Loneliness of a private doc Advice on how to dig yourself out of the isolation trap that private doctors fall into P10
You, robot?
Automation is playing an ever-increasing role in medical practice. Could you be replaced? P18
Longevity requires planning How today’s increasing life expectancy can impact upon the reality of traditional retirement P38
By Robin Stride
The target date for official publication of consultant-level performance measures has been scrapped following the failure of some smaller private hospitals to hand over all their data.
Instead, the Private Healthcare Information Network (PHIN) will publish hospital performance measures only in April 2017.
Consultant-level performance figures, which around 14,000 independent practitioners had been told would be issued at the same time, will be delayed until next year.
PHIN confirmed that many private hospitals – including all the larger national groups and a number of NHS private patient units – had begun submitting data to it in line with the requirements of the Competition and Markets Authority’s (CMA) Private Healthcare Market Investigation Order 2014.
The network will start publishing hospital-level performance measures on schedule, from 30 April 2017. But it said all hospitals had still not yet submitted data and some data quality issues remained, as highlighted in its annual report last year.
It is now working for an end of April 2018 completion for publication of consultants’ performance figures.
A PHIN statement said: ‘The CMA has begun enforcement action to
ensure all hospitals submit appropriate data where required. This lack of full compliance has an impact on the statistical reliability of measures to be published at consultant level.
‘As a result, PHIN has taken the decision to delay publication of performance measures by consultants until the data is sufficiently complete and robust.
‘The CMA is aware of PHIN’s decision and recognises the importance of ensuring the integrity of data published.’
Hospital-level measures to be published in April include comparative activity levels by procedure, lengths of stay and patient satisfaction. Other data, including adverse events rates and outcome measures, will follow, said PHIN.
Consultants can now expect to be invited to participate in data quality assurance later this year and to work with hospitals to improve data quality.
PHIN chief executive Matt James said: ‘PHIN is committed to fully implementing the information improvements required by the CMA, and we will be launching our new website with hospital performance measures at the end of April as planned.
‘However, the information we publish must be fair and based on accurate data, particularly where it is attributed to individual consultants.
‘We will publish consultant per formance only when we are confi dent that the data provided by hospitals supports that level of detail.
‘The onus now is on hospitals to continue to improve the validity and accuracy of their data as we approach publication. Where hos pitals are not yet participating, the CMA has taken important steps towards enforcement.’
Fiona Booth, the chief executive of the Association of Independent Healthcare Organisations (AIHO), said her organisation and inde pendent hospitals were working closely with PHIN to provide data and prepare for the publishing of up-to-date quality and outcomes information.
Three of a kind
‘Aligning the sector’s performance indicators and reporting standards with the NHS will improve transparency and help patients make informed decisions about their care,’ Ms Booth said.
‘We all realise the importance of getting this data right for the benefit of patients, and the independent sector and PHIN will continue to work collaboratively to ensure the data is robust.’
CMA responses to the planned fees timetable, from independent doctors’ bodies and others, were due as we went to press.
n See www.independent-practitioner-today.co.uk for latest developments
Dr Riaan Swanepoel, Dr Kelly Hermuzi and Dr Pip Singh (left to right) are offering a new private GP service at Nuffield Health Newcastle Hospital for patients struggling to see an NHS doctor. The pay-as-you-go service, costing £80-£120, has appointments available in the evenings, weekends and during the week.
GP liaison manager Beth Brook said: ‘Our new service will provide an alternative for those who don’t want to wait to see their regular GP or who want an appointment outside of normal practice hours.’
get best price when selling your clinic advice on maximising the sale of your practice, not just winding it down P8
How you can cope with burn-out
Guidance on looking after your health with support from your defence body P16
time you stopped chasing the clock
Some vital time-management tips to help you stop chasing your tail P22
don’t get snared in your own web exploring the legal pitfalls of running your website. do you own and control it? P24
the costs of doing medico-legal work
How to get your fees and terms right when starting medico-legal work P30
reflecting on revalidation revalidation is altering. an expert in the field gives his appraisal of the changes P42
PlUS oUr regUlar colUmnS
Doctor on the Road: Skoda octavia ‘Scout’ P44 starting a
editorial comment
If you’ve recently phoned the GMC or your defence body, the chances are you were looking for clarity on a confidentiality or disclosure issue.
The subject creates thousands of calls a year and, with changing laws and new scenarios, is the biggest topic the profession seeks help on.
We regularly publish medicolegal advice to help you navigate potential problem areas – there’s more confidentiality queries answered in this month’s Business Dilemmas (page 40).
And now there is far more reading to do, as the GMC has updated its website guidance
with a 76-page document Confidentiality: good practice in handling patient information.
If you haven’t heard, it comes into effect from 25 April and we suggest all private doctors ensure they and colleagues familiarise themselves with it and changes affecting them.
We can’t detail them all here.
Just listing the new bits takes the GMC another six pages. There is explanatory guidance too – and more to come.
But we will pass on the body’s accompanying stark warning: ‘Serious or persistent failure to follow this guidance will put your registration at risk’.
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
Independent practitioners who have recently received a clinical excellence award (CEA) could discover that the reward proves to be a substantial tax burden.
If you receive a CEA, your pensionable pay increases, which could force you to breach the annual allowance rate – the total amount which can be paid into a pension each year while still attracting tax relief.
The annual allowance was cut to just £40,000 a year in April 2014. Most senior doctors will find they may breach this rate by the yearly increase in NHS pension benefits alone, before considering the impact of private pension contributions.
In addition, individuals earning over £150,000 now face an annual allowance which is reduced further by £1 for every £2 of income. Those earning £210,000 or more will need to adhere to an annual savings rate of just £10,000.
Patrick Convey, technical director with specialist financial planners Cavendish Medical, said
senior doctors who had worked hard to gain a CEA might be disappointed to hear that the achievement could mean paying significantly more tax.
‘Your new CEA will be backdated to April 2016. Unfortunately, this means you may only find out if you are liable for a tax charge long after the current tax year is finished, as the NHS Pensions Agency will not write to those breaching the annual allowance cap until summer 2017 –and, sadly, little can then be done retrospectively,’ Mr Convey said.
‘It may be possible to use your allowances from the last three years, known as “carry forward”, but the exact financial position and the implications for your tax status, can only be ascertained with detailed analysis.
‘If you are not confident of your own position, you should seek help without delay. Remember, the onus will be on the individual to notify HM Revenue and Customs if you are liable for a tax charge.’
HCA’s The Harley Street Clinic has been rated outstanding by the Care Quality Commission, the capital’s first private hospital to gain the top award.
Inspectors said the 103-bed unit:
Provides innovative and patient-centred cancer care, giving patients access to the latest diagnostic methods and new cancer drugs through early-phase clinical trials;
Participates in several national audits and benchmarking, and in
certain examples was found to exceed standards, particularly in cardiac care;
Pioneered a new technique to spare hair follicles of patients undergoing radiotherapy cut hair loss and speed regrowth;
Collaborated with London Bridge Hospital to be the UK’s first to trial a robotic radiosurgery system on cardiac patients.
The hospital was praised for going the extra mile to deliver exceptional patient care.
by robin Stride
The Independent Doctors Federation (IDF) has welcomed many of Sir Keith Pearson’s recommendations in his review of medical revalidation last month.
These include:
To update the GMC’s guidance on the information doctors need to collect for revalidation to make clear what is sufficient and what is mandatory – and what is not;
Responsible Officers (ROs) to avoid placing revalidation requirements on doctors that go beyond what is specified as necessary by the GMC;
Ensuring fair decision-making;
Reducing duplication in the regulatory system;
Improving information sharing across designated bodies.
IDF RO Mr Ian Mackay told Independent Practitioner Today there was much to applaud in the review, although there were still doctors who thought the whole thing was a ‘complete waste of time’.
BMA Council chairman Dr Mark Porter said the review reflected many of his association’s concerns and highlighted the importance of making the process less burdensome and more consistent.
‘It also emphasises the impor -
tance of revalidation not being used as a tool to achieve objectives beyond the scope of the GMC’s requirements.
‘While many of the recommendations will be broadly welcomed by doctors, it not yet clear how this how these will be turned into a reality.
‘The BMA will continue to press the GMC and other bodies about the actions needed to relieve the unnecessary burden that revalidation can sometimes place on doctors to ensure the process delivers for patients, doctors and the NHS.’
See Mr Ian Mackay’s analysis, page 42
women are at the centre of london’s newest clinic, 25 Harley Street.
the team offers care in major fields of women’s health including osteoporosis, menopause, gynaecology, rheumatology, endocrinology, dermatology, aesthetics, minor plastic surgery, nutrition and emotional well-being.
Specialists working there under practising privileges arrangements have all credit control managed for them by the clinic.
owner Ukrainian entrepreneur anna tigipko said the clinic’s design strategy was driven by a desire to
give patients a fully-integrated service in a ‘sumptuous’ clinic, equipped with the latest on-site diagnostics and treatment technology. the team of consultants and gPs is headed by medical director and consultant rheumatologist dr Stephanie Kaye-barrett, formerly of the chelsea and westminster Hospital. She handpicked doctors and medical professionals for both their clinical expertise and integrated approach to treating patients. equipment includes the latest Fuji digital imaging, a full body deXa scanner, pathology laboratory and theatre for ambulatory gynaecological procedures.
A BMA private practice conference on 5 April in London aims to help established independent practitioners maximise their business potential and guide new entrants on key issues to be aware of.
Those starting out will be able to network with experienced colleagues and there are parallel sessions for established specialists and those just starting in private practice or planning to set up.
Speakers include BMA private practice committee chairman Mr Derek Machin, William Laing of LaingBuisson, speaking on the state of private practice, and private GP Dr Ian Cole.
Dr Andrew Vallance-Owen, of Private Healthcare Information Network, will advise on how to best engage with the body and will assess the workload implications.
Medico-legal adviser Dr Helen Hartley, of Medical Protection, will discuss medical indemnity, barriers and risks in private practice.
Registration starts from 9.30am at BMA House, Tavistock Square, and from 4.30pm-6pm a drinks reception will offer informal networking. For full programme and booking, go to www.bma.org.uk/ privatepracticeconference.
Existing and would-be expert witnesses are being invited to a BMA medico-legal practice conference on 10 March to address key issues facing doctors doing this work.
Dr Jan Wise will give an update on the work of the association’s medico-legal committee; a solicitor will examine the legal profession’s expectation of doctors as expert witnesses and there will be a session about when expert witnesses get it wrong.
Other topics at the meeting at BMA House, London, include communication skills for experts, sharing good and bad practice of medico-legal report-writing, med ical manslaughter, crossexamination and how to market and grow your practice.
Details at www.bma.org.uk/ medicolegalconference
See page 27
By a staff reporter
Hopes are high for a surge of private patients looking to consult independent practitioners in the months ahead.
Self-pay is seen as a likely option in the future by a high proportion of patients ( see story on opposite page) and a leading market analyst is reporting a recent ‘clear rise in interest in private healthcare’.
LaingBuisson economist Philip Blackburn said the increased focus on the private sector came this winter ‘as more and more people are dissatisfied with higher waiting on the NHS and increased restrictions on NHS treatment’.
He predicted: ‘Private medical cover will benefit from this, and there is a wide choice of policy options at different prices to
attract customers.’ Mr Blackburn was speaking as new figures from the healthcare market intelligence provider showed demand for UK private medical cover rose in 2015, reversing a declining trend in recent years.
The number of private medical cover subscriber policies in the UK grew by 2.1% to hit four million, following flat demand from 2012 to 2014 and shrinking demand from 2008 to 2011.
Private medical cover includes private medical insurance as well as corporate self-insured schemes, known as healthcare trusts.
LaingBuisson said its findings were ‘good news’ for a sector which saw the volume of subscriber policies drop by 8% since the end of 2008.
Reflecting the extension of a few
very large corporate schemes, growth was driven largely by a solid 8% increase in the number of subscribers to self-insured (Healthcare Trust) schemes, as private medical insurance subscribers rose by 0.4%.
Company-paid subscriber policies accounted for 76.3% of total market volume demand, representing 3,070,000 subscribers at the end of 2015 as the number of sub-
scribers – insured and self-insured – increased ‘strongly’ by 3.4%.
But the number of non-corporate individual subscribers continued to decline, falling by 1.7% to 952,000. This meant overall penetration of the UK population by private medical cover edged up to 10.6% at the end of 2015.
Claims paid to private medical cover subscribers in 2015 were valued at £3.6bn, including £2.9bn paid to insured claimants, and £688m paid to claimants covered by self-insured schemes. Overall claims paid increased by 2.1% over the year, while claims on self-insured policies (healthcare trusts) were up by 7% and insurance claims overall rose 1%.
LaingBuisson’s Health Cover 13th edition. Details available at www. laingbuisson.com
Insurance Premium Tax rises and Brexit are adding uncertainty to the private medical cover picture.
Talking of the 2017 outlook, LaingBuisson economist Philip Blackburn said a sharp increase in the tax had loaded significant additional cost for all medical insurance customers. It rose from 6% to 9.5% from November 2015, with a further rise to 10% from November 2016.
Now another hike to 12% in June 2017 would tighten this ‘taxation straitjacket’.
Mr Blackburn said in an industry where affordability was identified as the primary reason for a lack of growth in demand, this hefty additional burden was likely to mean demand for private medical insurance was vulnerable –although this might be balanced by a shift to healthcare trusts.
LaingBuisson’s latest report, Health Cover 13th edition, found no clear indication to date about the scale of the tax’s impact on the market.
It said much depended on how
changes in price shifted demand across customers, and whether many more customers choose different cover options to beat taxfuelled price rises, such as a larger excess, reduced coverage or favourable switching terms.
The choice and flexibility of medical cover offered by insurers had never been greater, and there was the option of self-insurance for corporates, which was tax-exempt.
Alex Perry, general manager of UK Insurance at Bupa UK, said:
‘An uncertain economic environment and a punishing insurance premium tax increase means we’re continuing our focus on affordability and quality. We have grown our corporate and SME customer base, seeing results from our direct-access offer and employee engagement services including our award-winning Bupa Boost.
‘Affordability and innovation are crucial in attracting more people to health insurance. We need to be bolder as an industry in talking about our contribution to the UK healthcare system.’
57% of people agree with the statement relating to insurance premium tax that, ‘people who pay for health insurance are being punished by government for looking after themselves’, with a quarter (24%) strongly agreeing*
50% believe it is unfair that people choosing to pay for health insurance are taxed on top of the taxes they pay to fund the nhs*
58% believe health insurance should be tax-free like life or critical illness cover*
70% believe those paying for private healthcare are relieving pressure on the nhs**
71% are concerned about the care they would receive on the nhs if they or a loved one became ill and if they could afford it; 41% would see value in taking it out for their children and 34% for their parents**
52% said rationing of nhs services would prompt them to consider purchasing health insurance**
* Populus survey of over 2,000 people, November 2016
**Censuswide survey of over 2,000 people, October 2016
dr doug wright, former medical director of aviva
Healthcode, the private healthcare sector online services specialists, has appointed Aviva’s UK medical director Dr Doug Wright to chair its board.
He will work with managing director Peter Connor to promote more effective use of technology across the sector.
Former GP Dr Wright succeeds Dave Clarke, AXA PPP operations director, who retires after six years in the chair.
Dr Wright said he believed Healthcode’s technology had an important part to play in connecting insurers and providers so they could operate more efficiently, securely and improve patient access to private health services.
Consultants and private GPs are gaining referrals from a new company set up to connect patients to leading clinical specialists.
London Medical Concierge offers customers fast-tracking and priority consultations to an extensive and expanding network of more than 100 doctors so far, in 25 specialties.
Chief executive and founder Kirsty Ettrick said patients used the service for second opinions, prescription services, scans, diagnostic tests and to access clinical trials.
Each case is treated individually, with a bespoke clinical patient pathway to connect each patient quickly to the right medical specialist, with costs starting at £195.
A more expensive service offers a superior lifestyle product for busy families, entitling them to a consultant/GP referral, member discounts on cosmetic treatments and newsletters with offers.
