February 2014

INDEPENDENT PRACTITIONER

THE BUSINESS MAGAZINE FOR DOCTORS WITH A PRIVATE PRACTICE

Today

your nose clean It’s not just making clinical mistakes that get you into professional trouble P30

THREE BIG ISSUES SHOW HOW PRIVATE DOCTORS ARE FACING MAjOR UPHEAVAL

Harley Street dominion under threat

By Robin Stride

Leading independent practitioners and key figures in the private healthcare market have been called to a high-level think-tank next month to discuss Harley Street’s future.

They meet amid fears for the future ability of the world-famous medical enclave to attract enough business in the face of growing overseas competition.

Keith Pollard, the man behind the initiative, told Independent Practitioner Today the topic could not be more important to the private healthcare industry.

He said: ‘The future of Harley Street is vital to the future of private healthcare in the UK, as it’s the brand everyone associates with private healthcare both in the UK and around the world.

‘That brand needs to continue to grow and strengthen in both the domestic and international marketplace to compete with emerging competitors.

‘This means continuing to offer the latest treatments, the best surgeons and the best levels of patient care as well as marketing and promotion of Harley Street around the world.’

But, as he warns in Independent Practitioner Today (page 14), he fears the street’s reputation and pre-eminence in the international patient market will become part of history if nothing is done.

An expert panel at the seminar – from 18.30-20.30 at The Royal Society of Medicine on 27 March – will review and discuss how Harley Street can maintain and strengthen its pre-eminent position as an international centre of

Greater competition on the way

medical excellence despite international competition and a rise of medical tourism.

Mr Pollard, managing director of Intuition Communication, added: ‘It will be fascinating to hear from some of the many stakeholders in the Harley Street brand, from landlords to consultants, to understand how the many disparate groups involved will tackle these challenges.’

Speakers and panelists include representatives from his company, The London Consultants Association, The Howard de Walden Estate, HCA International, London Healthcare, Anglo Medical, and Healthcare UK.

The free seminar, to be chaired by ITV News health correspondent Sue Saville, takes place in front of an invited audience limited to 100 guests. Invitation applications

‘We’ve got hundreds of consultants really angry that the Competition Commission hasn’t understood the market and hasn’t understood their point of view and is reaching conclusions that will damage patients. Consultants have said we’ve done a great job investing in their hospitals. Now they are worried about their future.’ HCA commercial director Keith Biddlestone SEE PAGES 7-9

In association with

are now being accepted on http:// future.harleystreet.com.

Doctors will hear and share views on how Harley Street can lead the way in an increasingly competitive marketplace and how it can compete with over 80 countries offering medical tourism opportunities.

Intuition Communication, the specialist publisher of consumer and business-to-business information on private healthcare and medical travel, said audience members and guests will receive market updates in advance so they can study latest figures and trends and take part in an informed debate.

Sponsors include The Howard de Walden Estate, HCA International, King Edward VII Hospital, London General Practice, London Women’s Clinic and Ten Harley Street.

➱ See feature article: ‘Overseas rivals are streets ahead’, p14

Mileage faces tighter scrutiny

‘Specialists face a hefty rise in their motoring costs following a far-reaching tax case judgment that will prevent them claiming mileage to and from their homes to regular places of business such as private hospitals.’ Leading accountant Ray Stanbridge reports on what is changing and gives advice on what to do now SEE PAGE 16-18 If they nick your bright idea We show you how to protect your invention when someone tries to infringe your patent P12 Investigating your staff How to tackle allegations of poor performance and conduct by your staff P25

February 2014

www.independent-practitioner-today.co.uk

international rivals are streets ahead can Harley Street maintain its historical dominance as a centre of excellence? P14

Journey’s end for car mileage tax case a leading accountant explains what the court ruling means for consultants P16

get yourself noticed our resident marketing guru answers your frequently-asked questions P20

real consent is based on information avoid the biggest source of negligence claims by ensuring informed consent P32

The power and peril of groups How you can avoid the setting-up mistakes which can scupper your group practice P36 as a complete bonus Staff bonus schemes are becoming popular. We show how to set them up properly P42

Plus our regular columns starting a private practice reviewing your practice P48 Doctor on the road Volvo Xc70 P50 Profits Focus: Gynaecologists P52

ediTorial commenT

Sector getting back in shape

Three big issues of concern affecting thousands of consultants take the spotlight in this issue but we detect rays of optimism for private healthcare as the days grow longer.

Market analysts LaingBuisson are talking of a ‘bright’ future as better economic news filters through (see story opposite).

And there seems to be some optimism in the City where we met investors and entrepreneurs recently at global law firm DLA Piper to consider challenges, risks and opportunities in private and public healthcare.

Former GP Dr Mike Shillingford, head of healthcare at

multi ­ fund investor MedicX, told the gathering there was now more opportunity for healthcare investment in the next decade than ever before.

Down on the street, members of the British Association of Aesthetic Plastic Surgeons are reporting ‘the economy appears buoyant once more as austerity gives way to augmentation’.

They clocked up a 17% rise in all cosmetic procedures last year, a trend not seen since before the recession. As president­elect Mr Michael Cadier observes, patient confidence in selecting appropriately trained and qualified surgeons is growing rapidly.

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 Circulation figures verified by the Audit Bureau of Circulations

Protect your pension pot now or never

by leslie berry

High ­ achieving independent practitioners are being advised to decide now how best to protect their pension pot from steep tax charges which are otherwise due to hit them in the next few weeks.

Following consultation, the Government has published its response on the proposed new ‘Individual Protection’ (IP14) scheme designed to safeguard a higher ‘lifetime allowance’ on pension contributions when the rate falls from £1.5m to £1.25m in April.

Individual Protection 2014 will allow doctors to protect the value of their pension rights as at 5 April 2014 up to a maximum of £1.5m. And they will still be able to accrue benefits through both occupational and private schemes without losing the protection.

To qualify, the value of the pension rights must exceed £1.25m at 5 April 2014. Meanwhile, savers can also apply for the updated ‘Fixed Protection’ (FP14) which allows doctors to hold pensions’ savings of up to a fixed amount of £1.5m as long as there are no further pension accruals.

Applications for IP14 will be open from August 2014 until April 2017 but applications for FP14 close on 5 April this year.

So financial advisers warn it is imperative for doctors to decide now which scheme is most appropriate for their circumstances.

Cavendish Medical technical director Patrick Convey said the firm now had the final information needed to help doctors decide the best type of pension protection.

‘While the three ­ year window to apply for IP14 suggests there is plenty of time to gather information and complete applications, it is simply not the case.

‘The results of this consultation have come very late in the day, as crucial decisions must be taken well in advance of the coming April deadline. Every situation will be different, so you should seek advice now, without delay.’

Doctors with ‘enhanced protection’ – a form of tax protection for pension schemes first offered in 2006 – were originally blocked from registering for the new IP14.

But this restriction has now been lifted following industry feedback.

Help to start your vein clinic

Doctors wanting to start their own private vein clinic without incurring the usual time­consuming setup and running hassle are being offered back­up from a new firm.

Everything Veins claims there are growing opportunities for cheaper local anaesthetic ­ based vein services by doctors who want to increase their private practice in specialist clinics.

Chief executive Karen Espley believes many would­be entrepreneurs do not want to take on business start­up responsibility. But by

using her model, she said, any surgeon, radiologist or doctor with basic surgical or catheter skills could open a vein clinic.

The Bart’s ­ trained nurse and business consultant has organised training for doctors at the Whiteley Clinic, Guildford, Surrey.

Everything Veins forecasts a proliferation of private vein clinics due to many factors, including new NICE guidelines last year on varicose vein treatment.

Details available by emailing info@everythingveins.com.

Patients slam doctors’ failure to show prices

by charles King

Private patients are increasingly complaining they are not being given adequate pricing information about the cost of outpatient appointments.

According to the Independent Sector Complaints Adjudication Service (ISCAS), gripes include a lack of transparency over doctors’ fees and a reluctance to discuss charges with customers.

ISCAS said: ‘While it may not sit easily with the clinical focus of a consultation, this is no time to be coy about charges. Understanding how much treatments cost is of

fundamental importance to patients when deciding whether to undergo independent healthcare.’

And it warned doctors they were wrong to think that only patients paying for healthcare directly were concerned about charges.

Those with a health insurance policy also needed full information to understand if they were reaching their limit for cover and might need to make co­payments. Some were also wary about the implications for future premiums.

The ISCAS said difficulties could also arise where investigations were ordered for patients during an outpatient consultation but

patients were not told how much each test cost.

It said one complainant inadvertently reached his insurance cover limit in a single consultation. But there was allegedly no discussion about the cost of tests, so he was unable to make an informed decision about proceeding with the investigations.

The Citizen’s Advice Bureau states: ‘Before having treatment, it’s important to check what the costs will be, including any charges that may be added to the bill if things don’t go to plan.’

This is not always so easy, admits ISCAS, but in the above

example ‘it means either providing the patient with an estimate before they decide to proceed with tests or, at the very least, giving them information containing indicative prices.’

It said without this information, doctors would continue getting complaints about unexpected charges and some patients’ experience would be marred by a lack of pricing transparency.

‘Upfront, clear and robust pricing information by ISCAS members – and clinicians with practising privileges – has to be the bedrock of decision ­ making about independent healthcare.’

More NHS cash goes to private sector

Private healthcare in the UK has a ‘bright’ future as public sector outsourcing continues to grow, according to market analysts.

The 2013 ­ 14 edition of LaingBuisson’s annual Healthcare Market Review calculates that revenues generated by independent sector providers in the 12 health and

care market segments it monitors stood at £40.5bn in 2012 ­ 13 (2011­12: £39.9bn).

Chief executive William Laing said: ‘Looking forward, LaingBuisson believes that the better economic news of the last few months will – if continued – boost private spending on healthcare

again, though past experience shows that there is often a lag, so it may not be until the end of 2014 that we see evidence of increased private spending on healthcare.’

Independent healthcare currently was still feeling the repercussions from the 2008 global credit and ensuing recession, he added.

‘Private demand for hospital treatment has been flat for five

years, and private demand for care homes for older people has only kept growing because of the expanding older population and because private payers fund longterm care out of assets rather than disposable income.’

The analysts said tight public sector budgets meant more outsourcing and the Government was promoting more choices for patients undergoing elective surgery.

Source: LaingBuisson Healthcare Market Review 2013-14

Network to aid doctors in appraisal

By Robin Stride

Independent practitioners are being offered appraisal support from colleagues in their specialty under a new initiative called the Independent Doctors Appraisee Network (IDAN).

The voluntary scheme aims to help them contact one another to work on the collection of supporting information for their appraisals.

Dr Paul Myers, the director of Doctors Appraisal Consultancy, launched the group after many of the independent sector doctors he saw over the last two years said it would be helpful.

Now he is contacting doctors to see if they are interested in developing ‘local colleague networks’.

The former GP said this would provide an opportunity for doctors from the same specialty to take on, for example, clinical case reviews, outcome studies and audits for their appraisals.

Documenting this would be powerful evidence that the doctors are not practising in isolation.

He said once he could get a group of doctors registering with the same specialty, he would send each of them the relevant details so they could contact one another.

Added Dr Myers: ‘This will be done in confidence and there is no charge for registering with this service. This is a personal initiative from me and is not related to any particular designated body. Taking part is open to any licensed doctor irrespective of whether I am providing their appraisal or not.’

More details at http://preview. doctorsappraisal.vpweb.co.uk/ appraisee-network-page.html.

In another development, Dr Myers has set up BAMA, The British Association of Medical Appraisers.

He said this was an attempt to develop a group of ‘approved appraisers’, doctors who were trained in ‘revalidation-ready’ appraisals and who could show through a quality assurance process that they provided appraisals of a high standard.

 More details: www.bama.uk.com

Capio’s redesign coloured by therapeutic properties

Private consultants at Capio Nightingale, London, have prescribed a change of colour for the mental health hospital’s £3m refurbishment.

They believe a new bedrooms colour scheme will assist with patients’ recovery.

There is green – said to promote balance, personal development and self-acceptance – and blue, ‘for its healing and mentally relaxing properties’.

Purple now features in shared spaces through the hospital because it is a colour considered liberating and freeing.

Hospital managing director Martin Thomas explained: ‘We have been working to design and develop the right environment to deliver the best possible care to our patients.

‘This has involved working closely with the therapists and consultants at the hospital to design treatment programmes, but also working hard to redesign

the buildings and interiors to complement the bespoke experience our patients want and need.

‘This is the culmination of working towards providing the best possible care environment at a time when more and more people are seeking private mental health support.’

Capio Nightingale Hospital has completely redesigned its therapy rooms, including modern group therapy facilities, consulting rooms and individual en-suite bedrooms to ensure maximum comfort and privacy for all patients. Its inpatient facilities are now more akin to contemporary hotel rooms and amenities, with kitchens, lounges and reading rooms available.

After extensive consultation with the hospital’s multidisciplinary team of clinical psychologists, psychotherapists, dieticians and consultants, it has introduced innovative treatment programmes not available elsewhere.

Bupa launches new CT clinic network

Bupa has launched a new, nationwide network of quality-assured outpatient CT scanning facilities.

It said the move aimed to ensure facilities providing outpatient CT scans to its customers met its quality standards developed in line with national guidelines.

Bupa’s director of hospital management, James Sherwood, said: ‘We are establishing a nationwide network of quality-assured CT scanning facilities to ensure our

customers have access to highquality, best-value CT scanning.

‘After a successful launch in central London, with almost unanimous support from our providers, we are now extending the network nationwide.’

Bupa CT network facilities will hold a valid, CT-specific quality assessment. This has been developed in line with national guidelines and includes new criteria for specialist CT scanning.

The insurer said they would also give it annual key performance indicators so it could ensure continued high-quality scanning for customers.

Bupa said all network facilities had agreed to charges which are fully inclusive of scanning, reporting, contrast and radiologist fees.

Mr Sherwood added: ‘We know that in some parts of the UK we are paying between five and ten times the NHS tariff for a CT scan

for our customers. The new network will offer patients better value for money and ensure private health insurance remains affordable for our customers.’

Applications to join the nationwide network close on 28 February. Bupa said it was contacting all its recognised CT scanning clinics to invite them to join the network.

 More information: www.bupa. co.uk/computed-tomography

The Capio Nightingale Hospital has been redesigned by medical consultants

Dangers of social media

By a staff reporter

A defence body has reminded doctors to be careful what they post online after several recent articles reported about confidential patient information being shared by doctors through social media.

The Medical Defence Union, which reports a 40% rise in calls about social media and the internet from members, warned doctors to be cautious about what they shared.

It said they should consider the GMC’s social media guidance when posting online.

MDU adviser Dr Richenda Tisdale said: ‘Social media sites such as Twitter and Facebook are informal environments and so it is easy for doctors to let their guard down and not follow the same rules as they would offline.

‘However, the rules of confidentiality apply as much when posting online as they do to when you are chatting to a friend on a night out.’

Doctors’ common concerns include:

 Complaints and allegations

BMI sees large rise in patients from overseas

Consultants at BMI Healthcare hospitals saw a 48% rise in international patients last year.

Foreign government-sponsored patients grew 86% and international insured patients rose by 28%.

International director Scott Feldman said: ‘The growth has been achieved through our pricing strategy and by focusing on promoting the high acuity services available in our hospitals.

‘The focus on complexity, in supporting patients in need of specialist care and highly focused treatment has driven a 20% increase in revenue.’

BMI said it had benefited from growing specialised centres of excellence away from the capital. It plans more in 2014.

If you uSe a SoCIal NeTwoRkINg SITe:

 keep your profile private –limit access to friends only and don’t accept requests from patients to become a friend

 Be professional in your comments, especially about patients or colleagues

 Be cautious about posting anything that may bring the profession into disrepute

 Be aware that anything you upload on to a social networking site may be distributed further than you intended

Source: MDU

made about them by patients on social networking sites;

 Friendship requests from patients;

 Difficulties after posting comments and images online.

