Smooth the path to your door
Make sure you gain and retain your patients by following these three simple steps P16
Zoom your practice into the 21st century
An app is revolutionising the way patients access GP services P20
By Robin Stride
The private healthcare sector’s new age of fee transparency, now well underway, is being welcomed by consultants’ representatives.
Specialists have started to be contacted by the Private Healthcare Information Network (PHIN) to enable them to meet the new requirement to publish the typical fees they charge patients when offering private treatment or consultations.
Hospitals are meanwhile being encouraged to support patient choice and sign up to price transparency.
The ‘fees for all’ requirement has finally arrived after years of planning and argument following an investigation by the Competition and Markets Authority (CMA), which found a lack of transparency in the charges patients can expect to pay for private care.
A 2015 landmark judgment from the Competition Appeal Tribunal paved the way for all consultants’ fees to be compulsorily published.
The Independent Doctors Federation (IDF) told Independent Practitioner Today : ‘The requirement to publish fees has been mandated and we would encourage our
members to enter the required data as soon as possible.
‘We endorse the need for transparency and recognise that this is just one step in ensuring that patients are fully informed to be able to make decisions in selecting a care provider.’
PHIN is the CMA mandated ‘information organisation’ responsible for publishing independent information for patients on safety, quality and costs in private healthcare. Last month it began the process of contacting all consultants treating privatelyfunded patients in the UK. They were asked to provide the typical fees they charge selfpay patients.
Dr Andrew VallanceOwen, PHIN chairman, said: ‘For as long as I’ve been involved in private healthcare, the fees patients can expect to pay have not always been clear.
‘Patients should be at the centre of their care, yet, along the way, a convoluted and unclear system of fees, particularly for self pay patients, has developed. We owe it to patients to rectify this by being transparent about charges.
‘PHIN has made this as simple as possible by allowing consultants to insert a range to cover the typical fees patients can expect to pay. This
When safety is critical
Our series on eliminating human error looks at how highly reliable organisations prioritise safety P28
will not be an exact science, but represents an important step in creating a more patient focused industry.’
PHIN said impact from the lack of clear information about price was particularly felt by those selffunding their care. They were also the most vulnerable to any changes in cost arising from escalations in clinical need.
CMA director Adam Land said both patients and doctors will benefit. ‘Patients will have the information they need to choose the services they can afford, and consultants will be able to have more informed conversations with them about the cost of treatment.’
Neil Huband, from the Private Patients Forum, said: ‘The ability of a patient to be able to compare the performance of a doctor or a hospital with others, and also to be able to compare costs, is essential. More over, it should be the right of every patient.’
n See page 11
Cosmetic surgeon Miss Sherina Balaratnam picked up a prize at the Aesthetics Awards. Find out in which sphere she was voted outstanding by turning to the full story on page 7
Over 1,600 consultants already appearing on PHIN’s website –where information on the scope of the treatment they provide is shown alongside the average length of stay for their patients following treatment – are the first to be invited to submit fees.
Thousands of other specialists will be contacted by the end of March and PHIN aims to publish this information for patients on its website from April.
To ensure the information is clear and useful for patients, hospitals are also being invited to submit their ‘inclusive package’ prices – where the consultant’s fee is rolled into the hospital’s charges and presented as a single cost to the patient.
PHIN said this would enable it to provide patients with a complete view of the price they can expect to pay.
Ensure callers always get through
Answer that call! It can be a big problem for many private practices –but Jane Braithwaite has some excellent advice to help you provide an exceptional service P12
Virtual practice
Boost your patients’ experience! Web designer and developer Grant Brookes sets out some effective ways of using technology and your online presence to make this happen P26
It’s time to cast away the errors
Beware of these five common practice management mistakes. An expert in computerised practice management systems shows how to avoid the pitfalls that foil the new private doctor P32
New GMC guidance for doctors on patient consent – on its way this autumn – should prove to be timely and useful for the medical profession.
It is being broadly welcomed by medical defence experts and, following the close of a consultation period last month, the final content cannot come too soon.
Early warning: there will be much to read and digest. The draft guidance, covering 102 main points over 24 pages, outlines what doctors should consider when discussing treatment and care with patients.
But it is the first update for ten years and its much-needed content covers new considerations that have emerged over the last decade.
Guidance hones in on the importance of communication, personalised conversations, and doctors and patients making decisions about treatment and care together.
There is advice and some helpful steps to follow for consultants and GPs making decisions in different circumstances.
As a defence body has observed, consent is a cornerstone of the doctor-patient relationship. Practitioners should have the flexibility to provide patients with the information they need to make decisions about their healthcare and in a way they will understand.
The MPS has described obtaining informed consent as one of the biggest challenges doctors face.
So hopefully this guidance will be much more meaningful for doctors of today, taking full account of new case law such as the Montgomery v Lanarkshire Health Board in 2015, requiring doctors to see that patients are aware of any material risks involved in a proposed treatment, and of reasonable alternatives.
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Lawyer Michael Rourke warns to beware of the potential intellectual property mistakes you could make if you are considering developing your own health technology P40
A plan that will weather the storm
So what are you saving for? Financial adviser Patrick Convey explains why this decision will help shape your best course of action when it comes to saving for retirement P42
Start a Private Practice:
Check your finances now to relax later on Accountant Ian Tongue looks at the areas to consider when planning finances at the start of the year P48
Doctor on the Road: Vantage versus Volante – two Aston Martins Motoring correspondent Dr Tony Rimmer becomes 007 for the day to test out two superior cars P50
Profits Focus: Eyeing a healthy future
Our unique benchmarking series looks at the financial fortunes of gynaecologists P52
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By Edie Bourne
Private consultants who also work in the NHS have just been notified whether they have secured a new Clinical Excellence Award (CEA) –but there may be a sting in the tail for those hearing the good news.
Financial planners have warned Independent Practitioner Today that many doctors may be shocked to discover the tax implications of their windfall.
Patrick Convey, technical director at specialist financial planners Cavendish Medical, warned that doctors could be caught by the much maligned yearly restriction on the amount you can contribute to your pension, known as the ‘annual allowance’.
Any excess pension savings above this figure may cause a breach of the allowance and trigger a tax charge.
Mr Convey said: ‘As the CEA
boosts your pensionable pay, and as you probably have complex income streams, you are more likely to breach this allowance.
‘The standard rate is currently set at £40,000, but there is now a new tapered annual allowance which reduces the limit down further – to as low as £10,000 per year for high-earning doctors.’
To make matters more challenging, doctors receiving new awards will have them backdated to April 2018.
Unfortunately, this means they may only find out if they 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 autumn this year.
Mr Convey added: ‘Getting your own position checked as soon as possible is key to avoiding a substantial extra tax bill on what should be a reward for your dedication to the
medical profession. With careful planning, it is possible to reduce your tax liabilities considerably.
‘You should also have the NHS sums checked, as we have found many of the computer-generated calculations to be wrong, causing
further complexity and distress.
‘There are multiple options for paying any annual allowance tax charge – via self-assessment, through NHS Scheme Pays or even utilising a personal pension which could prove to be very efficient.’
Concerns over the impact of current pension legislation is the second most important factor influencing consultants’ intended retirement age.
The NHS faces a future without hundreds of senior skilled hospital doctors as they consider leaving the health service years before they would be expected to, a BMA analysis reports.
Six out of ten consultants aim to retire from the NHS before or at the age of 60. Over a third expect to cut the number of days they work.
Dr Benjamin Holdsworth, director at specialist financial planners Cavendish Medical, said: ‘We have witnessed a similar pattern with many clients choosing to retire early. In practice, I come across few who genuinely want to stop work entirely at age 60.
‘By opting to “retire and return”, doctors can decrease professional commitments yet maintain their financial earnings by claiming pension benefits while working. Although their base salary may be reduced, doctors will save on pension contributions.’
John Reay is to become HCA UK’s president and chief executive when Mike Neeb retires in April after 12 years.
He is currently the company’s president of operations in the UK and chief executive at The Wellington Hospital, London.
Mr Neeb transferred from HCA in the US to become HCA UK’s chief financial officer in 2000. Under his leadership, the business grew from four hospitals into the largest provider of privately funded healthcare in the UK, with a network of hospitals and clinics in London and Manchester, and partnerships with leading NHS trusts.
Working with leading consultants, he pushed forward HCA UK’s ambitions to provide a full range of care to private patients, includ-
ing acute and complex treatment, not previously available in the private sector.
Mr Neeb said: ‘At the heart of HCA UK is exceptional patient care and I am honoured to have been
part of a team that strives to deliver that every single day.’
The Wellington Hospital’s deputy chief executive Jane WhitneySmith will act as chief executive until new leadership is announced.
‘Derisory’ pay rises for consultants in the NHS in England last year gave them an average weekly rise of only £6.10 after tax, according to the BMA.
Council chairman Dr Chaand Nagpaul said they had lost nearly a quarter of their take-home pay in the last decade, causing an untenable effect on motivation and morale.
The BMA says doctors have been severely let down by the independent pay advisory body and questions its real independence.
It is urging the Doctors and Dentists Review Body to assert its independence by recommending an uplift that is at least in line with inflation and to address the pay cut most doctors are experiencing.
By Robin Stride
Private consultants and their representative bodies are being asked for their input into a best practice handbook for the independent healthcare sector.
The ‘Consultant Oversight Framework’, due in the Spring, aims to ensure best practice and excellence found by the Care Quality Commission (CQC) is spread across all independent acute hospitals.
Former NHS England national medical director Sir Bruce Keogh is heading the Independent Healthcare Providers Network (IHPN) initiative.
The framework – part of the sector’s response to the Bishop of Norwich’s inquiry into the issues around the rogue surgeon Ian Paterson case – will apply to consultants engaged on both practising privileges and employed arrangements.
But IHPN chief executive David Hare told Independent Practitioner Today the document was not seeking to be a list of prescriptive rules. He said: ‘We are not in the business of saying “everybody must do it like this”; that would be a massive mistake.
‘It is intended to be a platform document to support people in understanding what works well and how they might implement that in their own organisations.’
The framework follows a CQC report last year revealing 41% of private hospitals required improvement and 1% were inadequate for safety. 30% required improvement and 3% were inadequate for being well led.
The IHPN said areas where governance systems could be strengthened by some operators include the oversight of consultants.
Sir Bruce said: ‘While the majority of care in independent hospitals is of high quality and underpinned by robust safety and clinical governance processes, more can and should be done to ensure consultants working in all independent hospitals are performing to the highest possible standards.
‘The development of a Consultant Oversight Framework will help foster a more standardised approach to clinical governance in the sector, including better collaboration and information exchange between private and NHS hospitals.’
Mr Hare said the framework would play a vital role in ensuring greater consistency in the regulation of consultants and that best practice around clinical governance was spread throughout the sector.
It will apply to independent acute hospitals only and be developed for the English healthcare system only, but will need replicating in the devolved nations.
Optegra Eye Health Care has invested £1.1m in SMILE laser technology at two more of its hospitals: in Birmingham and near Fareham, Hampshire.
This follows ‘outstanding’ results with the latest generation laser eye surgery technology at its London and Manchester hospitals.
SMILE – SMall Incision Lenticule Extraction – is a bladeless, flapless, minimally invasive alternative to
laser surgery. Launch events for GPs and optometrists are planned to showcase the technology while Optegra surgeons inform guests of the advantages of referring patients specifically for SMILE.
Considered the ‘keyhole surgery’ of laser, the technology means popular 30-year-old laser eye techniques can be performed without creating a ‘flap’ on the eye surface. This technology allows laser eye
The framework aims to improve consistency in the governance of medical practitioners across the independent healthcare sector by identifying and codifying best practice across a range of areas including:
Governance around medical practitioners
Information flows about consultants across the healthcare system
Whole practice appraisal and revalidation
The role of the Responsible Officer (RO)
The role of the Medical Advisory Committee (MAC) chairman and how the committees function
Practising privileges arrangements
Annual and biennial reviews of practising privileges
Monitoring scope of practice
Reporting and monitoring doctors’ activity levels and performance
Managing concerns about consultants
Obtaining patient consent
Multidisciplinary team working
The Framework is part of the IHPN’s work to support independent sector operators’ own efforts to ensure the highest clinical governance standards.
Other initiatives include:
Joint best practice workshops including with the Care Quality Commission on spreading best practice in key areas including safety, leadership, effectiveness, caring and responsiveness
Work with Healthcare Quality Improvement Partnership (HQIP) to increase sector participation in their National Clinical Audit and Patient Outcomes Programme (NCAPOP)
IHPN membership of NHS Digital’s Acute Data Alignment Programme (ADAPt) Board, which works to integrate data on privately funded healthcare into NHS systems to increase transparency and help drive up standards in both sectors
surgery with the smallest of incisions – 2mm wide – which naturally heals, maintaining the strength of the eye, so there is less risk of future issues.
Company chief executive Peter
Byloos said: ‘Our vision correction surgeons in central London and Manchester have been achieving fantastic results with SMILE, with our procedures securing a minimum of 20:20 vision for patients’.
Des Shiels, former chairman of the private hospital representative body the Association of Independent Healthcare Organisations (AIHO), has resigned as Aspen Healthcare chief executive.
Michael Davis, chief operating officer of NMC Healthcare, which took over Aspen last summer, said Mr Shiels had been a central part of Aspen for many years and was greatly admired in the UK independent healthcare sector.
‘We thank him for his many years of service to Aspen and wish him every success in his future endeavours.’
AIHO ceased last year when its role was taken on by the nownamed Independent Healthcare Providers Network.
NMC said Paul Hetherington had been appointed Aspen’s interim boss and would work closely with the leadership team to ensure it is business as usual.
Mr Davis said: ‘Paul has an extensive and rich experience of almost 40 years in the healthcare industry across the UK.’
Administrators report they have received a number of expressions of interest to acquire Baddow Hospital, a private hospital in Chelmsford, and are considering their options.
The hospital specialises in cosmetic surgery procedures, but also provides a range of hospital and private GP services. It employed 21 people, including 11 medical staff.
Work at the hospital was suspended upon appointment of an administrator last November and a limited number of core staff were retained while a buyer was sought.
Administrator Glyn Mummery, from specialist business advisory firm FRP Advisory LLP, said: ‘Baddow Hospital is a great facility with a team of talented professionals, but a lack of outsourced NHS work at sustainable margins and other key commercial factors have put significant cash flow pressure on the business.’
By Olive Carterton
The new chairman of the Federation of Independent Practitioner Organisations (FIPO) has predicted a hefty workload dealing with aspects of private practice in the years ahead.
Consultant ophthalmic surgeon
Mr Richard Packard said: ‘For the future, FIPO’s role will be critical, for there are a number of serious issues facing the sector.
‘Patient choice in the private sector has been increasingly at risk and, indeed, has arguably been diminished in the past few years. We face great challenges in the future, but one thing is certain: without the private sector, the UK’s healthcare system would not be able to cope.’
Mr Packard added: ‘Patient care and improving the human condition are at the centre of everything we do and FIPO will always take decisions on the basis of what will ultimately be in the best interests of patients.’
He takes over from the organisation’s founder, gastro-intestinal surgeon Mr Geoffrey Glazer, who has stood down.
FIPO was founded in 2000 by a group representing nearly all the specialist associations in the UK to represent the interests of both the medical profession and patients in the private sector.
Mr Packard, who along with Mr Chris Khoo has been one of the deputy chairmen for a decade, paid tribute to his predecessor. He said: ‘As specialists practising in the pri-
vate sector, we all owe Geoffrey Glazer a huge debt of gratitude for fighting our corner and helping to improve standards. Geoffrey has always been passionate about striving for the highest standards of patient care, increasing choice for patients and fighting injustice.
‘Geoffrey was one of the principal architects of FIPO, which protects, promotes and supports the interests and views of medical and dental practitioners in the UK. He developed the FIPO Charter for Patient Engagement and many other initiatives.