Mrs Ettrick told Independent Practitioner Today : ‘Most of the people we are dealing with are already in secondary care but
might want faster appointments, to see another doctor or are unhappy with the wait – be it in NHS or private practice.
‘Sometimes people say “I’m fed up with going to X private clinic –I have to wait an hour and a half!”’
She set up the company following the death from cancer of her husband Neil, wanting to help others in a similar situation reduce the time, anxiety and emotional challenges faced when researching doctors and treatments.
Consultant oncologist Prof Justin Stebbing, who met her at that time, said patients and their families could find the system frustrating, unwieldy and difficult to navigate.
But a medical concierge service could help bridge that gap, provide an empathetic and supportive approach for patients, and use extensive networks to give timely access to the most appropriate medical expert.
Patients are offered help with travel arrangements, accommodation, one-to-one nursing, translation and billing inquiries.
If undiagnosed, they are firstly referred to a GP to gain a comprehensive diagnosis before moving forward.
The company is working closely with an expanding network of private GPs including the London General Practice in Devonshire Street.
It said it wanted to hear from medical experts working in niche areas and those involved in clinical trials so it could offer the very latest expertise, treatments and techniques.
By Edie Bourne
A shock survey has uncovered a huge untapped self-pay market –revealing that most people do not even know what it is.
As many as 53% have never heard of it or do not understand it, according to a study by the UK’s biggest private hospital provider.
But over two-thirds of the UK public (68%) would possibly pay for private healthcare treatment in the future to avoid long wait times. Seventeen per cent said ‘yes, definitely’, 50.9% said ‘yes possibly’ and 32.1% said ‘no’.
The BMI Healthcare survey of
1,191 respondents reveals the biggest healthcare concern of almost half the British public is NHS waiting times.
Yet more than a third (38%) had never heard of the concept of selfpay healthcare and a further 15% do not understand what it meant.
BMI said the figures highlighted the growing demand for alternative options and the need for greater awareness of them.
After waiting times, the public’s biggest healthcare concern is success and speed of recovery (36%), followed closely by infection control (35%).
As well as a lack of understand-
ing of the self-pay market, the public reported being unaware of treatments that might be unavailable on the NHS.
Almost two-thirds (65%) are either unsure or unaware that some common medical procedures are not available to them. In some parts of the UK, procedures such as hernia, cataract and varicose vein procedures are not routinely NHS-funded.
Nearly half of the public (42%) believe they would have to be in severe pain before the NHS would react, and a further 12% think they would need to be in the worst pain possible before the NHS
would see them. Market analysts LaingBuisson estimate a 34% increase in self-pay treatments since 2012.
Peter Snuggs, BMI director of commercial relations, said: ‘We all have a responsibility to educate the public around the services available – for those on the NHS and those not – as well as the payment options available.’
BMI is running a three-month national campaign aimed at publicising self-pay healthcare, its costs and payment options available.
Research conducted in May 2016 by Censuswide of 1,191 respondents within England
By a staff reporter
Lip augmentation tops the list as the most popular cosmetic treatment of 2016, but cryolipolysis or ‘fat freezing’ is the fastest-growing UK beauty trend, with a 130% rise in inquiries.
Non-surgical facelifts are set to be the top treatment for 2017, with a 91% increase in inquiries for the procedure between October-December 2016, according to WhatClinic.com.
The insights are based on over 584,000 visits to its medical aesthetics pages last year, with over 63,525 online inquiries sent by UK patients to clinics on the site.
At number two on the list of the top ten most popular treatments are dermal fillers, with inquiries up 24% from 2015, and a price tag of £263 on average.
Fillers saw increases across the board, with non-surgical nose jobs – fillers placed in strategically on the nose to disguise lumps – at
2016’s tOp ten mOst pOpular nOn-surgiCal
COsmetiC treatments
(Based on volume of traffic to WhatClinic.com)
procedure Change in inquiries average price uK over the last year
1.
2.
3.
4.
Mini facelifts are the fastest growing cosmetic surgery trend with inquiries up by 135% over the past 12 months.
Breast implants remain the cosmetic procedure of choice in the UK. This is despite a slight decrease of 9% in inquiries compared to the previous year, according to WhatClinic.com
s
(Based on biggest increase in inquiries to WhatClinic.com over the last three months)
procedure Change in inquiries average price uK
number three, up 25% and with an average price of £343 in the UK.
Platelet-rich plasma filler (PRP), the ‘vampire facelift’, saw the biggest jump in 2016, with inquiries up 56%.
Dr Susanna Hayter, medical director of My Beauty Doctor in Marlow, said: ‘Fillers are definitely on the rise, probably because the cost of having them done hasn’t risen as much as inflation and so they have become a more affordable treatment, are lasting longer
and therefore give good value for money.’
WhatClinic’s Philip Boyle said: ‘In the UK, the medical aesthetics market is one of the biggest and is still growing, with over 4,528 clinics listed on our site at the moment.’
He detected a a ‘less is more’ trend with facial augmentation. ‘Patients don’t want a drastic change; they’re more interested in looking like a younger version of themselves.’
2016’s tOp ten Fastest-grOWing Beauty treatments
(Based on increase in inquiries to WhatClinic.com) procedure
£287
£263
£343
2016’s tOp ten mOst pOpular surgery prOCeDures
(Based on volume of traffic to WhatClinic.com)
procedure Change in inquiries average price over the last year uK
1. Breast implants -9%
2. eyelid surgery 8%
3. liposuction 64%
4. rhinoplasty 21%
5. tummy tuck 56%
6. Fat transfer -23%
7.
£4,118
£2,691
£2,954
£3,772
£5,168
£2,921
2016’s tOp ten Fastest-grOWing COsmetiC surgery prOCeDures (By increase in inquiries)
procedure Change in inquiries average price over the last year uK 1. mini facelift 135%
5. abdominal etching 57%
6. tummy tuck 56% £5,168
7. alarplasty 47% £3,098
8. Cheekbone reduction 47% n/a
9. FFs – Facial 30%
10. Butt lift 22% £4,203
By Olive Carterton
Every surgeon performing cosmetic surgical procedures is being urged by the Royal College of Surgeons (RCS) to apply for its new certification, which it says will enhance the profession’s reputation and make the surgery industry safer for patients.
The development aims to help patients identify a surgeon in their geographical area with the appropriate training and experience to perform a specific procedure.
Cosmetic surgery is not a defined surgical specialty and historically there have been no common standards available to the surgeons who perform it.
The new certification system will address this and, it is hoped, allow the public and employers to distinguish highly qualified, experienced specialists from those working without adequate insurance or the necessary specialist training.
Surgeon applicants will have to provide evidence of their training, professional skills, clinical skills, knowledge and experiences, and must attend an RCS-accredited professional behaviours masterclass.
The RCS said professional and ethical aspects of practice, including the relationship with the patient, are the most common reasons for unsatisfactory outcomes in cosmetic surgery. Therefore, demonstration of knowledge and skills in this area is an integral part of the certification process.
RCS vice-president Mr Stephen Cannon, chairman of the Cosmetic Surgery Interspecialty Committee (CSIC), said: ‘You only have to page through the adverts in lifestyle magazines to know cosmetic surgery is a booming industry in the UK. However, what many don’t know is that the law currently allows any doctor – surgeon or otherwise – to perform cosmetic surgery in the private sector.
‘The RCS believes this certification system will help patients to find a certified surgeon, who has
the appropriate training and experience to carry out a procedure such as a tummy tuck or nose job.
‘We also hope it will improve the reputation of a profession, which, at times, comes under intense criticism in the media, sometimes with good reason.
‘The vast majority of surgeons performing cosmetic surgery in the private sector are meeting the highest standards of patient care, but we want to make sure this is the case in every hospital and clinic around the country.’
Surgeons will be able to obtain certification in one or more groups of closely related procedures as long as they are on the GMC specialist register in a specialty that demonstrates training and experience in the chosen area of practice, and they can demonstrate they meet certification requirements.
the royal College of surgeons believes the cosmetic surgery certification scheme will improve the profession’s reputation
Following Sir Bruce Keogh’s Review of the Regulation of Cosmetic Interventions, the RCS was asked to set up a Cosmetic Surgery Interspecialty Committee (CSIC)
to make cosmetic surgery safer for patients.
In response, and in consultation with CSIC members, it agreed to develop a certification system for surgeons performing cosmetic surgical procedures.
The RCS has also published Professional Standards for Cosmetic Surgery on its website, stipulating that only surgeons with the appropriate training and experience should undertake cosmetic surgery, as well as the ethics and behaviour expected of them. Surgeons can apply for certification at: https://certify.rcseng.ac.uk. Professional Standards for Cosmetic Surgery can be viewed on the Royal College of Surgeons’ website: www.rcseng.ac.uk/ library-and-publications/collegepublications/docs/professionalcosmetic-surgery.
yes. an application in one or more groups of closely related procedures costs £1,500. this does not include the mandatory masterclass on professional behaviours in cosmetic surgery, for which there is a separate course fee.
hOW lOng Will CertiFiCatiOn taKe?
the expectation is it will take an applicant one to two hours to complete online if they have all their evidence to hand. how long it takes will also depend upon how many certification areas an individual chooses to apply for.
applicants will also have to attend a mandatory masterclass in professional behaviours in cosmetic surgery. Once a completed application is submitted, a response will be received by the applicant within 28 days.
hOW many surgeOns are expeCteD tO apply?
the rCs urges all eligible surgeons who perform cosmetic surgery to apply to be certified so they can demonstrate high professional and clinical standards in their area of practice. initially around 250 surgeons are expected to apply for certification. thereafter, it hopes around 100 will apply annually.
the rCs has already told them that surgeons will be able to apply for cosmetic surgery certification. they have been told that rCs-certified surgeons will have shown that they meet the standards the college has set to perform cosmetic surgery on a particular area of the face or body.
Can nOn-rCs memBers apply tOO?
yes, certification is open to all surgeons who are on the gmC specialist register in a relevant surgical specialty.
If 2017 is the year you decide to retire, make sure you maximise the capital by selling, rather than simply winding down, the business. Susan Hutter (right) advises on having all the appropriate information to hand if you decide to sell
There are two ways to sell a business.
You can just sell the goodwill –an intangible asset that reflects the value of the practice’s brand, patient base, good patient and introducer relations and good employee relations.
It is considered an intangible asset because it’s not a physical asset like buildings or equipment. alternatively, you could sell the whole thing: all the assets of the business.
If you trade as a company, either you sell your shares in the company or the company itself sells all or some of its assets, including goodwill.
This has a downside, as the company will pay corporation tax on any profit it makes on sale. Then when you close the company down and liquidate, you personally will have to pay capital gains tax.
So there’s an element of double taxation. however, if you sell the shares in the company, you should receive entrepreneurs relief (er) for capital gains tax (CGT) purposes, assuming you qualify.
To qualify for er, your business needs to be recognised as a proper trading company, not an investment company, and have held shares for more than a year.
The advantage of CGT is you only pay it at 10%. If you sell your shares for £100,000 you will only pay £10,000 in tax.
any potential buyer will need to be reassured that the figures add up and the business is a worth -
Any potential buyer will need to be reassured that the figures add up and the business is a worthwhile concern and the valuation is an accurate one
while concern and the valuation is an accurate one. The buyer’s advisers – both lawyers and accountants – will undertake the necessary due diligence.
If you are only selling the goodwill, the purchaser will have simple needs:
To review the latest accounts filed by hMrC, including any upto-date interim accounts;
To see the patient list and an analysis of sales/trading;
To look at the previous three years’ accounts to see how the business has been faring over a longer time-frame and look at any notable trends.
But if you are selling the whole business, the buyer will want much more:
➤ all of the above plus what is classified as debtors – money patients owe – and whether or not it is recoverable. It is best to have a purge and make sure all debts are either sorted out or written off before you present the report to the potential buyer.
You must include all your creditors in your interim accounts. If you fail to do this, then the pur-
chase price is likely to be reduced and there will be warranties in the contract of sale for clawback.
There may be a withholding of some of the purchase price until the buyer knows the exact position of the balance sheet.
➤ Details of staff roles and positions. If you have people on the payroll whom the purchaser does not want – perhaps they already have a good receptionist – then the responsibility falls on you to deal with any redundancies.
If they have been a long-standing member of staff, they will
have employment rights. You will also have to look at the contract of employment, so ensure the redundancy complies with the contract. as with anything involving due diligence, the devil is in the detail, so seek expert advice to ensure you present the best and most accurate picture of your business before you sell.
next month: Top tips on filing year-end accounts
Susan Hutter is a specialist medical accountant and partner at Shelley Stock Hutter
The Care Quality Commission’s (CQC) strategy, published last year, aims to deliver a more targeted, responsive and collaborative approach to regulation, so that more people get high-quality care.
The CQC intends to become more intelligence-driven by strengthening the way it uses data and information to underpin its decision-making and identify risks of poor care, which we welcome in principle.
In particular, the CQC has said it wants to bring together information from its inspections, service users and data from its partners to better equip it to monitor changes in quality. What this might mean in practice is where our concerns lie.
Over the course of the past year, we have raised concerns in a number of consultations that together have informed the CQC strategy.
One worry is that the CQC requesting information from the GMC prior to inspections could be prejudicial to the inspection and may not even be relevant.
This is particularly true if a doctor is subject to a complaint at the time of the CQC request to the GMC – a complaint which is subsequently found to be without foundation, but only after the CQC has concluded its inspection.
The CQC should carefully focus on how it can avoid prejudicing its inspections when gathering information from other sources and we will continue to monitor this closely on behalf of our members.
Clearly, patient feedback is a key tool for doctors in assessing and improving their practice. h owever, we would be concerned if the CQC were to find itself in a place where it relied too heavily on patient feedback about services on social media sites such as Twitter and Facebook.
Comments provided online may not be accurate or fair, and they need to be utilised with this in mind.
an inspection’s outcome can be
We would be concerned if the CQC were to find itself in a place where it relied too heavily on patient feedback about services on social media sites such as Twitter and Facebook
share and report on provider quality. It may be ambitious to expect a common meaning of quality, but this should not deter open dialogue and sharing to achieve such a goal.
The CQC rightly aspires towards a position where each regulator identifies which one of them is most suitable to deal with specific concerns. This is something we welcome, as, currently, a doctor may be investigated and censured by multiple agencies at the same time.
There is also a balance to be achieved between consistency and recognition of the varied nature of independent doctors’ services – for instance, managerial structures and resources.
detrimental to a practice’s reputation – which is why it is imperative that any information collected is robust, analysed and interpreted accurately. Care must also be taken to ensure a balance is achieved between the use of quantitative and qualitative data and information.
From our experience with doctors, we know CQC inspections can be disruptive and time-consuming. From the first notice of an inspection, through to gathering preparatory materials and evidence and the often lengthy wait for the report, it can be an extremely disruptive process for the doctor and the wider team too.
The strategy has recognised concerns with the frequency of re-inspections, with services rated as ‘good’ or ‘outstanding’ to be inspected less often with maximum intervals of five years.
In theory, this more targeted approach should cut the number of overall inspections, but simultaneously the CQC has said it is committed to conducting more unannounced inspections. how these seemingly opposing aims will work together in practice remains to be seen. It may mean a service rated ‘good’ or
‘outstanding’ could, in fact, still undergo a re-inspection within the five-year interval.
Therefore, much will depend on the weight given to these two aims and we will look to see if the frequency of inspections decrease or remain the same.
The CQC strategy proposes developing a single shared view of quality across the regulators, with a common understanding of what that would look like.
This would require collaboration among regulators and other national and local oversight bodies to
CQC inspections should reflect the fact that independent services are privately funded. Their administration and the use of resources should be assessed differently to an NhS GP practice. Therefore, the appropriateness and necessity of the CQC’s question about an independent doctor’s services’ ‘effectiveness’ is redundant.
We believe the CQC’s rating of independent services should only reflect the care being provided to patients.
We foresee a number of practical challenges for the CQC if it wishes to begin rating independent services in the future, given the sheer scale and number of specialties in this sector.