The GMC’s guidance, entitled

CHaNgeS To THe gMC’S CoRe guIdaNCe To doCToRS

The Mdu has issued advice to its members about the main changes in the gMC’s core guidance on its website www.themdu.com. They include:

 doctors will be expected to show they adhere to the principles of the guidance when they revalidate

 a new duty to take prompt action if a patient’s dignity or comfort is or may be seriously compromised

 a new obligation to tell the gMC if a doctor has been criticised by an official inquiry, which could include Care Quality Commission (CQC) investigations

 More detailed guidance on ending professional relationships with patient

 advice on avoiding conflicts of interest when commissioning services

– aimed at doctors serving on new clinical commissioning boards

 More detailed guidance on when it may or may not be appropriate to discuss personal beliefs with patients

 New advice on doctors’ duty to address concerns about a colleague’s sexual behaviour – which can include making inappropriate comments to patients

Doctors’ Use of Social Media, says doctors must not discuss individual patients or their care via publicly accessible social media. They ‘must not bully, harass or make gratuitous, unsubstantiated or unsustainable comments about

Insurer advises doctors on how to work with company

Bupa has published a new online guide for doctors working with the company.

Working with you: A step-by-step guide for Bupa-recognised consultants is available online at www.bupa.co.uk/ consultant-guide.

Dr Annabel Bentley, medical director of consultants and therapists at Bupa Health Funding, said: ‘Every year, more than 20,000 Bupa recognised consultants provide our customers with high-quality, affordable treatment and care.

The publication covers a wide range of topics, including:

 How the insurer promotes clinicians to its customers, GPs and the public through the Finder website

‘We want to make it as simple as possible for consultants to work with us, which is why we have developed this guide.’

– a free online directory of consultants, therapists and facilities, which gets over 20,000 unique visitors weekly;

 The benefits of being a ‘fee-assured’ Bupa-recognised consultant;

 The insurer’s approach to clinical quality and unexpected variation;

 The policies and processes for effective and efficient business administration, including fees and billing.

individuals online’ and ‘if you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name’. A number of doctors, however, continued to use pen names to protect their identity.

Chelsfield cheer

A £3m upgrade and renovation at BMI Chelsfield Park Hospital, Orpington, promises to improve facilities for consultants, patients, staff and visitors.

The 14-month project will bring a new open-plan hospital reception/waiting area, refurbished outpatients department, better patient bedrooms and an extended assisted conception unit with a new specialist male fertility/andrology laboratory.

Preventive steps

BMI’s HealthFirst wing is working with gym company 3d Leisure to extend services to clients’ employees and offer both health and fitness services under one umbrella ‘competing in a market which has remained relatively stagnant’.

What’s top in cosmetic op leagues

New statistics from a clinic comparison site shows what cosmetic treatments were hot or not in the UK in 2013.

WhatClinic.com said arm lifts saw a 473% rise as many patients waved goodbye to bingo wings with brachioplasty. The cost averaged £3,872 – 35% more than in 2012.

Inquiries into buttock lifts more than tripled (221%). The average price tag was £4,226.

Male breast reduction inquiries more than doubled (119%) last year. But more than a third (35%) of those looking to banish their ‘moobs’ went overseas to countries such as Poland, the Czech Republic and Belgium, ‘where

prices are considerably cheaper’.

Full abdominoplasty, or tummy tuck, saw inquiries fall by 46% last year, while abdominal etching dropped by almost a fifth (17%).

WhatClinic.com said demand for both procedures was now falling as many patients opt for alternatives like fat transfer, which saw a 126% increase in 12 months.

Mini-facelifts also dropped by 60% as less invasive treatments, such as non-surgical facelifts and dermal fillers (both up 93%) and Thermage skin tightening (up 80%) proved more popular with patients.

The site’s chief executive Caelen King said: ‘Although there has been a move towards non-surgical alternatives for many treatments,

Accolade for keyhole clinic

Consultants at King Edward VII’s Hospital in London have announced the setting up of the first private nationally-accredited endometriosis centre.

Called Gynaecology.co, the centre submitted more cases to The British Society for Gynaecological Endoscopy endometriosis national database than any other in the UK last year.

The society, responsible for setting national standards in gynaecological laparoscopic surgery,

Table 1 shows the treatments that have seen the biggest increases in inquiries in 2013:

accredits hospital units that meet specific criteria for endometriosis services in the previous year.

Gynaecology.co is run by laparoscopic surgeons Alfred Cutner, George Pandis and Arvind Vashisht. They also offer laparoscopic surgery in all other areas of benign gynaecology, especially the treatment of prolapse, incontinence and fibroids. The unit works closely with gynaecologist Mr Michael Dooley to offer a comprehensive infertility service.

2 shows the treatments that have seen the biggest decreases in inquiries in 2013:

the data shows cosmetic surgery is still big business in the UK.’

He said the website recommended patients researched their surgeon to ensure they were experienced in the procedure wanted. It urged them to check what aftercare was included, to read patient reviews to find out about other people’s experience, and to get feedback and guidance on specific clinics and practitioners.

GPs back private care but onus is on patient

Three-quarters of London GPs think a healthy private sector running alongside the NHS is good for patient choice.

According to a survey by BMI Healthcare, 55% of GPs believe most of their patients do not have a good understanding of their options outside the health service.

Now the company is encouraging patients to become more savvy about what the private healthcare sector can do for them.

Jan Hale, executive director at BMI The Clementine Churchill Hospital, Harrow, said NHS funding constraints had resulted in varying eligibility criteria for certain procedures across London.

‘In London, approximately one in six residents (17%) have private medical insurance; way above the

UK average of 10.8%. But the survey revealed that just over one in ten (11%) of the London GPs surveyed actually ask their patients if they have medical insurance.

‘Over three-quarters of GPs (77%) believe it is the patient’s responsibility to mention if they have private medical insurance during their appointment.’

Forty per cent of the GPs said they had seen an increase in patients using savings or other methods to pay for treatment.

When a treatment or service was unavailable or restricted by the NHS, 70% of GPs said they would discuss the self-pay option.

But, again, the majority of GPs said they believed it was the patient’s responsibility to bring up the option of them self-funding.

Table

Left to right: theatre sister Lynn Gunn, gynaecologist Mr Alfred Cutner, theatre practitioner Dayzy Gladyng, gynaecologist Mr Arvind Vashisht

Revised Competition Commission plans to increase private healthcare market competition, outlined last month, have brought a mixed bag of fierce criticism and cheer within the sector.

The latest proposals, based on a provisional report ( Independent Practitioner Today , September 2013), sparked a flurry of further consultations to the commission inquiry team ahead of a final report next month (March).

Its provisional decision on remedies proposes:

 Prohibiting or restricting private hospital incentive schemes to doctors that encourage patient referrals to their facilities or for particular treatments or tests.

 Requiring the collection and publication of information on the performance of private hospitals and individual consultants and provi-

sion of consultant information data to patients.

 The selling off of nine private hospitals. It says HCA should sell two hospitals in central London – London Bridge and Princess Grace. BMI should sell seven hospitals in greater London, Home Counties and the North-west.

 The Competition and Markets Authority will review any proposal by a private operator to enter into an agreement to operate a private patient unit (PPU) in an NHS hospitals in a local area where it faces little competition.

Commission chairman Roger Witcomb claimed the proposed measures offered practical and effective ways of improving competition and ensuring private patients got a better deal.

‘Requiring operators to sell hospitals is a big step and we have focused on those areas where a sale will be effective in increasing

competition – where a single operator owns a cluster of hospitals which face little rivalry.

‘As well as these measures, we will look to remove ways in which hospital operators can reinforce their position and close the door on potential competition. So we want to prevent incentive schemes that encourage patient referrals to particular hospitals.

‘We will also look to ensure that the option to partner with a NHS PPU is open to potential new entrants in areas which need greater choice.

‘We will also provide for greater information on the performance of hospital operators and consultants and for consultants on price as well to allow patients to make informed choices when deciding which hospital and consultant to choose for their treatment.’

Strong reactions from all sides Market to be opened up

HCA

HCA International is strongly contesting the Competition Commission’s plans to force the sale of London Bridge Hospital and The Princess Grace Hospital, two of its ‘world-class’ hospitals.

Chief executive and president Mike Neeb called the commission’s provisional recommendations ‘plainly wrong’.

He said the commission’s own report acknowledged there were nearly 50 competitors in greater London. HCA ownership of these hospitals encouraged competition and drove a higher standard of care among hospitals.

‘Thirteen years ago, we acquired the London Bridge Hospital in a merger specifically approved by the Office of Fair Trading. Since then, we’ve invested millions, transforming it into one of the best providers of quality healthcare in the world and now the Competition Commission is punishing this success.

‘The Competition Commission has misunderstood the market and is threatening unjustified and unfair remedies.

Dr Marmion added: ‘These proposals won’t provide an instant fix to the problems of the private healthcare market – it will be some time before customers will see the benefits.

‘But they do offer an important opportunity for insurers, clinicians and hospitals to work together to deliver better value for customers and patients. Together we can grow the market to make quality private healthcare more affordable, for more people.’

Mr Neeb said the group had an unparalleled record of investing in world-class innovative care and a global reputation for excellence. It had invested over £200m into its UK hospitals and other facilities in the last five years.

Bupa

Hailing the proposals as a decisive step forward for customers, Bupa said the commission had set out a series of actions to end behaviour by consultants and hospital groups that was leading to higher prices for insured and self-pay patients.

‘To forcibly divest hospitals from successful healthcare organisations cannot be good for either patients or our economy.’

Bupa Health Funding managing director Dr Damien Marmion believed the commission was right to address the dominance of some hospital groups and argued divestment should go ahead.

‘We are keen to support the independent publication of consultants’ outcome data and fees. It is something we have always argued for, as patients want this transparency to help them to make more informed decisions.’

The commission estimated that the potential extra cost to customers caused by excessive profits of certain hospital groups was between £173m-£193m a year between 2009 and 2011.

BMI

Strong criticism of the commission came from BMI Healthcare chief executive Stephen Collier, who warned if the commission’s final remedies were unfairly detrimental to the group, then it would ‘take whatever steps are appropriate to ensure that they do not undermine our organisation’.

Shareholders had taken nothing from the business they bought in 2006, instead re-investing every pound earned back into their hospital operating business.

‘It is therefore bizarre for the commission to claim that we are making excess profits and need to sell seven hospitals; a remedy that

HCA chief executive Mike Neeb

CoMpetItIon CoMMIssIon

Bupa boss Dr Damien Marmion

will have no benefit for patients because there is already sufficient competition and it won’t lower costs.’

He said BMI had always supported some aspects of the commission’s work, including clarification of the relationships between hospitals and consultants and the need for more transparency.

It also welcomed the commission’s U-turn in now deciding not to interfere in negotiations between hospital groups and insurers.

But he claimed the commission had still not grasped how the private healthcare market works. It had used flawed analyses to support its ‘unjustified’ provisional divestment remedy.

Mr Collier continued: ‘It has massively undervalued the investment required to provide highquality private healthcare, seriously suggesting that hospitals should be valued as if they stood in farmers’ fields, and hugely underestimating the necessary costs of the ever more expensive technology required to meet the clinical needs of patients, commissioners and insurers.

‘Recent examples of newly-built private hospitals not only undermine the commission’s arguments about barriers to entry, they prove it has got its sums wrong regarding the true cost of private healthcare.

‘While the commission estimates the cost of providing each new private bed at around £400,000, the reality – as proven by recent builds – is more than twice that. Only by understating the real investment costs can the commission reach the conclusion that we are making unreasonable returns on capital.’

Mr Collier said the commission’s cut in the number of pro-

posed divestments was a tacit recognition that its own analysis did not stand up.

BMI had spent inordinate amounts of time and money defending itself from unsubstantiated allegations – resources which could have paid for improving patient services.

nuffield Health group

Chief executive David Mobbs said the proposals would go a long way to improving market competition for patients’ benefit. He claimed forced hospital sales would reduce HCA’s ‘harmful dominance’.

But he criticised the commission for not addressing ‘the national market power’ of BMI and Spire in negotiations with insurers outside London. This had led to patients paying inflated prices.

He complained the commission had stepped back from introducing a solution to prevent a ‘tying and bundling’ tactic used by some hospital operators in negotiations with insurers ‘that drives higher prices’.

Mr Mobbs added: ‘The industry should strongly welcome the removal of consultant incentives, the improvements in patient information and the transparency of consultant fees. These remedies will not only improve the competitive environment but will also restore integrity and consumer confidence to the market.’

He said the charity would look with interest at hospital buying opportunities in London and beyond.

AIHo

Association

of Independent

Health care Organisations chief executive Fiona Booth said the commission had recognised that some of its provisional findings last Autumn were excessive.

It has massively undervalued the investment required to provide highquality private healthcare, seriously suggesting that hospitals should be valued as if they stood in farmers’ fields

Stephen Collier, BMI chief executive

She told Independent Practitioner Today her members had vastly different business structures, so it was no surprise their responses varied. But they all supported a diverse and vibrant market and giving patients the information they need to make an informed choice.

AIHO was pleased to see the commission recognised the ongoing work of the Private Healthcare Information Network, which had published data quality in a standard format for nearly a year.

‘By publishing standardised information on hospital and consultant outcomes, it will enable patients to make informed choices about their care and, as the data will be easily comparable, stimulate healthcare providers to drive up standards where necessary.’

But she agreed some commission remedies could do more harm than good. ‘Requiring organisations to divest hospitals could limit investment in facilities and staffing in other locations. Similarly, potential restrictions on setting up PPUs by existing operators can only fuel operational uncertainty, with a subsequent impact on investment decisions.’

Ms Booth said the health sector was unique in the way it interacted as partners to the NHS. ‘Business disruptions to independent providers cannot be viewed in isolation from the impact they may have on NHS patients. The commission must take this into consideration when finalising the remedies.’

Medical Billing and Collection

Managing director Garry Chapman, talking of publishing consultants’ fees and performance, advised specialists with a practice website not to publish this data separately.

He said they should act now to ensure they published this information together ‘in such a way that the consultant can quite clearly articulate the value of the services that they offer rather than just a price point’.

Consultants with no website should consider having a standard document to give patients before any treatment. ‘They should also ensure that when this is eventually enforced by the private hospitals, they use the same data so there is a consistent

How much more might have been saved if the insurers were subject to the same scrutiny as has been brought to hospital providers and doctors

BMI chief Stephen Collier

AIHO chief executive Fiona Booth

Don Grocott, Private Patients Forum

approach and set of data available in the market for their services.’

private sector adviser

Keith Pollard, managing director of Intuition Communication, said: ‘We have been lobbying for the collection and publication of performance data for some years and have been disappointed by the reluctance of private hospitals to share information on how well they’re performing and, perhaps more importantly, how much they’re charging.’

spire Healthcare

The group, which has escaped having to sell any hospitals, welcomed recognition it was not anti-competitive. It said it would work with the commission to make other proposed remedies as effective as possible.

Now it looked forward to seeing an end to a long period of uncertainty and would focus on growth and acquisitions. ‘If a hospital came up for sale, we would consider it carefully as an integral part of our long term strategy.’

Chief executive Rob Roger said the outlook for private healthcare and Spire was encouraging, especially as the economy recovered and employment rose.

Independent doctors federation (Idf)

The IDF said it did not condone financial incentives but felt it was not unreasonable to assist newly appointed specialists with rooms and secretarial services. Doctors could pay on a pro-rata basis.

Chairman Mr Ian Mackay said a lower percentage of NHS doctors were entering private practice and it this persisted, it would reduce competition and choice.

Producing information on per-

formance of individual consultants was consistent with the requirements for doctors generally and accorded with IDF policy of promoting independent medical sector excellence.

‘It will be easier in some specialties than others, but we are keen to work towards this goal.

‘We note that it has been suggested that hospital operators include as a condition of granting practising privileges that there should be an obligation on consultants to provide fee information to patients using standard letter templates.

‘We agree that specialists should be open and fair with all financial transactions with patients and that this should whenever possible be in advance. There may well, however, be exceptions to this when unexpected circumstances arise during surgery or medical treatment or when treating an emergency.’