‘He helped to formalise the processes and implementation of clinical governance. As a surgeon, he will always be held in the highest regard by his peers in the profession and by his patients. He is a hard act to follow and it is a privilege for me to take over from him.’
Mr Ian McDermott, consultant at London Sports Orthopaedics – part of London Bridge Hospital at HCA Healthcare UK – has been elected as a new vice-chairman of FIPO.
The BMA has welcomed proposals in the NHS Long-Term Plan around potential legislative changes to remove restrictive competition rules in the health service.
Council chairman Dr Chaand Nagpaul said: ‘Since the inception of competition rules embodied in the Health and Social Care Act in 2012, the BMA has consistently called for such a wasteful use of resource to be scrapped; so to see NHS England recognise this is long overdue.
‘At a time when the NHS can least afford it, too much time and money is currently spent on tendering processes for contracts. Given the long waits for treatment
and the cash-strapped state of our health service, time and money should be spent on the front line, delivering better care to patients, not on costly tenders.’
He said competition rules had resulted in a fragmented NHS driven by commercial motives rather than providing seamless care.
‘Clinical Commissioning Groups should have the flexibility to commission services to suit local need, not to suit competitive tendering regulation and without the fear of having to pay out millions to private providers for falling foul of existing legislation, as has been the case in recent years.
‘When Government rhetoric is
centred around integration within the health service, independent providers bidding on time-limited contracts sits entirely at odds with this philosophy. Only by removing the requirement to put service out to tender, can local systems work together to ensure cohesive patient-centred healthcare.
‘NHS England’s ambitions here are clear, and we strongly recommend Parliament take forward these proposals and push through these legislative changes.
‘We will be keen to see the finer details of any new system, and look forward to working with NHS England to ensure this becomes a reality in the interests of patients.’
Attendees at the BMA’s private practice conference in London on 5 April are in for a full day with presentations from a wide variety of businesses and organisations.
Topics include strategies to grow, indemnity, CQC registration, relationships with medical insurers, group practice, finances, practising privileges and accounting.
Speakers include Independent Doctors Federation president Dr Neil Haughton, medical defence organisation representatives, marketing and IT experts, and BMA private practice committee chairman Dr Shree Data.
Parallel sessions will cater for established consultants and GPs and specialists starting up.
The annual event is an opportunity for doctors to discuss issues affecting them in their day to day work. Register your interest at by emailing onfunit@bma.org.uk.
By a staff reporter
Doctors’ organisations along with defence and insurance providers and other interested parties have been compiling and sending in their responses to Government proposals advocating a huge defence cover shake-up.
As reported in last month’s issue, the Department of Health and Social Care is advocating the merits of insurance rather than the discretionary cover provided by traditional medical defence organisations (MDOs).
Doctors and others have until 28 February to file their reactions to the report entitled ‘Appropriate clinical negligence cover – a consultation on appropriate clinical negligence cover for regulated healthcare professional and strengthening patient recourse’.
The consultation has been welcomed by consultant orthopaedic
surgeon Mr Ian McDermott, who decided several years ago to move from a discretionary, occurrencebased model of indemnity.
He opted for an insurance product on a claims-made basis, as he felt this offered contractual certainty from a regulated insurance provider.
He told Independent Practitioner Today : ‘Patients and clinicians require and deserve certainty, knowing that significant compensation claims will be met and that the professional indemnity provider has sufficient financial reserves to meet such claims.’
He obtained professional indemnity insurance through membership of the Orthopaedic and Trauma Specialists Indemnity Scheme, a mutual firm exclusively for orthopaedic surgeons, owned and governed by its members, who are the policy-holders.
Now chairman of its board of
directors, he said: ‘Notwithstanding the significant financial savings that this gave me, I also genuinely believe that an insurance-based model offers the best solution for the healthcare profession and patients alike’.
He said the board communicated directly with its partner brokers and insurance underwriters ‘so that they truly understand our professional needs as orthopaedic surgeons, and to ensure that our members are provided with the best possible product’.
His comments came as the Medical Defence Union (an MDO) revealed it was assisting a consultant with a claim notified in 2018 from an event in the early 1980s.
Chief executive Dr Christine Tomkins said: ‘Clinical negligence claims are made many years – ten, 20, 40 or more – after the incident and to compensate patients, the indemnity must respond
fully at the time the claim is made.
‘We have offered insurance as well as discretionary indemnity in the past and each has pros and cons. The protection offered by regulation is tailored to claimsmade insurance. Insurers must only adhere to the terms of the policy and be adequately capitalised for risks taken on.
‘Those risks do not extend to unlimited indemnity, without exclusions, which can meet claims an unlimited number of years after the clinical event complained of –but this is what doctors and patients need.’
Fighting the MDOs’ corner, she said they had been indemnifying doctors and dentists and compensating patients for over 100 years.
This was a service from a mutual fund, subscribed by members, which could respond to requests for assistance however long after the clinical event the claim came in.
By Edie Bourne
Aesthetic practitioner and trainer
Dr Simon Ravichandran has been crowned Medical Aesthetic Practitioner of the Year.
His ABC Lasers Award was presented to him in front of more than 800 guests at Aesthetics Awards 2018 held at the Park Plaza Westminster Bridge hotel, London.
Twelve years on from starting as an ENT trainee, his achievements include co-founding Aesthetic Training Academy and Clinetix clinics and guest lecturing and course designing a Master’s degree at Northumbria University.
In 2011, he co-founded the Association of Scottish Aesthetic Practitioners, providing the first
annual conference of its type in Scotland.
Dr Ravichandran said: ‘Winning means a great deal to me, as it’s a reflection of the good work we try to do for the industry and for our patients’
Other doctor winners at The Aesthetics Awards, in association with Aesthetics Media Ltd, were:
Health and Aesthetics was awarded The iS Clinical Award for Best Clinic South England. Established in 2008 in Surrey by Dr Rekha Tailor, it was one of the first to offer Femilift and Ultherapy in the region. The clinic’s entry was described as an ‘exceptional’ entry by judges, who were impressed with the focus on customer service in preparation for mystery shoppers.
Taking home the trophy for The AesthetiCare Award for Best Clinic North England was Aesthetic Health.
Founded in 2009 by director Dr Julia Sevi, Aesthetic Health was born out of an aspiration to create an indulgent boutique clinic dedicated to delivering exceptional standards of integrated care that is innovative and evidence-based.
According to the entry, the clinic has a core of 2,000 patients and opened a pop-up Harley Street clinic to serve southern patients this year.
Aesthetic Health was congratulated by the judges for its ‘dynamic’ and ‘excellent entry’.
Eudelo Clinic picked up The Dermalux Award for Best Clinic
London. Dr Stefanie Williams founded the venture in 2007 and its flagship clinic opened in 2016, offering its treatment menu to 7,500 patients.
The clinic’s international reputation and have earned it a dedicated following including actors, supermodels, chief executives, diplomats and royalty travelling from all over the world.
Tay Medispa won The Aesthetic Source Award for Best New Clinic, UK and Ireland. It was established by husband and wife team Simon and Dr Julia Langford in February 2017.
The award for Clinic Reception Team of the Year was won by S-Thetics and presented to its founder Miss Sherina Balaratnam.
By Leslie Berry
A multidisciplinary intensive day clinic for eating disorders –claimed to be the UK’s first – has opened its doors in London.
Named Orri, the company aims to fill a gap by providing early and intensive treatment and so disrupt the cycle of waiting lists, hospitalisation, discharge and relapse.
It is currently self-pay, but plans to build more clinics in partnership with the NHS and private insurers.
Backed by leading UK social impact fund Impact Ventures UK, it has secured £2.75m of investment to open three centres in the UK.
Orri says people who seek help for an eating disorder are all too often told they are ‘not thin enough’ for treatment.
By the time many are treated, they may have deteriorated to dangerously unwell levels, where often the only option is hospital treatment, ‘a distressing, short-term solution that focuses on the physical symptoms and takes up a sig -
nificant proportion of NHS budget and resources’.
A team of 14, including psychiatrists, psychotherapists, psychologists, occupational therapists and dieticians, run a ‘stepped’ programme, providing everything from full-day support, to eveningonly programmes for those with daytime commitments.
Support is designed to fit around a patient’s needs as they return to their lives without an eating disorder – preventing expensive, longstay inpatient hospitalisation and the likelihood of re-admission.
Psychotherapist Kerrie Jones, Orri’s clinical director, said: ‘Patients and their families are crying out for treatment opportunities that permit them to continue to study and work, avoiding further disruption to their lives.’
She believes carers often feel sidelined during a loved-one’s treatment. At Orri, family inclusion is crucial to its approach and ethos.
Carers are encouraged to take an active role to support long-term
recovery, with education and peer support offered to address the significant impact the eating disorder can have on family dynamics.
Orri’s research and development director is Dr Paul Robinson, a former chairman of the Royal College of Psychiatrists’ Faculty of Eating Disorders.
He said: ‘There are not enough treatment options available for people and their families living with eating disorders, leading to a cycle of waiting lists, hospitalisation, and insufficient, inconsistent support.
Tony
taken on the
London Medical said: ‘The expertise and experience Tony brings with him will enable the
clinic to reach its full potential, adapting to the rapidly changing delivery of private healthcare and keeping London Medical as one of London’s leading private outpatient facilities.’
Mr Graff is an experienced senior executive with extensive healthcare experience. He has also worked as chief financial officer of Imperial College NHS Trust and Healthcare at Home.
He has helped several businesses achieve significant growth since he gained extensive experience with management consultants McKinsey & Company earlier in his career.
This is a new position at London Medical and comes after a five-year period during which Mr Neville Abraham served as part-time executive chairman, working closely with the clinic’s chief operating officer David Briggs.
‘Orri will transform the treatment landscape in the UK, providing a much-needed option for those who feel they have nowhere to turn at any stages of their disorder, including the earliest.’
He added: ‘At the heart of Orri’s philosophy is our comprehensive treatment approach. We don’t just focus on the physical manifestation of the eating disorder, but instead seek to get to the root of the problem, exploring how it has evolved and tacking the underlying issues that are reinforcing it.’
A look back through our journal’s archives of ten years ago reveals that although times change, some issues are not so new
How different things were a decade ago before the Competition and Markets Authority’s long-running investigation into private healthcare – and other big changes
We reported that highest-earning consultants in private practice could be on target for a winter bonus of as much as £33,000 for bringing business to their hospital.
Payments under Nuffield Health’s new Practice Privileges Plus scheme were being planned for loyalty and activity growth.,
Around 4,000 of the 6,000 consultants using Nufffield Health’s network of 32 hospitals were eligible for the scheme.
And hundreds signed up after talking through agreed fee structures and their business aims with their hospital manager.
But anaesthetists, radiologists and pathologists were concerned they could not earn rewards because they were not seen a generators of revenue.
We warned doctors would have to pay the GMC an extra £20 to help it meet projected expenses of over £83m.
The £410 annual fee would help pay for the introduction of the licence to practise in autumn 2009, for the implementation of revalidation and ‘a significant,
unplanned, increase in referrals by case examiners to fitness-topractise panels.’
A medical secretary’s article included the following tongue-incheek tips:
Hand dictation over at 4.30pm and say it needs to go in tonight’s post;
Ask for minutes to be taken at the meeting, then alter all the carefully taken working;
Change systems that are in place, work well and get results, just because they are not the way you think things should be done;
Squirrel important documents/ notes away in the boot of your car, never to be found again, and then demand to know where they are when not in the required file.
Private doctors were about to use the nation’s first robotic radiosurgery system to treat tumours using a £2.5m Cyberknife at The Harley Street Clinic.
Consultants were urged to act fast to protect their pension benefits from tax charges of upto 55%.
We said more doctors could be hit because for the forthcoming year the Chancellor had frozen the £1.8m limit on pension values before penalties kicked in.
A consultant praised the benefits of specialist medical transcription services using digital audio files –but lamented that many private consultants remained unaware of how this technology could revolutionise their working routines.
We warned consultants of the danger of paying their NHS secretary ‘casual labour’ payments rather than deducting PAYE and National Insurance contributions. Many consultants were said to naively consider that if they made
a payment to an employee and did not deduct PAYE, then any tax would be the responsibility of the employee.
‘Often they think that if they call this self-employment, then this will do the trick and ensure that the employee will have to meet any due tax or NIC.
‘But this is simply not the case. Invariably, HM Revenue and Customs will target the consultant and will ask for the tax and associated National Insurance, not from the employee, but from the employer.’
TODAY
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Susan
Hutter (right) sets out
some important areas that many established independent practitioners would benefit from brushing up on in the next financial year
Scrutinise your practice overheads costs
Looking at the costs of running your practice is often pushed to the back of the queue in the life of a busy private doctor.
But many practices, indeed many small businesses in general, tend to go on ‘automatic’ as far as the running costs are concerned.
This includes IT support, stationery and office costs. If you have an assistant, it is worth asking them to obtain, say, two alternative quotes for the larger office overheads, as often there are some cost savings to be made.
Keep on top of your administration
Keeping on top of the practice paperwork makes things easier in the long run and enables the practice to run more smoothly.
The mistake many GPs and consultants make is leaving their book-keeping work until the last minute, when the filing deadline for their accounts is looming.
It is advisable to update everything monthly. That way, you will keep up with the book-keeping and avoid a last-minute rush. Also, any issues can be ironed out along the way.
If your accountant has any queries on the records, it is often difficult, or indeed impossible, to remember what happened a year after the event. Also, by then it is usually too late to do anything about it.
As always, it is essential to keep debt collection under control. Many consultants outsource this to a specialist service.
This is definitely worth looking at, as even though there will be a charge, the cash-flow improve -
Don’t file away your office administration overheads under ‘forgotten’. If these tasks are getting too onorous, look to outsource them
ment outweighs this and the admin is taken away from you/ your busy PA (see page 34).
Make the most of your investments
Have a look at the type of investments you have and, if you are married, look at how the investments are divided between you and your spouse.
It is always wise from a tax point of view for the lower income-earning spouse to have the bulk of the investment income, as their marginal rate of tax will be lower.
This covers such things as dividends from share portfolios, bank and building society interest and even rental income.
See ‘Check your finances now’, page 48
Susan Hutter is a partner at Blick Rothenberg and part of the team that advises medical practitioners
TAX RETURNS – GET INTO THE HABIT OF PUTTING YOUR TAX ASIDE EVERY MONTH
Don’t procrastinate over your tax return.
Your tax return for the year to 5 April 2018 had to be submitted to HM Revenue and Customs (HMRC) by 31 January 2019. Any balance of tax for 2017-18 was due for payment on that date, as was the first payment on account for 2018-19.
Interest for late payment runs at 3.25% a year, but if the tax is still unpaid by 28 February, then there is 5% flat charge on any balance outstanding for 2017-18.
This can be expensive. Doctors in this position won’t have left much time for cash-flow planning, so hopefully they have enough money in their bank account to pay by the due date.
If not, they could try asking HMRC for time to pay. If that is you, then you will need to have a good reason for not having the tax money available.
The good news is that you now have five months to prepare for the second payment on account for 2018-19, which is due on 31 July 2019. With all the stress involved in last-minute filing of tax returns, ensure you do not procrastinate with the following year’s tax return.
Always ensure that a monthly amount is put aside towards your tax liability for next year. Your accountant will be able to provide guidance as to how much this should be.
Are you really job you do enjoy most? For 18 years large and organisations world transform, and improve manage their Making your And your Scott Hague Technology
Charles Rifkind Property
Hague Technology
Peter Goddard Performance
AS PATIENT advocates, the Private Patients’ Forum has often heard the frustration of anxious patients and others, wanting much faster progress towards a time when they could compare and contrast the performance of hospitals, doctors and – last but by no mean least –what the costs were going to be. It seemed to us that choice was being eroded while, at the same time, the cost of private healthcare was increasing exponentially. Insurers, trying to keep their spiralling costs down, began to restrict the number of consultants they were prepared to pay for. More and more patients found they were having to pay excesses –
Neil Huband Communications
never be true transparency in the independent sector without additional openness about pricing.