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With more doctors in private
practice
finding themselves suffering from the
ISOLATION TRAP,
dr Catherine spencer-smith (below) shows how you can treat yourself
Many of the clinicians I work with admit to feelings of isolation, particularly when first transitioning from the n HS to private practice.
I decided to investigate the extent of this, and carried out a survey of 100 clinicians working as independent practitioners to get a better understanding of the extent of the problem.
It’s a significant problem. Eightyeight per cent reported having experienced feeling isolated and, of those, half reported feeling that way on a frequent basis.
o ne of the hardest transitions for doctors when they move into
the private sector sometimes comes with the change of people around them.
In the n HS, you are probably used to being surrounded by a team you know very well. There’s always someone around you can ask for a bit of clinical advice or you can sneak a quick end-ofclinic ‘decompression’ coffee with – even it if is mid-dictation.
Eerie feeling
It often comes as a surprise to doctors the first time they experience clinic loneliness. We may anticipate that we’ll be meeting new receptionists, nursing staff or radi-
ology assistants, but we might not be prepared for that eerie feeling of starting and leaving a clinic without having chatted with a single sole, other than a patient.
The problem is often compounded by the ‘curse of comparison’. This frequently comes in two forms.
first is the ‘tumbleweed’ clinic experience. This is when you have a sinking feeling of selfdoubt when you endure a deathly quiet clinic with maybe just two or three patients booked in. Meanwhile, the patient flow in and out of the consulting room
opposite has been non-stop all afternoon.
Secondly, there is the ‘but we’re in competition’ experience, which occurs when you convince yourself you really must not fraternise with the enemy, as you’re both specialists in pemphigus.
If you think it’s just a problem just for the newbies, you would be mistaken. Many of us ‘Golden oldies’ fall into a trap of isolation when our clinic ‘busyness’ means we barely look or step outside our clinic room all day. Sounds like a good problem to have?
In one respect, it’s great to be ‘heads-down’ with patients, but when we fail to form new relationships, it stifles our professional development and may blinker us to making new connections for referrals.
There’s a very real danger we will miss out on the benefits of cross-pollination of ideas and clinical concepts, potentially
If you work completely alone, then there’s little opportunity to share the ‘burdens’ of clinic life
leaving us behind in the race to offer innovative techniques for managing clinical problems.
The classic example of this is when a consultant who has sat on their laurels, always doing the same thing the same way, suddenly finds a downturn in referrals when the new kid on the block appears.
If you work completely alone, then there is little opportunity to share the ‘burdens’ of clinic life. and there’s even evidence of a risk of increased poor health, as lack of back-up means you’re less likely to
take time off work or ask a colleague to step in to see patients for you.1
In the worst-case scenario, consultants who are isolated ‘lone workers’ may receive little in the way of peer-to-peer feedback, which can potentially lead to outdated or even dangerous practice.
Being isolated is a great way to avoid having your views challenged and it’s dangerous to rely solely on our self-perception when it comes to our clinical performance.
It’s no surprise that if you work alone, you’re more likely to end up in front of a GMC disciplinary panel.
So, in private practice, how do we ensure we find new friends and connections, keep up to date clinically and remain competitive?
➲ The first step is to admit you’re feeling isolated Better still, anticipate that it may happen and prepare to galvanise yourself against it. yes, it’s going
to take a little effort and, yes, you may need to dedicate time and some funds to the process, but it will more than repay you.
➲ Ask for help
If you’re starting out in a new work environment, you have the ideal opportunity – and ‘excuse’ if you need one – to get to meet people, simply under the guise of introducing yourself.
If you’re in hospital setting, ask a friendly staff nurse/sister/modern matron to introduce you to a new person each week. n ot only are most members of staff delighted to do this, they will naturally tend to link you up with approachable, connected clinicians.
It’s a bit like the buzz we feel when someone asks us for their opinion about a favourite restaurant or physiotherapist. Humans are wired to want to help. Make sure you actively share your contacts too.
➲ Follow up
When you meet with a colleague, make sure you get their contact details or business card and –here’s the important bit – make sure you follow up with them. So many people miss out on the opportunity to say in an email ‘Great to meet you yesterday – are you going to the meeting next week on x, y or z?’ or even ‘Let me know if you’re in need of a beer after clinic on friday’, for example. Try it. It works a treat.
➲ Ask for an opinion you might find yourself in need of a sounding board about a complex case. Most of us are flattered when asked for our professional viewpoint on something. not sure whom to ask? Consider all those folks in the know who could tell you ‘who’s the go-to person for this case?’, such as radiologists, theatre staff, even medical secretaries.
you’ve then got a great ‘opener’ for a clinical conversation if you start with the words: ‘I’m told you’re our resident expert on .....’ (insert ‘pemphigus’/‘frost bite’ etcetera).
➲ set up or ask to join a multi-disciplinary team There are so many great reasons to be part of an multidisciplinary team (MDT) meeting, getting together on a very regular basis to discuss cases. apart from the obvious examples of clinical governance and improved patient care, it can also increase your private referrals.
We all work in slightly different ways, with differing scopes of practice, and it’s a great way to showcase your skills and knowledge.
How often have you felt surprised when you’re asked the question ‘Do you see this kind of patient?’, when, to you, it seems
obvious that you see and treat those patients all the time?
If you don’t tell people what cases you can help with, how can they be expected to refer to you?
The broader the range of clinicians within the MDT, the better.
Some of my spinal orthopaedic colleagues in an MDT I’m involved with had never heard of rib stress fractures in rowers before we had a mutual case. now, thanks to my spinal buddies, I have regular referrals of patients with buttock pain who have been proven not to have sciatica. and I have a network of competent spinal injection folk I can refer to if I have an athlete in crisis with a persistent L5 root compression.
➲ Join professional organisations whenever possible
Get on their mailing lists so you don’t miss the opportunities to meet.
➲ be strategic and be consistent
Set up an educational and social events calendar.
Try setting yourself the goal of attending an educational event each month, and if there’s a scarcity in your area, consider setting up some regular training with other colleagues – for example, musculoskeletal ultrasonography, or shockwave therapy skills or resuscitation training.
offering to do the organising, with the promise of some drinks and a curry afterwards is a great way to draw colleagues together.
➲ Ask for introductions via a consultant liaison officer
Look laterally within the consultants who are working in your hospital or clinic and see if there is someone with whom you could have potential cross-referrals. f or instance, hip and spinal ➱
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For further information contact our team.
orthopaedics go together well, as does rheumatology and dermatology. Say ‘Hi’, and try to make an appropriate referral to that clinician as soon as a suitable patient presents themselves.
➲ offer to meet with other newbies and get an accountability buddy Private practice growth takes effort and encouragement. It’s so much easier to do when you’re in it together.
Share your thoughts and learnings about non-clinical matters, such as practice software, tech, blog writing and building an email ‘list’ of patients and clinicians you can broadcast your message to.
➲ get on social media ctively embrace the powers of LinkedIn and Twitter. Medics love to give their ‘tuppenth’ on a hot
topic or clinical conundrum – it’s a great way to seek out likeminded folk and link up with potential collaborators.
➲ Finally, don’t just hang out with medics
Some of the best advice I’ve gained has come from professionals in other spheres, such as design and marketing and the legal sectors. you may even find yourself joining a business mastermind group…
reference
1. Holden J.D.; Cox S.J. and Hargreaves S. (2012). Avoiding isolation and gaining insight, BMJ Careers Available at: http:// careers.bmj.com/careers/advice/viewarticle.html?id=20006663
Dr Spencer-Smith is a consultant physician in sports and exercise medicine. www.privatepracticeninja.co.uk
How long Have you been workIng In prIvate practIce?
How are you currently workIng In prIvate practIce and tHe nHs? I
Have you ever experIenced feelIngs of IsolatIon wHIle workIng In prIvate practIce?
wHat steps do you take to lImIt feelIng Isolated In prIvate practIce?
●
responses listed under ‘other’ included:
● after-clinic drinks with colleagues
● sharing a car commute with a colleague to clinic
● making the effort to meet up regularly with other musculo-skeletal groups, such as physio and osteopaths
Source: Private Practice Ninja Ltd
Private P ractice’s unique challenges may bring with it solo working and less obvious opportunities for team-working and collaboration.
The pressure of perceived competition for patients can stifle opportunity for case discussion and dissemination of new learnings.
There is also the danger of poor performance going unrecognised and unreported, and some underperforming clinicians may gradually slip into isolated working to avoid being challenged over their clinical practices.
This is particularly true of doctors working solely in private practice, and we know from past studies examining the performance of solo GPs that isolation can lead to ill health and more patient complaints.1
pressures
Commercial time pressures may mean that doctors see time out from clinic for continuing professional development events and networking to be ‘expensive’ or ‘a luxury’.
The nHS provides a very robust system of clinical governance and multi-disciplinary team review of patients, which may take effort to set up in private practice.
Thankfully, things are changing. Many private hospitals are expanding their growth of multidisciplinary team meetings, to help raise standards of patient care in surgical, oncological and cardiac disciplines.
a nd insurers are increasingly bringing pressure for this to be standard practice before complicated surgical procedures.
Mentoring schemes for newly qualified consultants – for example, as provided by the Royal College of Surgeons, are very helpful for those who are dipping their toes into the private practice world. nevertheless, feelings of professional isolation can extend well beyond the first few months of working privately.
Consultants of all professional backgrounds can improve their ‘connectedness’ by actively seeking to implement a few strategies. These can include ensuring they ring-fence and diarise time for meeting with other consultants and clinical practitioners, rather than viewing the activity as a lowpriority and ‘only if there’s diary time spare’.
Making better use of lateral referrals – for example, between rheumatology and dermatology disciplines – can increase the sharing of best clinical practices, as can regularly attending faculty evening meetings and social events.
Doctors who regularly mix and share clinical conundrums with other doctors are healthier, happier and less likely to face disciplinary action against them.
reference
1. Cox S.J, Holden J.D. Isolation and insight: practical pillars of revalidation?
BrJGenPract 2009; 59: 550-1.
In these highpressure times, Dr Philip Zack (below) discusses how independent practitioners can look after their health – and how your medical defence body can support you
There’s no doubt independent practitioners are under pressure from increasing workloads, patient demands and expectations – and this high-stress work environment can take a toll on doctors’ mental and physical health.
A recent r oyal Medical Benevolent Fund ( r MBF) survey of more than 1,000 doctors and charity supporters found 82% of doctors know of other doctors experiencing mental health issues such as depression and anxiety.
The unfortunate reality is that doctors who are unwell or struggling to cope may be more susceptible to errors and complaints because they may not be able to practise at their optimal level. This could land them with a complaint
or even a GMC investigation, making matters even worse.
That’s why it is so important for clinicians to look after themselves – for the sake of their own health, to prevent medico-legal issues, and in the interests of their patients.
In 2015, the MDU surveyed 138 doctors involved in a GMC complaint or negligence claim over the previous five years for their views on how they found the experience. s ome 45% (62) of respondents said it was either horrible and the worst experience of their lives or very bad and disruptive, and 10% (14) suffered health problems as a result.
In our experience, the GMC
tends to be sympathetic towards doctors with health problems if they co-operate with health assessments and show insight. The GMC’s own indicative sanctions guidance states: ‘ e rasure is not available in cases where the only issue relates to the doctor’s health.’
however, panels of the Medical Practitioner Tribunal service can suspend doctors indefinitely if there is a risk to patients. Most commonly, the doctor will be asked to make undertakings – binding promises – or will be able to continue working with conditions, such as regular contact with a GP or attending Alcoholics Anonymous meetings.
But, of course, no doctor wants to end up the subject of a GMC
complaint in the first place and that’s why it’s so important to seek help when it’s needed.
what help it out there?
The rMBF has developed a ‘Vital signs’ guide to provide doctors in training with practical advice, support and resources. But some of the key stress and pressure points set out in the guide could apply equally to more senior doctors. For example, the charity sets out seven early warning signs which might identify that you or a colleague need help – such as frequent sick leave or lateness, low work rate, bursts of bad temper, and failure to show insight that there may be a problem.
Family, close friends or col -
The unfortunate reality is that doctors who are unwell or struggling to cope may be more susceptible to errors and complaints because they may not be able to practise at their optimal level
leagues may be well placed to notice these signs before you are aware of them and it is important that doctors showing signs of stress get help early.
You should seek help – depending on the nature of the problem and your work – from an appropriate source, which may include:
Colleagues/managers/your medical or clinical director or deanery;
o ccupational health department;
Your own GP or specialist;
Counselling or therapy services;
specialist services for sick doctors in your local area, such as:
❍ The Practitioner h ealth Programme, covering London and some other parts of england;
❍ The GP health service, due to start early 2018 in england only;
❍ h ealth for h ealth Professionals;
you have an ethical duty to register with a GP outside your own family (paragraph 30, GMc, Good Medical Practice). If you are unwell, it is important to get an objective assessment and not rely on your own assessment of your health or ‘corridor consultations’ with colleagues.
The GMc’s online guide your health Matters advises doctors to ‘note early warning signs of illness and take them seriously’, suggesting that ‘feeling low or irritable, or having poor concentration and low energy may be signs of burn-out’.
If you know or suspect your judgement or performance could be affected by burn-out, you must consult a suitably qualified colleague – such as your GP, occupational health doctor or psychiatrist – and make any changes to your practice they advise.
Don’t be tempted to selfprescribe to alleviate symptoms such as exhaustion or anxiety, as this could leave you vulnerable to a GMc complaint. The GMc says cases involving selfprescribing or informal treatment of family and colleagues have increased from 36 in 2010 to 98 in 2012.
❍ enfys in Wales.
And, of course, your medical defence organisation is there to provide you with advice and guidance. Contact your defence body if you are referred to the GMC with health concerns such as burn-out.
Minimise the strain
In many cases, we have helped members agree undertakings with the GMC at an early stage which minimises the strain involved and means they are able to carry on working.
If you are off sick for more than a month, we can put your membership on hold, meaning you will not have to pay us a subscription for the period you are not able to work.
While on a break from MDU membership, you can continue to approach us for assistance with matters arising from work you undertook while in full membership. You can also come to us for help with Good s amaritan acts, provided you maintain your registration with the GMC.
The following case is a fictitious example of the type of cases where we offer support.
case study: consultant with burn-out
A private consultant came for help after the hospital he was working at suspended him, following an investigation of a serious incident in which a patient was harmed.
he said he had felt unwell for some time and that work pressures had been getting to him. Things worsened after he had undergone surgery recently and had hardly taken any time off to recuperate.
The consultant had been taking painkillers and was only getting a few hours’ sleep most nights, but he hadn’t consulted a GP because he was not registered with one.
The incident had happened because of an error of judgement on his part, he explained, and since being suspended, he was feeling very depressed and just wanted to resume work.
The MDU adviser explained that GMC guidance in Good Medical Practice says that if your judgement or performance could be affected by a condition or its treatment, you must consult a suitably qualified colleague.
You must follow their advice about any changes to your practice that is necessary. You must
not rely on your own assessment of the risk to patients.
The adviser suggested the consultant seek help from his own GP and/or occupational health department, if he had access to one, and follow their advice about his work and any treatment proposed. The doctor was also advised that he should keep senior colleagues informed so they could make appropriate arrangements for his work to be covered.
our adviser supported the consultant in responding to the hospital investigation into the serious incident. The hospital acknowledged the doctor’s insight into his health concerns and willingness to follow advice, such that they did not feel further action was required on their part.
The doctor later returned to work with the support of colleagues.
Dr Philip Zack is a medico-legal adviser at the MDU
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While it is doubtful you could ever be replaced by a robot, as Jane Braithwaite (right) shows, automation is playing an ever-increasing role in medical practice
IN 2011, IBM’s Watson computer won the game show Jeopardy and is now functioning as a diagnostic device for cancer patients. So what are the implications of automation in the medical world and how far could they reach?
Let’s take an objective look at automation and robots. We’ve already accepted extensive automation in our lives without necessarily having registered radical changes – self-service kiosks in supermarkets and petrol stations are now omnipresent, albeit irritating, devices.
Can we imagine life without automated teller machines?
Online banking is a good example of useful automation. Who today would envisage queuing at lunchtime to cash a cheque?
What can be automated?