Mr Mackay was disappointed there appeared to be no mention of what the IDF believed to be ‘the adverse effect on competition’ resulting from the relationship between some insurers and doctors.

federation of Independent practitioner organisations

Chairman Mr Geoffrey Glazer said FIPO backed the commission’s aims to remedy adverse effects on competition.

It welcomed the proposed restriction on doctors’ incentive schemes that encouraged patient referrals to particular facilities, and had itself advocated fee estimates to patients and quality outcomes data.

But it was disappointed the commission took no account of its evidence of insurers’ influenc-

ing the healthcare market, sometimes to patients’ detriment.

FIPO said the commission had failed to recognise how insurers’ activities such as open referral could work against true competition, particularly between doctors.

It also complained that greater transparency on costs and outcomes was accepted by hospital providers and consultants, but did not seem to extend to the benefits that subscribers might expect from private medical insurers (PMIs).

The commission had said it wanted to facilitate more effective choices by patients and others involved in a patient’s referral pathway and to allow patients to choose a consultant who offered the best value healthcare.

Mr Glazer said: ‘That is something as consultants we wish to achieve as well, but as the commission has already stated, PMIs influence the selection, pricing and delivery of services, through such mechanisms as the terms of the policies, approving or recognising hospitals, guidance to specific facilities or consultants, pre-authorisation procedures, setting of financial caps for individual treatments and agreeing reimbursement rates with individual consultants.

‘Since this is, by the commission’s own admission, the case, patients are still not receiving a fair deal from PMIs.’

Healthcode

The online solutions company said proposed information remedies would benefit all stakeholders ‘and we look forward to working collaboratively with providers and insurers to make private healthcare a sector where quality, outcomes and operational efficiency are second to none’.

the

private patients’ forum

The PPF welcomed the ending of inducements for doctors, appropriate transparency of relationships between doctors and hospitals, the publication of fees and the collection and dissemination of consultant and hospital performance data.

But spokesman Don Grocott claimed the commission had not understood the market and had failed patients ‘by entirely ignoring the role of insurers’.

‘The commission claims its proposed remedies package will reduce patient costs by at least £173m a year and not result in any material reduction in relevant customer benefits. That will be welcome.

‘How much more might have been saved if insurers were subject to the same scrutiny as has been brought to hospital providers and doctors? Only through a full market investigation will we ever know.’

Management Consultant

Philip Housden, of Housden Group, said time would tell if the proposals would make a more competitive market. But there was room for innovative responses that could benefit NHS trusts and consultant chambers at least as much as any hospital group or insurer.

private Healthcare Information network (pHIn)

Chairman Dr Andrew VallanceOwen called the commission’s remedy for performance information an emphatic win for patients and an endorsement of what PHIN had set out to achieve.

‘The commission has given private healthcare a road map for ensuring that patients get reliable information from an independent source to help them choose their consultant and hospital based on quality and price.

‘PHIN has always been open to the idea of a broader membership, and we are delighted that the commission has opened the way for insurers and consultants to join hospitals in a collective effort to develop independent and useful information for patients.’

Chief executive Matt James added: ‘We have the basis for developing a truly excellent service for patients, and a shared platform of information for the private healthcare sector.’ 

Keith Pollard, Intuition Communication

IDF chairman Mr Ian Mackay

FIPO chairman Mr Geoffrey Glazer

AccoUnTAnT’s clinic

Take control of your money

Some practices are increasingly diversifying and broadening their services with ventures like online shops and support medical care, such as massage therapists. Their original business model has changed as a result. So now more than ever it is vital for private doctors to be aware of the working capital requirements of their practices.

Here Susan Hutter talks about the ‘3C approach’ to working capital management, developed at her firm

cash

With the available sources of working capital now more limited, it is vital for practice owners to look at ways to improve their cash flow and ensure there is always enough cash in their business to operate and pay the bills.

This could include:

 Effective credit control procedures – collecting in money owing;

 Using the maximum credit period on offer from their suppliers;

 Offering early payment discounts to uninsured patients;

 Looking at Government­backed initiatives such as the Enterprise Finance Guarantee scheme. So, if your practice needs a loan but you don’t have the security to offer, the Govern ment will guarantee 75% of the loan for a premium.

costs

You should also negotiate on every line of cost, from the direct costs of providing services to overheads.

You may want to consider looking at new pay structures for staff to reduce the fixed costs of employment, renegotiating leases, and looking at discounts on other overhead costs such as stationery and professional fees.

control

For those that are looking to banks or other potential sources of finance to fund their growth, it is crucial to provide a detailed information pack which will include up ­ to ­ date, clear and accurate financial and management information, and evidence that the ability to report on practice performance is in place.

This will not only be a requirement for the providers of finance but will allow practice owners to make informed and rational decisions based on fact as opposed to instinct.

As an absolute minimum, quarterly – ideally monthly – manage­

ment accounts should be produced to include:

 A statement of profit and loss;

 A balance sheet detailing the assets and liabilities;

 A short­ and longer­term cashflow forecast.

In addition, you should prepare a forward forecast and business plan of at least the coming 12 months – ideally three years – to plan the working capital requirements along with the strategic development of the business.

The 3C approach will help to manage your day­to­day working capital, but where do you go to obtain the initial funding that may be required to expand the practice? The obvious answer will still be the bank, and the information pack mentioned above will be a key part of your approach including the business plan.

However, the ability to obtain funding from the banks continues to be a challenge, so practices may

want to look elsewhere for potential investment.

If expansion is on the horizon, it is well worth a conversation with your accountant to consider converting to a limited company. You would then be in a position to take advantage of some of the incentives for investors, such as the Enterprise Investment Scheme, to put money into businesses. Whichever route a practice takes, these decisions must be based on sound financial information and forecasts and not just instinct.

Many potentially successful opportunities have failed as a result of poor planning and implementation because the appropriate systems and finance were not put in place to support the plans. 

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

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If they try to nick

Consultants and GPs in private practice are well known for their inventiveness to improve patients’ lives. And, as our feature last month showed, taking out a patent is vital. But what if there is an infringement to your patent?

Adam Finch and Alexandra Cooper (pictured below) reveal their top tips for making a successful challenge

Once yOu have obtained a patent for your invention, you can be reasonably comfortable that your brainwave is now protected and you are less likely to have another party challenge it.

However, this will not prevent another party from potentially violating your patent – for example, by making, using, selling or importing a patented product or process without your permission.

If this happens, you can take steps to challenge that party for infringement of your patent.

Disputes relating to patent rights are often widely regarded as expensive and time-consuming. However, you are entitled to protect your invention, given the likely time, energy and resources used in creating and then registering the patent.

Therefore, any infringement will involve a careful considera-

tion as to the likely costs of protecting the patent.

If you do find yourself involved in an action for patent infringement, there are ways to manage that infringement to help you to ensure that the litigation is dealt with in an efficient and cost-effective manner; and that a commercially sound conclusion is achieved. you could even avoid being the subject of any such action.

1 is your patent valid? It is an obvious tip, but vital. check whether your patent is in force. If your patent is no longer registered, then there is little that can be done to prevent any infringement. In fact, you would have incurred considerable resources in protecting an invention that can no longer be protected.

Any action for patent infringement is likely to pose a significant financial burden on your practice. With this in mind, it is important to always remain open to settlement opportunities

2 Has it been infringed? carefully consider whether there has been an infringement of your patent. In pursuing a claim for infringement, you will need to be able to explain to a judge the invention in its broadest concept, and define the particular and limited applications of the invention. This can be difficult when it comes to complex medical prod-

your bright idea

ucts, and your lawyers will certainly need your support to be able to explain the product in a language readily understandable by a judge.

you will also need to explain the grounds of the infringement. Why does the rival product violate your patent? Has the infringer stolen your idea or copied a process? If the product does not fall directly within the words of one or other of the patent claims, then there will be no infringement.

3 consider settlement

Any action for patent infringement is likely to pose a significant financial burden on your practice.

With this in mind, it is important to always remain open to settlement opportunities. Granting the infringer a licence to use your patent or entering into a co-existence agreement whereby you agree to trade in the same or similar market alongside one another, in return for a royalty, may provide a means of avoiding the costs of litigation and present an opportunity for financial gain. This commercial approach is best pursued at the same time as robustly setting out the grounds of the infringement.

4 Prepare your defence if you are challenged If you find yourself on the receiving end of an action for patent infringement, consider whether you have a defence to the claim on the grounds that the patent is invalid because, for example, it is not novel, does not involve an inventive step or falls within one of the exceptions from patentability.

We have seen above the grounds on which a patent may

Entering into a licence agreement for royalties with someone who infringes your patent avoids the cost of litigation and can also be a money-spinner

be excluded, and these are particularly relevant to the medical sector.

consider whether the product is contrary to the public interest, does the invention involve a biological process for the production of plants or is it a simply a method of treatment?

5 Be water-tight

Validity can also be attacked on other grounds, even if it is established that the invention might have been patentable – for example, on the basis that the patenter has not given sufficient instructions in the patent to enable the invention to be carried out.

6 Keep an eye on competitors

Prevention really is better than the cure. To minimise the risk that you are found to have infringed somebody else’s patent in the first place, make sure you stay informed of what your competitors are doing. you may not be the only person to have discovered a new product or process, and it will save you time and money in the long run if

you are aware of any such products/processes at an early stage. It is far easier to have a conversation with a competitor at an early stage to agree a licence prior to the commencement of court proceedings.

7 Stay informed

Be alert to the upcoming eu patent changes. These will result in the introduction of the european unitary Patent enforceable across all eu member states and a u nified Patent c ourt to hear infringement cases from across these member states. These changes, which are expected to be introduced in Spring 2014, will dramatically change the way patents are enforced throughout europe and are likely to create much uncertainty and will lead to increased litigation costs.

8 choose the right court process

If legal proceedings are necessary, consider which court is the most appropriate to the value, complexity and importance of your action.

The Intellectual Property

enterprise court (IPec) deals with smaller, shorter and less complex intellectual property disputes relatively quickly, which means your legal costs are likely to be significantly lower than in the High court.

There is a cap of £50,000 on the costs which the losing party can be ordered to pay, which means your risk in relation to costs is reduced.

Damages awarded by the IPec are capped at £500,000, so consideration should also be given to the value of your claim. Longer, heavier and more complex, important and valuable actions belong in the High court.

9

get legal advice

Seek early legal advice from a solicitor with extensive experience in patent litigation. your solicitor can advise you on your rights and appropriate strategy, as well as identify any issues at an early stage, thereby enabling you to reach a cost-effective and commercially-focused outcome. He or she will be well placed to advise you in relation to the impact of the changes to eu patents outlined above.

10 Persevere

Finally, don’t give up. While the process to register and protect an invention can appear daunting, without these patents, the uK would not have one of the most advanced healthcare services in the world and inventions such as hip joint replacements, laserphaco probe or the excimor laser for vision correction would never have been invented. 

Adam Finch is a partner and commercial litigator and Alexandra Cooper is litigation solicitor at Harrison Clark Rickerbys

THE FUTURE oF HARLEy STREET

Our overseas rivals are streets ahead

Can Harley Street maintain its pre-eminence as a national and international centre of medical excellence? Keith Pollard warns that it now needs to be fought for

London’s HarLey street area boasts the biggest concentration of healthcare facilities and medical and surgical expertise anywhere in the world.

It is home to over 2,000 private consultants and an extensive network of supporting services.

o ver many years, the Harley street brand has become respected both within the UK and internationally. s o, how do we ensure that London’s private healthcare community continues to lead the way in an increasingly competitive marketplace for private healthcare in the UK?

and with more than 80 countries now competing for their share of the medical tourism and international patient markets, how can London and Harley street maintain its pre-eminence in the global healthcare market?

International patients benefit London’s economy and NHS

Private healthcare in Harley street and in London brings a great deal of benefit to the London economy in general, not just to the hospitals, clinics and doctors.

In a research project conducted for Visit London in 2010, it was estimated that the value of the international patient spend on medical treatment alone in London is between £280m and £330m a year.

the additional spend on accommodation and other services was estimated at £297m, giving a total value for the inbound international patient sector of around an annual £600m.

With the removal of the ‘private patient cap’, there has been heated discussion in the media in recent months about the role of the n H s in generating private patient revenue.

Harley street consultants ‘feed’ patients into London’s private hospitals and into the private patient units in London’s teaching hospitals.

London’s nHs hospitals generated over £270m of private patient revenue in 2012-13; 27% (£73m) of this is believed to be generated from the international patient market (see box below).

The ‘medical tourism cluster’ around the world, the concept of the ‘medical tourism cluster’ has been adopted by national and regional healthcare destinations. these clusters have been created to generate synergy between a

group of providers and to present a destination brand to consumers and purchasers of healthcare in other countries.

Private Patient revenue in London nHS HoSPitaLS

t hey may promote a city, a region or a country in terms of the healthcare services on offer to the international patient. In some cases, funding is provided by state-run healthcare or tourism bodies; in others, the providers direct funds to a central initiative. t he resulting organisation undertakes the marketing of the destination’s healthcare facilities in the targeted source countries for patients. they offer a central contact point for patients interested in visiting the destination for healthcare and may operate concierge services to support the needs of visiting patients.

Medical tourism clusters have been created in both low- and high-cost destinations for international patients: Mexico, thailand, Croatia, Bulgaria, s erbia, Latvia, Florida, Baja California, Bavaria, Lithuania and Brazil. Could a medical tourism cluster work for Harley s treet? Would competing providers work together to promote the Harley street brand?

The Malaysia success story one of the most successful government-driven initiatives to attract international patients is in Malaysia. Malaysia came relatively late to the international patient market, riding on the coat-tails of Korea, singapore and thailand.

the Malaysia Healthcare travel Council (MHtC) was set up by the Malaysia Ministry of Health in 2009 to establish Malaysia as the destination of choice within the asia-Pacific region.

It receives strong support from the association of Private Hospitals in Malaysia. seventy-two out of 253 hospitals in Malaysia are registered with MHtC to handle international patients.

MHtC is well resourced. It has a significant annual budget: 40 staff and regional offices which promote Malaysia’s healthcare with its target countries – Indonesia, Bangladesh, China, Japan and Korea.

It operates MHtC Concierge, a one-stop centre that provides medical travellers with easy access to all the information they need for a comfortable and fruitful stay in Malaysia. t he M t C Careline handles inquiries from potential customers for Malaysia’s healthcare services and supports patients during their treatment. the MHtC Lounge operates at Kuala Lumpur international airport and provides a first point of contact and support for inbound medical travellers.

Malaysia has climbed into the top five of medical tourism destinations worldwide and is spreading its wings. and it now has its eye on some of Harley street’s traditional source markets for international patients.

arabic countries were very well represented at the recent Malaysia International Healthcare travel expo and Conference, and there

is evidence that some high-value patients are being diverted from London to Malaysia.

Can Harley street afford to turn a blind eye to the quality of provision of medical and customer service now available in competing destinations? and to the level of investment which is being made by governments and providers in marketing their offering?

a s healthcare systems around the world develop, Harley street’s international business is coming under threat from both its traditional competitors and new entrants to the international patient market.

new opportunities are arising in r ussia and the former s oviet republics which are being explored by providers in Germany and switzerland. existing source markets in the Middle e ast are being targeted by new competitors such as Malaysia and turkey. these competitors are providing a better all-round ‘patient experience’, and getting their message across successfully to potential patients and healthcare purchasers.

If we do nothing, Harley street’s reputation and pre-eminence in the international patient market will become part of history. 

Keith Pollard is managing director of Intuition Communication, an online publisher in the healthcare sector that operates market-leading web portals such as Private Healthcare UK and Harley Street.com, and medical tourism sites such as Treatment Abroad

Join tHe deBate

the future of Harley Street will be discussed at a free, invitation-only event at the royal Society of Medicine on the evening of thursday 27 March 2014.