Keith Hague CEO
BY NEIL HUBAND,
The ability of a patient to be able to compare the performance of a doctor and a hospital with others and also to be able to compare costs, is, we have always believed, essential.
tor’s bill and what the insurer was
Making like-for-like comparisons was proving nigh on impossible. Put simply, the patient – the person everyone employed in the private healthcare should be focused on –was facing an increasingly opaque and confusing system.
Compiled by Philip Housden
New PPU for Thames Valley Frimley Health Foundation NHS Trust has been given the go-ahead for a £98m new Heatherwood Hospital to replace the existing hospital on the site and it is due to be completed in late 2021.
Separate bills for the hospital care, diagnostics, drugs, surgeon, anaesthetist and aftercare such as physiotherapy: a patient can be faced with umpteen bills for one procedure. As if they haven’t got enough to worry about already.
Howard Ware Medical
The advent of package deals has been a positive benefit in many ways. But even there, if a patient is faced with several hospitals offering similar package deals, how does he or she compare like with like?
Moreover, it should be the right of every patient.
Thanks to the huge effort of hospitals, consultants, the data collec tion and processing technologists and the Private Healthcare Information Network (PHIN), transparency is – we hope and trust – within reach.
One day, we hope published data will help a patient compare not only like with like in the private sector but also with the performance of the NHS. But there will
While you concentrate on caring for your patients, our role is to help remove the yoke of management.
Health, the trust’s growing private brand, which reported £9.15m revenues in 2017-18, holding onto its position as the highest revenueearning NHS trust outside London.
Not just the day-to-day logistics, but strategically, short and long term. Over the years we’ve transformed and grown countless practices and business. Planning and developing medical facilities. Marketing your healthcare services professionally, by knowing and employing the technology and media that deliver results.
The NHS hospital will have six operating theatres, 48 inpatient beds and facilities for 22 day-cases. Eight private patient beds and other facilities will deliver income that was considered vital to the business case approval.
The private patient unit at Noble’s Hospital, Douglas, closed last month to pave way for refurbishment. The 14-bed unit opened in 2003 and provides the only private inpatient care on the island.
So now physicians and consultants practising in our sector have another pivotal role to play: that of helping to create transparency around the costs of treatment and perhaps the follow-ups too. Transparency over costs, as well as performance, must and will make choosing the most suitable hospital and doctor easier for patients. It will help to grow greater trust and confidence in the sector and that will help grow the market.
But as PHIN begins the huge task of gathering and publishing prices, complex as it is, we believe this should not be looked upon simply as a burdensome legal duty, just fulfilling the orders of the Competition and Markets Authority. This should be done because it is absolutely the ‘right thing to
Dr.Danny McGuigan Leadership
And what is right for the patient,
and Social Care to turn round private patient services into a commercial success by reducing the outflow of patients to UK mainland.
Isle of Wight private patients recommended to mainland Bupa, Axa and Aviva have decided to suspend directing patients to the Mottistone Suite at St Mary’s Hospital, Newport, Isle of Wight, after a Care Quality Commission (CQC) ‘inadequate’ rating.
To give it a thorough examination, call Peter Goddard on +44 (0)203 356 9699 or mobile +44 (0)780 314 4954 really doing the do best? That you most? years we’ve helped small healthcare organisations across the transform, grow, improve the way they their businesses. your life better. patients.
A spokesperson for Aviva said: ‘Once St Mary’s Hospital meets CQC standards, we will add it back into our lists.’
Our teams are tailored to your needs. And if those needs change, so does our team. We have crisis management experts available 24 x 7.
We combine clinical expertise with commercial sense and experience.
This service will extend Parkside
Health and Social Care Minister David Ashford said discussions were taking place with potential partners.
The PPU remains open and chief executive of the Isle of Wight NHS Trust Maggie Oldham said: ‘Because of our status with the CQC, which is in special measures, I think the insurance brokers don’t recommend special measures trusts. But that doesn’t mean, on a case-bycase basis, that the brokers won’t support people receiving their treatment with us.’
We see the full picture, providing support when and where you need it most.
Improved facilities may enable the island’s Department of Health
The health insurers are presently not recommending the hospital, and are diverting patients to the Harbour Suite, Queen Alexandra Hospital PPU, Portsmouth, and to Spire Southampton.
We work with both public and private sector healthcare providers.
Philip Housden is a director of Housden Group. Read his feature article on page 46
Our case histories in operations management, clinical advice, consultancy and development are outstanding.
Answer that call! It can be a big problem for many private practices – but Jane Braithwaite has some excellent advice to help you provide an exceptional service
NOW THIS is a thorny subject for patients, medical secretaries and consultants alike.
Here’s two common scenarios: ‘The patient says she couldn’t get through’.
‘She was a new patient. That’s like gold dust. We need to answer every call’.
‘I just received a complaint from a GP who couldn’t get through to refer a patient’.
How do we answer every call? Is that even possible? How many calls are being answered at your practice today? 50%? 90%? Can you measure this?
This month, we are going to dis-
cuss how to ensure we offer an exceptional quality of service when it comes to answering patients calls.
Starting with a very basic point: it is vital for every consultant/practice/clinic to ‘own’ their own phone number.
Disastrous consequences
You will spend significant time and money promoting your phone number on websites, business cards, hospital websites and insurance company websites.
Patients will store your number on their mobile phone. The pros-
FOR YOUR PATIENTS WITH HR+, HER2–, NODE-NEGATIVE, EARLY-STAGE,
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Only the Oncotype DX Breast Recurrence Score® test:
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The Oncotype DX® test: Identifying the right treatment for the right patient1,3-5
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References: 1. Sparano et al. N Engl J Med. 2018. 2. Sparano et al. N Engl J Med. 2015. 3. Sparano and Paik. J Clin Oncol. 2008. 4. Paik et al. J Clin Oncol. 2006. 5. Geyer et al. npj Breast Cancer. 2018. 6. Nitz et al. Breast Cancer Res Treat. 2017. 7. Hortobagyi et al. SABCS 2018. Poster P3-11-05. 8. Stemmer et al. npj Breast Cancer. 2017;3:32 and 2017;3:33. 9. Genomic Health®. 2018. Data on file. 10. NCCN Clinical Practice Guidelines in Oncology. Version 2.2018. 11. NICE Diagnostic Guidance 10.2013.
This piece is intended to educate physicians on the clinical utility of the Oncotype DX Breast Recurrence Score® assay and should not be provided to patients. Genomic Health, Oncotype DX Breast Recurrence Score, Oncotype DX, Recurrence Score, Oncotype IQ, Genomic Intelligence Platform and Making cancer care smarter are trademarks or registered trademarks of Genomic Health, Inc. © 2018 Genomic Health, Inc. All rights reserved. GHI11469_1218_EN_UK
pect of changing your phone number part way through your career can have disastrous consequences.
The same is true of consultants sharing a phone number, perhaps because they share a medical secretary.
What happens if someone leaves? Who retains the number? You can’t split it in half! In these days of modern technology, it should be possible to ‘port’ a phone number from one system to another, but this isn’t always the case.
Please make sure you ‘own’ your own number from day one. It is equally important to ‘own’ your own email address.
As with most things in life, if we can’t measure it, we can’t manage it. We need to be able to measure how many calls we are receiving to our phone number and, most importantly, what percentage of these calls are being answered.
Ideally, we would review this information on a monthly basis. A sensible percentage to aim for is 80% of calls to be answered, but 90% would be excellent.
To answer 100% of calls is not impossible, but would be cost-prohibitive in terms of level of resource needed.
There will be busy periods on certain days of the week and at certain times of day. Most people find that Monday mornings are exceptionally busy, but Fridays are quieter. The busiest times of the day tend to be 9-10am, followed by a flurry at lunchtime and at the end of the day.
If we all employed enough resource to answer all the calls at these busy times, we could potentially have wasted resource for most of the day. One solution is to involve additional team members at these busy times, perhaps those who are normally engaged in typing.
I am not personally a fan of receptionists answering calls. There is nothing worse than a patient arriving at our clinics to find themselves ignored for several minutes while the receptionist deals with a call.
If we are consistently answering 80% of calls, we are half way there, but we also need to ensure that the 20% of calls that are answered by voicemail are returned promptly
and this can be achieved during those quieter periods.
Technology provides numerous solutions to help us improve our call-answering service. With a good phone system, you can set up a ‘hunt group’ so that incoming calls are delivered to a group of people automatically.
This ensures that calls are answered as quickly as possible by a member of the team. There are other pieces of technology that you may love or hate; for example, the option to press 1 for appointments, 2 for invoicing, 3 for address details and so on.
This is called an automated attendant. There are also callanswering bureaux who specialise in answering calls in a reliable manner and their percentage answered are very impressive; for example, ‘we answer 95% of calls in four rings or less’.
Extending ‘opening hours’
These services can be utilised as an overflow service to avoid patients receiving voicemail and can also be used to extend your ‘opening hours’ or even provide a 24-hour service. These services are generally large call centres and your calls will be answered with a pre-determined script.
A message will be taken and sent to your clinic by email or text message. There is a place for these services in the private medical world, but ideally most calls should, in my view, be answered by someone who can help the patient by booking an appointment or assisting with their questions, as opposed to simply taking a message.
I would also advise regular call audit. This is not high-tech, but simply asking those who answer the calls to keep a record of the nature of each call. A simple check list on a notepad kept by the phone will suffice.
Remember that the calls we desperately do not want to miss are the calls from new patients looking to book an appointment. On a typical day, say we receive 35 calls, if 15 of these are patients calling to confirm the practice address, then we can act to eliminate those calls. If we can do this successfully, we reduce the overall number of calls and improve our chances of answering the new patients in a timely manner.
To answer 100% of calls is not impossible, but would be cost-prohibitive in terms of level of resource needed
Own your phone number. Ensure you have a number for life
Measure it to manage it – Monthly reviews of our performance will ensure we continue to focus on this key element of practice management
Call audit – Address the reasons why patients are calling and look at ways to reduce the calls that are less productive
Technology solutions – Investigate the ways in which your phone system can support the process
Voicemail – Ensure messages are returned promptly
Appointment reminders – Ensure we include the address and details of how to find us. Ask patients to email to confirm not call
Online booking should be embraced by all
Call-answering bureaux/call centres – Can be used as a back-up option
Patient calls are vital and high priority. It is important to have a culture that treats them as such
I will leave you with the famous words of Blondie: ‘Don’t leave me hanging on the telephone.’
We could ensure that when we email the patient a reminder the day before their appointment, we should also include clarification of the practice address and how to find us.
Equally, if we are receiving numerous calls to chase results, then we need to look at why this is happening. Are the results being sent out in a timely manner?
Perhaps we are setting expectations that are too high?
Most clinics send out appointment reminders by text or email the day before their appointment and this is very good practice. I would recommend using email and asking each patient to send a quick reply to confirm. I would not ask people to call to confirm!
Numerous websites are offering patients the opportunity to book online. In practice, I have found that this is not as automated as it might look, but real online booking directly onto your practice management system is available on some systems and others are
Call-answering bureaux can be utilised as an overflow service to avoid patients receiving voicemail and can also be used to extend your ‘opening hours’
launching this capability in the early part of 2019.
See ‘Smooth a path to your door’, page 16
Jane Braithwaite (right) is the managing director of Designated Medical, which offers business services for private consultants, including medical secretary support, bookkeeping and digital marketing
Gaining and retaining clients is a key challenge for most independent practitioners and private practices. Stephanie Vaughan-Jones shares three simple steps clinics can take to ensure they are not unnecessarily losing new and existing business opportunities
A KEYNOTE SPEAKER I heard at a recent conference likened healthcare practices to a bucket.
A leaky bucket, in fact, with several holes spurting out water.
These small leaks, she said, represent the ways in which practices could be losing business and money on a daily basis without even realising it. Her analogy struck a chord with most people there.
In our busy lives, it can be all too easy to assume that the status quo is working ‘OK’; that we know exactly what is happening behind the scenes without regularly taking time to dig that little bit deeper and check our previous findings are still the same.
In my world of communications, I see a few challenges that consistently crop up for our clients. Here are the three most common and the actions you can take to make sure your business is as watertight as possible.
1Do you have the correct resource in place?
If you are in private practice, you will know how difficult it can be to juggle client appointments with the general demands of running and managing your own business. Patients have high expectations of the very best care and expertise combined with first-rate customer service, but, with heavy caseloads and busy diaries, can you really be sure that you are capturing every call and inquiry coming in?
We provide each new client with a report at the end of their first month with us and I am yet to encounter a practice that is unsurprised by the results. Often, for instance, the practice thinks that their busiest day is, in fact, completely different to the one they are actually receiving the most inquiries on.
This means they could be overstaffing at the wrong time and understaffing when they really need the added support. Our data, taking a sample of five key health-
care clients, found that Monday was the busiest day of the week on average for our healthcare receptionists, with 9-11am accounting for the most calls.
These calls and inquiries could be clients phoning for any number of reasons: an existing client who wants to follow up a recent visit, a new inquiry or an emergency appointment.
Whatever the reason, practices who don’t have the correct resources in place are risking both their reputation and the satisfaction of clients, as well as a potential loss in revenue.
Being able to see this bigger picture and to understand your clients’ needs and behaviour is a crucial part of offering the highest level of service.
2Embrace the 24/7 world
We live in a world where traditional working hours have all but disappeared. Technology and its effect on society has profoundly shaped the way we as clients
behave; and likewise it has unequivocally changed our expectations and perception of what ‘good’ looks like as a consumer.
That question is always at the forefront of our minds. And the same is true for many clinics.
But what does this mean in reality? How can practices create a first-class customer journey that meets, and then exceeds, these modern-day expectations?
The key is being available – and being available when and in a way, that your clients want, be it on the phone in the morning, over email at lunch or on your website after the practice door has closed. It might sound straightforward, but so many clinics fall at this first hurdle.
No two clients are the same and will naturally want to, or need to, engage at different times and in different ways.
This change is without doubt being recognised within the healthcare sector. Indeed, demand for our phone answering continues
Experts predict that experience –not price or products –will soon be the key differentiator for consumers when choosing between companies
delivering the kind of service that makes every single one of your customers and callers feel like your biggest and most important client. It is this experience that truly impresses and not only keeps people coming back, but ultimately grows your business and its reputation too.
Studies show that service is becoming ever more important when it comes to how clients make their decisions. According to the Customers 2020 report, experts predict that experience – not price or products – will soon be the key differentiator for consumers when choosing between companies.
In real terms, this means that simply meeting expectations isn’t enough; we all need to ‘wow’, and consistently so, –to keep our customers happy long-term as well as win new business.
to rise, and we are also seeing a steady uptake of our Live Chat service which enables clinics to talk to clients online out of hours.
The opportunities this 24/7 world presents are huge. A recent analysis of our data, for instance, found that 42% of live chats answered on behalf of our clients resulted in a new inquiry.
That’s a compelling number and, like most private practitioners, you will have, no doubt, invested much time and resources into marketing your services to generate the most inquiries possible and maximise your return on investment.
Every penny of that is critical to success, conversion rates and driving growth. But that money is only well spent if you are there to wow and capture the responses.
We love talking about rolling out the ‘red carpet’ for customers at Moneypenny. What we mean is
Think about the ways in which you already do this and what you could do to make your customer journey even better. Take a look at your competitors and compare how you measure up as well. What services do they offer? Can you book an appointment online, for instance? Is there anyone to pick up phone calls or inquiries once the doors close at 5.30pm? No? Herein lies your opportunity to exceed the ‘norm’ and the rewards of this are there to be reaped.