Anything that entails basic hand-eye co-ordination can be done by mechanical devices.
Routine, repetitive and predictable jobs are most suited to automation. The more transactional a task is, the more plausible this process. At the most basic level, automation requires capital investment to replace labour.
Tasks including large volumes of information are perfectly suited to automation, as machines are able to organise huge quantities of data.
Machines such as iPhones create and process vast amounts of information and we will increasingly use machines to organise and present data in a useful way.
Fortunately, doctors’ tasks and jobs involve personal contact, interaction, dialogue, debate and negotiation, and they cannot be performed well by a robot.
Current jargon on the subject includes disruptive technology and disruptive innovation. New corporations such as Airbnb and Uber have disrupted traditional business models and subsequently enjoyed huge success.
It is fair to observe that while these innovative businesses have generated employment and augmented customer satisfaction, they have also had a negative impact on incumbent businesses such as London’s traditional black cabs.
A study by the McKinsey Global Institute predicted that, by 2025, robots could replace 40m to 75m jobs worldwide.
Automation will largely affect tasks and jobs that are transactional in nature. Jobs that cannot be automated include those that rely on personal interaction, in which the calibre of customer service is highly relevant.
Consider the hotel industry. If you have booked into a Travelodge, you might be happy
to check in with your credit card. If you are looking forward to a celebratory stay at Claridge’s, you would undoubtedly prefer a warm, personal welcome.
impact on the medical profession
Given that the fundamental nature of a doctor’s work entails personal interaction and empathy, one might assume a minimal impact from automation in the medical field.
But I would envisage impact occurring in three separate areas:
① Diagnosis and treatment;
② Robotic solutions as medical devices;
③ Automation in the medical environment.
1. diagnosis and treatment
Automation will be hugely important in the area of diagnosis. The IBM Watson computer I mentioned earlier is able to suggest diagnoses and treatment options by analysing symptoms, a patient’s medical history and research studies.
In this instance, the ability to process large volumes of data is highly significant.
Automation can benefit patients by providing an increased quality and range of treatment options.
For example, the iBG star diabetes manager app is a blood glucose meter that can be attached to an iPhone. This enables patients to check blood insulin levels at any location, and obtain results almost immediately.
Automation offers huge possibilities for genomics. Genomics England is an exciting project; whose aim is to sequence 100,000 genomes from 70,000 people.
As I write, its website statistics show it has reached 12,256. The data from one sample is equivalent to 100GB or 20 HD movies. The stated aim is to improve diagnosis, especially in cancer.
These quantities of data will need to be processed by a computer, and the outcome will be precision medicine, speedy diagnosis and the ability to predict the success of different treatment plans.
2. Robotic solutions as medical devices
Numerous developments of robotic solutions to medical problems are underway. This is an exciting area and potential benefits to patients could be huge.
The ability to provide a prosthetic leg that can monitor and emulate a patient’s walking pat-
terns is a reality with the OttoBlock Microprocessor C leg.
The ‘knee’ adjusts accordingly, enabling the user to walk at different speeds and therefore increasing safety on stairs and ramps.
Exoskeletons are being employed to assist people with spinal injuries as well as enhancing rehabilitation for those learning how to walk again – for example, after having suffered a stroke.
Radio-frequency identification (RFID) chips are slowly making an impact in the medical world; the future will see greatly increased usage. At Sanraku Hospital in Tokyo, patients wear their RFID tag in a wristband. Their injection prescriptions are stored on a chip, which is read by a hand-held reader. This ensures the correct drugs are prescribed, while simultaneously linking back to patient records and the relevant hospital inventory.
There are also some exciting developments in ophthalmology taking place. An artificial silicon retina (ASR) has been used with great success. The device consists of a 2mm diameter ASR microchip.
It is a good solution for patients with retinal degeneration and works by converting light energy. One patient reported significant vision returning, having previously lost their sight entirely.
Robotic hearts have been used for many years as a temporary solution while patients await a human heart transplant.
A French company called CarMat – an unfortunate name in English – has created a permanent artificial heart solution. The device runs a five-year lithium battery, but it comes with a hefty charge at $200,000.
The benefits in terms of aftercare are enormous, as the heart effectively monitors itself. The greatest concern with such devices is the possibility of hacking. Dick Cheney, the US vicepresident under George Bush, had a temporary robotic heart and was so worried about it being hacked that he asked for the wi-fi to be disconnected!
We are destined to see huge changes in the medical environment. From robots delivering patients’ prescriptions on the ward to the filing of notes, vast changes in medical secretaries’ and admin staffs’ work practices will undoubtedly ensue.
Taking a wider view of the environment where doctors work, drones will be both innovative and daunting. They are likely to be used increasingly in disaster relief.
In 2012, drones were used to deliver small aid packages after the Haitian earthquake. Doctors Without Borders have also used drones to transport TB test samples to remote villages.
In the future, we may see drones being used to transport blood products to hospitals and large-scale incidents, along with drugs and defibrillators. The possibilities are limitless.
Within the practice and hospital environment, one of the first developments of automation will most likely be automated booking of patient appointments.
It is unlikely that many clinic staff will miss the incessant ringing of practice phones by patients requesting urgent appointments; this will be done automatically.
Many of the administrative tasks that are carried out manually at a doctor’s practice will be automated in the future. These include computer generation of bills subsequent to patient’s appointments and chasing of payments, if necessary. This could and should be more commonplace.
Will you need a medical secretary? We envisage changes occurring subtly over time, including a slow evolution of the medical secretary’s role.
But personal interaction will remain key: someone to meet, greet and reassure nervous patients will always be a fundamental requirement in the private medical world.
Jane Braithwaite is managing director of Designated Medical
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medical insurance work in Private Practice is big business, so let Code busteR! keeP you in the know every month, the clinical coding and schedule development group (ccsd) reviews its 2,000-plus procedure codes, and more than 3,000-plus diagnostic codes, that form the basis of private medical insurance. it is crucial for independent practitioners and their practices to know these codes, so they bill correctly. if they don’t, then it could cost them money
Changes to note this month
Specialties recently affected include: investigations, simple procedures and consultation codes (Code A); face, mouth, salivary & thyroid (Code B); eye and orbital contents (Code C); thorax and intra-thoracic organs (Code K); female reproductive organs (Code P); female reproductive organs (Code Q); spine, spinal cord and peripheral nerves (Code V); bones, joints and connective tissue/tendon muscle (Code W); radiotherapy (Code X); interventional radiology (Code XR).
theRe aRe seven new pRoCeduRe Codes
W4214 – Customised unicompartmental knee replacement; W4218 – Customised total prosthetic replacement of knee joint; W4216 –Customised bicompartmental knee replacement; W5830 – Robotic-assisted total knee replacement; 64301 – Echocardiography +/bubble contrast (including reporting) as sole procedure; P0610 – Laser destruction of lesion of vulva; B1280 – Ultrasound-guided radio frequency ablation of benign thyroid nodule.
theRe aRe 11 new diagnostiC Codes 4184A – Short biochemistry panel;
4185U – Urine pH level test; 4188U – 7X STD Infection by PCR; 4189B – Anti-phospholipase A2 recp;
4190A – Zika virus PCR – blood; 4191U – Zika virus PCR – urine; 4192A – Zika virus antibodies; 4193A – Histamine-release test penicillin antibiotic panel; 4194A – Histamine-release text drug allergen; 4196A – Histamine-release test peri-operative anaphylaxis panel; 4197A – Red cell transketolase. There are four narrative changes: K5040, C6012, C7123, C7124 ; one code inactivation W4211, with three new replacement codes depending on the type of knee replacement: W4214, W4216 and W4218.
t he R e a R e 37 una CC eptable C ombinations (also known as unbundling)
W3530 with X4810, X4822; C6180 with C6920, C6930, X3800; C6920 with C6010, C6011, C6012, C6110, C6111, C6120, C6130, C6150, C6160, C6170, C7122, C7123, C7124, C7125; C6930 with C7122, C7123, C7124, C7125; C7201 with AC100, C4340, C6920, C6930, X3800; C7202 with AC100, C4340, C4340, C6920, C6930, X3800; V2500 with A5290;
deClined oR withdRawn Request(s)
Code pRoposed naRRative Reason foR deClining
Xr120 Ct/mRi-guided biopsy(ies) Current code sufficient of soft tissues
Q1701 with Q0750, Q0751; W7420 with W7490
The special note this month involves ophthalmology. Codes C7201 and C7202 – laser-assisted phacoemulsification of cataract with lens implant – unilateral and bilateral (including topical or local anaesthetic) – are both no longer allowed with local anaesthetic (AC100).
Please remember, however, that codes are not mandatory by insurers. In other words, the inclusion of procedure codes within the CCSD Schedule does not indicate the automatic agreement of individual insurers to provide benefit for this procedure.
You need to contact each insurer directly to find out whether benefit is provided.
Code Buster data is provided B y Medi C al Billing and ColleCtion. For Full details, go to the Clini C al Coding sChedule developMent weBsite at www.CCsd. org.uk
Our monthly series by Jane Braithwaite gives some vital tips to help you stop time running away from you
It Is generally assumed that doctors are very good at managing time; after all, each patient’s consultation must be managed within a specific time-frame, whether that’s ten or 30 minutes. However, it is fair to say that we all want more time; whether that’s to get work done, to enjoy life or both.
t his month’s article on time management for doctors will explore several pertinent tips on how to manage your time – this most elusive commodity.
t he Wikipedia definition of time management is as follows: ‘Planning and exercising conscious control over the amount of time spent on specific activities, especially to increase effectiveness, efficiency or productivity’.
My favourite time-management technique is the Eisenhower method created by the U s President Dwight D. Eisenhower. It is also referred to as the Urgent/ Important Matrix.
Eisenhower said: ‘I have two kinds of problems: the urgent and important. t he urgent are not important and the important are never urgent.’
the matrix described by Eisenhower allows you to consider each activity in one of four sectors in his matrix.
An activity that falls into the urgent and important category is clearly something that you need to do immediately.
However, non-urgent but important tasks are often more significant, but as they are not
urgent, they slip down the list. Efforts should be made to deal with these tasks with urgency. At the other end of the scale, any task that fits into non-urgent and not important should be discarded completely. And if it is urgent but not important, should you bother to do it? Only you can decide, but do make a conscious decision instead of wasting your valuable time.
One of the biggest potential timewasters for all of us is the use of email and the Internet.
If time management consists of ‘planning and exercising conscious control’ over the amount of time spent on an activity, then email and Internet usage need to be manged with care.
If you are managing your own practice email and sifting out requests for prescriptions and follow-up appointments, why not ask your secretary to manage that account and to forward only the relevant emails to your separate ‘private’ account.
Personally speaking, I have picked up several tips over the years that have helped me in various ways. I tend to find one or two lightbulb ideas in each different method I research that subsequently stick with me.
Here are my tips for you:
➲ Plan. Establish a planning routine. some people do it at the start and end of the working day, others do it on a Monday and Friday at the start and end of the working week. Planning helps you avoid having to unexpectedly dedicate a chunk of time to dealing with an urgent issue.
➲ Prioritise. Use the Pareto principle or 80:20 rule. Prioritise the 20% of actions that will have the most impact.
➲ Delegate. Just because a task lands on your lap doesn’t mean that you must complete it. Immediate delegation is a very effective strategy, which brings me onto number four.
➲ Avoid procrastination. t his is a bad habit that needs breaking. Decide on the next action and do it.
➲ Use an app. Numerous app developers have focused on time management, and you can choose from a wide range of soft-
ware applications. I use toodledo daily, but there are many others to choose from.
➲ Email agenda. Always have an agenda in mind before you log into your emails. s tarting at the first email and working through them chronologically is not an effective agenda.
Decide how much time you can allocate to email and set your objectives. Have a list at the ready of your top five objectives and deal with the emails that relate specifically to those objectives.
➲ Analyse your time. think about what you spend the most time doing and look at changing processes to save time. there is a choice of time-tracking software programs, designed to help you measure the time you allocate to various activities.
For example, if you spend a notable amount of time phoning patients, perhaps the patient emails or letters you send could be amended to include more information. Enclosing guides on medications, symptoms and so on might help to cut down time spent on repetitive calls.
➲ Meetings. Before the existence of email, this was the number one time drain. Even if it’s not your own meeting – clarify your agenda and objectives in advance so you can focus on getting your desired outcomes. s et your boundaries by stating a time limit up front. Let the organiser know that you must leave at a certain time and stick to it.
➲ Filing system. How much time do we all spend looking for something that’s filed in a safe place? Most of us need both a paper and online filing system. Investing some time in a good filing system will save many hours in the long term.
I would like to finish with a great quote by stephen Bayne: ‘I am rather like a mosquito in a nudist camp; I know what I want to do but I don’t know where to begin.’
I hope these tips help you avoid being that mosquito!
Jane Braithwaite (right) is managing director at Designated Medical
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‘Here to help. Not to judge.’
OK, so it’s your website – but do you own and control it? Gill Hall and Nabil
Asaad continue our series to help doctor entrepreneurs avoid a growing number of legal pitfalls
Organisati O ns rightly devote significant time and resources towards ensuring their web presence reflects their values and the message they wish to convey to the outside world.
Even those that do not engage in e-commerce are expected to have a website – their shop-window in the electronic world – and will take steps to ensure that clients and prospective clients searching the internet will arrive at their own website rather than that of a competitor.
With the focus of this investment and effort being on finessing the website, it is easy to overlook two seemingly straightforward questions:
1) how much of your website do you actually own?
2) are you in a position to control it?
the answer to the first question is almost never clear cut.
having potentially paid a web-
developer a not insignificant sum of money to develop a website for you, it would not be unreasonable to expect that the website and its content would be yours. if you made that explicit agreement with the web developer then you may be most of the way there – but there are pitfalls, so please read on. i f you did not explicitly agree that you would own the content, then you are almost certainly not its owner.
the position at law is that copyright in the website code and content will be owned by its creator and not by the person who commissioned/paid for it. t his is unless there is agreement to the contrary or the software code behind the website and content is created by your employee in the course of their duties.
you would, of course, be entitled to use the website for the
purpose for which it was commissioned, but the default position is that legal ownership does not automatically transfer. the consequence of this is that the original creator is potentially at liberty to sell the same code or content to others, destroying the exclusivity that you may otherwise have considered was yours. it goes without saying that you should always read the small print – web developers will often have their own standard terms and conditions – which may deal with ownership of content, and those terms and conditions could become part of a contract when you place an order.
aside from ownership provisions, wording to watch out for includes: overly-complicated termination arrangements, automatic renewals, exit fees and being tied into support, hosting or other services.
it is best to have the option to switch support or hosting providers – even if you never will – and ideally the service provider should be obliged to give reasonable assistance with handover to a new provider on exit.
Even if you are contracting on a service provider’s standard terms, it is worth ensuring that you specify in as much detail as possible and record in writing what you have asked the service provider to deliver. if the commission is discussed at a meeting or over a phone, then it is worth following up with an email to the provider in order to capture a written record of what you are buying.
this may prove useful in a later dispute as to your instructions or what services were included in your agreement. Put it in an email that ends with ‘if there any issues or corrections, then please let me know right away’.
Independent Practitioner Today has joined forces with leading niche healthcare lawyers Hempsons to offer readers a free legal advice service.
We aim to help you navigate the ever more complex legal and regulatory issues involved in running and developing your private practice – and your lives.
Hempsons’ specialist lawyers have a long track-record of advising doctors – and an unrivalled understanding of the healthcare system as a whole.
call Hempsons on 020 7839 0278 between 9am and 5pm Monday to friday for your ten minutes’ of free legal advice.
Failing to do this can put you at a serious disadvantage: for example, in circumstances where the only written record is the service provider’s order form – which you later discussed by phone, agreeing something different – or where there are no documents at all.
Of course, what happens ‘on the ground’ may not always reflect what is agreed in the contract. an unscrupulous provider might stop returning your calls and emails at the first hint of you moving your account elsewhere.