Join the debate on the way forward in the domestic and international healthcare marketplace. Participants will gain insight into the size and nature of the international medical travel market, the activities of Harley Street’s global competitors and opportunities in new and traditional markets for Harley Street’s expertise. to request an invitation, visit: http://future.harleystreet.com

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the Malaysian Healthcare travel Council has its own airport lounge

Journey’s end f r mileage tax case

Specialists face a hefty rise in their motoring costs following a farreaching tax case judgment that will prevent them claiming mileage to and from their homes to regular places of business such as private hospitals.

Ray Stanbridge (below) reports on what is changing and gives advice on what to do now

car

Independent Practitioner Today has been following the case since our first issue in June 2008 (top, middle)

So, the long-running tax case regarding consultant motor expenses – reported in detail over many issues of Independent Practitioner Today – has finally come to a halt.

the Upper tax tribunal heard an appeal by Dr Samad Samadian, a consultant paediatrician in Surrey, against a lower court decision on 16 December 2013.

And in a swift response, the judge, Mr Justice Sales, has now ruled that:

 travel by consultants to undertake itinerant work – for example, home visits to patients – IS taxdeductible;

 travel expenses for journeys between places of business for purely business purposes – such as two private hospitals – IS taxdeductible;

 travel expenses for journeys between a location which is Not a place of business – for example, an NhS hospital – and a location which is a place of business, such as home or private hospital, IS Not tax-deductible;

 travel expenses for journeys between home, even where home is used as a place of business, and places of business – for example private hospitals – are generally treated as Not tax deductible.

t he Lower tax tribunal had previously ruled that a consultant’s home could be a place of business – though not the only place of business.

As a result, those consultants who have a genuine office at

home and/or use their homes for business purposes can make claims for the costs incurred.

Care has to be taken over the possibility of attracting business rates and a potential capital gains tax liability on sale of a home. however, the principle that consultants can and do use their homes for business purposes has now been established in case law.

Key finding

But the key finding that will upset many consultants is that claims to and from their homes to regular places of business – i.e. their private hospitals – are not allowable.

We can expect hM Revenue and Customs to be much more vigilant in seeking to disallow these expenses where consultants have regular private hospital clinics now that they have clear case law on their side.

Where a consultant has irregular visits to private hospitals, it may still be possible to make claims. h owever, we can expect scrutiny to be severe.

Mr Justice Sales supported the Lower tax tribunal’s decision that consultants travelling to their home office from another place of business have a dual purpose for their journey. t hat is to say, in addition to working, they are going home – for example, to eat, sleep or play with their children.

As such, and according to the rules established in the tax case Mallalieu v Drummond (see box on page 18), there was a mixed

purpose in making the journey and that it was therefore not wholly and exclusively for the purpose of their business.

t he judge ruled that this case was one of the leading authorities on the relevant ‘wholly and exclusively’ tests for deductibility of expenses for a trade or profession.

Paradoxically, the judge ruled that if a consultant travelled home from a private hospital to collect notes that were mislaid or forgotten, then this journey would be an allowable expense. the judge expanded his reasoning in his judgment. essentially, he argued that when a consultant attends a private hospital on a regular and predictable basis, it cannot be argued that his or her home is the only business base.

As a result, any consultant who has a ‘fixed’ pattern of work, like a regular clinic, at a private hospital will be adversely affected by the ruling.

the judge also expanded on his view as to why travel between NhS and private hospitals is not allowable. h e said that case law showed there to be an important distinction between travelling in the course of a business and travelling to get to the place where business is carried out.

he argued that any consultant travelling from his or her NhS hospital to a private hospital is only putting himself in a position where he can carry on his business away from his place of employment.

The lessons for consultants

1

It is now absolutely essential for consultants to maintain a comprehensive log to record all their business miles.

our view is that hMRC will no longer be willing to accept ‘estimates’ and will be looking far more closely at each specific journey. t he judge has allowed the opportunity for argument in appropriate cases.

2

If consultants do genuinely work at home, then this will become one of their ‘places of business’. t hey should ensure that appropriate claims are made – but these must satisfy the ‘wholly and exclusively’ tests.

3

If possible, doctors should formalise their relationship with their private hospitals. they should define their ‘rights’ – if any – in living room space and determine what their obligations are. In most cases, the private hospital will be a ‘place of business’

HMRC will no longer be willing to accept ‘estimates’ and will be looking far more closely at each specific journey

and will be caught up with the ruling.

h owever, if doctors can prove that their use of private hospital facilities is purely of an itinerant nature, then travel claims may still be made.

this may be helpful for consultants who have occasional consulting or operating commitments with no fixed pattern whatsoever.

4

It is important to note that employees of a consultant’s practice can still claim mileage expenses against the business if expenditure is of a ‘wholly and exclusively’ nature. Visits to the bank, post office or to collect papers will probably still be allowable.

5

t he ruling seems to affect those with regular places of business – that is to say, regular consulting or operating slots. those with a large medico-legal practice, who have to travel to court, to solicitors’ offices or to

A long And wIndIng RoAd...

THe dR SAMAdIAn CASe ConSIdeRed THe followIng TAx CASe PRInCIPleS In ITS deCISIon on ConSulTAnTS’ MIleAge ClAIMS:

1. newsom -v- Robertson

A barrister operating a private practice claimed a deduction for costs of travelling between his chambers and his home office.

The deduction was not allowed, the reason being that the home office was for Mr newsom’s convenience i.e. he wanted to live in the country.

It was found, therefore, that there was a mixed purpose to each journey: partly professional and partly ‘the requirements of his existence as a person with ... a home’.

The fact that he carried out a ‘significant part of his professional life’ from there was irrelevant. This did alter the nature of the journey to and from home. This is known as the ‘commuting principle’.

2. Horton -v- Young

A bricklayer who had no business premises simply operated from his home. He worked at several different locations and travelled between them as well as to and from his home.

The judges in this case compared it to Mr newsome and found that Mr Horton’s base of operations was his home (as he had no other) because here he agreed contracts, kept his tools and business records and customers knew where to find him. A primary point from this case is that it isn’t necessarily a business base just because you carry out work there.

3. Sargent -v- Barnes

A dental surgeon travelled from home to his surgery and to a laboratory. The laboratory was a mile away from his home on the direct route to it

The ruling seems to affect those with regular places of business –that is to say, regular consulting or operating slots

private hospitals to interview or examine patients can still continue to make claims for travel expenses where appropriate.

6

Do not forget it is important to claim travel expenses for items which are often forgotten. these include:

 Attendance at CPD conferences;

 Attendance at other educational meetings relevant to a consultant’s business;

 Visits to secretaries;

 Visits for research purposes –for example, to look at new equipment or techniques – and, probably, emergency business.

While this matter was not specifically addressed by the Upper tribunal, practice suggests that hMRC is generally considerate for claims made to deal with genuine patient or business emergencies. 

Ray Stanbridge runs an accountancy, finance and tax advisory service specialising in the medical profession

from the surgery, which was further away. He stopped at the laboratory twice every day to collect and deposit dentures. He claimed the cost of travel between the laboratory and the surgery.

It was decided that the dentist was not carrying on his profession at the laboratory and this was not considered to be a ‘base of operations’.

Just because the journeys were necessary did not mean that they were wholly and exclusively for the purpose of his trade.

4. Jackman -v- Powell

A milkman operated a milk round under franchise. every day he travelled to the depot to collect his milk float before embarking on the round.

He purchased milk and returned his float from the depot. He gave his home address as his place of business.

The judge disagreed, stating that his round was clearly his base of operation, not his home.

5. Mallalieu -v- drummond

A barrister claimed a deduction for wearing suitable clothes in court. The judge found that the clothing was necessary as a human being for warmth and decency; the clothing was not simply for his job as a barrister.

This case looks at the precise interpretation of the wording of the statutory restriction imposed by what is known as the S74 ICTA88 ‘wholly and exclusively’ test. The case looks at discovering the ‘object’ in making the expenditure i.e. the intention of the taxpayer at the time he incurs the expense.

If it has two purposes that cannot be separately identified, then there is a dual purpose.

mARkETing FAQs

Get yourself seen

We doctors are a sceptical bunch – we like evidence and, like everyone else looking to try something new, we want reassurance that what we are doing is right and going to work.

Here are the most common questions I get asked – and my answers – about growing and promoting your private medical practice.

1

isn’t it illegal/banned by the gmC to advertise your private practice? t his has to be the number one question about private practice marketing.

In short, no, it is not illegal, nor is it prohibited by the GMc. You are free to advertise and promote your private practice, but you must ‘make sure the information you publish is factual and can be checked, and does not exploit patients’ vulnerability or lack of medical knowledge’. ( Good Medical Practice, 2013).

You must also, of course, comply with the rules and regulations of the Advertising s tandards Authority.

2 isn’t advertising unprofessional?

c ertainly, many doctors are uncomfortable with the idea of promoting their services; after all,

we are used to giving advice freely and, hopefully, without bias in the NHs to anyone and everyone who asks us.

Most of us are used to keeping a low profile, yet when we promote our services, we are stepping out of the shadows into the limelight; in effect saying ‘Look at me!’ and this can be uncomfortable.

Also, we have all seen crass adverts and promotions for all kinds of products and services. one client of mine even told me about an orthopaedic colleague of his who used to drive around with advertising stickers all over his car – ‘Get your dodgy hip replaced here!’ – and a giant plastic femur stuck on the roof! I am told he earned more than £2m a year.

Few of us would want to promote ourselves in such a way. But always remember that the final arbiter of how any promotion is done is YoU. If you don’t like promoting yourself in a particular way, then don’t do it that way. simple as that.

Just remember, though, if you are an advertising wimp and/or unwilling to be visible to potential patients, the odds are stacked against you when it comes to private practice success. You can’t have it both ways: to hide yet to be seen. For a second opinion on questions about promoting

3

What is the ‘best’ way to promote my private practice?

there is no ‘best’ way to promote your private practice – at least, no way you can predict in advance. s o much depends upon your specialty, location and willingness to commit to any given promotional strategy.

However, there will certainly be two or three ways to promote a given practice that are highly likely to work very well – though the ‘best’ or most successful will only be found by trial and error. even then, sticking to only one way to get patients in through your door is fraught with danger: the more ‘doors’ patients have available to them to reach your practice, the lower the risk and, better yet, the more patients you will attract.

4

i’m just starting out in private practice and don’t have much cash. i can’t afford to market myself

When starting out, funds are limited, for sure, but there are three things to bear in mind.

Firstly, there are some very low-cost ways to promote your practice.

s econdly, as you experiment with different marketing methods, you only stick with the ones

that bring in more money than they cost to implement.

Anything else would be insane. that is why the only ‘right’ way to advertise is with direct-response marketing, where you can be certain of knowing if it is generating income for you or not.

thirdly, in the early stages of all private practice start-ups, there are significant ‘obligate costs’ –defence indemnity, secretarial services, room hire – and until your income exceeds those expenses, you are losing money.

e ffectively promoting your practice is the only way to reduce the time taken until your income exceeds your expenses.

5

i’ve held loads of gP educational meetings and still don’t get many referrals

the traditional route to growing a private practice has always been to court GPs through educational and networking meetings.

If you are someone who enjoys these kinds of meetings – and some people are born networkers – then go to it. Yet most of us dislike this kind of schmoozing – personally, I hate it with a passion – and really would rather not do so.

And GPs are plenty smart enough to see these events for what they

➱ p22

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are and have significant other demands upon their time – so why should they bother attending?

Why should a GP refer patients to you rather than the senior consultant whom they have likely known personally and professionally for many years?

Until you can answer those questions very well and present the answer to our GP colleagues in a persuasive way, you will struggle with low attendance rates and a trickle of referrals. Nevertheless, there are very many other more effective ways of growing your practice that don’t involve schmoozing.

6

marketing doesn’t work! i’ve held gP meetings/run adverts/got some PR/employed an agency and got nowhere I love this question, as it gives me an excuse to use a favourite phrase: Marketing is like sex – if

it’s no good, you’re doing it wrong! the idea behind marketing is to connect you and your expertise to the people who need and are willing to pay for your expertise. If you are not achieving that, it is because you are making a false assumption somewhere – either that there is no demand for your services (this must be incorrect or your NHs clinics would be empty), or you are presenting your expertise in a way that is unappealing or not persuasive, or you are presenting your services to the wrong group of people. the list of potential mistakes is very long.

If your marketing isn’t working, you need to reconsider your approach. Just like sex.

7

i’ve had a website for ages and never had any patients from it

First of all, how do you know that? do you ask every single patient –and you really should be doing

Marketing is like sex – if it’s no good, you’re doing it wrong!

this – how they found out about you?

s econdly, even if you haven’t been tracking the source of all your patients, you are very likely to be correct, because the vast majority of all websites are appalling at generating patients – which is the only purpose of a website. If it is not doing this, it is a waste of time, money and an exercise in vanity only.

Your website needs to be designed so that every element of it assists in generating patients.

‘ c reative use of white space’, pretty pictures, flash animation, ‘brand awareness’, seo, ‘the importance of engaging your audience’, social media tags, ‘you shouldn’t have too much text on the page’, your website as an ‘online credibility brochure/statement’, ‘memorable online experiences’, ‘cutting-edge design’ . . . these are phrases telling you that you need a new web designer. Fast.

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8

i just don’t see the point in marketing. if people want or need me, they will come e rm, no, they won’t. s orry. t he point of marketing your practice is so that people who need or want your skills and expertise know about you. then they can decide to come and consult with you or not, based upon how you present your ability to serve their needs. If they don’t know about you, they can’t come and see you. simple as that.

9 i read independent Practitioner Today and i got last year’s free guides ‘100 ways to grow your private practice’ (July-August 2013, September 2013). i just don’t know where to start in my marketing the key thing to do is to start. Go through the pages of this magazine, go through those two guides

Give journalists an interesting story and they will bite your hand off

I wrote, and pick something that you would like to try.

Public relations or Pr is a great way to start because it costs nothing and can be very effective in generating patients.

Perhaps you could raise some money for a charity related to your specialty and write to one of the local free papers telling them about it and inviting them to the presentation.

Perhaps there is a topic in the news related to your expertise and you could write to the local paper with a comment on that piece of news – for example, minimum pricing of alcohol, Angelina Jolie and her prophylactic mastectomy – the list goes on.

Journalists look hassled and harried for a reason – they are under constant pressure to provide interesting content for their readership. Give them an interesting story and they will bite your hand off.

Whatever marketing approach you try, invest only a small amount of money; money which, if you lost, you would not be too upset about.

this is because the dirty secret of growing your practice is that most marketing strategies do not work very well – at least at the early attempts.

s ome fail completely and beyond redemption.

Most work in a so-so way and require tweaking and tuning to get good results. And just a few work stormingly well, generating returns of hundreds or thousands of percent. t hose, of course, are the big wins we chase – but the only way to get them is by trial and error.

delay no longer. Just start.

Dev Lall (left) is an upper-GI surgeon and runs a specialist private practice consultancy. He is the owner and director of PrivatePracticeExpert.co.uk

MEDICO-LEGAL TRAINING

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When you need to

investigate

For doctors in independent practice, poor staff performance or poor conduct is not just disruptive, it threatens the quality of the care you are able to offer, your reputation and can even put your own career in jeopardy if a patient is harmed. Dr Mike Roddis (right) explains how to investigate allegations against employees

The evenTs at mid-staffordshire nhs Trust showed that failure to properly investigate serious concerns raised by staff and patients is almost as damaging to public confidence as the poor practice itself. By contrast, conducting a thorough investigation when allegations are made about employees is an important way of restoring trust. It is also an ethical response.

The GMC says that doctors in a leadership or management role ‘must make sure that there are clear and effective procedures for responding to concerns about colleagues’ conduct, performance or health. This includes referring them to occupational health or other services, where appropriate, and making sure that staff are aware of these procedures’.

And while it is clearly better to address concerns as they arise or through regular appraisals, an effective investigation provides an important opportunity to tackle allegations of poor performance or conduct which might put patients at risk.

The fact you are prepared to conduct an investigation is itself a ➱ p26

valuable signal of intent, but you also need to ensure that the process used is fair, transparent and efficient to make the exercise worthwhile.