Word quickly spreads about extraordinary service, and those recommendations are priceless.
Practices who raise the bar are inevitably the ones that rise to the top. Not only do they surpass their own expectations of what constitutes good service, but also the industry’s standard. This can be enormously powerful.
Stephanie Vaughan-Jones (below) is commercial manager at communications specialist, Moneypenny, which delivers phone answering, live chat, switchboard and multichannel customer services to 13,000 businesses across the UK
With 40 years’ medical experience, Mr Munchi Choksey is a highly respected consultant neurological and spinal surgeon. A former NHS consultant and assessor for the Intercollegiate Examination in Neurological Surgery, he is now employed as a private spinal neurosurgeon at the Nuffield Hospital. He also runs a busy medicolegal practice. Here he offers his thoughts on how recent Government announcements look set to overhaul indemnity rules for health professionals
SPINAL SURGERY is a high-risk specialty, with practitioners in the UK trained through either the orthopaedic or neurosurgical route. With individual pay-outs for spinal surgery negligence now potentially exceeding £10 million, the need for effective risk management and indemnity is only too clear.
However, concerns and deficiencies in the existing indemnity provision for medical practitioners have been highlighted by the recently published consultation document ‘Appropriate clinical negligence cover’.
Not least among these fears is the acknowledgment that relying on discretionary cover could leave healthcare professionals personally liable – and patients with little or no compensation.
The document – from the Department of Health and Social Care (DHSC) – states that the rising cost of clinical negligence is ‘a great source of concern’ for medical practitioners, impacting negatively on the workforce.
Clearly, the cost of cover has risen to the point where it adversely affects recruitment and retention.
Motivated primarily by the need to indemnify GPs for their NHS work only, the DHSC has announced a state-backed scheme for England.
However, this consultation document identifies a number of potential threats to the public because of a lack of clarity regarding current indemnity arrangements for medical practitioners in private practice, provided by medical defence organisations (MDOs). These may come as a considerable surprise to current members of the MDOs.
In summary, the document
states that the Government is aware of a limited number of cases where MDOs have exercised their discretion not to support a member. Hence, there is no guarantee that ‘patients harmed by the negligence of regulated healthcare professionals can access appropriate compensation’.
Furthermore, the increase in clinical negligence costs ‘may pose a risk that a provider who provides discretionary indemnity cover may use its discretion not to support a healthcare professional. This could result in a healthcare professional being personally liable, and insufficient, or no, compensation for the patient’.
The consultation document highlights that the MDOs are not regulated by the Financial Conduct Authority (FCA), or any established financial regulators. There is no requirement to comply with Prudential Regulation Requirements, so the MDOs do not need sufficient reserves to meet the cost of claims.
It states that professionals ‘face a lack of clarity regarding fairness and transparency obligations’.
In blunt terms, this means your defence organisation may exercise discretion in the event of a medical mishap. It may limit the cover it provides, or provide no cover at all.
In view of these inadequacies, the Government wishes to introduce legislation to make medical indemnity a regulated product. Very significant changes are envisaged:
n Contracts will be provided by an insurer, subject to very tight regulation.
n The current ‘no specific limit on cover’ will be replaced by specific limits, both on claims and specific clinical activities.
n The period of cover will have to specify the ‘run-off’.
n The insurer will have to comply with solvency regulations, with the Prudential Regulation Authority ensuring compliance.
n The FCA Principles of Business will apply.
n The insurer will have to disclose its full financial position and be subject to reporting and oversight.
n Importantly, policyholders will be eligible for compensation from the Financial Services Compensation Scheme if the insurer fails to meet a claim.
The current system is that private hospitals grant ‘practising privileges’ to consultants. These are based on a number of conditions, which are variably enforced in practice.
The surgeon has to demonstrate that he or she has professional indemnity. However, this is paper based and there are concerns this could potentially be circumvented by some individuals, for example by altering relevant dates or simply producing a bogus certificate.
He or she has to show that his or her GMC registration, revalidation and appraisals are current, and also has to satisfy the private hospital’s Medical Advisory Committee that he or she is fit to practise.
Sometimes, this process is subject to only a low level of scrutiny. An up-to-date NHS appraisal is almost always accepted by the private provider – for what that is worth.
In spinal surgery, for example, there is no obligation on private hospitals rigorously to scrutinise a surgeon’s practice; for example his or her clinical ability, patient selection, conversion rate to surgery or post-operative complications.
Having worked as a spinal surgeon for many years, I am only too aware the cost of indemnity for surgery has grown exponentially. For some surgeons, it may exceed £100,000 per annum.
The Medical Defence Union has withdrawn cover for all spinal surgery. While cover is available elsewhere on a discretionary basis, the DHSC notes that these providers ‘do not have to disclose their full financial position, meaning that healthcare professionals may be unaware of the extent of their financial cover’.
Spinal surgery negligence cases take a long time to come to court, so practitioners need assurances that claims can be honoured, even if years down the line.
There is a need for spinal surgery in the private sector. The public has the right to choose to pay for this service, and the insurance industry has a right to offer appropriate and prudent indemnity cover to spinal surgeons. However, this means there is a profound need for such cover to be regulated, and granted on a carefully selected basis. An individual spinal surgeon will have
to ‘prove’ he or she is worthy by accepting rigorous evaluation of his or her practice.
Continuous evaluation
I am determined that our profession takes a leaf out of the aviation industry book, which has pioneered continuous evaluation of performance of its pilots.
I am working with specialist insurance broker MRSL Enterprise on providing attractive cover for spinal surgeons. In this scheme, the surgeon will have to apply for cover and agree to careful scrutiny of his or her clinical practice, with consideration of surgical data. He or she will have to agree to have a senior surgeon ‘sit in’, both in the clinic and the operating theatre, and submit to such ‘real appraisal’ yearly. Clearly some will be offended. The wiser ones will realise there is a prize at the end of it. Lower premiums are obvious.
However, what will emerge is that surgeons who demonstrate they have been granted this form of cover will be the pick of the bunch, and deserve to thrive in private spinal surgery practice.
Mr Munchi Choksey is working with MRSL (Medical Risk Services Limited) to develop a mentoring scheme that will give spinal surgeons access to attractive indemnity.
He was invited by MRSL to offer his insights for this article.
MRSL is a leading provider of insurance, advice and services to medical practitioners. The company has been working since 2004 to help doctors and medical businesses mitigate and manage their risks and reduce their indemnity costs.
For further information on MRSL and its services, please phone 0203 058 3733, email enquiries@mrslenterprise.com or visit www.mrslenterprise.com
l Tax structuring to suit personal circumstances (LLP, limited companies)
l Solvent liquidations
l Consultant groups and consortia
l Assessment of pension contributions in light of tapering annual allowances
l Ad hoc assistance with HMRC investigations and reviews.
NHS GPs are being offered the ability to build private patient networks and develop their own private practices through a fast-growing company set up by a doctor. Naimah Callachand (below) tells the story
PERCEPTION OF what constitutes effective and quality healthcare has fundamentally altered over the past few decades.
Technological developments now mean we can bring healthcare to the patient much quicker.
But while many people may wish to have instant access to healthcare, they also do not want to sacrifice the face-to-face doctor experience for the sake of convenience.
As a result, doctor-on-demand services have created a whole new understanding of doctors’ visits. Whether via the phone or video, everything is now geared towards immediacy being paramount.
ZoomDoc has emerged out of
this cultural turning point as a provider with a difference; the service is fully committed to bringing back the personal experience to patients.
Its app is simple and tailored to the experience of each user. A patient can request a phone or video consultation with a doctor of their choice, which can be achieved within 60 seconds.
In what is perhaps the most innovative, yet traditional feature, it provides the option for face-to-face consultations with a doctor at a location of the patient’s choice –all within 60 minutes of a request.
More than 300 GPs are now registered with ZoomDoc and they can earn from £35 per telemedicine consultation to £200 for a home visit within a pay-as-you-go set-up.
Our team of doctors log on and off in real time, as a platform to deliver great care. We also have a group of GPs who are employed on a salaried basis up to £120,000 a year pro rata.
We now have several thousand registered patients, including many professional mums and dads with dependent children, and our doctors have delivered thousands of consultations since we launched.
Our service prides itself on being easy to use. The development of
A patient can request a phone or video consultation with a doctor of their choice, which can be achieved within 60 seconds
the app focused on prioritising individual user experience, ensuring that patients can effortlessly choose to contact a doctor, based on their location and profile, and arrange a consultation.
We believe anyone can use and understand ZoomDoc, which is
‘The future lies in video consultations. With a shortage of NHS GPs and retirements expected, the future of services like ZoomDoc is huge
perhaps why the service has continued to develop at an exponential rate across the sector.
The foundations
The company’s founder and chief medical officer is Dr Kenny Livingstone.
He describes the business as a passion which emerged from a desire to ‘bring back the connection between doctors and patients and remove some of the more bureaucratic barriers that prevent a doctor from being able to bring a caring, personal service directly to the patient’.
and they worked together to make the ZoomDoc vision a reality.
Initially launching in 2017 with private funding and further supported through a crowdfunding campaign on Seedrs, ZoomDoc received support from high-profile investors. These included tennis star Andy Murray, who was impressed by the company’s ability to provide GPs to people who need support ‘instantly’.
Established investor Ben Doltis – the former chief and founder of SJB Group before it was bought by Experis Manpower Group – not only invested personally in ZoomDoc, but is also an adviser within the ZoomDoc team.
We believe anyone can use and understand Zoomdoc, which is perhaps why the service has continued to develop at an exponential rate
He says: ‘The vision behind ZoomDoc is one of simple, quality face-to-face care. I became an adviser to the team after meeting the founder, Dr Livingstone, who has shown a deep commitment to offering a comprehensive and efficient service which benefits the end user.’
After exceeding its Seedrs target by making partnerships with Lexihealth, a secondary care services concierge, and Dr Julian, a app tailored towards supporting patients with a mental health care offering, the company has continued to build its profile and offering at a phenomenal rate throughout 2018.
This was quickly recognised by investors and app developers alike, ➱ p22
corporate route
The need for ‘on demand’ healthcare is evident, yet the corporate market has yet to fully acknowledge the needs and cost-effective solutions which have begun to emerge.
Private medical insurance is one of the only health benefits that employers offer, but may often fail to provide immediate healthcare solutions to employees.
Taking time off work has become costly to employees, who feel a pressure to keep up with the demands of the modern workforce.
ZoomDoc research has shown that 87% of people come into work sick at least once a year. The consequences of this are ultimately detrimental to every business.
Employees who feel like they cannot take the time off to recover from an illness are likely to become ‘ill-mongers’, who infect other staff members and cost businesses millions of pounds every year.
The opportunity lies in the fact that there is a simple, cost-effective solution for the daily health needs of the workforce – offering corporate on-demand healthcare. ZoomDoc offers access to doctors who can arrive at a patient’s home, office or location of their choice within 60 minutes of request.
Last September, the company announced the appointment of former Bupa UK chief information officer, Garry Fingland.
This is seen as a monumental step forward, as the former Diageo and Serco executive is expected to support the company’s expansion through implementing ZoomDoc’s corporate healthcare benefits.
Lucrative alternative
He says: ‘Virtual healthcare can undoubtedly support many of the more routine medical consultations.
But there is often no substitute for
Dr
Kenny Livingstone, founder and chief medical officer
Garry Fingland, ZoomDoc chairman
the presence of a highly experienced and qualified GP.
‘ZoomDoc’s ability to offer this on demand, typically within an hour of the first call, provides a valuable addition to options available to individuals, parents and employers.’
The option of flexible healthcare benefits is swiftly becoming a lucrative alternative to traditional benefits offered by businesses, and ZoomDoc’s combination of video, phone and face-to-face services is the most comprehensive solution on the market at this time.
One of the doctors who has signed on with ZoomDoc is Dr Nikesh Dattani, a GP partner and GP clinical lead at Barnet Clinical Commissioning Group. He continues to work at his surgery in between his private work commitments.
He says: ‘The speed of this service is different to the NHS. This is very good for the busy people of our world. Home visits are great for families with older people or children or those who are less mobile.
‘It’s even better if we can give them the medication that they need so there is no need to leave their home.
‘The future lies in video consultations. With a shortage of NHS GPs and retirements expected, the future of services like ZoomDoc is huge’.
We believe doctor on-demand services such as ZoomDoc ultimately benefit doctors as independent practitioners as well as the NHS.
The service aims to support the NHS to eliminate waiting times and to offer patients an out-ofhours service that they can access with ease.
The company is transforming what it means to have healthcare support in businesses in Britain and expanding on the remit of what an on-demand healthcare service can offer.
Services such as ours will offer independent practitioners a multitude of options. Whether this will be job opportunities, collaborations or referral options only time will tell.
Naimah Callachand is communications director at ZoomDoc
The service aims to support the NHS to eliminate waiting times and to offer patients an out-of-hours service that they can access with ease
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Boost your patients’ experience! Grant Brookes (below) sets out some effective ways of using technology and your online presence to make this happen
EACH INDIVIDUAL patient’s experience is much more than the time they spend in a doctor’s office. Their experience may be strongly influenced by how they feel after their face-to-face appointments.
But there are many other influencing factors. Everything from the first impressions when they enter your practice to the manner of the person who answers when they call can strongly impact how they feel about your practice.
Your online presence, website and technological abilities as an individual practitioner or private practice can have a lasting impact on patients and potential patients.
A combination of factors will
help a patient decide whether your practice is right for them and not all of it is something practitioners can control.
However, there are some things you can take advantage of, benefit from and use to help ensure you attract patients who are engaged and interested in their own healthcare and open to your advice and support.
Studies have found that 57% of patients want to be more engaged with their doctors and healthcare practitioners, which is why everyone should be doing more to attract and engage with patients and potential patients before they step in the door.
An effective digital strategy
If the patient experience is at the heart of all a practitioner does –which it absolutely should be –then a digital approach and technology-driven strategy is key to keeping patients engaged.
To sustain a patient-focused digital strategy, it is important to take advantage of patient-related and focused technologies.
These technologies exist to further improve and enhance every patient’s experience and drive stronger and better relationships between the practice and each patient.
The digital ecosystem your practice develops is entirely down to
you, but the more technologies you effectively implement, the higher the chance you can keep your patients engaged, impressed and essentially ensure they remain at your practice rather than look to others.
Below is a closer look at some key technological areas independent practitioners can benefit from and where their patients can enjoy an improved overall experience.
Your online presence
The internet is where people look for answers to everything. That is worrying when it comes to healthcare, as they may quickly find the wrong information or rely on resources which cannot be trusted.
This is where a reliable independent practitioner with a welldeveloped website can be invaluable.
If your patients know they can rely upon your website and related online channels as a reliable and trustworthy hub of information, they do no need to look elsewhere.
A 2015 Deloitte study into US Healthcare Consumers found almost 40% of those surveyed automatically looked online for help with health complaints and treatment options.
Your online presence could stop people looking in the wrong places and ensure that if one of your patients has a concern, they will turn to your website first.
Alternatively, they may visit one of your social media channels and be able to actively engage through asking a direct question or message. Of course, this is only possible if you have an online presence your patients can access.
This begins with your website, which can be as basic as providing appointment information, contact numbers and practitioner information.
Or it can be a much larger interactive content base with health information and guidance, so patients have a reliable knowledge source.
It is understandable that some practitioners may be uneasy about the extent of health information online, but it can mean patients are informed and armed with a little knowledge allowing for further testing and analysis when they arrive at your practice. For some patients without online access to
It works to the benefit of your practice to provide your patients with the information they need prior to them arriving at your door
health information, they may never visit a doctor at all.
In addition to a content-rich website, your social media channels are a powerful tool for providing patients with information.