Keeping copies of all your content and having log-in access that enables you to take control of the domain name could potentially save a lot of time and trouble if the relationship goes sour.
if you have had a website developed from scratch without, for example, using an existing website ‘template’ that is freely available, then you should push for ownership of the bespoke code.
dispute if unsuccessful, then you should consider whether the code should be placed in escrow with a third party agent – such as the national Computing Centre – whereby you can access it if the supplier becomes insolvent or defaults on its contractual obligations.
i f you do end up in a dispute, then always be sure to keep copies of all emails, together with lettercorrespondence and notes of all phone calls and seek legal advice early.
Even if you have contracted for ownership of the original content, website content will often include stock photographs and other media such as music and videos. t hese will often be licensed by a rights holder for a royalty payment rather than owned outright by the ‘buyer’. t he royalty fee might depend upon the intended use of the content and any exclusivity arrangements. the licence terms – that is to say, the basis upon which the content is made available – should always be respected.
For example, if permission has been obtained to use a stock photo for leaflets or business cards, then it should not be used on a website without obtaining the requisite permission.
some rights holders use tools to monitor the internet, looking for instances of their content appearing on websites without a licence.
t his can lead to the threat of legal proceedings from the rights holders or a costly settlement. this may be particularly harsh on a business owner who has unknowingly been provided with infringing content by a webdeveloper or in the mistaken belief that the content was public domain or available on a royaltyfree basis.
some providers of content such as stock photos guarantee that they own and/or have the right to license their content. this may be reflected in a higher royalty fee, but may give peace of mind and additional protection.
Due diligence as with any commission, exercising due diligence and selecting a reputable provider may turn out to be more advantageous than simply selecting the provider with the lowest quote.
What about open source software? Open source software is becoming increasingly popular and many websites incorporate open source elements.
there will often be a core suite of software that is made available free of charge together with a community of developers who contribute additional software on the same basis.
it should be noted that ‘free of charge’ does not mean ‘free of copyright’. there are usually conditions – for instance, licence terms – attached which may include stipulations about copyright messages, contribution of material back to the community and the terms upon which software incorporating open source elements can be provided to others.
advantages of the open source route may include not having to pay for the software itself – only
key poiNts to eNsure ArouNd coNtrol ANd owNersHip of your website
you keep copies of the terms of engagement for all services you commission, along with your instructions, your payment history and details of any disagreements
ownership of copyright in commissioned materials is transferred to you
the licensing terms for any third-party content, such as stock photographs, cover their intended use
contract terms, including web developer’s standard terms, are acceptable and do not unduly restrict your ability to change provider
if you do not have direct editorial access to the content, you have and maintain up-to-date back-up copies of the whole site
Arrangements are in place for the renewal of domain name registrations and hosting fees
for development work – and the developer being obliged by the open source licence terms to provide the source code to their client. this could enable you to take such software to another provider should you wish to.
Domain name
the website domain name itself, also known as the web address or Url, is distinct from the website content and is something that you may reasonably expect to own, but you may find your web developer registers it in their own name, particularly if they are providing hosting services.
t he registration and renewal arrangements for the domain name may even sit with a different provider than that hosting the website.
Make sure you either own the domain name or know who does. Particular care should be taken around renewal dates and whether you or perhaps a webdeveloper is responsible for the renewal.
Being late with payment could lead to your website going offline and also risks the domain name being sold to a third party. securing the return of a domain name in those circumstances
could prove costly or even impossible.
i n addition to issues around ownership and licensing, there is the question of who actually controls your website. if all the content and access to the content management system are in the hands of the web developer, then a business can find itself having to pay fees to that service provider every time the website needs updating.
i t may also prove difficult to move provider if all of the content is under the control of a third party.
Worse still, if such a provider becomes insolvent or suffers a serious technical incident, it may be difficult or impossible to obtain a copy of the website in order to get it back up and running.
Careful attention should therefore be given to issues around back-ups and access rights, as well as any minimum term provisions or exit payments.
t his may all seem as though you are entering a legal minefield but, in summary, check out the key points to consider around ownership and control of your website (see box above)
Independent Practitioner Today readers who need any help dealing with what can be a complex area of law, then please contact gill hall, partner, or nabil asaad, solicitor, at hempsons.
Gill Hall (far left). Phone: 0191 230 6056. Email: g.hall@hempsons.co.uk. Nabil Asaad (left). Phone: 01423 724102. Email: n.asaad@hempsons. co.uk
Differences of opinion between claimant and defendant experts need to be explored. It is important that misunderstandings are ironed out in a meeting and that areas of genuine disagreement are identified, says Michael r. young
t h E PU r PO s E of the experts’ meeting is not to reach agreement. there are many cases where this is not possible, as both experts have honestly-held but opposing views.
Most of the expert meetings i attended were face-to-face meetings. One or two were over the phone. they are now more likely to be over the phone on skype.
t he parties, the lawyers and experts should co-operate to produce the agenda for any discussion between experts, although primary responsibility for its preparation should normally sit with the parties’ solicitors.
t he agenda should indicate which matters have been agreed and summarise concisely those that are in issue. the agenda may include specific questions to be answered by the experts.
as you would before a case conference, prepare well. you should receive a copy of the agenda well ahead of the meeting in time for you to prepare for the discussion.
t he purpose of discussions should be wherever possible to:
identify and discuss the expert issues in the proceedings;
identify those issues on which they agree and disagree, and summarise their reasons for disagreement on any issues;
i dentify what action, if any, may be taken to resolve any of the outstanding issues.
One of the experts usually takes on the role of note-taker during the meetings, but if this is not you, then you should always make your own notes.
at the conclusion of any discussion between experts, a statement will be prepared by the solicitors to be signed by the experts, setting out a list of:
issues that have been agreed;
i ssues that have not been agreed;
a ny further issues that have arisen that were not included in the original agenda for discussion;
Further action, if any, to be taken or recommended.
this statement is not normally signed on the day of the meeting, which is why you need to have your own notes of the meeting to refer to when you are eventually asked to sign it.
i t can sometimes take several attempts to produce a statement that both experts agree on and which accurately reflects what was actually said.
adapted from The Effective and Efficient Clinical Negligence Expert Witness , by Michael r young, price £60 from Otmoor Publishing
speciAl offer! buy tHe book ANd sAve £20
the book costs £60, but independent practitioner today has secured discount of a third off for readers, so you pay only £40. listen to the audio content which accompanies the book at this website: www.otmoorpublishing.com/audio. for more information and to order, email stephen.bonner@ otmoorpublishing.com, quoting reference ‘young/ipt’.
experts’ meetings are not usually hostile affairs. they are normally business-like discussions between two professionals who just happen to disagree about something.
it was one of the first experts’ meetings i attended and i was very wet behind the ears. but i was not so wet that i was not able to recognise when i was being deliberately intimidated by the other expert: a senior and fairly well-known and vociferous member of the dental profession. He suggested that he had discussed my views with senior colleagues – surely a breach of confidentiality – and that frankly i was wrong, and that i’d better change my mind before i was made to look ridiculous. i didn’t change my mind. i wasn’t made to look ridiculous. we won the case. His behaviour was totally unprofessional. i never came across him again.
TV doctor and full-time writer Dr Michael O’Donnell (right) draws from his new book, Medicine’s Strangest Cases, to reveal how doctors have solicited business
LARGE FEES AND HOW TO GET THEM, USA, 1911
Doctors have never found it easy to balance the demands of Hippocrates and Mammon.
Those who practise in Europe try to disguise the conflict with the professional nonchalance recommended by author Anthony Trollope in Doctor Thorne: ‘A physician should take his fee without letting his left hand know what his right hand is doing; it should be taken without a thought, without a look, without a move of the facial muscles; the true physician should hardly be aware that the last friendly grasp of the hand had been made more precious by the touch of gold.’
Things are not the same on the other side of the Atlantic. In medicine, as in other forms of human endeavour, practices indulged covertly in Europe are proclaimed overtly in the US.
In the late 19th and early 20th centuries, a posse of American doctors published textbooks offering guidance to their colleagues on how to exploit their patients.
The least inhibited author, Dr Albert V. Harmon, whose seminal text Large Fees and How to Get Them appeared in 1911, had little time for Trollopian reticence: ‘One of the most potent causes of professional poverty is the mania of the doctor for a pretence of welldoing. He exhibits this in many ways. One of the most pernicious is an affectation of contempt for money.’
Harmon was echoing a senti
ment expressed in 1891 by Dr J. J. Taylor in How to Obtain the Best Financial Results in the Practice of Medicine: ‘Never allow sentiment to interfere with business. The “thank you” is best emphasised by the silvery accent of clinking coins.’
A serious business
Most of the authors laid great stress on presentation. Dr T. F. Reilly, author of Building a Profitable Practice, told his readers: ‘Try to look like a doctor. The doctor in the minds of most city dwellers today is tall and thin and wears a Van Dyke beard, or at least approaches this style …
‘Always seem serious and busy when patients come into your office; have medical books and journals strewn about, showing that you are studying.
‘Never let patients see you reading novels or other light literature; you must ever and always appear a serious worker in a serious business.’
Dr Harmon warned his readers against allowing waiting patients to talk to one another about their ailments or prescriptions. Discussion might encourage them to find fault with the doctor’s work.
A wise physician employed a well trained and faithful receptionist: ‘When she finds the conversation drifting into disagreeable channels, she can adroitly step in and change the subject.’
Harmon also offered detailed advice on how to drum up business. The doctor should scan local
newspapers for reports of sick people and send them unsigned letters enclosing samples of the latest treatments for their ailments.
The letters would awaken the recipients’ interest in possible medical treatment and the doctor could then write a note mentioning his ‘professional curiosity’ in their complaint.
Hooking the patient was but the first step. Harmon devoted a whole section to ‘Ways of getting additional fees from patients who have already paid well for the original treatment’:
‘One man (or woman) needs the eyes looked after and fitted with proper glasses, another should have the teeth fixed up, another requires a special surgical appliance, while still another should have a special prescription compounded.
‘The doctor always has a list of experts to whom he directs patients on a feesharing plan, and these fees are never overmodest.’
He recommended even less scrupulous techniques when aiming at lucrative targets: ‘You know, the rich are always in a precarious condition. It’s a mighty conscientious doctor who will tell a rich man that his trouble is only imaginary.’
And a rich man’s imagination could be a treasure chest:
‘It is a well understood fact among physicians that the average man of 50 or over takes more interest and pride in his sexual
virility than in any phase of his physical system.
‘Where men of ordinary means will haggle over a $250 fee for being successfully treated for some annoying, really dangerous ailment, they will pay $1,000 or more cheerfully on anything that seems like a reasonable assurance of having their sexual power restored to its pristine vigour.’
Dr Harmon favoured an indirect approach. The doctor should recommend ‘a thorough physical examination’:
‘While performing this, pay no attention to the sexual organs at first, but, when nearing the end of the examination say casually: ‘How long have you been in that condition, Mr X?’
‘This is a random shot, but it will strike home 99 times out of 100. You have got your human fly stuck on a gummed trap from which he couldn’t extricate himself if he would, and he doesn’t want to.’
A fly in a gum trap is an image rarely used today; modern doctors talk more ponderously about ‘the doctorpatient relationship’. But then, Harmon was writing 90 years ago and his techniques could never be used now. Could they?
Medicine’s Strangest Cases, recommended price £7.99, ISBN 9781910232941.
Published by Portico, an imprint of Pavilion Books
Many consultants start doing medico-legal work without due consideration to the fees they should charge or their terms and conditions.
Gary Nials (right) shows how to get it right
In the current economic climate, many consultants are looking at alternative ways of increasing the size of their private practice.
With the private medical insurance sector shrinking over the last number of years, it is difficult for many to increase market share, so consultants have been looking outside of that sector.
sands of solicitors working in this sector either independently or through a group as well as via the medico-legal agencies.
Due to this plethora of potential clients, it is absolutely crucial that you get your practice prepared correctly from the very first contact with these commercial organisations.
In our experience, many consultants start doing medico-legal work without due consideration to the fees that they should charge or, in particular, to their terms and conditions.
What tends to happen is that they then find out some time after the work has been done that the case they have been working on is on a ‘no win, no fee’ basis. And that means they often end up waiting years for their money.
Our analysis on the invoices we raised in 2016 shows that the private medical insurance market accounted for only 55% of the total, with the remaining 45% split between other organisations such as embassies, hospitals, solicitors (for medico-legal work) and other commercial organisations.
If you are thinking of expanding into the medico-legal sector, then there are some important things you need to know from a billing perspective.
t he medico-legal sector is extremely fragmented, with thou-
the obvious problem with this is the effect it can have on the cash flow of the practice. the biggest problem, often overlooked, is that once the invoice is raised, it means you end up paying tax on it. this means that, until you collect the money, you are actually paying to do the medico-legal work.
If you have a large medico-legal practice and charge VAt, the situation is so much worse, as you would have had to pay the VAt, currently 20%, to h M Revenue and Customs (hMRC) every quarter – which increases your overall debt and exacerbates your cash flow predicament.
t he worst case we have seen over the years is one practice which had started medico-legal work many years ago and every
How much do you want to charge for your standard report? This should be based upon the length of time taken to review a standard amount of medical records. Include any interview or examination of the client and all dictation and preparation of documents. You should also quote an additional cost per hour to give some flexibility for cases that take longer to review, particularly where there are a large amount of medical records to review or where the case is very complex.
Court cases. Where you are requested to attend court, you should have a fee schedule per day. Due to the nature of these, your fee should be for a minimum charge and not related to the amount of time you have to appear. You should also charge for travelling expenses as well as any other expenses that you incur attending the court.
Supplementary work should also be quoted at an hourly rate. This is to cover any further reviews and additional work on the case. These can then be invoiced at the hourly rate, typically in 15-minute increments.
DNAs, for those cases where the patient does not attend without prior cancellation within a given time-frame or where your court appearance is cancelled within a given time-frame, you need to decide what your charges will be.
You will need to decide what your standard payment terms are going to be for your medico-legal reports. These will need to be balanced according to the sector that you are operating in and should be ones that you are prepared to enforce.
You should have different payment terms for any court appearance and these should also take into account any charges you make when the court appearance is cancelled within your penalty period.
month it was invoicing more than it collected.
this had continued for so long that it led to an outstanding debt figure which had reached over £400k going back nearly ten years before we started working on it. there are many factors to consider before starting working on medico-legal cases and I have focused on the billing and collection aspects, with the major issues highlighted in the box above. t hese should form part of your terms and conditions.
Once the above is resolved and you have formulated your terms and conditions, the next key step is to ensure you have a robust system in place to chase up outstanding invoices.
this should entail making sure that, in the first instance, your fees and terms and conditions are accepted up front before taking on any case.
Once you have raised the invoice, it needs to be followed up with a phone call to ensure that it has been accepted and has been put on the solicitor’s/agency’s system with the correct payment terms.
e ven when all the above is
done, you will still need a system in place to chase payment on a continual basis to ensure payment is made in a timely manner.
Should you have issues collecting payment with a particular solicitor/agency, then you need to think long and hard about taking on other cases from the same company or you could end up paying to do work for them.
Chasing the money on a continual basis is the hardest part of this whole administrative process, as most practices are not geared up for this specific aspect.
It is both time-consuming and requires a specific skill set. It is rare to find a practice which has the time to chase these invoices on a continual basis; even rarer that they have the skills in-house.
the alternative is to use a professional billing agency. e ither hire them way before you start doing medico-legal work or, if you have been doing it for some time, then you need to gain control of this crucial aspect or run the risk of paying the hMRC for the privilege of doing the work.
Gary Nials is the managing director of Medical Billing and Collection
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Philip Housden’s (below) continuing series on private patient units (PPUs) explores tariffs and prices, both for insured and self-pay patients
A P r I l, N ow only a few weeks away, may well be a renewal date for one or more agreements with a major private medical insurance provider.
Most, if not all, PPUs consider that their tariffs with the insurance companies are too low. But what can be done about that? The opportunities for a wholescale tariff review are infrequent, perhaps happening only once every few years.
But when they do happen, it is an opportunity to put on the negotiating table issues not just of
price but also of new service proposals and network inclusions.
Most NHS PPUs are included in only some of the major insurers’ networks, and this is a legacy of existing agreements often pre-dating the PPU and based on national arrangements with the big four hospital provider chains.