A credible response

Maintaining High Professional Standards in the NHS, 1 the five-part national framework which all nhs trusts have been expected to follow since 2005, recognises that ‘unfounded and malicious allegations’ can cause lasting damage to the reputation and career prospects of doctor – as well as other healthcare workers.

It stresses that ‘all allegations, including those made by relatives of patients, or concerns raised by colleagues, must be properly investigated to verify the facts so that the allegations can be shown to be true or false’.

But unless you have previous experience of managing investigations, it can be difficult to know how to respond when complaints come to light.

For example, how do you determine whether an allegation of dishonesty or bullying is simply malicious?

What opportunity should you give the employee to put their side of the story? And when would you be justified in excluding staff to protect the public?

As someone who has been carrying out investigations in the health sector since 2008, the best advice I can give independent practitioners is to have a written procedure which is available to all interested parties.

having a model to conform to makes the investigation process more straightforward and also gives it credibility.

But conducting an investigation on the hoof leaves you vulnerable to claims of unfairness and could result in months of legal wrangling in an employment tribunal or over legal contracts, not to mention ill-feeling among your team.

The process

An effective written investigation procedure should help you uncover the facts and consider their implications, without jeopardising the rights of the person under investigation.

All members of staff with man-

agement responsibilities should understand the procedure to ensure consistency. And it is also worth providing additional training in handling discipline and grievances so that managers have the confidence to deal with minor problems informally or initiate investigations when appropriate.

The following step-by-step guide is based on my investigation work with nhs trusts and independent providers.

1 carry out an initial assessment

When a problem is identified, consider whether it can be managed informally though further training and development or whether it raises serious questions about the person’s capability or conduct which might justify disciplinary action.

The kinds of cases I have been asked to investigate usually involve accusations of dishonesty – such as forged prescriptions or falsifying records – or where a particular incident highlights growing concerns about an individual’s attitude or performance.

2 Define the terms of reference

In particular, be clear and specific about the allegations you want to investigate and the period under investigation.

If allegations only amount to a series of vague concerns, such as poor communication or attitude, it will obviously be difficult to substantiate or disprove them: a serious stumbling block in any investigation.

The terms of reference will also include a time-scale for the investigation to be completed.

3 notify the individual under investigation and give them the opportunity to respond

Individuals should be informed if allegations are made about them and given an initial opportunity to respond.

If you invite them to an initial meeting to hear the allegations, you may want to offer them the option of being accompanied by a colleague.

They may also require support to deal with the stress of the investigation, particularly if ques-

tions have already been raised about their health.

In a small practice, it will often be easy for the person facing allegations to work out who has raised concerns about them, so bear in mind that you have a duty to protect these employees from intimidation or bullying.

4 protect the public

In the past, nhs trusts have been criticised for excluding –formerly known as suspension –doctors for extended periods; a practice that was widely condemned as unfair and expensive.

exclusion will only be appropriate if the individual represents a clear danger to patient safety, but, in many cases, you could still consider alternatives, such as restricting their duties.

If it is necessary to exclude someone, it should be made clear that this is a neutral act and not a punishment. The reasons for the decision should be carefully recorded and the decision itself kept under review.

5 investigate the allegations

Investigators are responsible for reviewing evidence, interviewing the individuals under investigation and obtaining signed statements from witnesses without leading them or putting them under undue pressure.

This is a sensitive task, so your investigator should be suitably trained, experienced and able to ensure the investigation is conducted fairly and within an agreed time-scale.

It is essential that they respect the confidentiality of everyone involved so that aspects of the investigation do not become the subject of workplace gossip.

e ven if you initiate investigations with a preferred outcome in mind, it is important to ensure that the objectivity of the person investigating the allegations is not in doubt.

To ensure there is no conflict of interest, the person charged with conducting the investigation should not be the same person who will oversee any subsequent disciplinary proceedings. In a small practice, this is often not practicable, so consider calling in an external investigator.

properly conducted, an investigation can help you clear the air or give you the evidence you need to address a particular concern

6 conclude inquiries and make recommendations having weighed up the evidence, the investigator would then be expected to produce a written report for you, including all documents and statements, as well as their findings of fact and suitable recommendations.

possible outcomes include:

 There is no case to answer and the investigator recommends there should be no further action;  There is limited evidence to support the allegations but the investigator does not believe they warrant a disciplinary hearing. Instead they recommend the employee receives further training or support;

 There is evidence to support the need for a disciplinary hearing and the investigator recommends the individual is also reported to the regulator (the GMC or nursing and Midwifery Council). As an investigator, I would generally advocate sharing the report with the individual concerned in the interests of transparency and fairness.

next steps

An investigation should not itself result in disciplinary sanctions, but if the outcome of the investigation gives cause for concern,

you will want to consider further action.

This will largely depend on the employment status of the individual concerned. If the individual concerned is not an employee and you wish to terminate their contract, it’s important to take specialist legal advice.

Where the individual is an employee, the next stage would usually be to hold a disciplinary hearing where the employee can put their case and you can determine what action is appropriate –from a formal warning to instant dismissal.

ACAs, the independent arbitration service, has produced a code of practice for disciplinary and grievance procedures2 which sets out the main principles. It includes the statutory rights for employees to be accompanied to a disciplinary meeting which might result in a formal warning or other disciplinary action and the employee’s right of appeal. employment tribunals are expected to take the ACAs Code into account when considering relevant cases and can adjust awards up or down if they believe an employer or employee has unreasonably failed to follow the code. In some circumstances, you may also be justified in passing on your concerns to other organisations. For example, if you have serious concerns about whether a clinician presents a risk to patients, you would usually pass these onto the GMC and their nhs employer, if appropriate. In exceptional cases, you may also be justified in informing the police – for example, if you suspect fraud.

RuleS

no excuses

Of course, investigations present their own challenges – they can be stressful and must be conducted to the highest standards to avoid allegations of unfairness.

h owever, the alternative is simply ignoring allegations or making excuses for apparent instances of poor conduct or performance, which is clearly not in the interests of patients, colleagues or the individual whose professional reputation has been impugned, possibly unfairly. It can also make it much more difficult to address problems when it is inevitably forced onto the agenda.

Properly conducted, an investigation can help you clear the air or give you the evidence you need to address a particular concern. And if you approach it with an open mind, the process may also help you reflect on improvements you can make within your own practice, such as better training, career development or practice protocols. 

Dr Mike Roddis is a former consultant pathologist and NHS medical director. He is now a specialist in professional development and organisational troubleshooting in the independent sector and in NHS trusts

References

1. Maintaining high professional standards in the modern NHS. DoH, February 2005.

2. Disciplinary and grievance procedures, Code of Practice 1. ACAS, April 2009.

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scREEning sERvicEs

Healthy returns

Employee health screening is showing encouraging growth in the recovering market. Leslie Berry reports on BMI Healthcare’s experience

Healt H care market analyst l aingBuisson estimates that the B2B healthcare screening market was worth an estimated £100m in 2009.

Preventative health by the NHS is often put under the microscope, but, with private service providers, it has shown rapid growth in the past few years as employers look to benefit from a proactive approach to managing their workforce’s health.

a ccording to a Government review in 2011, employers paid £9bn a year in sick pay and costs associated with employees on long- and short-term leave.

Proactive health screening can help identify a wide variety of potential problems at an early stage, allowing a firm or individual to seek medical attention faster.

But there is another bonus. a laana Woods, head of HealthFirst Health Screening at B m I Healthcare, says: ‘ t he message and comments we receive from our clients and Hr teams we work with are that health screening helps keep their workforce fit and healthy. But, crucially, it delivers a return on their investment.

‘the growth of health screening has reflected the upward trend in the recovering market. But it’s the gateway effect to our business that offers the biggest opportunity.’

Patients return

B m I figures show that 41% of patients who have a health assessment return to BmI Healthcare for day case, outpatient or inpatient procedures within two years.

Patient satisfaction levels for health screening are high, with 81.2% saying they are likely to return to B m I Healthcare for a health assessment in the future.

B m I Healthcare last year rebranded its health screening department to HealthFirst. It says the change in name reflects its focus on this key market in driving patients into its business.

ms Woods adds: ‘Health screening and our e ssential, Select, advanced and advanced+ screens are a keystone to BmI Healthcare’s HealthFirst B2B proposition and the name change reflects the work we have undertaken in the past six months to develop it into a full service offering, working with our new and existing clients to diversify and meet their expanding needs.’

across 35 locations in the past 12 months, BmI Healthcare has seen a 13% growth in the number of people having health assessments. aiming to build on this growth, the company says it has been listening to its B2B clients to deliver new products that meet their needs and respond to the growth of the market.

B m I Healthcare’s flagship HealthFirst centre, B m I c ity m edical in the c ity of l ondon, has seen a 20% year-on-year

increase in patients and there are plans to open another four HealthFirst centres across B m I’s network in the next 12 months. a key focus of this new growth has been its physiotherapy and musculoskeletal offering. e mployers are evidently now more than ever looking to be proactive about early intervention and preventative measures than in the past.

integrated approach

One way of doing this is to take a more integrated approach; BmI’s offering to its client Surrey Police comprises two components: rapid access to physiotherapy treatment for all staff suffering from pain as a result of injury or degeneration, and targeted treatment.

t he latter provides private healthcare treatment to cases that meet certain criteria – there must be an 80% success rate of returning to full-time duties, for example. treatment can range from a scan to a knee or shoulder surgery. On average, the system reduces absenteeism by 25 to 60 days on each case.

But it is not just the high-acuity

work that HealthFirst deals with. ms Woods says perhaps the easiest way for a business to see a quick return from investing in its employee’s health is through flu vaccinations.

a n effective programme can reduce the average number of days off sick in a workforce and costs just a few pounds per employee. B m I Healthcare’s HealthFirst offering also comprises travel vaccinations, imaging, occupational health, and GP services.

ms Woods says the B2B healthcare market is providing an opportunity to work with clients on tailored solutions to reduce their absenteeism, improve employee morale and really provide a visible return on investment.

‘Often with preventative medicine there has been a perception that it is low volume and low margin. But, putting the brand at the forefront of people’s minds and by working with our clients to provide a tailored solution with integrated patient pathways that feed into secondary care, the potential market value is huge.’ n

BMI City Medical in St Helen’s Place – BMI’s flagship HealthFirst centre – has witnessed 20% growth year on year

To learn more or to subscribe risk-free, visit learn.uptodate.com/UKanswer Or call 1-888-525-1299 (US and Canada) or +1-781-392-2000 (all other countries).

Patients don’t just expect you to have all the right answers. They expect you to have them right now. Fortunately, there’s UpToDate, the only reliable clinical resource that anticipates your questions, then helps you find accurate answers quickly – often in the time it takes to go from one patient to another. Over 700,000 clinicians worldwide rely on UpToDate for FAST clinical answers they trust. Shouldn’t you? Join your colleagues and subscribe to UpToDate risk-free today!

Avoiding pRoFEssionAl piTFAlls

Keep your nose clean

Not every road to trouble begins with doctors making a clinical error. Problems with your conduct, professionalism and doctor–patient boundaries can lead to sanctions as damaging as any clinical negligence claim, warns Gareth Gillespie (pictured left)

For many doctors, the idea of ‘getting into trouble’ means a claim for clinical negligence, with all that entails – months of anxiety, stressful meetings with lawyers and experts, fear of a court appearance and adverse publicity.

But staying out of trouble in medicine is about more than keeping on the right side of the law.

your fitness to practise can also be called into question for matters related to your conduct – and this might involve the way you interact with social media or how you (mis)manage doctor-patient boundaries.

or it may be that your sense of professionalism may be questioned. These are all aspects of life as a doctor that are not easily defined, but they can attract complaints and GmC investigations if not properly observed.

professionalism

In its 2005 publication, Doctors in society: Medical professionalism in a changing world, the royal College of Physicians describes professionalism as: ‘ a set of values, behaviours and relationships that underpin the trust the public has in doctors.’

at mPS, we broadly recognise a set of characteristics that, together, form the foundation stone of the doctor-patient relationship: trust.

These characteristics are:

 Expertise;

 Standards;

 respectability;

 responsibility and reliability;  Probity;  Conduct;  respect.

Some will, no doubt, maintain that the ethos of professionalism and the instinct that tells us what a professional person would do in a given situation can only develop with experience.

o thers will argue that professionalism is simply about making the right choices, for the right reasons, no matter what stage in your professional career these decisions arise. There may be some truth in both perspectives, but it can never be too soon to think these issues through.

Professional integrity is a precious attribute that needs to be cultivated and protected from the very start of a professional career, including entry to medical school.

The G m C plays a key role in safeguarding professionalism in medicine. This stance is outlined in Good Medical Practice (2013) , para 65: ‘you must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession.’ In figures revealed by the GmC about allegations heard at fitness-topractise hearings in 2011, among the top five were probity, working

with colleagues and relationships with patients.

Maintaining boundaries as a doctor, you are expected to show compassion and empathy when treating patients, and it can be a challenge to show this human face without blurring the boundary between professional and personal relationships.

The GmC has published detailed guidance on maintaining boundaries in Sexual behaviour and your duty to report colleagues (2013). In paragraph 53 of Good Medical Practice (2013), the GmC says: ‘you must not use your professional position to pursue a sexual or improper emotional relationship with a patient or someone close to them.’

Knowing how to maintain this boundary depends largely on a doctor’s self-awareness and their ability to judge the particular situation:

 Be aware of how you portray yourself to patients.

 Do you feel uncomfortable with a patient? If so, try to identify the cause – is it something they said, or did, or was it their body language?

 Do you feel a special rapport or attraction to a particular patient? If so, seek advice from a colleague and deal with the situation before it escalates, either by establishing clear professional boundaries and sticking to them or by referring the patient’s care to another doctor.

The way in which patients interpret your behaviour can give them the wrong idea and you risk being reported to the G m C if there is the slightest suspicion that your intentions are unprofessional.

social media

Being aware of professional boundaries also increasingly extends to doctors’ use of social media. It is now practically everpresent in people’s lives, and doc-

tors should be particularly aware of the risks.

There have been numerous examples in the media about doctors revealing confidential patient information on blogs, Facebook, Twitter and other forums, while doctors who fail to restrict access to their private lives – and the particularly unsavoury photographs or videos that are a common feature for some – risk damaging their professional reputation.

mPS advises that doctors should treat everything posted to social networks as if it is something they have written down. It is never truly anonymous and exists in perpetuity, meaning that the chances of such comments being traced to the author should never be disregarded.

Comments made innocently about patients, treatments or particular procedures can potentially breach confidentiality, especially if they mention unusual symptoms

or conditions. If just one patient recognised themselves from your comments, it could be sufficient for the GmC to take action.

Social media is a new arena within which doctors must tread carefully, being mindful of their responsibility to maintain public trust and the standing of the profession.

It is for this reason that m PS strongly advises doctors to avoid adding patients as ‘friends’ on sites such as Facebook. The GmC has published explanatory guidance on this topic: Doctors’ use of social media (2013)

 This article is based on a presentation given by Dr Tom Lloyd, MPS medico-legal adviser, at a MPS/ASiT conference, held at the Royal College of Surgeons of England last autumn

Gareth Gillespie is responsible for editing Casebook , MPS’s flagship journal, medico-legal factsheets and MPS Update

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Case study: maintaininG a healthy distanCe

dr P, a consultant dermatologist, was working in his surgery one Friday morning when a patient, miss B, came to see him about her psoriasis. he began to take a history from the patient and, after they had been chatting, realised that she was one of his neighbours and they knew mutual friends.

they seemed to get on well during the consultation, so dr P invited her to be his friend on Facebook.

after a while, the relationship soured, and the patient complained to the GmC about dr P’s conduct in contacting her and starting a friendship as a result of meeting her as a patient.

dr P went through months of anxiety during correspondence with the GmC, before the case was concluded with a warning.

learninG Points:

 always maintain professional boundaries, which social networking can sometimes blur

 do not accept current or former patients as friends or followers

 exercise caution when accepting friend requests from colleagues

 always respect patient confidentiality, including in online forums

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Avoiding nEgligEncE clAims

Real consent based

Everybody knows the importance of consent. Nevertheless, failure to obtain valid consent remains a regular feature in clinical negligence claims, particularly against surgeons. Dr Gerard Panting investigates

F OR CO n S en T to be valid, the patient or proxy decision-maker must be competent, have the necessary information and make their choice freely.