This can be both related directly to your practice and wider health issues such as recognising awareness weeks, blood drives and similar health-orientated activities in your area and nationwide.
The same Deloitte Healthcare study found 23% of patients were already using social media for health-related purposes in 2014-15 and this figure is bound to increase.
It works to the benefit of your practice to provide your patients with the information they need prior to them arriving at your door, as it may make them more likely to attend appointments and maintain their healthcare.
An extension of your website and something a quality web development firm can design for your practice, patient portals are the core of all quality patient experiences outside of your practice.
Online patient portals allow patients access to all information they require with ease on one side. And on the other, they have a practice or professional side, where all patient information is safely stored and accessible by any healthcare provider given the details needed.
A comprehensive patient portal can incorporate appointment scheduling, invoicing and bill paying, lab result access, after-visit summaries and a patient-provider communication channel which is quick and easy.
A key frustration among patients is lack of communication with their practitioners and a well-built patient portal removes this problem.
Patients are able to take a leading role in their own healthcare with an effective patient portal, as they can have direct access to their personal health information. It also enhances the feedback process between patient and practitioner.
While remote monitoring devices and wearable technologies are very new developments, they
Technology can improve patient engagement significantly and the patient experience in turn is enhanced
should be a future consideration for independent practitioners.
Mobile apps are becoming a standard in many industries and there’s no reason a forward-thinking independent practice couldn’t have its own app developed for access to the patient portal or basic requirements such as appointment scheduling.
Remote patient monitoring devices can be used to enhance preventative health management for patients with low-risk concerns or even manage chronic disease in higher-risk patients.
Devices with the ability to execute interventions and make adjustments to care or warn patients of the need to find medical care quickly are already on the market and used by some practices.
Similarly, regular health tracking apps and devices can help to enhance the data that healthcare providers have to work from and use to deliver a higher level of healthcare overall.
Whether a practitioner wants to embrace technology or not, everyone must accept that patients already have. Technology can improve patient engagement significantly and the patient experience in turn is enhanced.
This, once again, further expands a practice’s appeal and, in time, increases a more healthfocused, engaged patient base.
Many independent practitioners have the basics in place but need to enhance their online presence and commitment to technology to further improve patient experiences.
Working with a professional digital marketing agency and web development specialists can help this process and ensure improved patient experiences.
Grant Brookes is managing director of the Web Surgery. Visit it at: www.thewebsurgery.com
Our trio of writers – two doctors and an airline pilot – are co-founders of a business on a mission to improve patient outcomes by helping healthcare professionals understand why errors occur.
John Reynard, Tim Kane and Peter Stevenson’s second article in a major series set to challenge attitudes and inspire you looks at the Highly Reliable Organisation approach to error reduction and the development of a safety culture
ber of fatal accidents occurring in a number of different ‘safety-critical’ industries, notably the airlines, the railways and the chemical and petrochemical processing industries.
Some organisations have actually managed to achieve the goal of ‘zero fatal accidents’ and sustain that achievement for many consecutive years.
level, whether they lead to an accident – cause harm – or not.
THERE IS a fallacy that airlines are only safe because they fly shiny, new aircraft which are so technologically sophisticated that errors have been engineered out of the system.
We have heard many doctors and nurses come to the conclusion – wrongly so – that healthcare has nothing to learn from the airline industry because we have to deal with old and infirm patients with multiple co-morbidities.
That fallacy conveniently forgets that planes are flown by humans and no matter how new and how technically sophisticated the hardware, if the pilot commits an error, the machine may not be able to compensate.
Indeed, technical errors are nowadays unusual in aviation and most errors that do occur – and they still do occur – are nowadays predominantly related to human behaviour: they are human errors. While errors will probably never be entirely eliminated where the ‘system’ relies on humans, it is noteworthy then that in the last three decades there has been an impressive reduction in the num-
So, for example, since the Kegworth air crash in 1989 –almost 30 years ago – at the time of writing, not a single death has occurred on a UK registered jet airliner.
Some – but only some – of this improvement in safety has undoubtedly resulted from the use of more reliable hardware; for example, better designed aircraft.
Organisational psychologists who have studied how this safety improvement has been achieved, have shown that organisations that have also managed to change certain behaviours of their staff have reduced error to very low levels. These have come to be known as ‘High Reliability Organisations’ (HROs).
A set of core principles underlie the HRO approach to developing a safety culture which has led to impressive safety records in those industries.
These principles are:
Data collection;
Analysis of errors and near misses;
Monitoring front-line operations;
Use of standard operating procedures;
Safety-critical communication procedures and training;
Training staff by story-telling –learning from previous mistakes.
No single component is enough, on its own, to make an organisation highly reliable.
A variety of international, national and internal reporting systems exist in the aviation industry. The system is multi-layered.
The Accident/Incident Reporting Programme (ADREP) collects data and disseminates it internationally. The Mandatory Occurrence Reporting Scheme (MORS) is a mechanism that allows adverse events to be notified at a national
A Confidential Human Factors Incident Reporting Programme (CHIRP) allows errors to be reported anonymously. An operational monitoring system allows the collection of information from flight data recorders of every flight, so providing almost immediate feedback to air crew on any errors or deviations from agreed standards.
➢ Analysis of errors and near misses using an error chain model
In most accidents, it is usually possible to identify a person or persons who made the final error which occurred immediately or almost immediately before the accident.
In simplistic, headline-grabbing terms, this individual could then be said to have caused the error. What could be called ‘let’s find someone to blame’ approach to the analysis of the cause of an accident may satisfy a basic instinct. But if, as is usually the case, the errors in the design or management of the system that are usually a component part of almost every error are not also addressed, then sooner or later the error will be repeated.
The Dr Bawa-Garba case is a classic example of the blame approach to error causation. Very little airtime has been given to the analysis of the systematic issues underlying the death of a little boy in her charge – for example, the rota gaps and issues with communication between members of the team on the day.
Rather, the focus of attention has been on the individual – what Dr Bawa Garba did or didn’t do on that fateful day.
The ‘blame’ approach to error causation analysis accounts, in part, for a number of high-profile medical manslaughter charges and convictions in recent years [Ferner 2000, Ferner 2006].
HROs have moved away from such an approach, because a blame culture means that :
a) Errors are repeated;
b) Which, in turn, leads to inefficiency. Cleaning up the mess takes time, energy and consumes resources;
c) Which, in turn, elevates costs and reduces profits;
d) Sanctioning the blamed individual by suspension or dismissal, as well as not preventing future errors, increases the workload for the remaining staff and demoralises the remaining workforce. And a workforce living in fear is not a happy, motivated one.
That is not to say that HROs do not apply legal sanctions for egregious acts. The pilot who boards a Boeing 747 in Washington bound for London under the influence of alcohol can and should expect to feel the full weight of legal and public opprobrium [ Guardian, 2003]. But such extreme sanctions need to be used only very rarely.
The HRO approach to error prevention involves thinking of errors in a new way. HROs consider error as an ‘organisational accident’.
Charles Perrow even created the term ‘normal accidents’ to challenge the view of senior managers
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in these industries that accidents were freak events that could not have been foreseen and could be wholly explained – and prevented – by blaming an individual.
While an individual is often the final component in an error, the other components up front of that individual can be viewed as a chain of events.
This ‘error chain’ approach to error investigation is helpful because it is not too great a leap to imagine that breaking just one or two links in the chain – ideally upstream, so to speak, of the individual’s involvement – can be an effective way of preventing the error chain from running its course towards disaster.
Such an analytical approach has allowed HROs to identify a number of recurring themes: elements that are shared by many error chains. Examples will be discussed in detail in the third of these articles next month.
A recurring theme is the way in which two individuals communicate, or rather miscommunicate, with each other.
They include failure to use readback when passing a safety critical message, failure to summarise plans and the use of ambiguous words. The pronoun is the classic example – more on that in our next article.
Some of these ‘minor’ elements in error chains seem so small and so seemingly innocuous and trivial when seen in the scale of a major accident, that they are easily overlooked as a way of breaking future error chains.
In the prevention of industrial accidents – specifically on construction sites – Heinrich recognised in the 1930s that every major injury was preceded by 29 minor injuries and 300 minor accidents [Heinrich 1950].
Marc de Leval, the great paediatric cardiothoracic surgeon at Great Ormond Street Hospital, realised the same concept applied in surgical practice. In the high-stakes speciality of paediatric cardiothoracic surgery, he identified the deadly cumulative effect of small errors, the explanation for this being that the small errors often go unnoticed and therefore unremedied [de Leval 2000].
While an individual is often the final component in an error, the other components up front of that individual can be viewed as a chain of events
➢ Monitoring front-line operations
Closely allied to the analysis of errors and near misses is the issue of monitoring front-line operations. Every airline pilot and train driver knows that his or her performance is being analysed.
Radio and phone messages are checked for compliance with safe communication protocols. Safeguards are in place to ensure that the monitoring systems are not used to victimise staff.
Pilots and train drivers now accept that the competent operator has nothing to fear from the system. Indeed, there have been several cases where operators were exonerated after an incident which was shown to have been beyond their control.
As well as enhancing compliance with standard operating procedures, when things do go wrong, monitoring systems allow data to be gathered on the operational and environmental conditions which led to an incident or accident.
Not only can this information translate into enhancing safety, but it can be used to improve the efficiency of operations.
In virtually every major accident, the management had not
been monitoring what was happening at the front line and whether the staff were following the existing safety procedures.
Collecting data about errors and, most importantly, analysing the cause of the error by focusing attention away from individuals and towards systemic causes of error is an approach that HROs regard as fundamental to preventing a repetition of an error.
➢ Use of standard operating procedures and safer communication
Once it has been established that a particular way of doing things is associated with better outcomes, that system can be adopted as a socalled standard operating procedure – an SOP.
HROs make use of check lists because they realise that human memory is such that we not infrequently forget to check vital steps in a procedure.
Check lists mitigate against the error of forgetting. HRO check lists tend to be short, concise and relevant because they appreciate that the longer check list is less likely to be completed properly, i.e. bigger is not better.
Safe communication protocols have been adopted by HROs because communication failure is recognised as a major – and easily preventable – source of error.
HROs provide their staff with socalled ‘human factors’ trainingtraining in the psychology of error and in simple techniques to mitigate or prevent error.
They have come to realise that focusing on safety training not only enhances an organisation’s reputation, but it also makes the organisation more efficient.
A major factor in this has been the improvement in the reliability of verbal communication between staff. Not only does better communication enhance safety but it minimises confusion, wasted effort and delays.
These improvements in effi -
ciency have resulted in the rise of the ‘low cost’ airlines in the last two decades, without compromising safety. Budget airlines are therefore just as safe as the ‘highend’ airlines.
Next month: We focus on just one aspect of the High Reliability Organisation (HRO) approach to error reduction and the development of a safety culture – training staff by story-telling as a way of genuine learning from previous mistakes.
John Reynard, Tim Kane, and Peter Stevenson are co-founders of Practical Patient Safety Solutions.
John Reynard is a consultant urological surgeon and honorary senior lecturer in the Nuffield Department of Surgical Sciences at the University of Oxford. He is an honorary consultant urologist to The National Spinal Injuries Centre at Stoke Mandeville Hospital.
Peter Stevenson has been an airline pilot and human factors instructor for over 30 years. He flies Airbus A330 airliners on intercontinental routes for a major UK airline.
Tim Kane is a consultant trauma and orthopaedic surgeon at Spire Portsmouth Hospital and the city’s Queen Alexandra Hospital.
Ferner R. Medication errors that have led to manslaughter charges BMJ 2000; 321: 1212-16.
Ferner RE, McDowell SE. Doctors charged with manslaughter in the course of medical practice. J Royal Soc Med 2006; 99: 309-14.
Virgin Atlantic Boston flight 2003 www.theguardian.com/business/2003/ dec/21/theairlineindustry.travelnews.
Heinrich HW. Industrial Accident Prevention: A Scientific Approach, 3rd Edition McGraw-Hill 1950 (first published in 1931).
de Leval M, Carthey J, Wright DJ et al. Human factors and cardiac surgery: a multicentre study. Journal of Thoracic and Cardiovascular Surgery 2000; 119: 661-72.
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Beware of these five common practice management errors. Kingsley Hollis shows how to avoid them
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THERE IS a unique museum in Sweden which showcases prod ucts and services that flopped with the public.
From Betamax video recorders to a short-lived Donald Trump board game, visitors to the Museum of Failure can relive, puzzle and occasionally wonder at the inno vations that seemed a good idea at the time.
But rather than mock failure, the museum’s creator, Dr Samuel West, wants to celebrate it. A message on the museum website reads: ‘It is in the failures we find the interesting stories that we can learn from’.
Here are five errors that I regularly see in independent practice. By being alert to the pitfalls, I hope that Independent Practitioner Today readers will be able to sidestep them.
Practising in isolation
For all its downsides, working in an NHS hospital is generally a collegiate environment where problems can be discussed with other doctors and healthcare professionals and you can seek support from teams of administrative and IT professionals.
One potential risk to independent practice is that it is easier to become isolated, which can be stressful, as well as making it harder to revalidate, keep up to date with new innovations and share best practice.
If you are working in a singlehanded practice, guard against isolation by connecting with fellow doctors at every opportunity, perhaps through the Independent Doctors Federation, BMA, your royal college or medical society.
Aside from professional and clinical matters, I would also recommend seeking advice on practice ownership from those who have been there. With more than 20 years’ experience in the independent health sector, I’m always happy to help practitioners who are unsure about any aspect of practice administration and management.
If you are just starting your private practice, it is possible to get by with separate spreadsheets, word processing and generic accounting software.
edly the most efficient way to manage the process, as it means you can create and submit bills online in a fraction of the time it takes to print and post.
E-bills submitted via Healthcode’s clearing system are secure and validated according to insurer rules, so they are ready for processing and payment.
Electronic billing ... means you can create and submit bills online in a fraction of the time it takes to print and post
However, you will probably waste precious time having to reenter data on different systems in order to complete routine administrative tasks and this will become more of a challenge as your practice grows.
A practice management system which is developed specifically for independent practice should allow you to manage your workflow from one place.
It should encompass capturing patient details and appointment scheduling to electronic medical billing and generating management reports, which help you keep track of the money you are owed. In short, a purpose-built system should save you time and quickly repay your investment.
Being an independent practitioner is incredibly rewarding, but no one can be expected to work for nothing.
Invoicing is often seen as secondary to chargeable work and a bit of a chore, but this attitude is counterproductive.
At Healthcode, we regularly see bills submitted months after the service date, but this presents problems for the recipient – some insurers have a time limit – and is storing up serious cash flow problems for the practice too.
Ensuring you are properly remunerated for your expertise, services and time is essential if you want your practice to stay afloat.
Electronic billing is undoubt -
Fees are a complex area, as each private medical insurer has its own pricing schedule, while some specialists within the same practice might charge more depending on their experience and qualifications.
The GMC says doctors who charge fees must tell patients about these, if possible before seeking their consent.
Besides this ethical obligation, lack of clarity or misunderstandings over pricing could leave you out of pocket, facing a patient complaint or in dispute with an insurer.
For clarity and consistency, I recommend drawing up a common pricing table that everyone in the practice can refer to and use to advise patients.
Use this to record your fees for consultations, procedures and diagnostic tests for every specialist and any exceptions for where these differ for particular insurers or patient groups.
It’s also in your interests to help prospective patients understand your basic charges before they make contact, by listing these on your website and providing information about insured and selffunded payment arrangements.
While you might have a clear image of how you want your practice to run, you can’t expect others to automatically adopt your working methods. And during busy times, it’s tempting to take a short cut to get the job done.
Whether it is how you want patients’ details to be recorded, making appointments, complainthandling, responding to subject access requests or credit control, it makes sense to invest the time in establishing clear step-by-step procedures for everyone to follow.
