoothness of the ride. Audis used to be renowned as having firm suspension, but this couldn’t be further from the truth with this A8.

Impressively, this is achieved with excellent chassis control. Make no mistake, this is no sports car, but it flows along with great control and steers accurately.

The next thing that struck me was the subdued road noise and near absence of wind noise. Why can’t they do this in all cars? It reduces the tiredness after long journeys significantly and my ophthalmic surgeon friend and I arrived at our North-west destination in a relaxed and rested state despite the traffic.

The materials used for the seat, dashboard and door trims are all top notch. And the steering wheel, driver’s seat and pedals are perfectly placed for comfort and efficiency

Certainly, one of the extras that helped was the active cruise control that uses radar to keep a safe distance from the vehicle ahead and then speeds up automatically when the lane is clear.

Also helpful and very impressive were the optional Matrix LED headlights. Using sensors and an inbuilt camera, they detect what lighting is required and adapt accordingly.

Clever stuff

They also use the A8’s satnav to provide best lighting as you negotiate corners, urban and country roads. Clever stuff and great use of new technology.

The six-cylinder 3.0litre turbo diesel engine remained a subdued companion and the balance of torque and power suits the car perfectly.

So did the fuel economy come anywhere close to Audi’s claims? Well, the A8 averaged 43.7mpg,

which is really very good for such a big, powerful car.

Even more extraordinary was that, because the fuel-tank is so generous, I covered over 730 miles without filling up.

As a new purchase for a successful independent practitioner, the Audi A8 is well worth a look, but it may be worth searching out a yearold car or an ex-demonstrator.

You would then get round the A8’s only disadvantage: higherthan-average depreciation.

So my friend and I arrived in Liverpool, had a really enjoyable weekend catching up with all our medic friends and colleagues and then cruised back down South.

The journeys had flown by and it is a measure of the A8 that I would have been happy to do the journey again the following weekend. That says it all.

Dr Tony Rimmer (right) is a GP practising in Guildford, Surrey

AuDi A8

Body: Five-seat saloon

Engine: 3.0 litre V6 turbo-diesel Power: 258bhp

Torque: 580Nm

Top speed: 155mph

Acceleration: 0-62mph in 5.9 secs

Claimed economy: (Combined) 47.9mpg

On-the-road price: £59,580

ProfiTs focus: oPhThalmologisTs

Looking to work harder

Latest figures show profits are up for ophthalmologists – but only because they are working harder to achieve it, finds Ray Stanbridge. Additional material by Martin Murray

The privaT e medical market is still full of surprises.

after the previous year’s rather unexpected fall in gross incomes, we have seen a slight increase in our latest earnings figures for ophthalmologists. and our initial observations on what happened in 2014 suggest that incomes are on the rise again.

Our headline figures show that gross incomes rose by about 1.7%, going up from £115,000 in 2012 to £117,000 in 2013.

Costs rose on average by 2%

from £50,000 to £51,000. a s a result, taxable profit rose slightly – by 1.5% from £65,000 to £66,000.

h aving said that the market seems to have stabilised, we must repeat again all the usual caveats about interpreting our figures.

Difficult comparisons

They are not statistically significant. increasingly, it is difficult to effect a year-on-year comparison. This is because some consultant ophthalmologists have chosen to aveRage INCOMe aND eXPeNDITURe OF a CONSULTaNT OPhThaLMOLOgIST WITh aN eSTaBLISheD PRIvaTe PRaCTICe

NhS business is playing an increasingly important role in some consultants’ practices

join groups and others have chosen to incorporate, with consequential changes in accounts reporting practices.

i n addition, N h S business is playing an increasingly important role in some consultants’ practices – they have increased activity at a lower unit cost.

a ll of these and other factors can lead to data distortions, despite our efforts to correct and smooth data.

i n addition, our definition of ophthalmologists for the purpose of our survey is probably becoming outdated.

Whom do we count?

Our income survey is still restricted to those consultant ophthalmologists who are not in full-time private practice. They:

 have had at least five years private practice experience;

Expenditure

 a re seriously interested in pursuing private practice as a business;

 earn at least £5,000 in the private sector;

 h old either an ‘old-style’ or a ‘new-style- NhS contract;

 May or may not be a member of a group or have incorporated.

The market for ophthalmology services has been volatile. it was

Source: Stanbridge Associates Ltd. Additional information: Sandison Easson and Co

WIGMORE medical TRAINING

JANUARY

FEBRUARY

MARCH

6 Advanced Toxins* (am)

Advanced Fillers-F* (pm)

Mini-Thread Lift*

glōTherapeutics

APRIL

9 Sculptra* 10 Advanced Fillers-TT* (am) 10 Advanced Fillers-CH* (pm)

Mini-Thread Lift*

13 CPR & Anaphylaxis Update 13 Medik8 Dermal Roller (pm)

Dracula PRP*

ZO Medical Basic

ZO Medical Interm.

Skincare & Peels

ZO Medical Basic (Dublin) 25 ZO Medical Adv. (Dublin) 25 Intro to Toxins*

Intro to Fillers*

Microsclerotherapy*

Skincare & Peels

28 ZO Medical Basic (Dublin) 29 ZO Medical Interm. (Dublin) 29 Intro to Toxins* 30 Intro to Fillers*

CH = Cheeks/mid-face F = Forehead LF = Lower face TT = Tear troughs

one of the first areas targeted by the insurers for fee reductions, and is still very much in their firing line.

it has also been an area where, as reported above, there is significant N h S growth. This has happened in the form of bursts of activity.

as a result of these trends, fees per unit have decreased and ophthalmologists gross earnings, on average, have only improved by virtue of extra activity.