The law on consent has evolved over time and it’s interesting to see how the courts’ and society’s expectations on information, disclosure of risks and alternatives have changed over the last 60 years – and just how much more is demanded of today’s doctors compared to their 1950s’ counterparts.

Back in 1954, the case of Hatcher v Black1 came to trial. Mrs Hatcher suffered from thyrotoxicosis. She was referred to a London teaching hospital where she saw Mr Black, who advised surgery.

Mrs Hatcher, who occasionally broadcast for the BBC, was concerned about the potential risks to her voice and specifically inquired whether or not there was any cause for concern.

She was assured that there was no risk to her voice even though the surgeon knew that this was not true.

Unfortunately, her recurrent laryngeal nerve was damaged during surgery to the extent that her

voice was affected and she was never able to broadcast again. At trial, the truth emerged, but it was accepted that the surgeon had lied ‘for her own good.’ In summing up the evidence for the jury, Lord Justice Denning said ‘…as far as the law is concerned, it does not condemn the doctor when he only does what many a wise man and good doctor so placed would do.

Paternalistic attitude

‘It only condemns him when he falls short of the accepted standards of a great profession: in short, when he is deserving of censure.’

Denning went on to tell the jury that none of the doctors who had given evidence had criticised the surgeon and so neither should they. Consequently, Mrs Hatcher lost her claim as well as her voice, and doctors had licence to practise as paternalistically as they saw fit.

Across the Atlantic, the courts took a different view 18 years later, in the case of Canterbury v Spence.2 Like many of the leading consent cases, it was a spinal surgery claim.

The patient, who was 19, suffered from severe pain between his shoulder blades and consulted

on information

Dr Spence, following which a myelogram and surgical intervention was recommended.

Prior to surgery, Dr Spence did not tell his patient of the potential risks and Mr Canterbury did not ask. During surgery, Dr Spence noticed that the spinal cord was swollen and attempted to relieve the pressure. However, postoperatively, Mr Canterbury had difficulty walking and was incontinent. He then slipped and sustained further neurological damage. Following further treatment, his condition improved. The case came to trial in 1972 and was initially dismissed. On appeal, the consent issues were examined in more detail. The court held that ‘The patient’s right of self-decision shapes the boundaries of the duty to reveal. That right can be effectively exercised only if the patient possesses enough information to enable an intelligent choice.

informed consent founded

‘The scope of the physician’s communications to the patient, then, must be measured by the patient’s need, and that need is the information material to the decision.’ And so the doctrine of informed consent was established in law for the first time. Other north American cases followed, with many reaching a different conclusion, so informed consent was far from set as the standard. Back in the UK, similar issues came before the House of Lords and, in 1985, the case of Sidaway v Board of Governors of Bethlem Royal Hospital and the Maudsley Hospital.3

Mrs Sidaway suffered from pain in her neck, right shoulder and arms. She consented to cervical cord decompression but was not warned of the small chance of paraplegia which she developed after the operation. This risk was

estimated to be less than 1%, even when the operation had been performed with due care and skill.

Mrs Sidaway sued, claiming damages for personal injury. The basis of her claim was that had the surgeon not failed to inform her of all the risks of surgery, she would not have given her consent and so avoided the resultant damage.

This was an important point, as it satisfied the ‘but for’ test. If she would have undergone the surgery anyway, she would not have avoided the harm she suffered. So there could be no damage from the ‘failure to inform’ and so no claim to answer.

Ultimately, Mrs Sidaway lost her case, with Lord Bridge stating that ‘…what degree of disclosure of risks is best calculated to assist a particular patient to make a rational choice as to whether or not to undergo a particular treatment must primarily be a matter of clinical judgment’.

Lord Scarman spoke up for informed consent but was in the minority, and so it remained the prerogative of the doctor to decide what information should be given to a patient before deciding whether or not to proceed with treatment.

This position was reversed in 1999, not by the courts or Parliament but effectively by the General Medical Council. With publication of its guidance on consent, Seeking Patients’ Consent: The Ethical Considerations , 4 the regulator set out the standards that it expected of doctors in seeking consent.

The GMC listed information ‘which patients want or ought to know, before deciding whether to consent to treatment or an investigation’.

This included ‘details of the diagnosis and prognosis, and any uncertainties; options for treat -

ment or management of the condition, including no treatment; the purpose of a proposed investigation or treatment; details of the procedures; how to prepare for the procedure; common and serious side-effects and serious or frequently occurring risks; the probability of success; and a range of other issues. In short, all information material to the decision’.

Unavoidable risk

The next development was the case of Chester v Afshar which was decided by the House of Lords in 2004. This was a high-profile clinical negligence claim concerning a patient who suffered from repeated back pain. She was advised to have surgery but was not warned about an unavoidable risk, thought to be between 1% and 2%, of cauda equina syndrome, which unfortunately did occur. Representing the majority view in the House of Lords, Lord Steyn held that ‘as a result of the surgeon’s failure to warn the patient, she cannot be said to have given informed consent to the surgery in the full legal sense. Her right of autonomy and dignity can and ought to be vindicated by a nar-

row and modest departure from traditional causation principles’. So, in this case, the ‘but for’ test was not found to be necessary for the claim to succeed and so it broke new ground in clinical negligence.

However Chester v Afshar has not opened the floodgates to ‘failure to warn’ cases. Generally, it is held to be an ‘unusual case’, where the departure from the traditional ‘but for’ test was necessary for policy reasons.

So Chester v Afshar did not establish a new general rule on causation but represented exceptional circumstances where the rules regarding causation had been modified by the House of Lords on policy grounds.

But there’s a lot more to consent than information.

In the next issue of Independent Practitioner Today, I will be looking at competence to consent, powers of attorney and ensuring that there can be no allegations of duress – and other big issues.

Dr Gerard Panting is medico-legal adviser to a number of specialty specific indemnity schemes including PRASIS for plastic surgeons, OTSIS for orthopaedic surgeons, AOOSIS for ophthalmic surgeons and SIS for general surgeons

REFERENCES

1. Hatcher v Black (1954); Times, 2 July (QBD). 2. Canterbury v Spence 464 F 2d 772 (DC, 1972).

3. Sidaway v Board of Governers of the Bethlem Royal Hospital and the Maudsley Hospital [1985] AC 871.

4 Seeking Patients’ Consent: The Ethical Considerations; General Medical Council 1999.

If only I had known that

Wouldn’t it be nice if more ‘old hands’ in private practice were inclined to share their tips for success with the next generation? Fortunately, an eagle-eyed Garry Chapman – tongue firmly in cheek – unearthed this letter to a new independent practitioner from a kindly newly retired specialist

20 February 2014

Dear New Consultant,

I know that we have not met, but I have been told that you will be taking over my consultation rooms now that I have retired.

This has made me think back to when I started in private practice – which seems a lifetime ago. I thought about ‘things I wish I had known’ when starting way back then.

So it is with this in mind that I write to you in the hope that, should you take only one piece of my advice, it will make your private practice life so much smoother than mine was in the early years.

The first thing you should be aware of (if you are not already) is that you will have been used to sharing medical knowledge with your colleagues throughout your career.

But when it comes to the commercial aspects of running a private practice, you will find the majority of your colleagues, for obvious reasons, will be shy about sharing information.

The most common mistake new consultants make is not to recognise that, once they enter private practice, they are now running a business with all the associated costs that are involved with that.

In the first instance, it would be prudent to set up a business bank account in order to keep your finances separate from any domestic ones. I certainly wish I had contacted an accountant before I had started out in private practice to get expert advice on the best way to structure my practice from a business and tax perspective.

This would have saved me an awful lot of stress in dealing with the taxman as well as saving me thousands of pounds in tax fees. This is especially true today when taking into account the myriad of ways that a business can be structured and the associated complex tax rules.

Another key area is to make sure that your practice wife –your secretary – is one that matches your personality. You are likely to spend considerable time with her, so it makes sense that you should both get along with each other.

A mistake I made in the early years was to persevere with a secretary where we clearly had different ideas on how things should function on a day-to-day basis. Ultimately, this affects the practice, so make sure that you spend the necessary time in finding the right secretary to work with. It will be time well spent.

Remember, your private practice has running costs, so it is vital to make sure that this crucial area is dealt with correctly and that you collect what you have billed. This was my biggest area of weakness and, for many years, I lost thousands of pounds a year! It was a painful experience and I regret it even more so now that I am retired.

The assumption I made at the beginning was that this was a simple thing to do and that everyone would pay me for my

The Old Consultant Practice Consulting Rooms Any Private Hospital UK

time and expertise. Looking back, I cannot believe how naive I was.

The first thing I got wrong was that I billed my codes at incorrect prices. I made an assumption that all insurance companies paid the same fee. How wrong I was. I found out much later that the prices for the CCSD codes could differ by 100% depending upon the specific code.

On top of this, I later found out that there are rules regarding which codes can be billed together which can also be different for each insurance company. This lack of knowledge also cost me thousands of pounds.

I also found out – way too late – that there were quite a large percentage of my patients that were not paying me for my services. At the time, I could not understand why they did not want to pay.

As I had come into private practice to focus on the medical side, I did not want to have to discuss finances with my patients. Back then, I thought it was poor business practice to be chasing them for money. This attitude cost me a lot of restless nights and huge tax bills on money that I had invoiced but never collected.

The answer to my problems regarding the medical billing and collection was when I was introduced to a company that specialised in this field. It took on my backlog of unpaid invoices and was very successful in collecting these.

It billed my procedures at the correct rate for each insurance company and kept my bad debts down to less than half of one per cent on all my billings. On top of this, it dealt with all the queries from both the insurance companies and patients. This enabled me and my secretary to focus on the patient.

My practice was transformed and my only regret was that I had not been told about them sooner, as it would have saved me a lot of money and enabled me to sleep at nights without worrying about the bills that had to be paid.

You have spent a major part of your life becoming the expert in your specialty. Other people have spent a similar amount of time becoming an expert in their field, so if you only take one piece of advice from this letter, it would be to employ experts in their respective fields. This leaves you to focus on what you do best, which is the medical side.

I wish you all the best for the future and hope your journey in private practice is as enjoyable as mine was. But without the bumps along the way.

Yours sincerely,

Garry Chapman is managing director at Medical Billing and Collection

Power and peril of

groups

There is much potential for group practices to go badly wrong unless consultants are aware of the dangers. Maitland Cook (left) sets out the basics of setting one up

In The building industry, many state that ‘the prelims’ (preliminary planning and works) are the most important aspect of a successful development.

This, and the old football adage from the 1950s, ‘Keep it Simple –Keep it Quick’, are both relevant today for independent practitioners who want to successfully set up a group practice.

The ‘prelims’ are the careful, detailed planning of the project from concept to reality and include basic, major decisions that will affect the project throughout the years to come. They are, therefore, vitally important.

And why ‘Keep it Simple’? Simplicity equates to clarity, and transparency. Both are essential to maintain harmony and clear understanding between the members of the group practice, however large or small, and whether it be GP, consultant specialist or a clinic/hospital.

I advocate ‘Keep it Quick’ because doing so equates to speedy access to service and information. A quick service in every aspect is the most important key to patient satisfaction.

Speedy access to information is also important for the group practice because it provides clarity and

If you are thinking about setting up a group practice with a colleague, consider very carefully the personal relationship with and between potential partners

transparency throughout all areas of the operation.

So let us look in more detail at these elements, from preliminary planning, to formation, to ongoing running of the group practice. On a purely human level, it is of paramount importance to have the right partners and partner mix. If you are thinking about setting up a group practice with a colleague, consider very carefully, and in detail, the personal relationship with and between potential partners.

Qualities of a partnership

Being a partner in a group practice is a completely different relationship to working with a colleague. You should ask yourself:

 Do you respect their clinical ability?

 Do you respect their personal conduct?

 Do you see eye to eye on medical and non-medical matters?

 Is there mutual trust?

 Is there equal ambition?

 Do you both have financial clout in the context of the proposed practice?

 Are you at ease communicating with each other?

If the majority get a tick, there is a chance. But if the majority get a

Being a partner in a group practice is a completely different relationship to working with a colleague

cross, think again. Find others who do tick all the boxes.

Once the potential partners have identified themselves and agreed they wish to move forward, it is wise to formalise the arrangement. While this has minor cost implications, it has the benefit of bringing clarity and transparency from the very beginning.

To ensure no misunderstandings or grey areas between the partners in any group practice of whatever size, specialty or complexity, there has to be clarity and transparency on all matters. e ssentially, getting the basics right at the beginning ensures no pain at the end.

In the ideal, a limited liability partnership (LLP) should be formed. This will include an agreed split of equity, to which capital investment requirements can be linked.

It will clarify the order of seniority between the partners and a voting structure. The LLP formation should be supported by an equity-holders’ agreement. This document should be created after in-depth discussion by the potential partners as to how their business, the LLP, should be structured and operated.

These two documents create an entity, which is legally binding, and a working agreement, also legally binding, between all the partners and – most importantly – a decision-making structure.

The formation may initially seem complicated, but, in fact, it creates clarity and transparency, giving protection to all parties for the future. It is the basis for moving forward.

Serious consideration should also be given to specialty mix and market research needs to be carried out. This can be done before, during or after the formation of the LLP, but must be done at an early stage.

getting the mix right

Assuming the practice is in the private sector, the market research must identify a need for the practice specialty or the practice mix. Where there is a mix, crossreferral – for example, dermatology and plastics – is a benefit to keeping the practice and partners busy. If it is a single specialty, consideration should be given to whether there can there be a division of subspecialties. Is the specialty or mix dependant on recognition by insurers? If so, will this be forthcoming or is that market committed in the area to other existing providers? Finally, and most importantly, will the chosen specialty or mix keep the partners fully occupied and the partnership profitable?

The location and the property requirements are the next consideration at a preliminary stage of the set-up. The location can be key. Public transport, parking, access, shops, reputation are all key considerations for the success of the venture.

It is only once these matters have been considered and answered that the venture can move forward.

There will inevitably be a financial funding requirement, either from personal investment or, in all probability, from a financial institution. So a detailed business plan, with full details of capital expenditure and for a minimum of three years, will need to be written. The bank will probably require personal investment from the partners as a prerequisite of any funding for the LLP.

The formation may initially seem complicated, but, in fact, it creates clarity and transparency, giving protection to all parties for the future

On the assumption the group practice has inherited a location with existing facilities, there may only be refurbishment and reregistration to be dealt with. however, refurbishment and reregistration can both be fairly complex issues unless planned and managed. This leads to essential consideration by the LLP of management or use of independent specialist consultants during the pre-opening period.

hiring a manager

Management will be an ongoing requirement, so if a chief executive or general manager with experience of project management in the healthcare sector can be appointed at the outset to oversee the refurbishment and registration with the Care Quality Commission (CQC), the position can continue once the unit is operational. If no manager is available, an independent firm of consultants in the healthcare sector can be appointed. They could co-ordinate all aspects of the development, including planning – both financial and operational. They could also deal with all propertyrelated statutory requirements,

The business plan can and should be the commercial bible for the business side of the practice for years to come

architects, design, specialist fitout and contractors to ensure the group practice obtains the building it requires, as well as CQC registration, liaising with the bank in relation to the funding after creating the business plan.

This will include writing all policies and procedures and compliance with all current requirements. Also, medical insurer recognition as a registered provider will have to be processed.

It is essential to have secure funding in place to be able to budget for the development of the chosen site and also to plan the working capital requirement for the early days of the group practice.

The business plan can and should be the commercial bible for the business side of the practice for years to come, whether or not independent consultants are project managing and co-ordinating the process to registration and opening.