That way, you can provide an efficient, consistent service for every patient or visitor to your practice and, as with any form of safety-netting, it minimises the chance of a costly mistake.
It is often said that those who do not learn from mistakes are condemned to repeat them. While success stories are important in independent practice – as they show what can be achieved – it is just as important not to gloss over mistakes.
Being aware of what can go wrong provides insights that can help us all to progress.
Next month: Is it really possible to go paperless?
If more doctors reviewed their incomes, it would show them it’s time to find new ways of running their private practice because their business efficiency is no longer what it was. Garry Chapman reports
RUNNING A PRACTICE in private medicine even only a decade ago was relatively simple.
Of course, back then you would have found it difficult to find someone that would agree with that statement.
But now, when you look at the big changes that I’ve set out below, I think most consultants would agree.
Running a private practice in 2009 was mostly based around insured patients. People who had private medical insurance had peaked at 12.4% of the population.
Dealing with the insurance companies was a painless process; the invoicing was sent by post with no time limits being enforced.
Most of the insurers would pay fees that they would term custom-
ary and reasonable and there were some that did not even publish a fee schedule.
This meant that the practice could set its own fees and oversee its own pricing policy.
More than 70% of insured patients had their policy as a benefit through their employer. This meant they were not preoccupied with costs, as their policy typically met all the costs.
The number of shortfalls or policy excesses they incurred were low. Consequently, dealing with patients was a relatively simple process, so the amount of interaction was at a low level.
Back then, self-pay patients did exist but the NHS was in a different place regarding waiting lists and the level of care patients received,
so most people did not need to look outside it to get the treatment required.
Those who did so generally did not need to worry about private treatment costs.
All this meant the medical secretary or practice manager could find time to deal with the practice’s demands. There was no industry policing; they did not have to publish fees nor meet deadlines for billing, and the patients were not so demanding.
Our company Medical Billing and Collection (MBC) was established in 1992 and only had 50 clients in 16 years of being in business. Outsourcing the billing and collection was just not recognised as an adopted business model a decade ago.
On 15 September 2008, Lehman brothers bank filed for bankruptcy and this set off a chain of events which has changed the face of private practice in the UK beyond recognition.
This event started with what many economists called the worst financial crisis since the Great Depression of the 1930s and it became known as the Global Financial Crisis.
All the highlighted points below would have had a significant impact on the practice on their own. But add them all together and you can see why the running of a private practice has dramatically changed.
The practice now has a multitude of different dynamics to deal with on the insurers’ front. A key area has been around the fees a practice can now charge.
The main changes are:
Reduced doctors’ fees across the board from the majority of insurers;
Reduced acceptance of using multiple codes, thereby limiting fees;
Fee-assured schedules enforced by many insurers;
A constant downward pressure on fees, continuing to this day.
On top of the fee reductions and multiple code changes, the majority of insurers require the practice to submit the invoices electronically and within a given time
frame or they will reject the invoice totally and refuse to pay.
The Clinic Coding and Schedule Development Group (CCSD) fee schedule was introduced in 2006 and, since then, has become a major part of running a private practice. Each month, a list of changes is published which can include old codes being deleted, new codes added and combination rules changed.
This all needs to be kept on top of by the practice, particularly as each insurer can decide to accept the schedule in whole or in part, meaning that they can have their own rules – and that is frequently the case.
The self-pay sector has increased dramatically, with growth starting slowly in 2010 and increasing exponentially over the past few years. There are many reasons for this, but the main ones are:
Long NHS waiting lists;
High premiums on medical insurance, making patients selfinsure;
Fixed-price packages making it easier to choose treatment at a competitive price;
People wanting choice for their treatment and choosing to use their disposable income.
The patient has also become much more demanding. Over the past ten years, the use of the inter-
The major points of difference which make running a private practice so difficult today when compared to a decade ago are highlighted below.
On average, the self-pay sector has become the largest source of revenue and activity in private practice when compared to individual private medical insurers and it continues to grow at a fast rate
Patient expectations are much higher and with the use of email/ internet, the patient can be in contact with the practice on a 24/7 basis creating unprecedented levels of activity
Increased compliance within the health sector with the publication of fees and medical competence via the Private Healthcare Information Network (PHIN)
Practice manager/medical secretary must deal with a multitude of administrative tasks and is expected to be an expert in everything –which is unrealistic
In 2008, the average invoice value we raised was £270.16
In 2018, the average invoice value we raised was £202.89
The last point means that, over this period, there is a staggering drop of 25% for carrying out the same treatment, while at the same time dealing with all the increased compliance, administration and levels of patient activity has greatly increased the running costs of the practice during the same period.
net has become widespread and the all-pervading presence of Dr Google means that everyone has become an expert.
Email use is now prevalent in everyday life, particularly with the advent of smartphones, and patients communicating this way want an immediate response. If they do not get a reply, they resend the email and that means more activity for the practice to deal with.
It seems everyone has a mobile or smartphone these days, meaning patients can call the practice anytime during the day. So interaction levels with the patient are at an unprecedented level.
In 2014, the results of the Competition and Markets Authority investigation into the private healthcare market were published, resulting in a fundamental change to the way information must be made available.
This, combined with the introduction of the General Data Protection Registration (GDPR) rules regarding data protection around patient information, has added another layer of complexity for the practice to deal with.
If we accept running a private practice has become far more dif-
ficult and complex over the years, then what is the answer?
If consultants want to address the issues that the practice is facing daily, then they need to decide how they can change things to enable the practice to work faster, smarter and be more efficient. One way is to outsource certain tasks currently done by the practice.
Areas a practice can consider include a transcription service where the dictation by the consultant is outsourced to a company who will transcribe the letters and send back for approval prior to sending them out.
Another area is to outsource the phone calls. As most practices have only one phone line, you can outsource the overflow calls to a designated organisation.
But the area which saves most time and money is the billing and collection.
Using a specialist organisation means the consultant reduces the amount they must invest in both time and money in administration
The main option to consider for reducing the secretarial workload is outsourcing your medical billing and collection to a specialist organisation.
Otherwise billing and collection takes up an enormous amount of time and requires the secretary to liaise with the patient about both medical and financial matters, which, for most secretaries, is not ideal.
Many consultants feel their secretary will not like this, but from our experience, that is not true. While some secretaries are initially reluctant, once the transition has taken place, they would not want to revert, as it removes a huge burden from their shoulders. Using a specialist organisation means the consultant reduces the amount they must invest in both time and money in administration.
They will also not have to spend
valuable time learning and keeping abreast of the changes in the CCSD schedule. They can maximise time for their patients – and generate further income.
Consultants may be nervous about outsourcing their finances, but they need to balance that feeling against the benefits and the amount of time the secretary would save without needing to carry out the billing and collection tasks.
Outsourcing benefits include:
➲ The relationship between the consultant and the patient is kept purely at the medical level, which ensures the relationship is not tainted in any way regarding the commercial aspects.
➲ Expertise in both medical codes and the nuances of each insurer about how the codes should be used ensures the billing revenue is optimised.
➲ Expertise in ensuring that all the relevant information is pre -
SPECIALIST MEDICAL ACCOUNTANTS
Since starting in the mid 1970’s Sandison Easson has continued to grow and is one of the largest independent medical specialist accountants in the UK.
Since starting in the mid 1970’s Sandison Easson has continued to grow and is one of the largest independent medical specialist accountants in the UK.
Since starting in the mid 1970’s Sandison Easson has continued to grow and is one of the largest independent medical specialist accountants in the UK.
Sandison Easson acts for medical professionals throughout all stages of their career and has clients in almost every town in England, Scotland and Wales.
Sandison Easson acts for medical professionals throughout all stages of their career and has clients in almost every town in England, Scotland and Wales.
Sandison Easson acts for medical professionals throughout all stages of their career and has clients in almost every town in England, Scotland and Wales.
We provide the usual services you would expect from an accountant such as preparation of your accounts and tax declarations but offer so much more including advice on:
We provide the usual services you would expect from an accountant such as preparation of your accounts and tax declarations but offer so much more including advice on:
We provide the usual services you would expect from an accountant such as preparation of your accounts and tax declarations but offer so much more including advice on:
• Setting up in Private Practice
• Setting up in Private Practice
• Setting up in Private Practice
• Developing your Private Practice
• Developing your Private Practice
• Developing your Private Practice
• Tapering of the Annual Allowance
• Tapering of the Annual Allowance
• Tapering of the Annual Allowance
• Lifetime Allowance planning
• Lifetime Allowance planning
• Lifetime Allowance planning
• Personal Allowance planning
• Personal Allowance planning
• Personal Allowance planning
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• Expenses that you can claim and those you cannot
• Expenses that you can claim and those you cannot
• Expenses that you can claim and those you cannot
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• Reviewing your PAYE Coding Notices
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Many consultants need to decide if any action is needed to ease the workload on their secretary.
Carrying out your own health audit will help you decide this.
Establish:
How much time is spent in dealing with each aspect of the daily tasks
When was the last time your practice reviewed the codes it uses
When fee schedules were last reviewed
How much money you are owed and how old the debt is
Which patients owe you the most money and when they were last chased
Whether you are behind with administrative tasks such as billing, typing letters and responding to patient emails
Outsourcing should never be seen as a reflection on any secretary’s ability to manage the practice
sent and correct when raising the invoice means there are no delays in the insurer or the self-payer accepting the invoice.
➲ Resources to ensure no delays in raising invoices so they can be chased in a timely manner and give you the best chance of minimising bad debts.
➲ Resources combined with an efficient process in place for chasing unpaid invoices, following up on shortfalls and dealing promptly with any problems with claims. This results in vastly improved cash flow combined with bad debts being greatly reduced.
➲ A variety of management and tax reports which can be tailored to the requirements of each practice.
➲ Practice disruption, such as secretarial absence for sickness or holiday, does not affect the allimportant billing and payment collection, and continuity is assured.
Secretaries are extremely hard working and loyal to the practice they work for and outsourcing should never be seen as a reflection on any secretary’s ability to manage the practice.
It should be seen as simply another tool to assist in running the practice and at the same time freeing up valuable time to spend on the other important patient facing tasks.
Garry Chapman (below) is executive chairman of Medical Billing and Collection
Where we are today in private healthcare owes much to the development of the NHS. Dr Ellen Welch (below) presents some more of the key milestones down its 70 years
1980 MRI Scans are introduced providing detailed information about the soft tissues of the body by using a combination of magnetism and radio-frequency waves.
Laparoscopic surgery is used for the first time to remove a gallbladder.
The Black Report , commisssioned by the Labour Government in 1977, investigates inequalities in health, finding that those in lower socio-economic groups suffer higher rates of mortality.
Access to health services, particularly preventative services, is poor among the working class. It recommends increased spending on community health and pri -
mary care, and government intervention with increased child benefits, improved housing and agreeing minimum working conditions with unions. The new Conservative government did not endorse these recommendations due to the scale of expenditure involved.
1981 First UK death from AIDS. A 41-year-old man dies from an acquired immunodeficiency syndrome-related illness in London. Terry Higgins was one of the first people to die of the disease a year later, leading to the formation of the Terrance Higgins Trust. By 1984, scientists had identified that the human immunodeficiency virus (HIV) caused AIDS and testing was introduced in 1985. The ‘Don’t die of ignorance’ public
health campaign was launched in 1987.
1982 NHS Reorganisation –the area tier of NHS management is abolished, resulting in the creation of 192 district health authorities that are responsible to the regional health authorities with the aim of simplifying the structure. This is the start of many more re-organisations over the next three decades.
National Confidential Enquiry into Patient Outcome and Death (NCEPOD) is born. A review of surgical and anaesthetic practice is analysed over a year in 1982, known as the Confidential Enquiry into Peri-Operative Deaths (CEPOD). The venture is given government funding and renamed NCEPOD in 1988,
extending its remit to include medical patients in 2002. Today, NCEPOD is an independent charity that reviews patient care by undertaking confidential surveys and research. NCEPOD reports have shaped the way healthcare is delivered in the UK, and their recommendations have created good practices such as peer review of mortality after surgery and ensuring hospitals admitting emergency patients have access to 24-hour radiology, operating and recovery rooms.
1983 The Mental Health Act introduces the issue of consent to treatment. Prior to this, a detained patient could be treated against their will, even if they were a ‘voluntary’ patient. The Mental Health Act allows
people to be detained – or ‘sectioned’ – against their will for the urgent treatment of mental disorders if they are at risk of harm to themselves or others.
The Griffiths report is published, heralding a new managerial age in the NHS. It advocates NHS management boards at arm’s length from the government, and general managers with responsibility for performance and budgets in hospitals and district health authorities, bringing their experiences of business school and the private sector to NHS leadership.
Doctors are encouraged to become involved with corporate decision-making.
The UKCC (United Kingdom Central Council for Nursing, Midwifery and Health Visiting) is set up to replace the General Nursing Council in maintaining a register of nurses.
1986 First case of BSE in cattle is reported by the State Veterinary Service in the UK. Bovine spongiform encephalopathy – or ‘Mad Cow Disease’ –caused fatal changes to the brains of cows. In 1990, a domestic cat was diagnosed with the disease, raising concerns that transmission to humans was possible. Up until 1996, when the link is acknowledged, the government told the public there was no evidence the disease could be passed onto humans. An estimated 400,000 cattle infected with BSE entered the food chain in the 1980s and over the next 25 years, 177 people contracted and died from a disease with similar neuro-
logical symptoms called new variant Creutzfeldt-Jakob disease (vCJD) thought to be from eating contaminated beef.
Mass slaughter of infected herds takes place and a ban on exporting British Beef is imposed by the EU.
The BSE inquiry is published in 2000 and concludes that the crisis was a result of intensive farming and cows being fed with dead animal remains. The government’s reassurance campaign was branded a mistake, which left the public feeling betrayed.
1987 Promoting Better Health – The government’s plans for improving health are published in this White Paper, pledging a fee for primary care doctors taking part in health promotion work such as health checks and immunisations.
These proposals formed the basis of the 1990 GP contract.
The world’s first heart, liver and lung transplant takes place in Cambridge at Papworth Hospital, carried out by Prof Sir Roy Calne and Prof John Wallwork. The patient survives ten years and her healthy heart is then donated to another transplant patient.
1988 National cervical screening introduced.
Breast screening introduced. The Forrest Report on breast cancer screening concluded there was a convincing case to screen women over the age of 50 with mammograms as long as there would be effective resources in place to deal with any abnormalities found through the process.
Routine newborn hearing testing is introduced at Whipps Cross University Hospital, Leytonstone, east London, using otoacoustic emission technology.
1989 Working for Patients –
The government’s White Paper sets out plans to reform the NHS, introducing the creation of the internal market by splitting the bodies that provide care from those that purchase it.
Health authorities are required to manage their own budgets to purchase the best possible healthcare services for their areas – even if that means favouring external organisations over their own local hospitals.
Meanwhile, hospitals can apply to become NHS trusts – independent organisations with their own management.
GPs with registered populations of at least 11,000 patients are able to apply for practice budgets to purchase hospital services.
The nineties saw increasing choices for patients and the creation of services such as NHS Direct. Advances in technology and the rise of the internet shaped society, leading to the emergence of expert patients and multiple health charities.
The Human Genome project took off and gene therapy developed, as did cloning and the use of human tissue in medicine, while the MMR Scandal and GP serial killer Harold Shipman hit the headlines.
The concept of commissioning was introduced to the NHS in the early 1990s, when the ‘internal
market’ was born – internal, because both buyers and sellers of services were NHS organisations.
Until 1989, health authorities decided on the amount of care needed and provided it through their own hospitals.
The Conservative government introduced these market theories into healthcare on the premise that the public sector is inefficient and the private sector brings growth and innovation.
It argued that by making providers compete for resources, greater efficiency and innovation would be encouraged.