We would expect to see continuing income growth in the market

– but as a result of ophthalmologists working harder.

Costs have shown some increase over the past year.

Staff costs have risen, on average, from £14,000-£15,000. as we have seen in other sectors, this is largely the result of consultants who employ family members in their businesses ‘tracking’ the growth in tax-free personal allowances.

market costs for rooms

Consulting room hire costs have shown a modest increase, on average.

again, our view is that this move reflects an increasing trend among hospitals and other providers to charge ‘market costs’ in anticipation of findings by the Competition and Markets authority.

Consultants with smaller practices still seem to have been charged relatively more than those with larger businesses.

Surprisingly, professional indemnity costs seem to have shown a slight decline. This perhaps reflects the fact that some consultants have chosen cheaper indemnity cover options.

Other costs have remained fairly constant – though there has been a slight increase in ‘other’ costs. This is primarily for marketing and business promotion purposes.

We reported last year ( Independent Practitioner Today , December 2013-January 2014) that marketing and promotion was the key for success.

For many, this has proved to be true. For others, growth in N h S contract business seems to be the way forward to maintain income – but at a time cost.

 next month: gynaecologists

Ray Stanbridge runs an accountancy, finance and tax advisory service specialising in the medical profession. Martin Murray is a partner at Sandison Easson & Co, specialist medical accountants

years ending 5 april

Source: Stanbridge Associates Ltd

what’S in our februarY edition

Make sure you don’t miss our next issue, published on 19 February 2015. Only subscribers to the magazine are guaranteed to receive every copy and we don’t think anybody who is serious about continuing private practice in the future, when there is so much happening that will affect them, can afford to miss any issue. Coming up next month:

 Big changes ahead for private doctors! The Competition and Markets authority’s ‘remedies’ for independent healthcare have some farreaching implications. Now that the Private healthcare Information Network has been charged with improving information for patients, its boss Matt James tells us what you can expect to happen next

 Ten tips on revalidation

 accountant Ian Tongue issues some vital pre-year-end planning tips for private consultants and gPs

 how free walk-in clinics are bringing private consultants and potential patients together

 are centres of excellence the way to go for the private medical profession?

 The leasing route as an option for buying equipment

 a consultant group that markets itself to gPs and others – using an in-house art gallery

 With lots of doctors taking to the ski slopes this winter from their second homes, our new series on property investment picks out the top ten ski resorts for you to buy houses in France

eDITORIaL INqUIRIeS

 association of Independent healthcare Organisations’ chief executive

Fiona Booth shares her hopes for boosting private healthcare in 2015 –using ITN’S know-how

 One of the most difficult things for an expert in any field to learn is how to communicate. Marketing guru and surgeon Dev Lall has some valuable tips for independent practitioners

 getting divorced: we examine the financial implications of divorce –splitting assets, implications for the family home and tax concerns

 ‘Doctor on the Road’ columnist: the Nissan X-Trail

 Regulation of medical devices and medicines – MDU medico-legal adviser Dr Nicola Lennard answers some of your business dilemmas

 amazing facts and figures from Medical Billing and Collection

 Profits Focus investigates gynaecologists

 Plus all the latest news affecting you and the marketplace

aDveRTISeRS: The deadline for booking advertising for our February 2015 issue is 23 January

Robin Stride, editorial director

Email: robin@ip-today.co.uk

Tel: 07909 997340

aDveRTISINg INqUIRIeS

Margaret Floate, advertising manager

Published by The Independent Practitioner Ltd. Independent Practitioner Today is editorially independent and thanks Bupa for its assistance with distribution.

Printed by Williams Press

Material is governed by copyright. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form without permission, unless for the purposes of reference and comment. Editorial layout is the copyright of the publishers. If you wish to use it for promotional purposes on websites or for reprints, we would be happy to discuss licensing the copyright to you.

Registered office: 7 Lindum Terrace, Lincoln LN2 5RP

Write to Independent Practitioner Today PO Box 198, Cranleigh GU6 9BB

Email: margifloate@btinternet.com Tel: 01483 824094

Publisher Gillian Nineham Tel: 07767 353897.

Email: gill@ip-today.co.uk

SUBSCRIPTIONS

£75 independent practitioners.

£75 GPs and practice managers (private & NHS). £200 organisations.

But if you pay by direct debit, individuals pay only £60, and organisations £175 Call Proact Ltd on 01752 312140

Email: lisa@marketingcentre.co.uk

Robin Stride, editorial director @robinstride

gUaRaNTee yOUR COPy

To guarantee your copy of Independent Practitioner Today by taking out a subscription (at the rates shown on the left), phone 01752 312140 or send off a subscription form on page 28 or email lisa@marketingcentre.co.uk or go to the ‘about’ page of our website www.independent-practitioner-today.co.uk

If you pay by direct debit, individuals pay only £60 for a subscription – just £36 after tax. Just fill in the form on page 28 and send it to the Freepost address shown at the bottom of the form.

BaCk ISSUeS: £10 including post & packaging ChaNgINg aDDReSS OR SUBSCRIPTION DeTaILS?

Phone 01752 312140 or email lisa@marketingcentre.co.uk