But being outside a network doesn’t mean that the PPU cannot target the achievement of a specific specialty or seek procedure recognition such that the activity
in that clinical field, say cardiology, no longer needs to be individually authorised when it is clear that the local private hospital does not deliver that service. watch out, though, for issues that the insurers want to discuss with the PPU. These may be their own view on processes, quality, volume or price.
Insurers are increasingly working to direct activity towards providers that can meet quality specification requirements. For PPUs that perhaps form less than 1% of their NHS trust’s activity and
turnover, it is difficult to disentangle quality and access issues from the NHS service in such a way that they are described in the manner that insurers want to see them.
Insurers are seeking to bear down on all tariffs, claiming long-term low inflation, increased hospital efficiency – for example, from shorter lengths of stay – and pressures they face with customers renewing premiums.
w hat this amounts to is that PPUs can be faced with proposals
to, at best, hold prices and, at worst, reduce tariffs to retain the business – just when the PPU is planning a significant uplift.
PPUs should take a view in the round on all these matters, as there is rarely an offer from insurers to direct any guaranteed volume towards a PPU that could mitigate downward pressure on tariffs.
And with increasing costs pressures within trusts, it is vital that PPUs become aware of the relative value of the range of private procedures undertaken.
That means checking that no service is offered at lower than NHS Tariff, and also taking a view on the relative resource efforts required by the organisation to deliver the financial margin.
So, what can be practically done? NHS PPUs should not chase activity that the local private hospital can do more cheaply, but instead concentrate on under -
standing the work that the private unit cannot perform cheaper.
This is likely to be procedures related to specialist skills and equipment: those based on critical care support and treatment of patients with co-morbidities and other areas of relative higher risk.
All of these are reasons to engage with insurers to ensure that PPU tariffs reflect the ‘lower volume but higher costs’ nature of the cohort of patients that consultants choose to use the PPU for.
Therefore, it is often better to work out a limited list of procedures on which to negotiate specific uplifts, citing specific internal expertise and costs pressures, than it might be to seek a ‘one-size-fits-all’ blanket acrossthe-board percentage increase.
For self-pay patients, much the same applies. The independent hospital providers can set prices
that absorb some risk across their whole network, enabling a fixed price promise and also ongoing aftercare.
They can do this in the knowledge that the occasional very high-cost patient can either be admitted to the NHS with complications, or minor losses can be offset across the general profitability of the patient cohort.
In a PPU, it is different. Private hospitals have quite likely screened out the prospective patients with raised risk of complications and co-morbidities.
But the PPU cannot risk a loss against NHS tariffs, and certainly cannot offer a ‘stop-loss’ fixed price, given that every once in a while the catastrophic ‘£100k patient’ will come along.
For these reasons, PPUs should carefully consider offering selfpay treatment at a robust price point that emphasises the patient safety back-up, which usually
only the NHS can deliver. To the right patient and their family, this is priceless.
For both insured and self-pay tariffs, it makes sense for PPUs to do what they can to understand the local and national market.
PPUs often engage the help of a sector expert with access to up-todate benchmarking information, or perhaps support for the negotiations with insurers.
In any event, there should certainly be some internal analysis and consideration of which are the clinical specialties and procedures where the NHS PPU has a relative position of strength in the market.
Next month, some further thoughts on areas for growth, including amenity beds
Philip Housden is a director of Housden Group, a management consultancy specialising in commercial support in the healthcare sector
MeMbership organisations can be many things to many people. but, fundamentally, the body should serve a purpose and a need for those who choose to join.
t his was the key thought and challenge for the i ndependent Doc tors Federation ( i DF) as it reviewed its strategy and course for the future earlier this year.
t he strategy clearly involves some change for the organisation to survive and thrive, and this can cause both uncertainty and excitement for its members.
t his underlines the need for improving communication with the membership to foster engagement rather than alienate.
new approaches
t he i DF has implemented some organisational changes aimed at streamlining administrative functions and committee work, and, critically, to put in place a structure that encourages and enables new additional services of value to members.
the iDF seeks to increase its relevance in this rapidly evolving healthcare market. this is key to its mission of promoting excellence in the independent sector to its membership, which will only be satisfied if they perceive value from their membership.
the Care Quality Commission’s (CQC) new strategy sets out to be more targeted, responsive and collaborative and is looking in its inspections for a demonstration of ‘effectiveness’. this is a worthy
objective for the iDF to emulate when making the changes that it may embrace.
t he i DF must constantly be aware of the pressures facing members and, through their voice, provide a powerhouse of practical support and guidance –an invaluable service at any point in a doctor’s medical career. the problems may change, but the pressure and the disruption they cause do not.
there is a strong representation of specialties in our membership and much wisdom and personal expertise. to build on this network for others’ benefit is a key objective.
We are particularly fortunate to also have diversity and strength among our corporate members, who are able to readily provide professional support to doctors. We wish to harness such strengths among the members and encourage greater participation.
Doctors who train in the UK gain their experience and credentials within the nhs as they graduate to a consultant post in their specialty, they begin to consider how to best utilise their time and expertise and plan their future. For many, this has meant a gradual migration to practise independently to the public sector.
For many years, this pathway was relatively uncomplicated to undertake and became an established option for both specialists and gps.
We reported on the launch of the IDF’s new strategy last month
t he decision-making and the practical aspects of this are now significantly more complex, with wider implications for career and financial income. With the influx of non-UK trained doctors and the proliferation of digital medicine, there are many different factors at play.
regulation for providers and clinicians is onerous and accountability significantly more transparent. While this focus has been to improve the safety for the patient, the need for a network of support for the doctor has become greater. to support increased accountabilities, the iDF will need to remain relevant and sustainable in the future, as will many other organisations that collectively have
responsibilities and accountability within the healthcare sector. the healthcare market, particularly in the public sector, has been in some degree of turmoil over many years, with no clear resolution in sight. in the independent sector, the pressure upon independent providers has been exacerbated by the approach adopted by the private medical insurers and the recent activities and report delivered by the Competition and Markets authority. the additional regulatory environment monitored by the CQC has changed the way independent clinicians are able to set up and run their practices. balancing clinical care, management of a practice and fulfilling the regulatory requirements of the gMC to ensure the delivery of safe care to patients has become considerably more difficult.
How the idF can help as the current climate continues to exert new and different pressures, the iDF is ideally placed to enlarge its portfolio of services that can address the most pressing concerns that doctors in the independent sector are facing. Key ideas are already in the planning stages and include: an enhanced relationship with the private medical insurers to encourage positive dialogue and understanding; a service as a pathfinder in the complex area of medical indemnity.
there can be strength in numbers, but the main challenge is the engagement of members and to truly present a formidable voice on the many issues that need to be discussed and influenced positively for the benefit of the profession and patients.
We want to hear from doctors on the issues that affect them, what support they feel would be of the most value and at what level they can personally be involved – or not.
What is key is the strengthening of the community of doctors and recognition that engagement looks different for everyone, depending on professional and personal circumstances.
For the i DF to achieve this strengthening of membership and greater engagement, many things need to change, such as: our communication channels
need to be enhanced and recognise current trends and portals;
the look and feel of the website needs updating so that its functionality and usability is improved;
Communication needs to be relevant, timely, focused and more personal to each doctor’s needs. in short, the iDF needs to be relevant – and to appeal to a more diverse membership. and it must particularly encourage doctors to join earlier in their career and provide mechanisms that enable access for meaningful support and debate.
the administrative changes that are now embedded through the revision of our articles of association and a comprehensive handbook adds a new dimension for the iDF.
our many services will continue and, where appropriate, will be
strengthened. the appraisal and revalidation service is widely recognised as a key strength and receives many commendations from the various regulatory bodies.
t he team, led by the r esponsible officer (ro) Mr ian Mackay will continue to not only provide the service but to be vigilant in responding to changes in the national framework and ensure that our membership continues to receive a first-class service.
The London Healthcare conference
a key feature of the iDF has been the e ducational trust that oversees a range of educational activities to appeal to the broad membership base.
on 4 July 2017, a new key activity is planned: the London healthcare Conference.
the wealth of expertise among the membership and our colleagues, not only in London but
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also in the regions, will be harnessed with a clinical conference entitled ‘ p romoting i nnovation and excellence in patient Care’. We are also offering a range of social networking events this year that will aim to offer something for everyone.
new office
the iDF moves to its new offices in a pril. t his is a space within the Medical s ociety of London in Chandos street W1 that will provide improved facilities for meetings and which is closer to the area where many members work.
as a newly appointed chief executive, i, together with the board, look forward to both maintaining our services and also improving the range and value of offerings that will assist the different needs of doctors practising in the independent sector in 2017 and beyond.
See ‘Reflecting on revalidation’, page 42
A new type of conference next month aims to help doctors expand their private practice from being just varicose veins to a whole venous service.
Consultant vascular surgeon Prof Mark Whiteley (right) outlines his plans
I have been thinking about setting up a new veins meeting for many years. What has inspired me to launch our meeting now is the fact that we are ready to offer something new.
vein meetings, on the whole, tend to follow certain patterns. The established academic meetings tend to have a series of lectures on a wide variety of topics, which in most cases are a blend of basic science and clinical studies, either selected by abstract or by invited speakers.
The more moralistic meetings typically have expert speakers teaching about their own subjects. but, in my experience, very few, if any, meetings focus on one topic at a time and start from the basic understanding, through to the latest advances, while showing how this works in practice and then allowing delegates to ask questions.
hence the reason for The College of Phlebology’s 1st International veins Meeting on 15-17 March 2017 at 30 euston Square, London. The mainstream session each day will concentrate on one subject at a time, including thermal ablation, non-thermal ablation, pelvic vein embolisation, perforator vein disease and venous leg ulcers. Subjects will be followed through in order, allowing all delegates to find their own level of understanding of the subject and then add to their own knowledge base:
Learn: each subject or technique will start with presentations on the basics. Why we do it, who is suitable, what devices are used, how this subject or technique developed. This will enable delegates with little or no experience in the area to get to grips with the subject or technique.
Understand: Subjects and techniques will then be analysed further with presentations of the latest studies, devices and the relevant basic science, to deepen understanding and help delegates understand how to improve their own practice.
Watch: There will then be live links to ultrasound suites, operating theatres and radiology rooms where live cases will be performed by recognised experts in the field.
Depending on the subject or technique being explored, the live cases may be both diagnostic and treatment.
Delegates will be able to ask the specialists questions during the procedures, mediated through the session chairman. They will not only see the latest procedures but will be able to clear up any specific points of interest or technique immediately.
Ask: Finally, each subject or technique will be opened up for questions to ensure delegates have a chance to express their views or ask questions.
each of the Learn/Understand/ Watch/ask sessions will last two hours, enabling delegates to explore two subjects each day in great depth and detail.
Of course, not all delegates will be interested in all of the sessions each day because we all have our own specific areas of interest. Therefore, there will be two parallel lecture theatres also going on throughout the conference offer-
ing alternative learning and discussion experiences.
Parallel lecture theatres
Parallel 1 – Veins: Hands-on workshops/lectures/basic science. This will have a diverse array of sessions of interest to specialists from all backgrounds.
These will include phlebology and the basic science related to it, lectures on more obscure areas of phlebology that are not covered in the ‘learn/understand/watch/ ask’ sessions.
There will also be a variety of hands-on workshops where delegates can experience the equipment they might not be used to. They will be shown how to get the best out of each device.
Parallel 2 – Leg Ulcers: run by t he Leg u lcer c harity and supported by the Lindsay club. as we know, leg ulcers are principally venous in nature, typically treated by traditional methods of dressing and compression. Research shows us that almost all can be cured by intervention.
ambulatory endovenous techniques can cure some 50-85% and stenting the obstructive disease can increase this further. a cross the three days, this parallel theatre will delve into the assessment and whole range of treatments that are now becoming available for this chronic and debilitating disease.
The speakers
Most meetings invite members to join the speakers’ faculty because they are well known in the field or because they are regular attendees. Usually this means delegates who go to more than one meeting will often hear the same people giving the same talks.
To remain in line with the ‘Learn/Understand/Watch/ a sk’ methodology, we have specifically invited speakers who are practical experts in their field and who have huge personal experience in the procedures they are talking about.
This way, our faculty speakers will be able to guide the delegates into understanding the new concepts in each subject or technique discussed, and should also be able to give tips from their wide experience, rather than figures that
have been published and can be read outside of this meeting.
who will get the most benefit from attending?
The College of Phlebology has always been a society that offers mutual advice and support to anyone involved in phlebology. Until now and the creation of this meeting, this has only been possible through our online forum.
This 1st International veins Meeting aims to help build the community we have been developing online while allowing members to meet, learn and exchange ideas and experience.
We believe anyone treating patients with varicose veins, pelvic congestion syndrome or other venous disease, or who are looking after patients with leg ulcers, will benefit greatly from this meeting.
Exclusive launches at the meeting aside from all of the sessions outlined above, we are due to launch several new things at the meeting itself.
at the time of writing, this these items are being completed and agreements are being finalised.
Live cases of pelvic vein embolisation will be shown (above), as will live cases of endovenous techniques including radiofrequency ablation, glue and endovenous laser ablation (right). Delegates can ask questions during the procedures
Most conferences consist of lectures and slides, but a major part of the college of Phlebology’s 1st International Veins Meeting is live operating where delegates can ask doctors questions during procedures. the conference basis is ‘learn, understand, watch, ask’. No matter what experience delegates start with, we will go through varicose veins, pelvic congestion syndrome, leg ulceration and so on, starting with the very basics, moving onto the latest scientific research, showing live cases and then allowing questions and discussion. this will help doctors expand their private practice from being just varicose veins to a whole venous service.
Many people still regard varicose veins as a single subject and do not understand pelvic veins, perforating veins and aesthetic veins of face, breasts and arms. to expand a venous practice, the college of Phlebology meeting will cover all of these areas of phlebology.
Simon Bruce (right) looks at the impact of today’s life expectancy on the traditional retirement
A b A by girl born today has a one-in-three chance of living to 100 years old. A baby boy has a one-in-four chance of reaching their 100th birthday.
Data from the Office of National Statistics shows that, by 2066, there will be more than half a million people in the UK aged 100 or over. Today’s 20-year-olds are three times more likely to reach 100 than their grandparents, and twice as likely as their parents.
One major consequence of this change in our national demographic is the impact on our working lifestyle.
in 1960, the average life expectancy in the UK was around 70, with many men retiring at 65. Today we are expected to live to about 80, but the average retirement age is 64. Despite living longer, we are retiring earlier.
This, we are told, is unlikely to be the case in the future, where people will be working into their 70s and 80s.
Already people are choosing to take life at their own pace – perhaps marrying and having children later, enjoying mid-career sabbaticals and going back to education without the need for a student loan. How often do we hear that 50 is the new 40, 70 the new 60?
if you are lucky enough to live to 100, you would have an extra 100,000 productive hours than those who live to be 70. Work is likely to remain a focus, either through choice or necessity. but would you wish to continue with only one vocation for the duration?
A new book called The 100 Year Life by gratton and Scott, two professors from the london business School, suggests the idea of a three-stage life – where we go to school for 20 years, work for 40 and retire for 20 – will cease.
i nstead, people will enjoy a multi-stage life where they dip in and out of education and work, punctuating both with increased
leisure time and supplementary ‘hobby’ jobs.
Careers will have many different ‘acts’ with more choices for the worker – should i work this year or take time to learn a new skill?
Should i change profession?
This exercise of freedom might be tricky to put into practice for the average NHS worker bee, but medical careers could take new twists in the future.
Would consultants continue to spend 30 years in clinical practice before being able to enjoy a range of honorary and remunerated committee posts? Would those interesting research/community/ voluntary jobs be accessed sooner?
The authors propose that if our working lives last seven decades, then we cannot rely on a single period of education in our youth as adequate preparation for what lies ahead. The technological developments which will occur in 70 years would make the training we received from 50 years ago redundant in any case. instead, the notion of education will be ever present in future lifestyles, as individuals retrain for each new working adventure.