When Labour came into power in 1997, it fiercely opposed the internal market and abolished GP Fundholding . . . only to reverse its position and re-introduce it under a new name a few years later in the form of practice-based commissioning.
Labour also devolved power to an elected parliament in Scotland and an elected assembly in Wales and Northern Ireland, resulting in four separate health systems.
☛ Adapted from The NHS At 70 – A Living History, by Dr Ellen Welch, a cruise ship doctor and GP in West London. £12.99 from www.pen-and-sword.co.uk
Independent Practitioner Today readers can get 25% off 'The NHS at 70', plus free UK p&p. Quote NHS70 at www. pen-and-sword.co.uk
Since 2011, I have used CPS exclusively for all my histopathology. Altogether an excellent service that I recommend to all my consultant colleagues.
Mr George Fowlis – Consultant Urological Surgeon
Calling doctor entrepreneurs: lawyer Michael Rourke warns to beware of the potential intellectual property mistakes you could make if you are considering the development of your own health technology
TECHNOLOGY AND innovation is at the forefront of current medical practice, with new software, apps and websites being released regularly.
Over the past few years, there have been numerous stories about new health care apps and ideas that have appeared in both industry journals and in the wider media.
The sector has seen a growing number of doctors embarking on the development of software, apps and websites which they hope will improve the delivery of services to patients.
Intellectual property (IP) is the term that is used to describe things
that can be owned but are not physical in nature. Examples of this would include copyright, the code forming part of an app or the design behind a company’s logo. IP is something unique that you create or that is created for you but which you have the right to control. Ideas by themselves are not IP in the law, but things that result from an idea can be. One error we see is practitioners not necessarily realising what IP is or who may own this seemingly elusive thing. The owner of IP doesn’t own something that is physical but instead has the right to control how an intangible thing is used;
One error we see is practitioners not necessarily realising what intellectual property is or who may own this seemingly elusive thing
for example, a logo or brand name. Outside of healthcare, these IP rights are sometimes more obvious.
For example, it is the ownership of the branding for ‘Nero’, ‘Starbucks’ and ‘Costa’ which prevents rival coffee shops opening under these names.
You can have joint ownership of IP; it can belong to individuals as well as businesses and you can also sell and dispose of IP in a similar way to a normal physical object.
It is important for businesses to be aware that IP is a company asset, which can carry a significant value. This is emphasised by figures from a recent report published by the UK Government, which showed that the world’s five most valuable companies are worth £3.5 trillion together, but their balance sheets show just £172 bn of tangible assets.
This means that 95% of their value is in the form of intangible assets such as IP and data. It is therefore fundamental that any business which requires IP to be operational has the appropriate rights to make use of that IP. There can often be confusion over IP rights held by small or start-up companies.
Often new start-ups begin in a relatively informal manner. A good idea by an individual or group of interested investors may lead to some seed money to pay for the development of a website or app.
A business may be even more informal, with family members or friends assisting with the designing of your company logo or writing the initial code for a potential app.
In the absence of a clear agreement or an employment contract
with the individuals providing these roles, the ownership of IP may be difficult to discern and may lie with them and not necessarily with you or any company you may create.
In the majority of cases, especially with family members, it may be relatively simple to arrange for any unclear IP ownership issues to be resolved.
There are two main ways in which this can be done: firstly, the company can be given permanent ownership rights through what is known as an IP Assignment, whereby ownership of that particular IP is ‘assigned’ by the owner to the company.
Alternatively, the owner of the IP can retain ownership of it but license the right to use it to you by way of an IP licence.
In general, if someone is an employee of a company, the law states that any IP created during the course of their employment will automatically lie with the company, unless there is an agreement to the contrary.
However, for non-employees such as consultants or freelancers, the IP will typically remain with that individual, unless there is an agreement to the contrary. Quite often the position in relation to IP will be dealt with under a consultant’s terms and conditions or similar agreement, but it is important to check this carefully.
IP rights are key at any stage of business, but are often overlooked during the early stages, which can have negative consequences in the future. Where the rights over, for example, a name or logo are disputed, it may prove easier and cheaper to change these than to dispute ownership.
But this may damage the business or potentially leave competitors able to exploit this. The written or video materials on your website, the operational code of your app, the very name of your business are important, and the ownership and right to use these should be clear.
Michael Rourke (right) is a partner at Hempsons Solicitors
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what are you saving for? Patrick
Convey explains why this decision will help shape your best course of action
EVERY YEAR, the ‘basket’ of goods used to calculate the Consumer Price Index rate of inflation shows how our collective lifestyle has evolved.
Last year, we saw the arrival of women’s gym leggings, raspberries, GoPro cameras, non-dairy milk, liver and medium-density fibreboard (MDF).
I was surprised that those last two were not featured in the basket back in the 80s, but was more interested to read that the cost of bouncing a cheque was only removed last year.
No doubt, our own personal
inflationary basket would look somewhat different. Have you ever considered what eclectic mix of regular purchases make up your own annual expenditure?
Retirement basket
In fact, many of us do not have an accurate picture of our total outgoings and yet, without this figure, how can we ensure our savings are on the right track? Are you diligently saving without a clear idea of what you are saving for?
New clients will often ask us how much money they will need in retirement. The finances, however,
are never the starting point of properly planning the future.
First, we explore your current lifestyle and what you would like this to look like in retirement. What will be in your ‘basket’? We discuss your aspirations for the years ahead and whether there are projects or ambitions still to be realised.
Do you intend to finish work completely or scale down your commitments over time? Will you wish to maintain current standards of living or intend to change direction? For example, you may wish to downsize drastically or
instead, host weekends for three generations of your family. Individuals have varying designs on what ‘their time’ might look like. Only when we have clearly defined life objectives can we then consider a realistic and credible financial plan to achieve them.
In most cases, you will need significantly less to live on in retirement, as mortgages are paid off, your offspring have flown the nest – hopefully – and there is no costly commute to work. What is important to factor into
the equation is that you may enjoy a three-decade retirement. Life expectancy is such that you may well enjoy a work-free third age nearly as long as your career.
A further challenge is that, at times, it can seem as if the goalposts are always changing. New pieces of financial legislation, changes to the NHS pension scheme and tinkering with tax relief can make it difficult to calculate if you are on the right path.
Detriment to saving
The reduced lifetime pensions savings limit, which now sits at £1,030,000, is one such obstacle. Senior doctors are discouraged from boosting their retirement fund beyond the lifetime allowance because doing so will attract substantial tax penalties of up to 55% on excess savings.
We have already seen the impact of this – clients considering retiring earlier than anticipated
New pieces of financial legislation, changes to the NHS pension scheme and tinkering with tax relief can make it difficult to calculate if you are on the right path
because staying on in the NHS could be financially detrimental.
The calculations are complex and the reduction in the lifetime allowance figure, which once stood at £1.8m just seven years ago, means that retirement planning as early as possible is now essential.
In a similar way, the annual allowance which restricts tax-free savings per year to just £40,000 is penalising doctors tied into making pension contributions and therefore likely to walk into an excess tax charge.
The new ‘tapered’ version of the annual allowance for those with adjusted income earnings over £150,000 reduces the limit further, down to as low as £10,000 for those earning £210,000 or above.
The key to navigating testing financial waters is ensuring your overall financial plan is fit for purpose. It should be able to weather any storm and keep you on the
right track to a happy and financially stable retirement.
Patrick Convey (right) is technical director of Cavendish Medical, specialist financial planners helping consultants in private practice and the NHS
The content of this article is for information only and must not be considered as financial advice. Cavendish Medical always recommends that you seek independent financial advice before making any financial decisions.
Levels, bases of and reliefs from taxation may be subject to change and their value depends on the individual circumstances of the investor. The value of investments and the income from them can fluctuate and investors may get back less than the amount invested.
Independent Practitioner Today has joined forces with leading healthcare lawyers Hempsons to offer readers a free legal advice service.
We aim to help you navigate the ever more complex legal and regulatory issues involved in running and developing your private practice – and your lives.
Hempsons’ specialist lawyers have a long track-record of advising doctors – and an unrivalled understanding of the healthcare system as a whole.
Call Hempsons on 020 7839 0278 between 9am and 5pm Monday to Friday for your ten minutes’ of free legal advice.
Advice is available on:
Business structures (including partnerships)
Commercial contracts
Disputes and litigation
HR/employment
Premises
Regulatory requirements and investigations
Dr Kathryn Leask (right) advises a private GP on what to do when a patient threatens violence
QI am a private GP and have been seeing a patient who has a number of minor medical problems. He has also suffered with depression and alcohol misuse in the past and has previous criminal convictions for violence.
When I saw him for a followup appointment this morning, he was very agitated and angry because his partner had left him for another man, whom he knew.
The patient had been drinking more heavily over the last week or so and said that ‘they would not get away with this’.
The patient said he knew where the other man lived and which pub he went to and was going to stab him with a kitchen knife to ‘make him suffer’. The patient was still very angry when he left my clinic room.
How concerned should I be about this and should I inform the police?
AThe trust between a doctor and patient is extremely
important in order to establish an appropriate therapeutic relationship. However, there may be times when you have to consider breaching a patient’s confidentiality. One of those times may be when it is in the public interest to do so. This may be to protect individuals or society from harm, such as serious crime.
This patient has made a very specific threat towards an identifiable individual and has engaged in violent behaviour in the past. While this may increase the need for disclosure of relevant information to an appropriate authority, you do still need to consider patient confidentiality.
If it is safe to do so and it would not put you or anyone else at risk, you should discuss your concerns with the patient explaining that while you do have a duty of confidentiality to him, you also have an obligation towards public safety.
As well as your concern for the intended victim, the patient would also be putting themselves at risk if they carried out any violent act against a third party. If you feel that the threat is real, and outweighs the benefits of maintaining confidentiality, you should explain to the patient why
you feel you have an obligation to tell the police.
Reassure him that you will only give the minimum amount of relevant information necessary, without disclosing personal information from his medical history.
You should clearly document your discussion with the patient, including your reflection on any objections he makes to disclosure, and your justifications for breaching his confidentiality.
Having raised your concerns with the police, they may ask you for more information about the patient’s past medical history and also for a statement regarding the threats the patient made.
You should ask the police to provide you with the patient’s consent to disclose any additional information to them, particularly if the threat has been removed and he is no longer a danger.
References
1. GMC: Confidentiality: good practice in handling patient information, paragraphs 63 to 70.
2. GMC: Confidentiality: good practice in handling patient information, paragraph 63
Dr Kathryn Leask is a MDU medicolegal adviser
Dr Kathryn Leask advises how to handle a patient who objects to her past medical history being shared with a new specialist
QI am a private GP and have had a patient under my care for a number of years. She has a long medical history and our electronic system lists the main problems on a problem list. This list is automatically printed out and included when a referral letter to secondary care is made, along with a current list of medications.
The patient was recently referred to an orthopaedic consultant due to knee pain she had been experiencing after an injury. As is my usual practice, I copied the referral letter to the patient for her own records.
A few days later, I received a letter of complaint from the patient due to the fact that the problem list was included in the referral letter.
Her complaint was that some of the information was not relevant for her referral; for example, that she had had a termination of pregnancy when she was in her late teens.
I had felt that it was appropriate to include the patient’s problem list to ensure that the doctor the patient was being referred to had all the information they needed. However, this complaint has made me reconsider this.
AWhen making a referral to another health care professional, it is obviously important to include all of the information that is relevant to ensure the provision of safe and effective care.
It may not always be obvious to a patient why a medical problem in the past is relevant to a problem they are currently experiencing and a clear explanation should resolve their concerns.
The GMC says that you ‘should
share relevant information with those who provide or support direct patient care, unless the patient has objected’.
If you feel that information is relevant, but the patient may not appreciate this or may object to its disclosure, you should discuss this with them so that they understand the purpose of the disclosure and have the opportunity to refuse. If a patient refuses for certain information to be disclosed, which you feel is relevant and important, you should explain the potential consequences of their decision and the impact this may have on their care.
You should consider carefully whether information is relevant and, in this case, you may feel, with hindsight that the consultant did not need to know about the termination and possibly other problems on the automated list.
The complaint should be investigated and dealt with through your usual complaints procedure. In your response, you can advise the patient of any changes you have made to your practice as a result of her complaint, in addition to apologising for any distress this has caused her.
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The North-east is our stop-off this month in Philip Housden’s tour of NHS private patient units (PPUs)
THIS MONTH, we review private patient revenue growth for eight – soon to be seven – NHS acute trusts across the North-east region covering the conurbations of Tyne and Wear and counties of Durham and Northumbria.
The figures used here are from the recently published 2017-18 annual accounts, although one trust has not included private patient revenues in that document at the time of writing, and so the prior year total has been used.
For this regional group, the accounts show total private patient revenues rose in 2017-18, making up around half of the significant reduction experienced the year before. Total revenues are recorded at £6.3m in 2017-18, up approximately 9.4% from £5.8m in 2016-17 (Figure 1).
This level of income represents an increase to 0.19% of these trusts total patient-related activity revenues, up from 0.17% in 2016-17 and still below the long-term regional average of 0.22%.
These figures are below the combined national average outside of London of 0.5%.
These eight acute trusts vary significantly by private patient revenues (Figure 2, opposite).
The regional top earner is The Newcastle Upon Tyne Hospital at £3.9m, up £384k year on year (11%).
This is 0.43% of the trust’s total patient revenues and the trust is
the only one in the North-east with a private patient inpatient ward: the newly opened five-bed Park Suite at the Royal Victoria Infirmary. The trust also has dedicated private outpatient consulting rooms located in The Lodge, also on the RVI site.
Across the river, Gateshead Health has also seen private patient income growth, rising to £610k last year from £538k in 201617. Cumulative growth has been over 50% in the past three years.
South Tees Hospitals is the other significant private patient earner in the North-east. Revenues last year totalled £1.15m, up 11%.
However, these totals are well down on the £1.7m to £1.8m achieved three to five years ago and represent a decline from 0.33% of trust revenues to circa 0.2%.
The trust offers private patient services from the Wensleydale Suite at Friarage Hospital in Northallerton through a four-
room treatment and consultation outpatient area.
Also, at the James Cook University Hospital in Middlesborough, there are private patient fertility and therapy services and a commercial arrangement with Sk:n, the dermatology provider.
City Hospitals Sunderland have reported a flat circa £400k revenue in recent years, but their 2017-18 accounts is one of a handful in the NHS not to contain a specific private patient earnings figure.
This represents around 0.11% of total patient related revenues, well above the negligible 0.01% of South Tyneside, with whom it has been in a strategic alliance since 2016 as a precursor to merger.
To the north, neither North Tees and Hartlepool (£113k) nor Northumbria (£76k) are showing private patient growth. Northumbria, though, is developing
links with both Ireland and with China to share expertise on providing high-quality health and, over time, this commercial approach may enable international patient services to develop.
To the south, County Durham and Darlington also has flat, and relatively low, revenues at £51k last year.
With the exception of Newcastle, the regional and supra-regional services centre, private patient earnings provide little in the way of significant additional income for these NHS trusts in the North-east.
The only PPU in the region is where the service is doing best, although it is clear that there are underlying levels of demand across the area. Given the complexities of opening, managing and growing a trust in-house private patient service, this may be a good market for trust collaboration.
A ‘chain’ approach, most likely led by Newcastle – where presently 61% of the region’s private patient revenues are earned – could be the way forward.
Models of hub and spoke and back office-sharing or even cobranding would offer synergies, cost savings and a fresh market approach for the future.
Next month: The annual review of NHS trusts across England
Philip Housden (right) is a director of Housden Group
With the commencement of the new tax year in the next few weeks and spring almost upon us, it is a great time to look at your finances for the year ahead. Ian Tongue (right) considers some of the key areas you should review
DREAM RETIREMENT: But the rules when saving for it are complicated, so take advice now
face an ever-changing world of pensions and taxation regulations, so it is always a good idea to periodically review your circumstances, especially for doctors new to private practice.