Whichever route is followed to opening, it is vital to have strong commercial management in place in adequate time to plan the operation of the group practice facility. There have been many disasters over the years where spouses or partners have been entrusted with

the day-to-day management, with dire consequences for all. Strong management is essential and the group practice members should set the rules for the establishment, which should include all information and reports that are required daily, weekly, monthly, quarterly and annually. And once the rules are set, they must abide by them.

The management must be responsible for the day-to-day administration of both the clinical and non-clinical aspects. It is their responsibility to deliver a high level of customer care to all patients. In this quest, they must be supported throughout by the clinicians, whether they are partners or associates.

The game starts

The LLP will, by this time, have a legal entity, a partners’ agreement, a business plan, management or independent project managers in place, funding, a location, planning, building regulation approval, an indication of CQC and insurer approval. Only now can the partners say with any certainty that the project will become reality.

The ‘prelims’ are essentially over and the game can commence.

If the management is worth its salt, it will produce a timetable responsibility chart to opening day. This will include weekly site meetings and meetings with the partners. It will ensure all schedules are met and the opening takes place as scheduled.

During this period, recruitment and a management reporting structure will be implemented.

This should include:

 Daily reports on income, complaints and orders to be authorised;

 Weekly reports on income, patient numbers, average income per patient, per procedure, capacity utilised, bank liquidity and cash flow;

 Monthly management accounts detailing all income, expenditure with bank liquidity and cash flow, staffing levels and analysis of all expenditure.

The partners’ agreement should include clarity on all payment processing, both of income and expenditure.

An essential factor is a robust

Nobody should ever hide behind the ‘I am a consultant’ mantra. The partners are business members of a medical business

complaints process and review. This should be fully discussed and action taken to ensure no repeat. The same detailed focus should be given to any adverse clinical incidents.

having set up their basic partners’ structure and now the management process, the group practice partners must make the time available to assist the management in monitoring the business and developing it forward.

Demotivating factors

The most depressing, demotivating situation for the management is not having adequate opportunity to report, discuss, improve and develop the group practice, and then being blamed by the disinterested partners when they perceive failure.

A group practice is owned by the partners through the LLP; it must be run as efficiently as any other commercial business and this can only be achieved by a partnership between management and equityholders in the LLP.

n obody should ever hide behind the ‘I am a consultant’ mantra. The partners are business members of a medical business. It is a business in the service industry, just like a hotel or restaurant. Patients are actually clients; they have choice. If they do not like the offering, they can choose to be treated elsewhere. Then the problems begin...

So, for each partner in the group

practice, it is important to check the income against the budget and check the orders before signing. They should keep their fingers on the pulse.

And they should also be sure to make time for regular weekly and monthly meetings with the clinical and non-clinical teams. They need to listen and contribute. It is a partnership for all involved. Ideally, the partners should also have their own weekly and monthly meetings to consider and discuss the group practice performance.

To obtain the maximum benefit from these meetings, they should be structured with an agenda and minutes including action responsibilities.

They should not be a chat; they are the key to progress, co-operation, harmony, understanding, clarity and transparency.

Any disagreements, which are inevitable at times, should be solved quickly within the framework of the equity agreement. Retain your commitment to the ideals and aims of the LLP – successful business is a team game even in medicine.

Get ‘the prelims’ right, keep it simple, keep it quick … and enjoy the rewards. Your patients certainly will. 

Maitland Cook is director of The Cadogan Clinic and also founder/ director of Maitland Cook Medical Management Services Ltd

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

Be realistic about

Experience shows that well-educated, intelligent people can be duped too. Simon Bruce believes it is important to search for simplicity in the world of investment

H ARLEY S TREET

OccasiOnal and sessiOnal cOnsulting ROOms

Monday to Friday 9am to 9pm Saturday and Sunday 9am to 5.30pm

telephone 020 7467 8301 email: info@tenharleystreet.co.uk www.tenharleystreet.co.uk

CONFuCIuS APPARENTlY once said that life is very simple, but we insist on making it complicated. You could say the same thing about investment.

last year, Prof Eugene Fama of Chicago university was named as a joint winner of the prestigious Nobel Prize for Economics following his 50 years of academic research into financial markets.

Fama’s empirical studies demonstrated that market prices for publically-listed securities incorporate all available information and that you cannot systematically outperform the market unless you have information other people do not or can access parts of the market others cannot.

That does not mean it is impossible to make money – just that long-term returns come from putting your money at risk rather than stock-picking or market timing.

Deliberately misconstrued Fama argued that, over time, you can expect – but are not guaranteed – that riskier assets will generate higher returns. Stocks, on average, return more than bonds in the long term. It is a straightforward concept but one that is often poorly understood – or deliberately misconstrued by those with a vested interest.

Peter Englund, secretary of the committee that awards the Nobel Prize in Economic Sciences, said: ‘Fama’s research at the end of the 1960s and the beginning of the 1970s showed how incredibly difficult it is to beat the market, and how incredibly difficult it is to predict how share prices will develop in a day’s or a week’s time.

‘That shows that there is no point for the common person to get involved in share analysis. It’s much better to invest in a broadly composed portfolio of shares.’

Writing on the Nobel Prize in The Financial Times , economist Tim Harford said Fama had helped millions of people by showing them the futility of picking stocks, finding value-adding managers or timing the market to their advantage.

This might be a counter-intuitive idea to many people. After all, in other areas of our lives, the secret to success is to study hard, compete aggressively and constantly look for an edge over our competitors.

Harford said: ‘If more investors had taken efficient market theory seriously, they would have been highly suspicious of subprime assets that were somehow rated as very safe yet yielded high returns.’ However, with constant media

noise and access to 24/7 financial news channels, how does the average independent practitioner investor stay focused?

Although American business magnate Warren Buffett professes that he is always greedy when others are fearful and fearful when others are greedy, this approach is not one that the private individual finds easy.

Disciplined strategy

We can all be affected negatively in times of market stress and are overly complacent when markets are on the rise. Adopting a disciplined strategy to conquer emotions is difficult for even seemingly experienced investors. Five years since Bernie Madoff’s arrest for operating the biggest ever Ponzi scheme – he is serving 150 years in prison – his employees are now on trial. Many people still question how he was able to dupe so many well-educated investors. Is it possible that welleducated, intelligent people can make bad decisions too?

Bill Gates once said that ‘success is a lousy teacher, as it seduces people into thinking they can’t

lose’. Success has a way of driving people into irrational decisionmaking.

The same month that Madoff’s scheme was exposed, an erudite psychologist Stephen Greenspan released his book on avoiding unwariness in the fields of finance and academia called A nnals of Gullibility: Why We Get Duped and How to Avoid It

Ironically, the well regarded Greenspan lost 30% of his retirement savings to Madoff. Why was he drawn to investment returns that looked, in retrospect, too good to be true?

Baron Jacobs of Belgravia – one of Britain’s richest men – was one of Madoff’s most high-profile British victims. The peer has enjoyed a long and distinguished career in business, running the British School of Motoring and the Spudulike fast-food chain. Despite his diligence and business acumen, he allegedly lost tens of millions of pounds, saying recently: ‘I went into some detail with him of how it worked. What makes me look so foolish is that I was a fairly savvy investor. It may not look like it now, but I really was.’

Ask questions

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

The consequence of being human and acting emotionally is one of the primary sources of poor investment decision-making.

Estimates suggest that investors lose 2-5% of potential returns each year simply because being human makes the principles of academically-supported, logical investing hard to follow.

In general, we pay too much attention to the short term; we overreact to market movements; we buy when markets are doing well and sell when markets are low; and we retain large portions of our wealth in cash, unused and unproductive.

One of the other two academics that Fama shared the Nobel with last year – Robert Shiller – discussed the term ‘irrational exuberance’ in his book of the same name.

The consequence of being human and acting emotionally is one of the primary sources of poor investment decision-making

He explains that the fact ‘so many people seem to be making big profits on an investment, and telling others about their good fortune, makes the investment seem safe and too good to pass up’. Shiller takes the view that markets can be irrational and subject to human error. In this, he is frequently cited as a philosophical opponent of Fama. In practical terms, though, both men agree that it is very, very difficult for the average investor to get rich in the markets by trading on publicly

available information. Most people trade too much or underestimate the unpredictability of prices.

The ‘simpler’ approach is to adhere to three core principles:

 Markets reflect the aggregate expectations of investors about risk and return;

 Diversification reduces uncertainty;

 You can add value by structuring a portfolio focused on known market premiums.

For the individual investor, the essential add-ons to this are a nonemotional, disciplined approach, keeping a lid on fees and costs and taking a longer-term perspective.

To quote l eonardo da Vinci, simplicity is the ultimate sophistication. 

Simon Bruce is managing director of Cavendish Medical, an independent financial practice helping senior consultants in private practice and the NHS

BESPOKE MEDICAL INDEMNITY FOR

YOUR PRACTICE

KEEP iT lEgAl: sTAFF bonUs PAy

As a complete

With bonus schemes becoming increasingly fashionable as means of rewarding strong performance, Chris Inson considers the types of schemes available, looks at some legal pitfalls to be wary of and gives some top tips for when it comes to documenting your bonus scheme

We all know that staff retention, at least of good people, can be vital to ensure a successful and thriving private medical practice.

So it is important for all practice managers to consider remuneration structures that will attract and retain key members of staff.

This may range from the sole medical practitioner employing his/her own secretary to a prominent consultant group with a pool of talented associates to keep incentivised.

Types of bonus scheme

Bonus schemes are usually categorised as either contractual or noncontractual.

In a non-contractual, or discretionary, bonus scheme, the bonus will be payable entirely at the employer’s discretion and on the

employer’s own terms. Clearly, then, this may seem the favourable position for an employer.

In most discretionary schemes, the employer sets out conditions or criteria to be applied before the discretion is exercised. These may include, in particular, that merit and performance will be considered before deciding whether and how to exercise the discretion.

In terms of conditions as to performance, this could either be individual performance – for example, the individual billings of an associate member of a consultant orthopaedic group – or team performance, such as the overall financial performance of a practice to determine a bonus pool for a group of medical secretaries.

Performance criteria need not only be linked to financial perfor-

mance and, in many schemes, there is far greater subjectivity –for example, with a percentage of the bonus being based on a general assessment of the employee’s performance.

Performance targets

even where a bonus scheme is discretionary, an employer must still exercise its discretion as to whether to make an award in a way which does not destroy the implied term of trust and confidence – for example, by making capricious decisions on the award of bonuses.

Therefore, should you operate a discretionary bonus scheme where payment is stated to be subject to hitting specified performance targets, and all performance targets have been satisfied, ➱ p44

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then you would be in difficulty if you subsequently refused to make any payments without any objective justification.

Contractual bonus schemes are much more certain, by nature, and will be more attractive to employees. However, even in contractual bonus schemes it is usual to include performance conditions, so an employer may have discretion to decide whether those performance conditions have been met.

The crucial distinction with a contractual bonus scheme is that where the performance conditions have been met, an employer will effectively be obliged to award the bonus.

Terminating employment

a bonus scheme may become a central issue in severance negotiations, so you will need to be careful in structuring your bonus arrangements.

Schemes normally provide that no bonus is payable to employees who are dismissed for gross misconduct

In a wrongful dismissal action, where an employee is dismissed in breach of their notice entitlement, that employee could be entitled to loss of any bonus that would have been payable if they had still been in employment.

But, in a well-drafted scheme, an employer will provide that payment of the bonus is conditional on the employee being in employment and not under notice. This would apply where an employee tenders his/her resignation also.

Some schemes will distinguish between ‘good’ and ‘bad’ leavers. e mployers commonly provide that employees who are made redundant, or who leave because of ill health, qualify as a good leaver and will be entitled to receive a bonus, if appropriate, in respect of the final period of employment.

On the other hand, schemes normally provide that no bonus is

You also need to be careful with part-time workers and not exclude them from any bonus scheme arrangements

payable to employees who are dismissed for gross misconduct –i.e. a bad leaver.

Discrimination and pregnancy-related issues

This is a complex area and something of a minefield, but a failure to pay a bonus may – depending on the circumstances – give rise to an equal pay claim, or a claim for discrimination on the grounds of sex, sexual orientation, race and disability to name just a few.

The impact of pregnancy and maternity leave on an employee’s right to receive a bonus is one of the most difficult discrimination law issues that arises in connection with bonuses.

If a woman takes maternity leave, is she entitled to receive a bonus that would otherwise have been payable had she not taken maternity leave?

The law is not entirely clear in this regard and in any case, this

scenario is beyond the scope of this article but should you be faced with this issue in your practice be sure to take professional advice to ensure legal compliance.

You also need to be careful with part-time workers and not exclude them from any bonus scheme arrangements. Under the Part Time Workers Regulations 2000, part-time workers’ bonuses should generally be pro-rated. Differential treatment is only permissible if it can be objectively justified by the employer.

You should assume that you will not be able to rely on this defence in the case of your parttime workers. 

Chris Inson (right) is a partner in the healthcare team at commercial law firm Capital Law LLP

TOp TIpS fOr dOCuMEnTIng YOur bOnuS SCHEMES

A well-drafted contractual bonus scheme will typically address the following points:

 Specific provision for payment of bonuses in the year of joining. This may provide for payment of a bonus in the year of joining including any arrangements for a pro rata payment or that no payment will be made unless the employee has been in employment for the entire year.

 That the employee must remain in employment, and not be under notice of termination on a stipulated payment or qualification date in order to receive the bonus.

 Mechanism for payment on termination of employment, perhaps including good/bad leaver provisions, to allow certain employees to be treated more favourably – for example, those who are terminated by reason of ill-health, retirement, redundancy or death.

 The bonus entitlement itself and whether there is a cap on the level of bonus in relation to basic pay.

 What triggers bonus payments so the employee knows when he/she might be entitled to a payment. Obvious triggers relate to financial performance, but this would not be appropriate in the case of a medical secretary – at least not in the individual sense – so you may need to look at other performance standards instead.

 Whether bonuses relate to individual performance only; individual performance and employer’s financial performance; operational unit in which employee works; practice-wide performance.

 How the bonus payment is to be determined: whether a specific monetary figure, percentage of salary or subject to an overall maximum.

 Ensure that those in your practice responsible for making decisions as to bonus payments exercise any discretions reasonably and put in place an objective and consistent process.

Can patients make covert recordings?

Dr Carol Chu answers more of your

tricky ethical dilemmas

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Dilemma 1 Can they record me in secret?

QI recently discovered that a patient had recorded a consultation with me at my private clinic.

I would have been happy for it to be recorded if only I had known, but as I had not been told, it has made me feel uneasy.

Is a patient really allowed to record me without my permission?

AIf you suspect that a patient is covertly recording you, you may be upset by the intrusion. But if you act in a professional manner at all times, then it should not really pose a problem.

It is understandable to assume the worst if a patient has tried to secretly record your consultation, but it would be a mistake to think they are trying to catch you out or that a complaint or claim will inevitably follow.

If you are concerned that the patient’s actions are a sign that they do not trust you, you may want to discuss this with them.

Although you may feel uncomfortable to discover a patient has recorded you, patients do not need their doctors’ permission to tape a consultation, as the information they are recording is personal to them and therefore exempt from data protection principles.

Section 36 of the Data Protection Act states: ‘Personal data processed by an individual only for the purposes of that individual’s personal, family or household affairs (including recreational purposes) are exempt from the data protection principles and the provisions of Parts II and III.’

You may wish to invite patients to record their consultations openly and ask them whether you can have a copy of the recording, which can then become part of the patient’s own medical records. In seeking their consent to this, you should reassure them that the recording will be stored securely and only used for this purpose of personal medical records. It is important to bear in mind that while recordings can be submitted as evidence of wrongdoing by the GMC and in court, they can also prove the opposite.

If you have acted ethically and professionally, you should have no reason to be worried and they could even help you if you find yourself in a situation where a complaint is made.

Where a doctor wishes to make a visual or audio recording, the GMC expects them to obtain patients’ consent. It also expect them to only make covert recordings with appropriate legal author isation ‘where there is no other way of obtaining information which is necessary to investigate or prosecute a serious crime, or to protect someone from serious harm’.