This idea of lifelong learning gained credence recently when the head teachers of the UK’s 275 top independent schools met to discuss how to change the way they teach children to accommodate this new thinking.
rohit Talwar, chief executive of Fast Futures – which advises business and schools on how to plan for the future – told the teachers’ conference: ‘What are you preparing your children for? They might well have 40 jobs in that period between now and when they stop working – and as many as ten different careers. We’re going to be living longer and we’re not going to be working in the same way.’
Clearly, an important considera-
tion of living to 100 years old will be financial. How would you provide for a retirement which could last 40 years?
This is not just something your children’s children need to think about. Even if you are due to retire in the next ten years, you are statistically likely to enjoy a threedecade retirement, so these issues should be a valid consideration for you now.
being at liberty to choose how and when to work in your later years is a luxury not afforded to many and certainly not without careful consideration of your options.
Former pensions minister Steve Webb said: ‘The dramatic speed at which life expectancy is changing means that we need to radically rethink our perceptions about our later lives … We simply can’t look to our grandparents’ experience of retirement as a model for our own. We will live longer and we will have to save more.’
life planning
getting a clear vision of what you may want to do with your life after formal work has finished means focusing not just on financial planning but on life planning. Only by deciding what you would like to achieve can you take the necessary steps to make those things happen.
A good financial planner will listen carefully to your aspirations and put into place a realistic plan to help you and your family reach your goals.
Often people tell us that they would like to become financially independent in retirement, to have choices and opportunities readily available. Seeing this become the reality for many of our clients is certainly a bonus of the job.
With constant change in the pensions landscape and talk of the NHS Pension Scheme hitting the red for the first time, it is more important than ever to spend some time arranging your affairs in order to achieve a long, happy, stressfree retirement. Otherwise, our increased longevity could become a curse rather than a blessing.
Simon Bruce is managing director of Cavendish Medical, specialist financial planners helping senior consultants in private practice and the NHS
Getting a clear vision of what you may want to do with your life after formal work has finished means focusing not just on financial planning but on life planning
The content of this article is for information only and must not be considered as financial advice. Cavendish Medical always recommends that you seek independent financial advice before making any financial decisions.
Levels, bases of and reliefs from taxation may be subject to change and their value depends on the individual circumstances of the investor. The value of investments and the income from them can fluctuate and investors may get back less than the amount invested.
Today’s 20-year-olds are three times more likely to reach 100 than their grandparents, and twice as likely as their parents
Dr Nicola Lennard (right) gives advice in two scenarios where patients’ confidentiality is at stake
QA 38-year-old woman has been attending my private practice for treatment for alcohol dependency. She is on medication to reduce her cravings but has relapsed on several occasions and is prone to risk-seeking behaviour.
The patient has been in a steady relationship for six months and her partner has now asked her to move in.
However, he has young children who regularly stay at weekends and holidays and the patient has confided that she will be left in charge while her partner is at work.
I raised concerns about the level of child supervision, but she refuses to accept there’s a problem and will not provide consent for me to discuss the matter with her partner.
I’m worried that she isn’t ready for this responsibility and the children might be at risk, but I don’t want to alienate my patient when she is getting her life on track again.
Should I report my concerns?
AIf you suspect that a child or young person is at risk of abuse or neglect, you have an ethical duty to act.
Remember that you’re unlikely to be criticised for acting in good faith in these circumstances: doing nothing is a far greater risk. However, if you are unsure, you can seek advice from a child pro
tection specialist, such as the duty manager in Children’s Services at your local authority.
If you decide to make a referral to social services, you should ordinarily discuss this with the patient first and seek her consent, unless this would be impracticable, put others at risk of harm or prejudice the purpose of disclosure.
You will need to tell her what information you are going to disclose, why and explain what will happen next.
While this will be a difficult conversation, you could use it as an opportunity to offer her additional reassurance, encouragement and support.
You could also encourage her to talk to her partner, as his cooperation will be necessary if the local authority implements a child protection plan.
If the patient refuses consent, you should disclose information promptly and let the patient know that you have done so, if it would not prejudice the purpose of disclosure.
Referrals to children’s services
are usually done by telephone and followed up in writing within 48 hours.
Disclose only relevant information about the patient.
You should also document in the patient’s record 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.
Finally, it’s a good idea to reflect on your understanding of your own role and responsibilities with regards to child protection.
The GMC expects you to ‘have a working knowledge’ of local procedures for protecting children and young people in your area.
You should know who your named or designated professional or lead clinician is, or you should have identified an experienced colleague to go to for advice and know how to contact them.1
The Government has also produced detailed guidance which sets out how different organisations should co operate to keep children safe.2
QI am an orthopaedic specialist and have written a medical report about a patient with a knee injury for their employer. As is my usual practice, I emailed the report to the patient in the first instance.
However, this morning I was horrified to receive an email from a patient with the same first name, saying the report had been sent to him in error and he has deleted it without opening the attachment.
I must have selected the wrong name from the auto-complete list of suggested recipients which appeared when I started typing. What should I do now?
AThe first step is to inform the patient whose confidentiality has been breached and explain what has happened and
why. Apologise for your mistake and reassure him that the recipient has deleted the email without reading the report.
You should also tell the patient what you are going to do to ensure this cannot happen again. An immediate step would be to disable the autocomplete option in your email system.
However, in the circumstances, you should also consider more fundamental changes to your approach to data protection, in line with your ethical and legal responsibilities:
The GMC expects you to ensure ‘that any personal information about patients that you hold or control is effectively protected at all times against improper disclosure’.3
The Data Protection Act 1998 requires you to take appropriate technical and organisational measures to ensure personal data is protected from unauthorised or
unlawful processing, accidental loss, destruction or damage.
The MDU recommends that all practices have an information security policy in place to protect patient data and a designated person to oversee data protection.
Such a policy should cover email, and the IT security tips from the Information Commissioner’s Office (ICO) are a useful starting point,4 but you could also seek professional advice from an IT specialist.
Finally, the ICO says that ‘serious breaches of security which result in loss, release or corruption of personal data’, should be reported.
There is no legal definition of a ‘serious breach’, but the ICO’s guidance 5 says you should consider the potential detriment to data subjects, the volume and sensitivity of the data concerned.
Under the Data Protection Act,
‘sensitive data’ includes information about a subject’s physical health.6
Breaches should be reported using the ICO’s data protection breach notification form, which can be downloaded from its website.
The ICO takes into account the nature and seriousness of the breach and the adequacy of any remedial action taken when deciding whether to take further action – such as enforcement action or a fine. So it is important to take active steps to address any failings.
1. Para 4, Protecting children and young people: doctors’ responsibilities, GMC, 2012. www.gmc-uk.org/guidance/ethical _guidance/13257.asp.
2. Working together to safeguard children: A guide to inter-agency working to safeguard and promote the welfare of children, HM Government, 2015. www.
gov.uk/government/uploads/system/ uploads/attachment_data/file/419595/ Working_Together_to_Safeguard_ Children.pdf.
Scotland: National Guidance for Child Protection in Scotland, The Scottish Government, 2014. www.gov.scot/ Resource/0045/00450733.pdf.
3. Para 12, Confidentiality, GMC, 2009. www.gmc-uk.org/guidance/ethical_guidance/confidentiality.asp.
4. IT Security Top Tips, ICO website, accessed 27 October 2016. https://ico. org.uk/for-organisations/guide-to-dataprotection/it-security-top-tips/
5. Notification of data security breaches to the Information Commissioner’s Office, ICO, accessed 27 October 2016. https:// ico.org.uk/media/for-organisations/documents/1536/breach_reporting.pdf.
6. Section 2, Data Protection Act 1998, Crown copyright, 1998. www.legislation. gov.uk/ukpga/1998/29/pdfs/ukpga_ 19980029_en.pdf.
Dr Lennard is a medico-legal adviser at the MDU
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Your revalidation is changing. Mr Ian Mackay analyses the implications for independent practitioners
Taking RevalidaTion Forward, Sir Keith Pearson’s review of medical revalidation, was published last month.
Sir Keith, chairman of the GMC’s Revalidation Advisory Board since 2009, interviewed a range of doctors working in the NHS and the independent sector.
He is at pains to point out that he interviewed both supporters of revalidation, but also sought out doctors who were less than enthusiastic about its merits.
The Independent Doctors Federation (IDF) welcomes many of Sir Keith’s recommendations, including the need for: Updating the GMC’s guidance on the information doctors need to collect for revalidation to make
clear what is sufficient and what is mandatory – and what is not;
Responsible Officers (ROs) to avoid placing revalidation requirements on doctors that go beyond what is specified as necessary by the GMC;
Ensuring fair decision-making;
Reducing duplication in the regulatory system;
Improving information sharing across designated bodies.
The GMC’s response to Sir Keith’s Review identifies five priority action areas:
1
Making revalidation more accessible to patients and the public
There is a perception that the term ‘revalidation’ means very little to
the public and perhaps this applies equally to many doctors. Sir Keith has suggested replacing the term ‘revalidation’ with ‘relicensing’.
Meaningful feedback from patients is essential and is indeed mandatory for revalidation for all doctors other than those who have no contact with patients – or clients.
There are some who think that patient feedback is seldom anything less than extremely complimentary and, for many, this may well be true. But when doctors compare their feedback with that of their peers, some may become aware of the need to improve.
Most doctors working in the independent sector pride themselves on the fact that they offer
an excellent service and are keen to demonstrate this.
For independent doctors who work outside managed organisations, feedback from patients and peers is essential, as it may be one of the few items of supporting information that is not provided directly by the appraisee.
Sir Keith makes it clear that he wants to make it easier for patients to give feedback on their doctor.
Currently, a doctor may obtain and reflect on patient views only once in each revalidation cycle. He would like to make it easier for patients to feedback on any interaction with a doctor.
‘Real-time feedback should over time become commonplace,’ he says.
burdens and bureaucracy for doctors
There is considerable confusion regarding the supporting information required for appraisal not only between the NHS and private sector, but also from one designated body to another and even between one appraiser and another within a given designated body.
There is variation between the requirements of the GMC, the royal colleges, the NHS and independent employers.
We welcome the fact that the GMC is undertaking a review of its supporting information guidance, looking at how requirements can be made clearer and more accessible.
The review will include discussion with key revalidation partners and revised guidance is expected to be available by the end of 2017.
Sir Keith is concerned that there can be confusion between
employed nor are they granted practising privileges. This presents a major challenge as far as clinical governance is concerned, but, despite this, I agree with Sir Keith that having a prescribed connection which can enforce a robust appraisal and collect information regarding concerns and complaints is preferable to having no connection.
revalidation criteria and local jobrelated requirements, particularly around mandatory training, and considers it unacceptable for employers to add management objectives to the evidence required for revalidation.
The IDF welcomes the fact that the GMC plans to continue to ‘work with the CQC and NHSE in England to reduce workload and duplication for GPs’. However, this applies not only to GPs but to many independent doctors working in privately-owned clinics and consulting rooms that require registration with the CQC.
There is a need to avoid duplication of the same material for both appraisal and for the CQC, and these doctors will be pleased to learn that the GMC, CQC and NHS England have recently published a joint statement of intent around reducing regulatory burdens, which we hope will apply to both the independent sector and the NHS.
3
increasing oversight of, and support for, doctors in short-term locum positions Locum doctors provide cover for the NHS and the independent sector and fulfill a vital role. However, there is concern that oversight of, and support for, these doctors needs to be strengthened.
The GMC is aware that relevant information is not always transferred when these doctors move between locations, which can make it difficult for locum doctors to engage in meaningful appraisal in addition to the potential risk to patient safety.
The GMC says it ‘will work with Responsible Officers (ROs) in provider organisations to make sure that short-term locums are provided with the information they need to support their appraisal
following every placement and that any concerns about performance are raised directly with the doctor’s own RO’.
4
Extending the Ro model to all doctors who need a UK licence to practise
The review states: ‘Doctors without a connection are most likely to be working as independent practitioners, in a part-time capacity or in some form of advisory or managerial role… My concern is that doctors without a connection are sometimes falling outside the most exacting standards of revalidation.’
Indeed, in some instances, these may be the very doctors where robust appraisal and revalidation may be most necessary and yet where there is no obvious mechanism for identifying and dealing with low level concerns.
Sir Keith believes the ‘GMC and UK health departments should explore ways to bring doctors without a connection into the mainstream of revalidation’ and every licensed doctor should have an RO.
In his closing thoughts, Sir Keith states: ‘I have encouraged the GMC and national governments to take another look at the RO Regulations with a view to strengthening oversight of locums and doctors who work outside managed environments.
‘Legislation is not the only possible avenue for increasing assurance in relation to these doctors, but I believe the overall revalidation system would be considerably strengthened if all doctors who practise in the UK were to be given a prescribed connection to a designated body.’
Doctors working outside managed organisations are not
There seems little doubt that one of the ways revalidation has succeeded is that it has significantly increased appraisal rates, although the quality and consistency of appraisal varies.
We note that the GMC’s response to Sir Keith’s Review states that it is committed to monitoring the impact of revalidation requirements on doctors’ professional development and the safety and quality of the care they provide.
It has commissioned independent academic research – the UK Medical Revalidation Evaluation coLLAboration (UMbRELLA) whose final report, due in early 2018, is eagerly awaited.
The GMC says it plans to ‘work with ROs to better understand the impact of appraisal and revalidation at local level. In addition, we look forward to working with partners to identify a range of measures that will track the developing impact and value of revalidation to patient care and safety over time’.
An additional concern for doctors working in the independent sector relates to weaknesses in information-sharing in respect of doctors who move between designated bodies.
The IDF welcomes the GMC’s plans to ‘investigate the barriers to sharing of information and work with others to seek improvements in local IT systems that support revalidation’.
For doctors who work in both the independent sector and the NHS, there are particular problems regarding information sharing. Appraisal should be ‘whole practice appraisal’, but NHS appraisers and ROs are not always enthusiastic about including a doctor’s scope of work in the inde-
pendent sector, nor do all independent healthcare providers supply sufficient information for the doctor to include in their supporting information for their NHS appraisal.
Sir Keith, however, reports: ‘I heard that one designated body in the independent sector collates a data pack of all complaints, incidents, outcomes, prescribing information, audit results and other governance information for their doctors each year and sends it to them in advance of their appraisals.’
He notes that ROs of locum agencies and membership organisations, who do not directly employ connected doctors, are not always able to obtain information about concerns.
These ROs are often reliant on the employer/contractor to notify them when there has been a concern, and to undertake the investigation. This represents a weakness in the system.
I believe there is much to applaud in this review. I know, as indeed Sir Keith has confirmed, there are still doctors who think the whole thing is a ‘complete waste of time’.
At a recent meeting I attended, a well-respected colleague reminded me that when it first became apparent that some form of revalidation was inevitable and that the public would not only expect it but demand nothing less, an annual appraisal was considered to be a far more attractive proposition than repeated examinations.
An increasing number of doctors now accept that appraisal is helpful in terms of their own professional development and, in my experience, there is evidence that increasing numbers of doctors are keeping themselves up to date and safe to practise.
Mr i an Mackay (right) is the idF’s Res ponsible o fficer and chairman of the Revalidation Forum of the a ssociation of i nd ependent Healthcare organisations
For the independent practitioner with a growing family who needs a good-value car with occasional off-road or towing capabilities, this Octavia could be all you need, says Dr Tony Rimmer (right)
it’s time to forget that brand snobbery and take a good look at Skoda
As An independent practitioner, you will be funding your business premises and equipment either directly or indirectly. These expenses have significant impact on profit margins and anything that can minimise them will be welcome.
Getting the right balance between quality, effectiveness and cost can be really difficult and we don’t always get it right. Regular maintenance and updating also pressures the bottom line, so we like to look for great versatility and value from our investments and purchases.
The same goes for our choice of personal transport. I am sure that we would all like to cruise around in a BMW, Mercedes or Audi, but if we cannot justify their expense, then do we suffer much by buying something significantly cheaper?
On the basis of my most recent test, I would suggest that we do not. I have been driving the latest version of the skoda Octavia scout, a Golfsized estate with fourwheel drive and offroad pretentions.