Probably the most important topic to discuss with any doctor at present is their pension position to determine if they have any tax liabilities from exceeding the pension annual allowance.
This is one of the most complex areas to understand, as often it feels like the tax charge is a penalty for working hard and, for some, this is sadly the case.
For the 2016-17 tax year, HMRC introduced a system of reducing or ‘tapering’ of the normal level of pension annual allowance of £40,000 down to as little as £10,000, depending on earnings.
If you work in the NHS, then there is a natural thought process to look at the contributions that you pay through your payslip and conclude that you are well within the annual pension allowance. But this would be incorrect.
All of the NHS Pension Schemes are a special type of pension scheme and the annual allowance is compared against pension growth rather your your actual contributions.
If you are an active member of any of the NHS Pension Schemes, there is a high chance of you exceeding or being close to exceeding the pension annual allowance. Therefore, discussing this with your accountant and financial adviser is essential to determine if these pension tax charges can be mitigated.
When it comes to trading structure, there is no ‘one size fits all’ approach. Often, a business commences with one type of structure – for example, self-employment –but is then converted into another later on, such as a limited company.
With appropriate circumstances, forming a limited company for your private practice may be the most tax-efficient structure and savings may be further amplified in relation to the pensions annual allowance tax charge.
Depending on your retirement plans, a limited company can also be used with a view to it being a tool to extract a further tax-efficient lump sum or perhaps bridge that gap between when you may want to retire and can access your pension in full.
In light of the new 2015 NHS Pension Scheme and pension annual allowance charges, considering your trading structure with your accountant is essential.
Doctors’ private practices often commence with basic record-keeping and accounting systems, but with significant changes to the tax system looming, a consideration of your systems is required.
HM Revenue and Customs (HMRC) is phasing in a new tax regime referred to as ‘Making Tax Digital’ and the key element of this is to report your business’s financial results more frequently than the historical annual tax return.
The new regime, which we have drawn attention to a number of times in Independent Practitioner Today , will require businesses to report their financial results quarterly. There have been no changes to the payment system announced ... yet!
Realistically, all private practices will need some form of electronic record-keeping which, in turn, can be used for reporting results to HMRC. The more sophisticated accounting packages will have facilities to report directly into HMRC’s systems, but it is anticipated that many private practice management packages will use a third-party software package to ensure compliance.
The new regime comes into force in April 2019 for VAT-registered businesses and, providing this is a success, all remaining businesses are to follow suit from April 2020.
If you are VAT-registered, it is important that you consider your accounting systems urgently, but for everyone else, discuss your position with your accountant to formulate a plan to ensure compliance from the scheduled implementation date of April 2020.
Aside from the requirements for VAT-registered businesses to comply with the new tax regime, there
are many private practices that are close to the VAT registration threshold because of the nature of the work performed and are not VAT-registered.
Most practices do not need to consider VAT registration due to the work performed being medical, which is exempt from VAT.
But for doctors carrying out medico-legal or purely cosmetic work, these activities are not regarded as medical, so if you are doing more than the VAT registration threshold level, currently £85,000, you have to register and charge VAT.
It is important to note that you are required to consider whether VAT registration is required monthly and on a 12-month rolling basis rather than when your accountant prepares your accounts. If you have overlooked considering this and are carrying out these non-medical activities, it is important for you to look at this at the earliest opportunity.
With the push to move people away from petrol and diesel vehicles, there are tax incentives for owning a car that is regarded as an ultra-low emission vehicle: emissions of 50g/ km or less. Many of these are fully electric, but some hybrids also fall under this category.
Aside from these vehicles currently attracting the least amount of tax as a benefit in kind, proposed tax rates for 2020-21 are extremely low for most fully electric vehicles.
If you are considering a new car, it may be worth asking your accountant’s advice on the costs of
having a company car if you are trading as a limited company or perhaps using the NHS fleet scheme irrespective of your private practice trading structure.
Depending on the vehicle, the NHS fleet scheme can be good value and also reduce pension annual allowance charges, as the salary sacrifice is from superannuable income. A word of warning, though; if you cease to have the vehicle and your superannuable income increases, it may spike your pension growth and a tax charge could arise. Your accountant should be able to advise you further.
If your private practice is within one of the more competitive sectors, such as plastic surgery, you should consider your approach to marketing and PR.
While everyone acknowledges that websites are essential, their quality and their links to social media and digital marketing generally are becoming more important. There are many companies out there to assist with this. They understand the medical profession and can often be very good value for money.
Regular assessment of your private practice is essential to ensure that you are best placed within the market you operate and are set up efficiently for tax. Meet with your accountant and financial adviser to review your circumstances. Next month: Plan for a successful private practice
Ian Tongue is a partner with Sandison Easson accountants
Independent Practitioner Today’s motoring correspondent Dr Tony Rimmer becomes ‘Double-O Doc’ for the day as he puts a couple of Aston Martins through their paces
IN THE public’s perception, London’s Harley Street enclave is synonymous with high class and successful independent medical practice.
But in truth, many private clinics and businesses there have, over the years, stumbled and some have failed. But the address still possesses an enviable international kudos and its value to any on-going medical business is incalculable.
In the world of cars, the same could be said about the quintessentially British brand, Aston Martin. Since it was founded in 1913 it has suffered some turbulent financial times, including bankruptcy on a couple of occasions.
But despite this, the brand is strong and globally renowned. Currently in a stronger position than it has been for some years, it is a company on the move.
The first all-new model for several years appeared in 2016, the DB11 coupe. Now we have the convertible iteration, the stylish DB11 Volante and an all new version of the Vantage, Aston’s most successful model. I have been lucky
enough to have driven both models along a few hundred miles of testing Cotswold roads.
Both cars sit on an all-new bonded aluminium structure that combines rigidity with lightness. Also, both cars are currently only available with the Mercedes AMGderived 510bhp 4.0litre twin-turbo V8.
Let us first consider the Volante. What defines this model is, of course, the roof. The eight-layered fabric structure gives all the weather and acoustic protection you could ask for.
The engine sits at the front but nicely behind the front axle-line to give a 47-53 per cent front-rear weight distribution. There is an eight speed ZF automatic gearbox transmitting the power to the rear wheels with steering-wheel paddles for when you fancy manual mode.
There are three selectable driving modes: GT, Sport and Sport Plus. Each one ramps up the sportiness with a combination of damper stiffening, gearbox responsiveness and exhaust sound. It is impossible not to be excited to be climbing behind the wheel of an Aston Martin. All of us petrolheads have been influenced by the iconic DB5 in several James Bond movies ever since it first appeared in Goldfinger in 1964.
It helps that the DB11 Volante looks a million dollars. The pearl blonde bodywork of my test car exudes style from any angle, hood up or down. Owners will be glad of the occasional rear seats; perfect
The Vantage is seen as a direct competitor to the Porsche 911
for small children or extra luggage space when touring.
You sit low and the driver controls have a wrap-around feel as in most good sports cars. The drive selector buttons are similar to those in a McLaren and the infotainment screen and controls are modern. You cannot fail to feel pretty special, sitting behind the wheel.
Setting off and left in default GT mode, the Volante immediately impressed me with its ease of use. The primary ride is particularly remarkable; firm but comfortable. The steering is perfectly weighted and very direct. There is a great feeling of structural solidity with no vibrations or rattles to upset the sense of engineering excellence.
As I picked up the pace, the reactive gearbox with ultra-smooth changes linked to the plentiful torque from the twin-turbo engine allowed effortless progress.
The DB11 is physically a big car but, with such tight dynamics, shrinks around you. Road and wind noise are suppressed to executive saloon levels and you are just aware of a lovely V8 thrum when you push on. You could cover big distances in this mode in great comfort with not a second thought.
A cross-country route allowed me to play with the Sport and Sport Plus modes. Each is a step towards releasing the inner beast. The revs are held longer before change-up, the dampers firm up and the exhaust is allowed to sing without restraint.
Make no mistake; the DB11 is a proper sports car. Corners can be attacked with great confidence and great satisfaction. The fact that this dynamic playfulness is in a car that can also play the topdown cruiser role when the sun shines only enhances the appeal. Next, the new Vantage. Smaller in dimensions than the Volante, this is a strictly two-seater sports car that is designed with the driver in mind.
Porsche competitor
Aston Martin sees it as more of a direct competitor to the faster Porsche 911 variants and owners will be offered regular track-day outings. It has a more perfect 50:50 weight distribution and a clever electronic rear differential to maximise traction even under the most challenging of conditions. Driving modes are Sport, Sport Plus and Track.
Sitting behind the wheel is just as much of an event as in the Volante and out on the road it feels really taut with a firm but not uncomfortable ride.
Performance, with over 500bhp on tap, is immense and addictive. A swift drive on a clear B-road in Track mode using the paddles to change gear brought a wide grin to my face, helped by the pops and bangs from the exhaust on the over-run.
Aston has done a great job with both new cars. The Volante looks fantastic hood up or hood down and the Vantage looks dramatic and purposeful. The V8 engine suits both perfectly and build quality is top notch.
They ooze character that is missing from many rivals.
Pricing is at a level that will be within the reach of only the most successful private practitioners but it ensures exclusivity and fulfills the brand ethos.
They are confident athletic sports cars dressed in Saville Row suits. Mr Bond would approve.
Dr Tony Rimmer is a former NHS GP practising in Guildford, Surrey
Body: Two-plus-two convertible Engine: 4.0 litre V8 twin turbo Power: 503bhp
Torque: 675Nm
Top Speed: 187mph
Acceleration: 0-62mph in 4.1 seconds
Economy: 28.3mpg combined cycle
CO2 emissions: 230g/km
On the road price: From £159,900
Body: Two-seater coupé
Engine: 4.0 litre V8 twin turbo Power: 503bhp
Torgue: 685Nm
Top speed: 195mph
Acceleration: 0-62mph in 3.6 seconds
Economy: 27.4mpg combined cycle
CO2 emissions: 236g/km
On the road price: From £120,900
All you need to know about accountancy for private practitioners
Consultant gynaecologists have notched a massive 28% profits rise. Ray Stanbridge explores the reasons in his analysis of the figures in our latest benchmarking survey
JUST A YEAR ago in our February 2018 report in Independent Practitioner Today, we commented that it was increasingly tough for many consultant gynaecologists, but that many continued to rise above the financial storm.
We must confess that we were perhaps overly pessimistic in these comments, as gynaecologists in private practice seem to have ‘bounced back’ profit-wise.
Our headline figures suggest that gross incomes from private practice on average for gynaecologists have increased by 12% from
£115,000 to £129,000 between 2016 and 2017.
Costs have actually shown a small fall of about 3% on average from £59,000 to £57,000. As a result, taxable profit has increased on average by 28% from £56,000 to £72,000.
Feast or famine
This is a much higher rate of increase than we have observed from many other subspecialties. Why then has this increase incurred in a climate when gynaecologists’ fees are still subject to
AVERAGE INCOME AND EXPENDITURE OF A CONSULTANT GYNAECOLOGIST WITH
Expenditure
Source: Stanbridge Associates Ltd.
intense scrutiny and pressure from insurers?
Certainly, in the country town areas outside the M25 there has been a growth in Choose and Book work, and what increasingly looks like to be a picture of feast or famine.
And as this journal reported only last month, the self-pay market has been rising again and an increasing number of patients pay themselves for minor procedures.
In London particularly, the growth in the number of private GPs seems to have a modest effect on the growth of named referrals. This has certainly benefited some gynaecologists.
Some costs have shown a reduction over the year. Medical supplies/assistants fees have fallen slightly from £4,000 to £3,000 on average.
Professional indemnity costs have shown a modest decrease from £16,000 to £15,000. Really? Yes, because an increasing number of gynaecologists – who do not do obstetrics work – have managed to obtain cheaper cover on the market than from the traditional providers.
There has also been a fall in ‘other costs’ from £8,000 to
An increasing number of gynaecologists – who do not do obstetrics work – have managed to obtain cheaper cover on the market than from the traditional providers
£4,000. Mostly, this reflects marketing/website costs. In the previous year of 2015-16, there seems to have been quite a concerted spend on marketing by a number of consultants.
Staff costs and consulting room hire expenses seem to have been fairly constant between the two years. There has been a modest increase in costs for use of home, motor and travel and conference costs.
So what is the future for gynaecologists in private practice?
Initial study of preliminary 2018 data suggests that the improved performance noted in 2017 has continued. There is a growing interest in groups from gynaecolo-
gists and of a number of new ‘women’s health centres’ are being considered in London and elsewhere. Some of these are inviting consultant financial participation. Many structural changes are going on in the market and gynae-
As in previous reports, note that our figures are not statistically significant. Rather they are an average of what a typical gynaecologist with private practice is doing. GYNAECOLOGISTS SAW
cologists look as if they are not missing out.
There are difficulties in reflecting year-to-year comparisons – but we still know many specialists find this benchmarking survey well worth doing.
Some consultants have incorporated, others have formed groups and yet others have changed the nature of their practices by focusing on Choose and Book work and/or eliminating any obstetrics or high-risk gynaecology work.
For the record, our survey is restricted to those consultant gynaecologists who are not in fulltime private practice. They:
Hold either a new style or old style NHS contract;
Have at least five years’ experience in the private sector;
Are seriously interested in private practice as a business;
Earn at least £5,000 a year from private practice;
Work as a sole trader, a member of a formal or informal group or through the means of a partnership or limited liability company.
Next month: Radiologists
Ray Stanbridge is a partner with accountancy, finance and tax advisory medical specialists, Stanbridge Associates
Years ending 5 April Source:
Make sure you don’t miss our next issue, published on 21 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:
In a new series for Independent Practitioner Today, David Hare, chief executive of the Independent Healthcare Providers Network, tells more about the new Consultant Oversight Framework (See our story in this month’s issue, page 4)
Accountant’s Clinic columnist Susan Hutter has some useful tips to help independent practitioners prepare for the financial year ahead
Responding to digital transformation in independent practice. Why not having a good online presence is no longer an option. PLUS...
...Technology in practice: Is it really possible to go paperless?
More people are open about their own mental health than ever before. That is, it seems, for everyone but medical professionals. In her ‘Keep It Legal’ column, Amie Roadnight advises on what steps you can take and lists some organisations who can help you, a colleague or member of staff
Planning for a successful private practice
– accountant Ian Tongue has some excellent advice
Tackling the disease of error in healthcare – risks and opportunities in the private healthcare sector. Our third and final article studies what can be learned from the High Reliability Organisation approach to error reduction and the development of a safety culture
The
Circulation figures verified by the Audit Bureau of Circulations
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Email: robin@ip-today.co.uk Phone: 07909 997340
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Cavendish Medical’s Patrick Convey shows why high charges can impact your investment returns
Business Dilemmas highlights the case of a psychiatrist who has been contacted by the Fixed Threat Assessment Centre in London about a patient whose letters to a member of the royal family suggest an unnatural fixation. Is the doctor obliged to disclose information?
A doctor asks for help after feeling uneasy about a woman’s request for him to write a certain letter to her daughter’s school
In his ongoing PPU series, Philip Housden presents his annual review of income they bring to NHS trusts across England
Tracing our roots – some big milestones in the NHS that got us to where we are today
Doctor On The Road: our tester Dr Tony Rimmer finds the Volvo XC40 a refreshing alternative to the German brands
Our unique benchmarking series, Profits Focus, looks at the earnings of consultant radiologists
Top Tips for Busy Doctors: Resourcing your practice. What are the options for resourcing your practice and which solutions will suit you?
Ten Years Ago in Independent Practitioner Today
The Independent Doctors Federation gives its response to the Government’s defence cover consultation
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