There are instances when a doctor’s overriding ethical duty would be to disclose information to protect others

Dilemma 2 Can I disclose his confession?

QI am a consultant psychiatrist. A patient of mine has recently confided in me that he has inappropriate thoughts about children. He has two children of his own and works in a teaching environment. I am concerned that they could come to harm. Should I report him?

APatients must be able to speak to their doctor in confidence without fear that what they say may be shared with others and this is something which is often at the forefront of a doctor’s mind when they treat a patient. However, there are instances when a doctor’s overriding ethical duty would be to disclose information to protect others. The GMC states in its guidance, Protecting children and young people: the responsibilities of all doctors (2012), that doctors have a duty to act if they think a child or young person is at risk of abuse or neglect, even if they don’t routinely see them as patients.

If you are considering disclosing information about a patient in

the public interest, you should ordinarily seek their consent, unless to do so would be impracticable, put others at risk of harm or would undermine the purpose of disclosure.

If, ultimately, you cannot obtain their consent, or decide you should not seek it, you should disclose information promptly to the appropriate person or authority and let the patient know you have done so, as long as it would not prejudice the purpose of the disclosure.

Document any steps you took to seek or obtain consent, your reasons for disclosing information without consent and why you have not informed the patient if that is the case. You should disclose information promptly to the appropriate authority and only provide the minimum necessary for the purpose.

If you are unsure whether to disclose information, seek advice from your local child protection lead or contact your defence organisation. 

Dr Carol Chu (right) is a medico-legal adviser at the Medical Defence Union

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STARTING A pRIvATE pRACTICE

Take stock

Reviewing the financial aspects of your private practice regularly is essential. Time constraints often intrude, but taking a step back and evaluating where you are and where you want to be is essential to keeping you on the path to long-term success, says Ian Tongue (right)

With good signs that the worst of the recession is behind us, many independent practitioners are seeing an increase in their private practice income and so now is a great time for them to take stock of their position.

Advertising and marketing depending on your specialty, this can be one of your largest costs after indemnity cover – with some doctors now paying more!

having an up-to-date and eyecatching website is essential, as patients use the internet to research their physician or surgeon. Some web development companies offer monthly packages that include a periodic refresh of the website, which can help spread the cost and keep things fresh.

Search engine Adwords and optimisation can be particularly expensive as can a premium/ sponsored link, but statistics show that unless you feature in the upper half of page 1 on an online search, the chances of success are very low.

For certain specialties, this type of advertising is essential, so make sure you are reviewing the analytics data supplied by your search engine optimisers to ensure that you are getting good value for money.

Joint events and seminars with g Ps and private hospitals can often work well to cement relationships and promote yourself in the area you work.

Having an up-to-date and eye-catching website is essential, as patients use the internet to research their physician or surgeon

For most specialists, gPs are still a substantial referral base and there is nothing better than meeting face to face and working together.

From acting for our gP clients, we are finding more and more consultants are renting surplus rooms at gP practices. this can be particularly effective if the practice is some distance away from a private hospital.

Mix of work and pricing

Consider the composition of your work and always keep an eye out for private hospitals in the area that may have a shortage of consultants in your specialty.

i often hear from consultants joining a new private hospital that patients were already lined up and therefore making inquiries outside of your existing structure can pay dividends.

All consultants have been under considerable price pressure from insurers, but you should always ensure that you are maximising your charges and increasing them where possible.

Trading structure

Many consultants start off as a sole trader, as this is the easiest structure to commence with –but, ultimately, it is likely that a company or other structure will be considered.

it is important to stress that the tax savings to be made are very much dependent on your circumstances. For example, if your

Indemnity insurance is one of those essential costs that you cannot get away from and it is a false economy to scrimp on them

spouse is also a high earner, then the savings are likely to be limited to National insurance in contrast to someone whose spouse is not working, who could save significant tax as well.

Many have avoided companies in the past due to the potential disruption and if you are thinking the same, speak to your colleagues who have gone down this road, as i suspect they will say it was not as problematic as they were anticipating.

other trading structures exist, such as partnerships and, again, any savings will be dependent on your circumstances.

i t is important to keep your accountant updated during the year on progress, as often your private practice may grow faster than you expected and this can accelerate the consideration of trading structure and tax planning generally.

Indemnity cover

i ndemnity insurance is one of those essential costs that you cannot get away from and it is a false economy to scrimp on.

With rising income/profits, the figures provided to your insurer can be out of date and frequently a catch-up payment is required. When informing your insurer of your expected income for the next 12 months, be realistic, as it will no doubt be easier to pay a higher premium, as you are earning the money, rather than in arrears, at which time you will be

paying a higher premium as well. if you are in the position of paying back premiums, make sure you let your accountant know so that they can include the additional expense at the earliest opportunity.

Groups

With the ever-changing landscape that is the NhS, opportunities often present themselves to work with other colleagues to bid for work or to strengthen private practices.

Speak with colleagues and keep aware of changes taking place locally to you. Working together can often be a successful way of working. As always with these arrangements, the biggest challenge is usually getting things off the ground, which requires time and money.

i f you have an idea, take the lead to bring people together.

Consider your accounting systems

As your practice grows, the volume of transactions increases and your accounting systems need to accommodate this. Aside from the obligation you have to h M Revenue and Customs to keep adequate records, having useful information on billing levels and costs is essential for running any business.

i f you are running on simple spreadsheets, it may be time to consider practice management software.

Practice management software not only provides more robust accounting information but helps run the practice.

t here is inevitably financial investment and training required, but i hear regularly from consultants who have gone down this road that it pays for itself through time saved over a relatively short period.

Meet with your accountant

Make sure that you have regular contact with your accountant every year to keep them updated on your current circumstances and future plans. this is the best way to ensure that effective tax planning can take place at the earliest opportunity. t hey can also be a useful sounding board for ideas and plans for the future.

Reviewing your private practice regularly is essential to ensure that you are best placed in the ever-changing world facing independent practitioners.

taking the time to identify what worked well and – importantly –what was less successful is essential to maximising the profit you make.

Keep your accountant informed and make changes to your private practice when necessary.

 Next month: Key considerations when taking on rooms

Ian

Tongue

is a

partner at Sandison Easson & Co, specialist medical chartered accountants

A luxury workhorse

Doctors have been high on the list of Volvo’s target market. After testing its latest fourwheel drive this winter, Independent Practitioner Today motoring correspondent Dr Tony Rimmer reckons it is certainly an intelligent choice for the professional

There have been car brands that have always seemed to suit medical professionals while avoiding the flashiness of sportier rivals.

They have usually sidestepped modern and fashionable styling to offer solid practical products to appeal to the pragmatic and intelligent buyer.

The Swedish makers Saab and volvo spring to mind, but now that Saab has fallen by the wayside, we are left with the Scandanavian stalwart volvo.

Over recent decades, the car world, like private practice, has become highly competitive and no organisation can stand still. New products and new services are essential to attract new clients. Unfortunately, as happened with Saab, ignoring investment and

development for the future can produce a fatal outcome.

So how has volvo survived?

Well, in 2010, it was sold by Ford to Chinese manufacturer Geely, so has acquired the necessary funding to develop new models.

r ecent products include the v40 and v60 and their SUv siblings, the XC40 and XC60. however, when most of us think of a volvo, we picture a large boxy estate car, currently the v 70.

Many of us will have been taken on family holidays as youngsters in the v70’s predecessors.

To see if this classic motoring icon can still cut it in the modern stylish world of BMWs, audis and Mercedes, I have been testing the latest four ­ wheel ­ drive version, the ‘Cross Country’ XC70.

With a body kit that gives it a tougher looking exterior and a higher ride height for greater ground clearance, this is volvo’s offering for those who want the benefits of a full­size 4x4 in a normal estate car body.

Plenty of room

a ny worries about the possible lack of modernity are quickly dispelled in the interior. a state­ofthe­art digital instrument display (you can even choose the background colour) is complemented by the large, central touch­screen that serves the standard satnav, excellent audio system and other optional systems.

r eally comfortable seats give you plenty of room and passenger space is excellent. This really

makes for a superb family car and, with the large boot area, it has more interior space than many full­sized 4x4s. No wonder it was always a popular choice.

There are two diesels and one petrol engine to choose from. Forget the petrol model: it is way too thirsty and my choice would be the more powerful of the two diesel variants, the 215bhp 2.4litre turbo­diesel as in my D5 test car.

Overtaking, using the advantage of the wide turbo ­ diesel torque band, is completed swiftly and safely. Matched to a modern eight­speed automatic gearbox, it gives the XC70 really sprightly performance with the smoothness of a luxury car. economy is good with an overall 44.1mpg quoted

and a real­world 40mpg should be possible.

In fact, this impression of comfort continues on the open road. The ride from the electronically variable suspension is superb and wind noise is kept to a minimum.

This volvo really is a great longdistance car. h andling, as you would expect, is not top class and not helped by the raised stance, but all­round vision is helped by the taller seating position.

The steering can be slightly vague and you couldn’t call the XC70 a fun car to drive, but that’s not why you would buy it in the first place.

Rural life

You would buy it for its dual­pur­ sionally tow a horsebox across useful than you would imagine.

true one being the a udi a 6 allroad Quattro.

Overall, my impressions are of a solid, well­built dependable luxury workhorse with a bit of character, different from the crowd and generally underrated.

You could do far worse than buy this classic volvo and it can certainly be an intelligent choice for the professional. 

Dr Tony Rimmer is a GP practising in Guildford, Surrey

VolVo

Body: Five-seat estate Engine: 2.4 litre five-cylinder turbo-diesel Power: 215bhp

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ProfiTs foCus: gYnaECologisTs

Having to labour harder

Our latest unique analysis of accounts confirms what many consultants in this specialty already know. They are working harder to stay pretty much where they were, finds Ray Stanbridge. Additional data from Martin Murray

In our February 2013 report, we commented that the market was in a real state of flux. There were problems arising from the pressures on fees, a growth in n HS Choose and Book-type work at cheaper margins and a general increase in costs.

What’s new? The current environment is very similar, but gynaecologists, as a whole, have demonstrated great robustness in maintaining incomes.

our headline figures suggest that

average gross earnings increased by 1.3% between 2011 and 2012, from £112,000 to £114,000.

Costs rose faster, however, by 8.9%. They went up from £45,000, on average to £49,000. As a result, taxable profits fell by 3%, from £67,000 to £65,000.

It is right and proper to comment here on the data difficulties we have in compiling this survey and the statistical problems. Firstly, the survey is not statistically significant, but rather an

aveRage incoMe anD eXPenDituRe oF a conSultant gynaecologiSt With an eStaBliSheD PRivate PRactice

Expenditure

Year ending 5 April. Figures rounded to nearest £1,000 (percentage is also rounded up)

Source: Stanbridge Associates Ltd. Additional information: Sandison Easson and Co

overview of the movements in typical sample practice incomes and expenditure.

Comparability costs

There are increasing data consistency and comparability problems. Some consultants, for example, have incorporated and, for the purposes of this analysis, we have to try to treat them as unincorporated.

others have formed groups and have had a stimulus to their incomes. Meanwhile, other consultants have become more sophisticated in taking on tax planning in their private practice.

Given the previous income trends we have seen between 2011 and 2012, we were a little surprised to see that gynaecologists’ incomes, on average, rose marginally.

Per unit, fees have slipped and our conclusion is that gynaecologists have had to work a little harder for the same cash. It is in the cost area, however, where we have noticed the biggest changes.

Firstly, assistants’ fees have risen. We are not sure if this is because there are more complicated procedures being undertaken – or just that they are being remunerated better.

Staff costs have shown a further increase from £11,000 to £12,000 on average. Particularly where there are family staff members employed, there is evidence of ‘tracking’, meaning incomes have risen in line with the rises in personal allowances.

Consulting room hire costs

Who ouR gynaecologiStS aRe

our survey is restricted to those consultant gynaecologists who are not full-time in private practice. they:

 hold either an old-style or new-style nhS contract

 have at least five years’ experience in the private sector

 are seriously interested in private practice as a business

 earn at least £5,000 a year gross from private practice

 Work as a sole trader, a member of a formal or informal group, through the means of a partnership or a limited liability company

We regularly publish highly informative supplements, written by experts in their field, to help independent practitioners tackle those essential tasks and skills required to run a thriving private practice. here are just a few examples: these

those who subscribe

our

have shown some increases. Hospitals have become increasingly interested in the ongoing Competition Commission inquiry into the private healthcare market and have sought gradually to increase rental, secretarial and support costs to market rates.

With the final report of the Competition Commission due soon, we would expect this trend to accelerate strongly.

indemnity costs

Professional indemnity insurance costs have shown their own inexorable rise. While few gynaecologists undertake obstetrics work – where

PRoFitS FocuS iS the inDuStRy BenchMaRK

Doctors and their specialist medical accountants use the statistics published in our ‘Profits Focus’ series to look at how their earnings compare with others and see where they can cut costs and boost their income.

now all this information is available on our website and is free when you take out a subscription. either fill in the subscription form on page 24 or phone 01752 312140 or email lisa@marketingcentre.co.uk. get a discount by paying by direct debit.

www.independentpractitioner-today.co.uk

indemnity costs are extremely high – many have not been attracted to the ‘new’ brand professional indemnity insurers, and have to rely on established providers.

There has been some reduction in expenditure on travel and conference (fewer exotic trips, perhaps?), but there has been a growth in ‘other’ expenditure.

As with other sectors, this expense is primarily in the area of marketing, promotion and business developments. Increasingly, gynaecologists are becoming more commercial in relying on the skills that professional marketers can sometimes bring to a practice.

gynaecologiStS’ eXPenSeS

SuBScRiPtionS/PRoFeSSional

What of the future? our view is the same as it was a year ago. We said then: ‘our conclusion is that income levels [for gynaecologists] are likely to hold – though consultants will have to work harder to achieve the same results.’

Perhaps, from 2013 tax selfassessment returns, we could even be slightly more positive.

 next month: radiologists

Ray Stanbridge runs an accountancy, finance and tax advisory service specialising in the medical profession. Martin Murray is a partner at Sandison Easson & Co, specialist medical accountants

How arE You doing?

use these benchmarking statistics to help you compare your financial performance with other specialists in private practice. Subscribers can check out their specialty in full at www.independentpractitioner-today.co.uk

urologists

years ending 5 april Source: Stanbridge Associates Ltd

coMing in our March iSSue

Don’t miss our next issue, published on 20 March. only subscribers are guaranteed to get a copy. to be sure you receive it, and all future issues of independent Practitioner today, why not take out a subscription – from as little as £50 a year? you can even offset much of the cost against your tax bill! See rates and signing-up details at the bottom of this page.

 coming free with your March edition of independent Practitioner today is the Private doctors’ guide to tax 2014 by accountant vanessa Sanders

 going bust! you don’t often hear of it happening to doctors – but it can. a medical director in harley Street shares the story of his rise and fall and shows how he is now thriving again four years on

 Doctors in partnerships: Many fail – and Maitland cook shows how to make sure yours does too!

 turn your patent into profits! an expert answers your questions

 an accountant’s top tips to help your practice flourish in 2014

 independent practitioners and moral leadership in the changing health environment: Mike Roddis focuses on the importance of providing effective, moral leadership in the private sector and shows how consultants can provide effective and ethical leadership in different situations, including when engaging with commissioners of healthcare and when competing with other providers

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 So why is the medical world lagging behind the rest of the commercial world when it comes to using it?

 We report on a new scheme to promote self-pay to patients and gPs

 our motoring correspondent Dr tony Rimmer gets behind the wheel of the Porsche Panamera e-hybrid, an impressive car that shows you don’t have to drive a toyota Prius to be green

 Profits Focus looks at radiologists

 cavendish Medical’s Simon Bruce explains why it’s important to have a well-developed and written investment plan – and to stick to it

 Marketing questions from independent practitioners – answered

 ian tongue’s monthly ‘Starting a Private Practice’ series looks at the key considerations when taking on rooms

 PluS all the latest news

aDveRtiSeRS: the deadline for booking advertising for our March issue is 24 February

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