The Czechoslovakian car maker has a long history stretching back to the turn of the 20th century.
The first cars to be imported into the UK in the 1960s were basic and rearengined.
Unfortunately, at this time during the s oviet occupation of Czechoslovakia, they also gained a reputation for poor build quality and unreliability. In 1989, the company was taken over by the Volkswagen group and has not looked back since.
Unfortunately, the negative image persisted and it is only now that skoda is finally shaking it off.
The Octavia sits on VW’s common MQB platform as used on the current Golf and Audi A3 and is available as a fivedoor hatchback or estate car.
The scout is a 4x4 version of the estate with raised suspension and a body kit to give a rugged offroad look. It is only available with Volkswagen’s 2.0 litre turbodiesel engine in two states of tune, producing 148bhp or 181bhp.
Economy is, as expected, excellent and skoda claims a combined fuel consumption figure of 58.9mpg for the 148bhp manual version that I had on test.
The latest Octavia looks smart and modern and I think that the estate body only enhances the appearance. The additional scout
body styling is not too excessive and does give it a more purposeful and rugged look.
step inside and the interior will be instantly familiar to any Golf Mark 7 driver. However, the rear passengers will thank you for extra head and legroom and the boot is huge. You get a lot of car for your money.
What really impressed me was the level of equipment supplied as standard and even the options are really good value.
s ophisticated features like Bi xenon headlights, adaptive cruise control and a navigation system with wifi are normally only seen on topflight executive cars, but are all available on this humble skoda.
It proves the point that the gap between premium cars and normal everyday cars has never been slimmer.
Out on the road, the Octavia drives like its Volkswagen Group cousins. That means decent handling, direct steering and ample performance. Of particular note is the excellent ride quality probably helped by the higherprofile tyres on 17inch wheels.
Out on the road, the Octavia drives like its Volkswagen Group cousins. That means decent handling, direct steering and ample performance
Body: Five-seat estate
Engine: 2.0 litre four-cylinder turbo diesel
Power: 148bhp
Torque: 340Nm
Top speed: 129mph acceleration: 0-62mph in 9.1 secs claimed economy: (combined cycle): 58.9mpg
Real-world economy: 45-50mpg
On-the-road price: £25,700
The scout is a really comfortable motorway cruiser. The manual box is pretty slick, but I would go for the sixspeed DsG dualclutch automatic option that suits the more relaxed nature of this skoda and is standard on the 181bhp version.
Although you will not want to tackle really rough terrain that you might in a Land Rover, the scout is surprisingly able on loose and slippery surfaces.
The intelligent 4x4 system is frontwheeldrive dominant and only engages the rear wheels when needed, so it does not waste energy – and therefore fuel –unnecessarily. The s cout would make a great tow car.
For the doctor with a growing family who needs a goodvalue car with occasional offroad or towing capabilities, I would suggest this Octavia could be all you need.
The fact that it comes with some impressive standard features and can be jazzed up with some really advanced optional extras is just icing on the cake. It is time to forget that brand snobbery and take a good look at skoda.
Dr Tony Rimmer is a former NHS GP practising in Guildford, Surrey
When starting out in private practice, it is easy to forget that you are running a business and you need to understand requirements at the outset if you are to avoid the long arm of the tax inspector. Ian Tongue (right) outlines the importance of good record-keeping and gives some useful tips
Keeping adequate clinical records is a given, but business records must also meet certain requirements and HM Revenue and Customs (HMRC) has the powers to fine businesses that do not comply.
there is also an important link between the two, as certain procedures may be subject to Vat and therefore it is vital that the clinical notes support the Vat status. More on that later.
Why so much emphasis? t he two words that HMRC will highlight are ‘complete’ and ‘accurate’ and in ensuring records meet this
basic criteria, you can rely on them to prepare a tax return and pay the appropriate amount of tax.
Your accountant should also encourage you to keep appropriate business records to ensure their job is not compromised and this should also help ensure your fees are kept reasonable.
What are the basics?
the first advice i always give consultants when discussing recordkeeping is to keep everything separate from your personal finances from the off, no matter the size of private practice.
this ensures that should HMRC look into your affairs years down the line, it won’t be asking you to prove that re-imbursement of money from a family or friend was not income.
Records can be sophisticated software packages with some acting as a clinical database and bringing together the clinical and accounting requirements. t hese can be particularly good and the initial investment usually pays for itself in a short time.
For more modest practices or perhaps those who do not need to maintain a practice management
software package, a simple spreadsheet will suffice, for now at least.
in relation to income recording, the following are a minimum:
date of procedure;
patient details;
description of work carried out;
amount;
date paid;
date reminder letter(s) sent, if payment not received a ny invoices issued should be retained as well as remittance advices. these are important to be able to match up income received into the bank, particularly if an
A couple of years ago, HMRC introduced new powers to fine businesses up to £3,000 for not keeping adequate accounting records
insurer is paying more than one patient in a batch.
the date of receipt and chasing the debt is important, because should a debt be written off, HMRC would have expected you to make reasonable efforts to recover the debt.
this is an important part of running your private practice and again comes back to the point of running a business: why do work for free?
in relation to expenses recording, the following are a minimum:
date of expenses;
description;
amount.
it is important that you retain all hard-copy invoices in case they are required. it is also very important that the invoices are made out to the business, and this becomes a vital part of recovering Vat if your business becomes Vat registered at any time.
Business records visit a couple of years ago, HMRC introduced new powers to fine businesses up to £3,000 for not keeping adequate accounting records. it does not define what is adequate, but any accountant will have had this drummed into them, so they can explain things
in more detail and whether you are at risk.
Most likely down to resource constraints, it is not particularly common to have HMRC actually visit a consultant who is carrying out private practice. the volume of its checks has been wound down.
But a client of mine that springs to mind literally received a knock on the door of their clinic and they requested to see the records and go through the systems. a shock to the proprietor and disruptive to the business.
Historically, the more common scenario is for your accountant to receive a letter as your agent and a quick call by them to HMRC deals with matters.
Making tax digital is HMRC’s latest project and it seems completely committed to this project, with the first effects being felt from april 2018, although we are still in the consultation phase at the time of writing.
d igital tax is a fundamental shake-up of the tax system and the details are still subject to negotiation and consultation. However, the basic principle is that you will report your earnings
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OUTSIDe THe medical profession, VAT is an accepted part of running a business of a reasonable size, but in the medical world it is still relatively uncommon to be VAT-registered.
VAT is not actually supposed to be an extra tax on the business and your role in being VATregistered is to act as the taxman and collect VAT on their behalf. However, if you can’t put the price up by 20%, it effectively does become your cost net of the tax you would have paid on those earnings.
The reason for this is that medical services generally have an exemption from VAT and therefore the vast majority of private medicine is not subject to VAT. There are three key areas where this is not the case and you could be caught out. They are:
Medico-legal work;
Royalties or licences;
Purely cosmetic or aesthetic work.
The VAT threshold is currently £83,000 per year and this is on rolling 12-month basis and represents the aggregate of all services that are subject to VAT – or ‘standard rated’ as it is known.
Medico-legal work is standard-rated because the principal reason for the work to be carried out is for a third party to make a decision rather than supplying medical care.
Royalties and licences could arise from various areas, but the most common one is the development of a machine, drug or other
intellectual property which generates income over time.
In relation to purely cosmetic work, this has been a hot topic for years and it seems that the medical profession is not much closer in finding out what is ‘purely cosmetic’.
HMRC could have reached a sensible basis for this years ago by liaising with the relevant bodies representing doctors, but the offers to work together seems to have fallen on largely deaf ears. I suspect it will not be until someone takes their case to at least an upper tax tribunal before any legal traction is obtained.
There is no doubt that being VAT-registered increases the burden of record-keeping, as HMRC wants to make sure that you are collecting its tax for them and not claiming VAT back on expenses you shouldn’t be. However, for those that are not VATregistered and have an income over the VAT threshold, it is vital to keep adequate records to support your status that you don’t need to be VAT-registered.
This is particularly important if you are carrying out a range of exempt and standardrated services. If HMRC proves that you should have been VAT-registered in the past, it can go back to that date to recover the VAT and charge you interest and penalties.
If HMRC is looking to challenge your position, particularly in relation to cosmetic work, they will always say that you need to review things on a case by case basis rather than being able to rely on the headline points of the VAT rules. This ultimately means that you have to look at things on a patient by patient basis.
The key factor is that where a medical condition is being treated, you clearly record this in the notes. It may be obvious to you, but think of a third party looking at these records: would they think that a medical condition is being treated – as opposed to a cosmetic one?
HMRC is not qualified to question a medical diagnosis, so it is important that the notes highlight all factors leading to the medical diagnosis. This is a complicated area and your accountant should be able to discuss this further with you.
There has been a well reported recent VAT case within Independent Practitioner Today (page 1, September 2016) with further cases running through the systems and therefore, at some point, things should be a little clearer. One thing is clear, though. If you are relying on the medical exemption for VAT, you must document the medical condition within the notes to have a chance of being successful, as HMRC still takes a largely ignorant view of focusing on a procedure rather than the medical reason for having it.
Buy-to-let landlords are also proposed to be affected from april 2018. For those trading as a company or larger partnership, the rules are to come in from a pril 2020, so there is more breathing space.
on a more regular basis and through a digital tax-compliant software package. the reporting will be quarterly and an annual ‘adjustment’ can be made to allow for everything to be reconciled.
digital tax will change the relationship with your accountant, but could increase your risk errors if adequate accounting records are not maintained.
no doubt, your accountant will be working on solutions for their clients. So 2017 will be a year of change for those who are sole traders and small partnerships, although the definition of small is not known at the time of writing.
i t is also expected that some other businesses will receive a reprieve until a pril 2019, but again the detail is not known at the time of writing.
Keeping adequate records is a fundamental part of running your private practice. With the risks over the Vat status of work, it is important that you are able to link certain clinical data to the accountancy side of things.
Change is on the horizon and the next few years will see fundamental changes to the tax system and you must ensure that your obligations are met. Next month: Tax issues around pensions revisited
Ian Tongue is a partner with Sandison Easson accountants
It’s not a big rise, but at least gynaecologists have enjoyed inflation-busting profits, according to our latest figures. Ray Stanbridge looks into the reasons
One OF the striking features of our monthly unique benchmarking survey is the very wide range of private practice incomes between gynaecologists in private practice.
t he range seems to be wider than for most other specialties (see table on income ranges).
But our headline figures suggest that gross incomes for gynaecologists in private practice have, on average, risen by 3% from £106,000 to £109,000 in 2015.
Costs have gone up by a lower amount, by about 2%, from
£54,000 to £55,000. a s a result, taxable incomes have increased, on average, by 4% from £52,000 to £54,000. now, if the average figures seem to be on the low side compared with what you are earning, then do bear in mind that we impose a number of restrictions on the survey. it is restricted to those consultants who are not in full-time private practice. it also includes those who:
Hold either an old-style or new style nHS contract;
Work as a sole-trader, a member
AVeRAGe InCOMe AnD eXPenDITURe OF A COnSULTAnT GYnAeCOLOGIST WITH An eSTABLISHeD PRIVATe PRACTICe
of a formal or informal group, through a partnership and/or a limited liability partnership;
Have at least five years’ experience in the private sector;
are seriously interested in private practice as a business;
e arn at least £5,000 a year in private practice.
Since Independent Practitioner Today launched its profits Focus series in 2008, there have been fundamental changes in the market – more groups, more gynaecologists incorporating, more self-pay (on average) and more Choose and Book work.
the market structure is very different to what it was ten years ago. added to these factors is the relentless pressure from insurers to drive fees down. Readers should consider all these points. it seems that the small growth in income for this survey is the result of many consultants doing more self-pay work.
national figures, published by market analysts LaingBuisson, suggest that insurers’ share of the total private medical market is declining. Our evidence from these surveys, on a micro-level, supports this view.
there is still a relatively strong
demand in certain parts of the country for self-pay obstetric work and this is stimulating consultants’ incomes.
Some costs have increased through the year. Staff expenses have risen as we have seen with other specialties in previous issues of Independent Practitioner Today. t he average figure reflects the costs of consultants using family members for secretarial services and/or professional secretaries. t here is an obvious correlation between the growth of these costs and the rise in personal allowances for income tax.
there has been some increase in costs of consulting room hire –though the real rise will not have affected incomes until after april 2015, when the full force of the Competition and Markets authority (CM a ) rulings came into effect.
‘Other’ costs have shown a modest increase. these are primarily marketing and promotional related. n ew young gynaecologists in practice are especially well aware of the power of marketing.
Surprisingly, indemnity costs seem to have stabilised. t hese have been showing an inexorable
Year ending 5 April. Figures rounded to nearest £1,000 (percentage is also rounded up)
Source: Stanbridge Associates Ltd.
rise, with very heavy initial costs for those engaged in obstetrics work.
But a small number of consultants have opted for cheaper insurance on the Lloyds market or elsewhere.
Obviously, in some cases, there is an immediate short-term saving – but the long-term benefit and
It seems to be more profitable to do Choose and Book work than insured work
costs of such a move has yet to be determined.
t here have been small reductions in the costs of medical supplies/assistants and office costs. t here does not seem to be any particular overall reason for this. What then of the future? Our results suggest that there has been some stabilisation in terms of income – and that consultants have been able to offset insurance company fee pressures with additional self-pay work or, in some cases, Choose and Book work.
it is remarkable that in certain situations it seems to be more profitable to undertake nHS Choose and Book work than insured work. But we are sure it won’t be long before nHS cost managers realise this discrepancy and make appropriate adjustments.
an initial review of 2016 results further suggests that incomes have stabilised and, if anything, have tended to show a modest rise. We look forward to reviewing this prediction in 12 months’ time.
Next month: Radiologists
Ray Stanbridge is a partner with accountancy, finance and tax advisory medical specialists Stanbridge Accountants
use
benchmarks to compare your financial performance with others
Years ending 5 April
Source: Stanbridge Associates Ltd
Make sure you don’t miss our next issue, published on 23 March. You may not receive every issue if you have not yet subscribed to the journal. Don’t risk missing out on vital topics we tackle next time, including:
So do you know the ramifications for your practice of the March 2015 landmark case of Montgomery v Lanarkshire Health Board? It redefined the legal relationship between doctors and patients. But some doctors fear it places too high an obligation on them in warning patients of the risks of treatment. Lawyer Paul Sankey reviews its impact. Don’t miss his report!
Create an income surge in your private practice!
A profitable disease of the rich
Top tips for busy doctors: how to make the most of your free time
Our ‘keep it legal’ lawyers continue their series for doctor entrepreneurs with advice about protecting your hard-earned intellectual property in independent practice.
‘Please don’t tell my GP’. Dr nicola Lennard answers more of your questions in our Business Dilemmas series
Getting the interface between your private patient unit and the rest of the nHS trust exactly right can drive growth in financial surpluses
Launching a new brand from an established practice. A chief operating officer shares experiences
eDITORIAL InqUIRIeS
‘Doctor on the road’ columnist Dr Tony Rimmer finds the latest Renault Scenic a real improvement over the previous model and says it is worth a look for the doctor who needs a good-looking family car that is cheap to run, feels modern and scores highly for practicality
Is your portfolio benefiting from the decline in sterling? Cavendish Medical’s Simon Bruce explains why your investments should have a global outlook
Top tips on filing your year-end accounts
Does your practice need a spring-clean?
Mr Stephen Cannon, chairman of the Cosmetic Surgery Interspecialty Committee, tells more about the new Royal College of Surgeons’ cosmetic surgery certification scheme
Code Buster! Check you’re using the right codes for private medical insurance in next month’s update from Medical Billing and Collection
Starting a Private Practice: Tax issues around pensions revisited
The effective and efficient clinical negligence expert witness: court appearances
Profits Focus: Radiologists
PLUS all the latest news and views
ADVeRTISeRS: The deadline for booking advertising for our March issue falls on 24 February
Robin Stride, editorial director
Email: robin@ip-today.co.uk
Tel: 07909 997340
ADVeRTISInG InqUIRIeS
Margaret Floate, advertising manager
Published by The Independent Practitioner Ltd. Independent Practitioner
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